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Based on record review, video recording review, interviews, and policy review, the facility failed to protect/promote the right to be safe and free from neglect for one (#4) patient of eight patients reviewed.

The findings included:

Medical record review revealed Patient #4 was admitted to the facility on November 28, 2011, at 12:30 p.m. with diagnoses of Schizoaffective Disorder. Further review of the medical record revealed Patient #4 was an involuntary commitment to the facility, and the commitment documentation stated, "Pt (patient) is acutely psychotic with no insight and wants to harm self and others. Pt with Auditory and Visual Hallucinations...Pt poses immediate harm to self with self injury threatens same on others...actively homicidal and suicidal."

Review of the Nursing Assessment Summary, dated November 28, 2011, at 2:00 p.m. revealed the patient has auditory hallucinations and heard, "Voices tell...various things." The Nursing Assessment Summary also stated, "Placed on close observation for safety. Will monitor closely."

Review of the Admission Order form, revealed physician's orders dated November 28, 2011, at 2:00 p.m. for Patient #4, which ordered, "Observation Level...Close (15-minute checks)"

Review of Discharge Summary, dated December 13, 2011, revealed Patient #4 was admitted after, "tried to pluck out ...right eye with fingernails...". Further review of the Discharge Summary revealed, "...was placed on close observation." The Discharge Summary also stated, "At approximately 1:45 a.m. on 11/29/11...was found face down in the toilet, a shower curtain behind...neck and around the commode."

Review of Patient #4's Autopsy Report, dated November 29, 2011, revealed, "Cause of Death: Drowning...Manner of Death: Suicide...Circumstances of Death: Submerged head in toilet." The report also stated, "...found unresponsive with head secured inside an overflowing toilet...A bed sheet had been used to secure the bathroom door shut...and secure...head inside the toilet.

Review of the facility's policy number 0214.01, titled, "MANAGEMENT OF PATIENTS AT RISK", revision date October 6, 2011, revealed, "...Close Observation...all patients will be observed or accounted for at least every fifteen minutes..." Further review of the policy revealed, "The RN/LPN (Registered Nurse/Licensed Practical Nurse) will observe the patient's behavior, condition, and will assess for the patient's well-being during their hourly checks; along with providing supervision to the Psychiatric Technician on an hourly basis or more frequently if needed..."

A digital video recording, from a camera in the hallway outside Patient #4's room, recorded on November 29, 2011, from 12:30 a.m. to 1:46 a.m., was reviewed on March 1, 2012, at 11:30 a.m., in the Quality Management office. Review of the video recording revealed no staff opened the door to Patient #4's room, or visually checked on Patient #4 from 12:30 a.m. to 1:44 a.m. (total of 1 hour and 14 minutes/74 minutes) on November 29, 2011.

Interview with the Assistant Superintendent for Quality Management (ASQM), on March 1, 2012, at 11:45 a.m., in the Quality Management office confirmed the ASQM had reviewed the video recording and confirmed no staff entered Patient #4's room, or visually checked on the patient, from 12:30 a.m. to 1:44 a.m., on November 29, 2011. Further interview with the ASQM confirmed Patient #4 was on close observation which meant the patient was to have been assessed visually by the psychiatric technician every fifteen minutes and by the nurse every hour.

Interview with the Chief Executive Officer (CEO) and the ASQM, on March 1, 2012, in the administrative office conference room, at 2:00 p.m., revealed the facility had made multiple changes in policy, environment, and monitoring of at risk patients. These changes included:
1) Hospital Policy #0214.01, "Management of Patients at Risk" revised December 20, 2011, to include Safety Guidelines for Treatment Units. These guidelines will instruct nursing staff on the following:
a. Staff shall maintain an attitude that all patients are at risk of self-harm at all times.
b. Each staff person is responsible for the safety and health of all patients on the unit, regardless of their assignment.
c. Safety checks are the Psychiatric Technician's primary responsibility, and other duties shall not prevent, replace, or interfere with timely and proper completion of patient safety checks.
d. In the Acute Treatment Program, all patient rooms shall be locked each day from 7 a.m. to 7 p.m., and patients will only be given access by physician ' s order or for limited times under the direct supervision of a staff person.
e. In the Acute Treatment Program, closets in patient rooms shall be locked at all times.
f. Bedroom doors shall remain completely opened at all times when patients are in their rooms - this includes sleeping hours and other times when the patients have access to their room.
g. In the acute care units, the doors of bathrooms that are located inside the patients ' bedrooms shall remain locked at all times, even when patients are present in the bedroom. The Psychiatric Technician who is responsible for monitoring the patient shall unlock the bathrooms to allow the patient access to the restroom and shall insure the doors are relocked immediately after the patient leaves the restroom.
h. During sleeping hours, the staff responsible for the patient's observation should be stationed in the hallway outside the patients' bedroom(s) at all times. This shall be that technician's observation area for the total time he/she is assigned to do the fifteen-minute checks.
i. Nursing shall make patient observation assignments for Psychiatric Technicians as follows: Psychiatric Technicians shall be assigned an observation area, which shall be located in the hallway immediately outside the bedroom(s) of the patient(s) for whom he/she is responsible for observing, and must at all times be visible on by the unit observation cameras. All patients who are assigned to an individual psychiatric technician for observation must be assigned to the same room or, if in separate rooms, the rooms are located contiguously (rooms are side by side and touching) or immediately across the hallway. The technician may not leave his/her observation area unless the following has happened: a) the technician has completed and documented that the patient safety checks are current and will not expire prior to the technician's return (in this case the technician may not leave the observation area for more than 10 minutes and must return prior to the next scheduled patient observation time); or b) the technician's assignment has been changed, the change has been documented, and the relief person is present to take over his observation assignment.
2) The Patient Accountability Checksheet was revised to allow the nurses a separate box to initial every hour which is different than the previous design in that the nurse was required to sign in the same box with the psychiatric technician's name for their hourly patient checks.
3) 100% of active nurses and 100% of active psychiatric technicians were retrained December 28, 2011, on revised Hospital Policy #0214.01, "Management of Patients at Risk". Specific emphasis shall be placed on insuring that patients who are placed on observation levels are observed according to the requirements specified in the hospital policy and procedures.
4) Program Nursing Supervisors will be scheduled to provide supervision on night and evening shifts in order to provide more nursing supervision on the units during these shifts. This supervision will be enhanced by "real time" video observation.

Evaluation Method:
100% of active nurses and psychiatric technicians shall be retrained on revised Hospital Policy #0214.01, "Management of Patients at Risk". Specific emphasis shall be placed on insuring that patients who are placed on observation levels are observed according to the requirements specified in the hospital policy and procedures. Nurses and psychiatric technicians who are on extended leave at the time of the training will complete training prior to resuming their duties. This training has also been added to the New Employee Orientation program for all newly hired nursing staff.

Video monitors have been purchased and installed in the program nursing supervisors' office. These video monitors will provide nursing supervisors with "real-time" monitoring of all acute treatment units at all times. Nursing's Unit Supervisory Rounds Checksheet will be revised to require nursing supervisors to check that patient observations are being conducted as required by hospital policy. This monitoring shall be conducted at least one time per shift, and corrective action shall be taken when problems are identified. This monitoring and corrective actions shall be reported to the Nursing Executive Council monthly.

Review of in-service records and staff rosters/sign in sheets, on March 1, 2012, at 3:00 p.m., revealed staff were in-serviced, by the nurse managers of individual units, on December 20 and 28, 2011, and January 11, 2012, regarding the policy and practice changes. Review of the sign in sheets and staff roster revealed 100% of current employees were in-serviced on the policy changes. Interviews with staff working on the units revealed 100% were knowledgeable of the policy changes. Interview with the CEO and ASQM, in the administrative office conference room, on March 2, 2012, at 10:00 a.m. confirmed 100% of current staff had been in-serviced, and new staff were being oriented on the new policy during orientation.

Observations, on March 1, 2012, at 3:45 p.m., of the nursing supervisor's office revealed the real time monitoring being performed by the nursing supervisor. The observations revealed each of the patient care units have video monitors in each hall way which enables the nursing supervisor to visually check for compliance with the facility's policy for observations of the patients.

Interview with the nursing supervisor, on March 1, 2012, at 3:45 p.m., confirmed the supervisor was randomly monitoring at least one unit per shift for compliance with facility policies. This monitoring is documented on a "Nursing Supervisory Video Monitoring Review" form each shift.

Observations of the patient units, on March 1, 2012, from 1:00 p.m. to 2:00 p.m., and March 2, 2012, from 9:30 am to 10:30 a.m., revealed the patient rooms were locked between 7:00 a.m. and 7:00 p.m.. Observations also revealed the bathrooms and closets in the patient's rooms were locked as well.

Review of two current medical records, on March 3, 2012, revealed the new Patient Accountability Check Sheets are being completed as required by the revised policy.

Based on record review, video recording review, policy review, and interviews, the facility failed to protect/promote the right to safety for one (#4) patient of eight patients reviewed.

The findings included:

Medical record review revealed Patient #4 was admitted to the facility on November 28, 2011, at 12:30 p.m. with diagnoses of Schizoaffective Disorder. Further review of the medical record revealed Patient #4 was an involuntary commitment to the facility, and the commitment documentation stated, "Pt (patient) is acutely psychotic with no insight and wants to harm self and others. Pt with Auditory and Visual Hallucinations...Pt poses immediate harm to self with self injury threatens same on others...actively homicidal and suicidal."

Review of the Nursing Assessment Summary, dated November 28, 2011, at 2:00 p.m. revealed the patient has auditory hallucinations and heard, "Voices tell...various things." The Nursing Assessment Summary also stated, "Placed on close observation for safety. Will monitor closely."

Review of the Admission Order form, revealed physician's orders dated November 28, 2011, at 2:00 p.m. for Patient #4, which ordered, "Observation Level...Close (15-minute checks)"

Review of Discharge Summary, dated December 13, 2011, revealed Patient #4 was admitted after, "tried to pluck out...right eye with fingernails...". Further review of the Discharge Summary revealed, "...was placed on close observation." The Discharge Summary also stated, "At approximately 1:45 a.m. on 11/29/11...was found face down in the toilet, a shower curtain behind...neck and around the commode."

Review of Patient #4's Autopsy Report, dated November 29, 2011, revealed, "Cause of Death: Drowning...Manner of Death: Suicide...Circumstances of Death: Submerged head in toilet." The report also stated, "...found unresponsive with head secured inside an overflowing toilet...A bed sheet had been used to secure the bathroom door shut...and secure...head inside the toilet.

Interview with the Assistant Superintendent for Quality Management (ASQM), on March 1, 2012, at 11:45 a.m., in the Quality Management office confirmed Patient #4 was on close observation which meant the patient was to have been assessed visually by the psychiatric technician every fifteen minutes and by the nurse every hour. Further interview confirmed psychiatric technicians had not performed the fifteen minute checks, and the nursing staff had not performed the hourly assessments of the patient. Further interview confirmed the staff's failed to ensure Patient #4's safety, had placed the patient in an unsafe condition/environment, which provided the patient enough unmonitored time to drown self.

Refer to A115

Based on record review, video recording review, interviews, and policy review, the facility failed to protect/promote the right to be free from neglect for one (#4) patient of eight patients reviewed.

The findings included:

Medical record review revealed Patient #4 was admitted to the facility on November 28, 2011, at 12:30 p.m. with diagnoses of Schizoaffective Disorder. Further review of the medical record revealed Patient #4 was an involuntary commitment to the facility, and the commitment documentation stated, "Pt (patient) is acutely psychotic with no insight and wants to harm self and others. Pt with Auditory and Visual Hallucinations...Pt poses immediate harm to self with self injury threatens same on others...actively homicidal and suicidal."

Review of the Nursing Assessment Summary, dated November 28, 2011, at 2:00 p.m. revealed the patient has auditory hallucinations and heard, "Voices tell...various things." The Nursing Assessment Summary also stated, "Placed on close observation for safety. Will monitor closely."

Review of the Admission Order form, revealed physician's orders dated November 28, 2011, at 2:00 p.m. for Patient #4, which ordered, "Observation Level...Close (15-minute checks)"

Review of Discharge Summary, dated December 13, 2011, revealed Patient #4 was admitted after, "tried to pluck out...right eye with fingernails...". Further review of the Discharge Summary revealed, "...was placed on close observation." The Discharge Summary also stated, "At approximately 1:45 a.m. on 11/29/11...was found face down in the toilet, a shower curtain behind...neck and around the commode."

Review of Patient #4's Autopsy Report, dated November 29, 2011, revealed, "Cause of Death: Drowning...Manner of Death: Suicide...Circumstances of Death: Submerged head in toilet." The report also stated, "...found unresponsive with head secured inside an overflowing toilet...A bed sheet had been used to secure the bathroom door shut...and secure...head inside the toilet.

Review of the facility's policy number 0214.01, titled, "MANAGEMENT OF PATIENTS AT RISK", revision date October 6, 2011, revealed, "...Close Observation...all patients will be observed or accounted for at least every fifteen minutes..." Further review of the policy revealed, "The RN/LPN (Registered Nurse/Licensed Practical Nurse) will observe the patient's behavior, condition, and will assess for the patient's well-being during their hourly checks; along with providing supervision to the Psychiatric Technician on an hourly basis or more frequently if needed..."

A digital video recording, from a camera in the hallway outside Patient #4's room, recorded on November 29, 2011, from 12:30 a.m. to 1:46 a.m., was reviewed on March 1, 2012, at 11:30 a.m., in the Quality Management office. Review of the video recording revealed no staff opened the door to Patient #4's room, or visually checked on Patient #4 from 12:30 a.m. to 1:44 a.m. (total of 1 hour and 14 minutes/74 minutes) on November 29, 2011.

Interview with the Assistant Superintendent for Quality Management (ASQM), on March 1, 2012, at 11:45 a.m., in the Quality Management office confirmed the ASQM had reviewed the video recording and confirmed no staff entered Patient #4's room, or visually checked on the patient, from 12:30 a.m. to 1:44 a.m., on November 29, 2011. Further interview with the ASQM confirmed Patient #4 was on close observation which meant the patient was to have been assessed visually by the psychiatric technician every fifteen minutes and by the nurse every hour.

Based on record review, video recording review, policy review, and interviews, the facility failed to provide nursing services needed to meet the needs of one patient (#4) out of eight patients reviewed.

The findings included:

Medical record review revealed Patient #4 was admitted to the facility on November 28, 2011, at 12:30 p.m. with diagnoses of Schizoaffective Disorder. Further review of the medical record revealed Patient #4 was an involuntary commitment to the facility, and the commitment documentation stated, "Pt (patient) is acutely psychotic with no insight and wants to harm self and others. Pt with Auditory and Visual Hallucinations...Pt poses immediate harm to self with self injury threatens same on others...actively homicidal and suicidal."

Review of the Nursing Assessment Summary, dated November 28, 2011, at 2:00 p.m. revealed the patient has auditory hallucinations and heard, "Voices tell...various things." The Nursing Assessment Summary also stated, "Placed on close observation for safety. Will monitor closely."

Review of the Admission Order form, revealed physician's orders dated November 28, 2011, at 2:00 p.m. for Patient #4, which ordered, "Observation Level...Close (15-minute checks)"

Review of Discharge Summary, dated December 13, 2011, revealed Patient #4 was admitted after, "tried to pluck out...right eye with fingernails ...". Further review of the Discharge Summary revealed, " ...was placed on close observation." The Discharge Summary also stated, "At approximately 1:45 a.m. on 11/29/11 ...was found face down in the toilet, a shower curtain behind...neck and around the commode."

Review of Patient #4's Autopsy Report, dated November 29, 2011, revealed, "Cause of Death: Drowning...Manner of Death: Suicide...Circumstances of Death: Submerged head in toilet." The report also stated, "...found unresponsive with head secured inside an overflowing toilet...A bed sheet had been used to secure the bathroom door shut...and secure...head inside the toilet.

Review of the facility's policy number 0214.01, titled, "MANAGEMENT OF PATIENTS AT RISK", revision date October 6, 2011, revealed, "...Close Observation...all patients will be observed or accounted for at least every fifteen minutes..." Further review of the policy revealed, "The RN/LPN (Registered Nurse/Licensed Practical Nurse) will observe the patient's behavior, condition, and will assess for the patient's well-being during their hourly checks; along with providing supervision to the Psychiatric Technician on an hourly basis or more frequently if needed..."

A digital video recording, from a camera in the hallway outside Patient #4's room, recorded on November 29, 2011, from 12:30 a.m. to 1:46 a.m., was reviewed on March 1, 2012, at 11:30 a.m., in the Quality Management office. Review of the video recording revealed no staff opened the door to Patient #4's room, or visually checked on Patient #4 from 12:30 a.m. to 1:44 a.m. (total of 1 hour and 14 minutes/74 minutes) on November 29, 2011.

Interview with the Assistant Superintendent for Quality Management (ASQM), on March 1, 2012, at 11:45 a.m., in the Quality Management office confirmed the ASQM had reviewed the video recording and confirmed no staff entered Patient #4's room, or visually checked on the patient, from 12:30 a.m. to 1:44 a.m., on November 29, 2011. Further interview with the ASQM confirmed Patient #4 was on close observation which meant the patient was to have been assessed visually by the psychiatric technician every fifteen minutes and by the nurse every hour.

Based on record review, video recording review, interviews, and policy review, the facility failed to provided supervision by a Registered Nurse (RN) for one (#4) patient of eight patients reviewed.


The findings included:

Medical record review revealed Patient #4 was admitted to the facility on November 28, 2011, at 12:30 p.m. with diagnoses of Schizoaffective Disorder. Further review of the medical record revealed Patient #4 was an involuntary commitment to the facility, and the commitment documentation stated, "Pt (patient) is acutely psychotic with no insight and wants to harm self and others. Pt with Auditory and Visual Hallucinations...Pt poses immediate harm to self with self injury threatens same on others...actively homicidal and suicidal."

Review of the Nursing Assessment Summary, dated November 28, 2011, at 2:00 p.m. revealed the patient has auditory hallucinations and heard, "Voices tell...various things." The Nursing Assessment Summary also stated, "Placed on close observation for safety. Will monitor closely."

Review of the Admission Order form, revealed physician's orders dated November 28, 2011, at 2:00 p.m. for Patient #4, which ordered, "Observation Level...Close (15-minute checks)"

Review of Discharge Summary, dated December 13, 2011, revealed Patient #4 was admitted after, "tried to pluck out...right eye with fingernails...". Further review of the Discharge Summary revealed, "...was placed on close observation." The Discharge Summary also stated, "At approximately 1:45 a.m. on 11/29/11...was found face down in the toilet, a shower curtain behind his neck and around the commode."

Review of Patient #4's Autopsy Report, dated November 29, 2011, revealed, "Cause of Death: Drowning...Manner of Death: Suicide...Circumstances of Death: Submerged head in toilet." The report also stated, "...found unresponsive with head secured inside an overflowing toilet...A bed sheet had been used to secure the bathroom door shut...and secure...head inside the toilet.

Review of the facility's policy number 0214.01, titled, "MANAGEMENT OF PATIENTS AT RISK", revision date October 6, 2011, revealed, "The RN/LPN (Registered Nurse/Licensed Practical Nurse) will observe the patient's behavior, condition, and will assess for the patient's well-being during their hourly checks; along with providing supervision to the Psychiatric Technician on an hourly basis or more frequently if needed..."

A digital video recording, from a camera in the hallway outside Patient #4's room, recorded on November 29, 2011, from 12:30 a.m. to 1:46 a.m., was reviewed on March 1, 2012, at 11:30 a.m., in the Quality Management office. Review of the video recording revealed no RNs, LPNs, or other staff opened the door to Patient #4's room, or visually checked on Patient #4 from 12:30 a.m. to 1:44 a.m. (total of 1 hour and 14 minutes/74 minutes) on November 29, 2011.

Interview with the Assistant Superintendent for Quality Management (ASQM), on March 1, 2012, at 11:45 a.m., in the Quality Management office confirmed the ASQM had reviewed the video recording and confirmed no RNs, LPNs, or other staff entered Patient #4's room, or visually checked on the patient, from 12:30 a.m. to 1:44 a.m., on November 29, 2011. Further interview with the ASQM confirmed Patient #4 was on close observation which meant the patient was to have been assessed visually by the nurse at least once every hour.

Based on record reviews, video recording review, policy review, and interviews the facility failed to follow the nursing care plan for one (#4) patient of eight patients reviewed.

The findings included:

Medical record review revealed Patient #4 was admitted to the facility on November 28, 2011, at 12:30 p.m. with diagnoses of Schizoaffective Disorder. Further review of the medical record revealed Patient #4 was an involuntary commitment to the facility, and the commitment documentation stated, "Pt (patient) is acutely psychotic with no insight and wants to harm self and others. Pt with Auditory and Visual Hallucinations...Pt poses immediate harm to self with self injury threatens same on others...actively homicidal and suicidal."

Review of the Nursing Assessment Summary, dated November 28, 2011, at 2:00 p.m. revealed the patient has auditory hallucinations and heard, "Voices tell...various things." The Nursing Assessment Summary also stated, "Placed on close observation for safety. Will monitor closely."

Review of the Admission Order form, revealed physician's orders dated November 28, 2011, at 2:00 p.m. for Patient #4, which ordered, "Observation Level...Close (15-minute checks)"

Review of the Initial Treatment Plan (ITP) form, dated November 28, 2011, at 12:40 p.m., Patient #4 was assessed at "Risk of Self-Harm" and "Risk of Harm to Others". Further review of the ITP form revealed Initial Psychiatric Interventions checked included, "Evaluate and order appropriate level of observation or supervision."

Review of Discharge Summary, dated December 13, 2011, revealed Patient #4 was admitted after, "tried to pluck out...right eye with fingernails...". Further review of the Discharge Summary revealed, "...was placed on close observation." The Discharge Summary also stated, "At approximately 1:45 a.m. on 11/29/11...was found face down in the toilet, a shower curtain behind his neck and around the commode."

Review of Patient #4's Autopsy Report, dated November 29, 2011, revealed, "Cause of Death: Drowning...Manner of Death: Suicide...Circumstances of Death: Submerged head in toilet." The report also stated, "...found unresponsive with head secured inside an overflowing toilet...A bed sheet had been used to secure the bathroom door shut...and secure...head inside the toilet.

Review of the facility's policy number 0214.01, titled, "MANAGEMENT OF PATIENTS AT RISK", revision date October 6, 2011, revealed, "...Close Observation...all patients will be observed or accounted for at least every fifteen minutes..." Further review of the policy revealed, "The RN/LPN (Registered Nurse/Licensed Practical Nurse) will observe the patient's behavior, condition, and will assess for the patient's well-being during their hourly checks; along with providing supervision to the Psychiatric Technician on an hourly basis or more frequently if needed..."

A digital video recording, from a camera in the hallway outside Patient #4's room, recorded on November 29, 2011, from 12:30 a.m. to 1:46 a.m., was reviewed on March 1, 2012, at 11:30 a.m., in the Quality Management office. Review of the video recording revealed no staff opened the door to Patient #4's room, or visually checked on Patient #4 from 12:30 a.m. to 1:44 a.m. (total of 1 hour and 14 minutes/74 minutes) on November 29, 2011.

Interview with the Assistant Superintendent for Quality Management (ASQM), on March 1, 2012, at 11:45 a.m., in the Quality Management office confirmed the ASQM had reviewed the video recording and confirmed no staff entered Patient #4's room, or visually checked on the patient, from 12:30 a.m. to 1:44 a.m., on November 29, 2011. Further interview with the ASQM confirmed Patient #4 was on close observation which meant the patient was to have been assessed visually by the psychiatric technician every fifteen minutes and by the nurse every hour.

Based on record review, video recording review, interviews, and policy review, the facility failed to maintain accurate medical records for one (#4) patient of eight patients reviewed.

The findings included:

Medical record review revealed Patient #4 was admitted to the facility on November 28, 2011, at 12:30 p.m. with diagnoses of Schizoaffective Disorder. Further review of the medical record revealed Patient #4 was an involuntary commitment to the facility, and the commitment documentation stated, "Pt (patient) is acutely psychotic with no insight and wants to harm self and others. Pt with Auditory and Visual Hallucinations...Pt poses immediate harm to self with self injury threatens same on others...actively homicidal and suicidal."

Review of the Nursing Assessment Summary, dated November 28, 2011, at 2:00 p.m. revealed the patient has auditory hallucinations and heard, "Voices tell...various things." The Nursing Assessment Summary also stated, "Placed on close observation for safety. Will monitor closely."

Review of the Admission Order form, revealed physician's orders dated November 28, 2011, at 2:00 p.m. for Patient #4, which ordered, "Observation Level...Close (15-minute checks)" .

Review of the Patient Accountability Checklist revealed documentation of Patient #4 being checked by a Psychiatric Technician on November 29, 2011, at 12:00 a.m., 12:15 a.m., 12:30 p.m., 12:45 p.m., 1:00 a.m., 1:15 a.m., and 1:30 a.m.

Review of Discharge Summary, dated December 13, 2011, revealed Patient #4 was admitted after, "tried to pluck out ...right eye with fingernails ...". Further review of the Discharge Summary revealed, "...was placed on close observation." The Discharge Summary also stated, "At approximately 1:45 a.m. on 11/29/11...was found face down in the toilet, a shower curtain behind his neck and around the commode."

Review of Patient #4's Autopsy Report, dated November 29, 2011, revealed, "Cause of Death: Drowning...Manner of Death: Suicide...Circumstances of Death: Submerged head in toilet." The report also stated, "...found unresponsive with head secured inside an overflowing toilet...A bed sheet had been used to secure the bathroom door shut ...and secure...head inside the toilet.

Review of the facility's policy number 0214.01, titled, "MANAGEMENT OF PATIENTS AT RISK", revision date October 6, 2011, revealed,"...Close Observation...all patients will be observed or accounted for at least every fifteen minutes...documentation of the observations is to be completed on the Patient Accountability Checksheet" Further review of the policy revealed, "The RN/LPN (Registered Nurse/Licensed Practical Nurse) will observe the patient's behavior, condition, and will assess for the patient's well-being during their hourly checks; along with providing supervision to the Psychiatric Technician on an hourly basis or more frequently if needed. These actions will be documented on the checksheet..."

A digital video recording, from a camera in the hallway outside Patient #4's room, recorded on November 29, 2011, from 12:30 a.m. to 1:46 a.m., was reviewed on March 1, 2012, at 11:30 a.m., in the Quality Management office. Review of the video recording revealed no staff opened the door to Patient #4's room, or visually checked on Patient #4 from 12:30 a.m. to 1:44 a.m. (total of 1 hour and 14 minutes/74 minutes) on November 29, 2011.

Interview with the Assistant Superintendent for Quality Management (ASQM), on March 1, 2012, at 11:45 a.m., in the Quality Management office confirmed the ASQM had reviewed the video recording and confirmed the checks documented on the Patient Accountability Checklist were incorrect because no staff entered Patient #4's room, or visually checked on the patient, from 12:30 a.m. to 1:44 a.m., on November 29, 2011. Further interview confirmed the documentation on the Patient Accountability Checklist was inaccurate.

Based on record review, video recording review, interviews, and policy review, the facility failed to maintain an accurate medical record for one (#4) patient of eight patients reviewed.

The findings included:

Medical record review revealed Patient #4 was admitted to the facility on November 28, 2011, at 12:30 p.m. with diagnoses of Schizoaffective Disorder. Further review of the medical record revealed Patient #4 was an involuntary commitment to the facility, and the commitment documentation stated, "Pt (patient) is acutely psychotic with no insight and wants to harm self and others. Pt with Auditory and Visual Hallucinations...Pt poses immediate harm to self with self injury threatens same on others...actively homicidal and suicidal."

Review of the Nursing Assessment Summary, dated November 28, 2011, at 2:00 p.m. revealed the patient has auditory hallucinations and heard, "Voices tell...various things." The Nursing Assessment Summary also stated, "Placed on close observation for safety. Will monitor closely."

Review of the Admission Order form, revealed physician's orders dated November 28, 2011, at 2:00 p.m. for Patient #4, which ordered, "Observation Level...Close (15-minute checks)" .

Review of the Patient Accountability Checklist revealed documentation of Patient #4 being checked by a Psychiatric Technician on November 29, 2011, at 12:00 a.m., 12:15 a.m., 12:30 p.m., 12:45 p.m., 1:00 a.m., 1:15 a.m., and 1:30 a.m.

Review of Discharge Summary, dated December 13, 2011, revealed Patient #4 was admitted after, "tried to pluck out...right eye with fingernails...". Further review of the Discharge Summary revealed, "...was placed on close observation." The Discharge Summary also stated, "At approximately 1:45 a.m. on 11/29/11...was found face down in the toilet, a shower curtain behind...neck and around the commode."

Review of Patient #4's Autopsy Report, dated November 29, 2011, revealed, "Cause of Death: Drowning...Manner of Death: Suicide ...Circumstances of Death: Submerged head in toilet." The report also stated, " ...found unresponsive with head secured inside an overflowing toilet ...A bed sheet had been used to secure the bathroom door shut ...and secure ...head inside the toilet.

Review of the facility's policy number 0214.01, titled, "MANAGEMENT OF PATIENTS AT RISK", revision date October 6, 2011, revealed, "...Close Observation...all patients will be observed or accounted for at least every fifteen minutes...documentation of the observations is to be completed on the Patient Accountability Checksheet" Further review of the policy revealed, "The RN/LPN (Registered Nurse/Licensed Practical Nurse) will observe the patient's behavior, condition, and will assess for the patient's well-being during their hourly checks; along with providing supervision to the Psychiatric Technician on an hourly basis or more frequently if needed. These actions will be documented on the checksheet..."

A digital video recording, from a camera in the hallway outside Patient #4's room, recorded on November 29, 2011, from 12:30 a.m. to 1:46 a.m., was reviewed on March 1, 2012, at 11:30 a.m., in the Quality Management office. Review of the video recording revealed no staff opened the door to Patient #4's room, or visually checked on Patient #4 from 12:30 a.m. to 1:44 a.m. (total of 1 hour and 14 minutes/74 minutes) on November 29, 2011.

Interview with the Assistant Superintendent for Quality Management (ASQM), on March 1, 2012, at 11:45 a.m., in the Quality Management office confirmed the ASQM had reviewed the video recording and confirmed the checks documented on the Patient Accountability Checklist were incorrect because no staff entered Patient #4's room, or visually checked on the patient, from 12:30 a.m. to 1:44 a.m., on November 29, 2011. Further interview with the ASQM confirmed the documentation on the Patient Accountability Sheet was inaccurate.