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Based on observation, record review, policy and procedure review, and staff interview, the Hospital failed to protect and promote each patient's rights by failure to ensure care in a safe setting for patients who displayed suicidal ideation and/or attempts.

Findings include:

The hospital admitted patients with suicidal ideations/attempts and placed these patients in rooms which contained environmental hazards and lack of visual monitoring. The toilet and shower rooms had grab bars which were not anti-suicide (Refer to A144). Staff failed to follow the policy and procedure requiring visual observation and documentation of patient activity for patients on 15 minute checks (Refer to A144). The cumulative effect of these findings placed these patients in serious and immediate jeopardy for harm.

The survey team determined an immediate jeopardy situation existed at 6:00 p.m. on 01/07/15. At 6:15 p.m., the survey team notified administrative staff members (#1, #3, #4, #5, #6, and #7) of the immediate jeopardy situation. On 01/08/15 at 1:00 p.m., administrative staff members (#1, #3, #4, #5, #6, and #7) provided the survey team with a plan for responding to the immediate jeopardy. The plan included the actual visual observation of patients on 15 minute checks with staff education initiated on 01/07/15 prior to the next shift with all on-coming staff required to sign that they understood the expectations of visual checks and the removal of shower grab bars from all patient rooms. The plan included staff would place any patient identified as a suicide risk in an intensive level room (with cameras) and if unable due to current occupation of the room, staff would place that patient on 1:1 supervision. The survey team verified the Hospital's plan and determined the immediate jeopardy situation was abated at 3:30 p.m. on 01/08/15. Condition level noncompliance continued post abatement.

Based on observation, record review, policy review, and staff interview, the Hospital failed to ensure care in a safe setting for 1 of 1 suicidal patient (Patient #12) closed record reviewed who accomplished hanging himself/herself in the psychiatric unit, 5 of 11 current patients (Patient #1, #2, #7, #8 and #9), and 5 of 5 closed records of patients (Patient #13, #14, #15, #16 and #17) admitted with suicidal ideation/attempts. The environment of the unit presented hazards including lack of visual monitoring by Hospital staff and the presence of environmental hazards including non-suicidal proof grab bars (open grab bars) within the unit shower stalls. The procedures implemented by Hospital staff and the environmental hazards limited the Hospital from providing care in a safe setting.

Findings include:

Review of the policy "Patient on Suicide Precautions" occurred on 01/07/15. This policy, revised 01/17/11, stated, "Purpose: To assure safety of patients admitted . . . with a physician order for suicide precautions. Policy: . . . 2. All patients admitted . . . with a physician order for suicide precautions, follow the Suicide Precautions Algorithm. 3. Video surveillance is used as an additional safety measure. Definition: Suicide Risk - The presence of risk factors for self-induced harm with the possibility of evidence that the person intentionally tried to take their own life. . . . 15 minute checks - Maintain visual observation of patient and documentation of patient activity every 15 minutes. . . . Procedure: . . . Nursing assessment and expectations . . . 1. A suicide risk assessment is completed. a. The risk assessment is documented on either the Suicide Risk Assessment form . . . or in nursing and/or physician notes. 2. The nurse collaborates with and reports to attending psychiatrist and multidisciplinary team with the nurse's suicide assessment. Based on this assessment, the team determines if the level of observation (1:1 or 15 minute checks) needed to keep the patient safe. a. The nursing unit evaluates their ability to staff 1:1/15 minute checks utilizing CNA [certified nursing assistant], LPN [licensed practical nurse] or RN [registered nurse]. i. If unable to provide staffing, the unit contacts the Administrative Associate and/or the Manager of Psychiatry or their designees to assist with staffing. 3. Inform patient/family about suicide precautions and the level of observation. 4. Search patient's . . . room for potentially dangerous objects . . . and remove all potentially dangerous objects. . . . c. Determine the need for additional monitoring via video surveillance. . . . 5. Collaborate with the patient to develop a safety plan. a. Document verbal safety contract. . . . 6. Document 15 minute check on all patients on suicide precautions on the Psych flow sheet . . . i.e. Suicidal statements, interventions, patient response. 7. The nurse continually assesses patient regarding suicide risk and presence of suicidal thoughts. . . . The physician writes the order to discontinue suicidal precautions when determined that the patient's safety is secured. a. Nursing inquires and documents at least once per shift regarding patient's suicidal intent and more frequently if a positive response or suspicion is high. . . . "

Review of the policy "Flowsheet: 1:1 Surveillance, 15 Minute Checks" occurred on 01/07/15. This policy, revised July 2013, stated, ". . . Policy: . . . 3. Patient and patient room is checked for any possible hazardous objects. 4. Patient is placed in scrubs at nurse's discretion. 5. At least every 15 minutes documentation regarding patient status and behavior is documented on 1:1 Surveillance Flow Sheet or 15 Minute Checks Flow Sheet. . . ."

During observation and interview with psychiatric unit staff members (#1 and #3) on the morning of 01/07/15, the unit current capacity included 23 total beds with 17 beds on the adult unit, and six beds on the children's unit. Current construction of one room in the children's unit reduced the capacity to four patients in this area. All of the rooms included standard grab bars in the showers/tubs of the bathrooms, except for two rooms. One room on the adult unit and one room on the children's unit included suicide prevention grab bars. Staff identified these two rooms as "safe rooms." In addition, observation showed standard grade door closures throughout the unit which could pose a hanging risk for patients at risk for suicide.

- Review of Patient #12's record occurred on all days of survey. The emergency room (ER) record identified Patient #12 arrived to the emergency department (ED) at 11:53 p.m. on 12/27/14. The ED provider noted the chief complaint (CC) as "Attempted hanging." The history indicated the patient presented from a local facility and attempted to strangle herself with a belt and scarf on that evening. Past medical history included "Suicidal behavior" and an admission drug screen positive for amphetamines. The ED physician's assessment stated "1. Attempted hanging 2. Possible overdose with a positive urine drug screen . . ."

Patient #12's admission to the psychiatric unit occurred on 12/28/14 at 2:05 a.m. The admission note stated ". . . Pt [patient] contracted for safety while on unit. . . . Monitor pt's safety with suicide precautions and 15" [minute] checks."

A History and Physical (H&P) note, timed 12/28/14 at 10:51 a.m., stated the patient's 20 year old brother committed suicide by hanging one or two months ago. The provider examination included ". . . is wearing hospital scrubs. . . . She reports that her suicide attempt was impulsive and 'I regret it.' When asked if she remains suicidal, she reports 'yes and no.' . . ." The treatment plan included ". . . We are going to continue with 15-minute checks." The record showed the patient admitted to the room currently under construction on the children's unit.

Review of the "1:1 surveillance or 15 minute checks flow sheet" showed 15 minute checks initiated upon admission to the floor. The flow sheet showed on 12/28/14 at 8:30 a.m. the patient was meeting with one of the providers. The flow sheet showed on 12/28/14 at 9:15 a.m. the patient was in the bathroom. The flow sheet did not indicate in what manner the staff made this determination.

Review of a provider progress note made on 12/28/14 at 10:31 a.m. stated the provider ". . . observed security cutting patient loose in her bathroom. Her body was on the floor as he cut her loose. We slid her out of the bathroom into the room, I checked for a pulse, there was none . . . started CPR [cardiopulmonary resuscitation] . . ."

The record identified Patient #12's suicide attempt resulted in respiratory and cardiac arrest, endotracheal intubation, and mechanical ventilation.

Review of a progress note on 12/28/14 at 12:21 p.m. stated, ". . . doing rounds [staff member] heard pt's [patient's] bathroom door shut and noticed patient had gone into the bathroom, as the bathroom door was closed and the light was on. This [staff member] gave patient less that 10 minutes using the restroom and checked on pt. again before the next 15 minute round at 0930 [9:30 a.m.]. This [staff member] knocked on the door and pt did not answer . . . immediately opened pt's bathroom door and found pt unresponsive, wedged between the toilet and wall with scrub pants wrapped around her neck, attached to grab bar. [staff member] pushed panic button and attempted to lift patient and loosen the knot . . . ran to main nurse's station for help."

During interview on the afternoon of 01/07/15, a supervisory staff member (#1) stated a 15 minute check of patient "in bathroom" "usually" means they were checked on, and there was some kind of interaction which may be verbal only. The staff member stated observation does not occur in the bathroom for privacy purposes.

During interview on the afternoon of 01/07/15, a supervisory staff member (#1) stated all standard rooms (non-intensive rooms) on the unit including the three children's and six adult rooms had horizontal grab bars next to the toilet and staff had removed these bars. The staff member (#1) stated these rooms still have the grab bars in the bathrooms within the shower and/or tub.

Additional information provided regarding the event which occurred to Patient #12 identified potential contributing factors included the patients strong suicidal thoughts, previous attempt at hanging, "only one staff on the peds [pediatric] unit at the time of the incident; panic buttons not communicating as previous which staff were not aware of; patient being placed in a room that wasn't an identified suicide proof room."

During interview on the afternoon of 01/07/15, a nurse (#2) stated the following:
* the expectation for 15 minute checks includes a visual observation,
* the panic buttons do not identify the location of the staff member pressing the button (except that it is coming from the psychiatric unit),
* the panic button alert comes across on a screen at the nurse's station and alerts the in-house security staff,
* staff could also use the call lights in the bathroom and bedrooms to call for help,
* staff complete a patient "contract for safety" verbally and document this in the medical record,
* if a patient cannot contract for safety, staff place the patient in the intensive room for closer observation.

Additional records reviewed on all days of survey included other patients admitted to the psychiatric unit with suicidal ideations/attempts and not placed in "safe rooms" for their protection/safety. These patients included:

- Patient #13's record identified an adult patient admitted on 11/15/14 with suicidal ideation and a plan of using a razor blade to cut his/her throat. The patient's care plan identified a goal to "remain safe" and not cause injury to self or others. Review of the ". . . 15 minute checks flow sheet" showed on 11/15/14 at 7:15 a.m. and at 7:30 a.m. staff documented the patient as "showering." The documentation did not identify if visualization occurred to verify this, if staff remained within the room or bathroom until the completion of the shower, or if it was a verbal communication with the patient.

- Patient #14's record identified an adult patient admitted on 11/11/14 for possible suicidal ideation as the patient refused "to answer if SI [suicidal ideation] present in ED . . ." The record identified the patient admitted on 15 minute checks.

- Patient #15's record identified a pediatric patient admitted on 12/19/14 with suicidal ideation of cutting herself and having thoughts about hanging herself. The record identified the patient admitted on 15 minute checks.

- Patient #16's record identified a pediatric patient admitted 11/20/14 with suicidal thoughts including "A month ago a fight got so bad that she grabbed a knife and was running around the house threatening to kill herself." The care plan identified a goal to "remain safe" and not cause injury to himself or others.

- Patient #17's record identified a pediatric patient admitted 12/25/14 with a suicide attempt with an overdose of melatonin. The record showed the patient "Contracted for safety" with staff.


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- Review of Patient #1's active medical record identified the patient presented to the ED on 01/06/15 due to suicidal thoughts. Review of the patient's ED provider notes stated, ". . . History of Present Illness: . . . presents to the emergency department accompanied by police escort with complaints of not feeling safe alone. . . . describes long-standing depression with more recent overwhelming thoughts of suicide. . . . tells me that . . . had thoughts about 'not being here.' When I ask if . . . has a plan . . . tells me . . . has had thoughts about pills simply driving off. . . . Past Medical History 1. Depression. 2. Previous suicidal ideation and psychiatric hospitalization. . . . Emergency Room Course and Discussion: . . . will be admitted for stabilizing treatment, a safe bed, and psychiatric treatment/psychiatric care . . . Provisional Diagnosis: Depression with suicidal ideation."

Record review identified Patient #1 admitted to the psychiatric unit from the ED on 01/06/15. A suicide-risk assessment performed by a nurse upon admission at 5:00 p.m. identified the patient had thoughts or a plan for self harm and showed the patient indicated feelings of hopelessness/helplessness as well as circumstances which trigger suicidal thinking. Patient #1's provider ordered 15 minute checks upon admission for safety.

- Review of Patient #2's active medical record identified the Hospital admitted the patient to the psychiatric unit on 12/30/14 with diagnoses of suicidal ideation, mood disorder, and alcohol withdrawal. An admission H&P, completed on 12/30/14 at 9:37 a.m., stated, ". . . Chief Complaint/Reason for Admission: 'I don't want to breath' [sic] History of Present Illness: . . . reported that he was suicidal. . . . stated multiple times that he just did not want to live . . . states that he has been suicidal for a couple of months now. . . . states . . . a history of bipolar disorder and has attempted suicide 'a dozen times.' . . . reports he does drink about every other day 'to kill the pain.' . . . Recommendations/Treatment plan: . . . 4 - Safety: 15 minute safety checks. . . ."

Review of orders identified Patient #2's provider ordered 15 minute safety checks on 12/30/14 at 9:54 a.m. A provider progress note, completed on 12/31/14 at 10:51 a.m., stated, ". . . does state that he does not feel like leaving and is very suicidal. . . . does state that this has been worse the last 2 days . . . does not have any family or anything to live for . . . does state that he has not consistently taken his medications. . . . Diagnosis: . . . Suicidal ideation . . . Plan: . . . He will be monitored for safety. . . ."

A suicide-risk assessment for Patient #2 performed by a nurse upon admission on 12/30/14 at 10:12 a.m. identified a suicide attempt in the past, showed the patient indicated feelings of hopelessness/helplessness as well as circumstances which trigger suicidal thinking, and identified a history of suicide in family/friends/significant others.



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- Patient #7's medical record showed a physician's order to admit the patient to the psychiatric unit after an attempted suicide. The physician's orders included suicide precautions with every 15 minute checks. Psychiatric unit staff failed to place the patient into a "safe room" identified as intensive level for suicide risks.

Review of the "1:1 surveillance or 15 minute checks flow sheet (Suicide precautions)" identified 15 minute checks ordered by the physician for patient safety. Staff initialed the form and noted where the observation took place. On six separate days staff indicated the patient "in the shower" for two consecutive 15 minute checks. The form did not indicate if staff completed a visual or audible check during those times.

- Patient #8's medical record showed a physician's order to admit the patient to the psychiatric unit after the patient exhibited suicidal thoughts with a plan to overdose on medications. The physician's orders included suicide precautions. Psychiatric unit staff failed to place the patient into a room identified as intensive level for suicide risks.

Review of the "1:1 surveillance or 15 minute checks flow sheet (Suicide precautions)" identified 15 minute checks for patient safety. The first entry stated, "Brought in with family, suicidal."

- Patient #9's medical record showed a physician's order to admit the patient to the Psychiatric unit after the patient threatened to hang himself. The physician's orders included suicide precautions with every 15 minute checks. Psychiatric unit staff failed to place the patient into a "safe room" identified as intensive level for suicide risks.

Review of the "1:1 surveillance or 15 minute checks flow sheet (Suicide precautions)" identified 15 minute checks ordered by the physician for patient safety. Staff initialed the form and noted where the observation took place. On one day staff indicated the patient "in the shower" during one 15 minute check. The form did not indicate if staff completed a visual or audible check during that time.