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Based on observation, interview, and record review, the facility failed to ensure patients on the "700 Unit" received care in a safe environment when Patient 1 was not consistently monitored every 15 minutes according to facility policy.

These failures resulted in Patient 1 making a suicide attempt on 12/3/24 and contributed to an unsafe environment for patients on the 700 Unit by leaving them unsupervised.

Findings:

During a review of Patient 1's "Psychiatric Evaluation," dated 12/1/24, the evaluation indicated Patient 1 was admitted to the facility for "DTS (Danger to Self)." The note further indicated Patient 1 was at a county jail and was found "...in her cell attempted to hang herself" and, "...reportedly tied a blanket around her neck and tied the other end... to the toilet". The evaluation included, "[Patient 1] could not clearly engage in safety planning." A continued review of the note indicated Patient 1 had a history of bipolar disorder (a mental health condition that causes extreme mood swings). The diagnoses listed in the evaluation included major depressive disorder (a mental condition characterized by a persistently depressed mood often with symptoms such as suicidal thoughts). The note indicated the "Level of Observation" for Patient 1 was to be "Every 15- minute observation".

During a concurrent observation and interview on 12/16/23 at 3:00 p.m. with the Risk Director (RD), video footage on 12/3/24 of the 700 unit hallway outside of room 724 (Patient 1's room) was viewed. The video footage indicated an RN and staff exiting Patient 1's room at 6:28 p.m. Two staff members are seen conducting what appeared to be shift-to-shift handoff rounds at 6:59 p.m. (a 31 minute lapse since Patient 1 had been observed). At 7:08 p.m., the new staff member starts rounds in the hall. At 7:13 p.m., the staff member enters Patient 1's room. Immediately, RN and other staff are observed running down the hallway responding to room 724 (a total time lapse of 45 minutes).

A review of the "Patient Observation Sheet" used to document every 15 minute rounding for Patient 1, dated 12/3/24, included a check mark for the times between 6:30 p.m.- 7:00 p.m. with the code "R4" indicating Patient 1's location was in her room (R) and the activity was "Lying/Sitting" (4). The next time, 7:15 p.m., the staff oncoming staff documented "Code Blue".

During a review of Patient 1's "General Progress Note," dated 12/3/24 at 8:06 p.m., the note indicated Patient 1 was "Transferred out to the emergency department after she was found hanging from the chair in her room. Staff found the patient during rounding and called for assistance... The patient had the shower curtain wrapped around her neck and also wrapped around the weighted chair."

During a review of the "General Progress Note," dated 12/4/24 at 12:17 a.m., Patient 1 was received back from the hospital where she was medically cleared to return to the facility. The note included, "Because patient is at a heightened risk for suicide attempts, an order for 1:1 observation and a denial of rights for linens and shower curtains was obtained from the on- call provider."

During an interview on 12/16/24 at 3:30 p.m. with the RD, the RD stated staff did not round on Patient 1. The RD stated, "the (Staff) was terminated for falsifying q15's (every 15 minute observational rounds).

During a review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment and Prevention", dated 7/25/24, the P&P statement was, "All patients seeking treatment at [Hospital Name] are screened for suicide risk, and receive care, treatment, and services in an environment that minimizes or eliminates that risk." The P&P directed, "..Ensure that the individual's immediate safety needs are met. At a minimum, the patient will be monitored at least every 15 minutes in a safe environment".

During a review of the facility's policy and procedure (P&P) titled, "Observation Rounds", dated 11/2024, the P&P defined, "'Observation Rounds' are defined as clearly specified times of visual monitoring of every patient". The procedure stipulated, "...Observation Rounds are to be completed by the assigned staff every 15 minutes on every patient around the clock..." and, "Observation Rounds... are to be completed in a timely manner. All documentation on Observation Rounds sheet is to be the original and mist not be modified or obscured". The P&P continued, "Falsification of Observation Rounds is grounds for termination".