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Based on observations, interview, record review, review of facility policies and procedures, staffing review, and environmental inspection review, the facility failed to implement a system to provide patient care in a safe environment. This failure resulted in finding the Condition of Participation for Patient Rights out of compliance. The facility failed to have safety monitoring checks made every 15 minutes per physician order for sampled Patient #1. Patient #1 had attempted suicide as part of the reason for admission to the Adult Psychiatric Unit (APU) on 12/4/10. Patient #1 successfully committed suicide by hanging self in room on the APU on 12/05/10. By 12/09/10 the facility identified the procedure for conducting 15 minute checks had failed. The facility failed to correct and identify an unsafe patient environment of potential hazards for suicidal patients including:
-patient access to 6 foot and 15 foot electrical cords;
-looping and hanging risks related to the accordion folding bathroom doors;
-suffocation risks related to heavy, vinyl shower curtains;
-and failure to identify or correct the failure of the Code Blue team to provide on location advanced life support.

The facility census was 445. The facility census for Cox North Psychiatric Units was 52.

Based on observations, interviews, record review, and facility policy review for patient monitoring and code blue response, the facility failed to provide psychiatric care in a safe setting for one patient ( Patient #1) who expired after committing suicide. The facility failed to provide Patient #1 with safety monitoring checks by staff every 15 minutes as physician ordered. The facility failed to provide a safe environment by allowing psychiatric patients access to safety hazards such as:
-6 foot and 15 foot electrical cords;
-looping and hanging risks related to the accordion folding bathroom doors;
-suffocation risks related to heavy, vinyl shower curtains;
-and failure to identify and correct the failure of the Code Blue team to provide on location advanced life support.

Findings Included:

1. Medical record review showed patient #1 was admitted on 12/04/2010 after being seen in the emergency room for major depression, borderline functioning, problems with support systems and previous suicide attempts. Patient #1 had been living in homeless shelter.

Patient #1's History and Physical (H & P) dated 12/04/10, showed:
-The patient was having suicidal thoughts;
-The patient had a plan to jump in front of a truck or slice his/her wrists;
-The patient stated he/she did have a history of overdose; and
- Diagnosis of Major Depression.

Review of the Adult Inpatient Psychiatry Admitting Orders dated 12/04/10 showed:
-Precautions: Close Observation for risk of harm. (Check/Observe patient every 15 minutes.)

Patient #1's psychiatrist documented in the H & P on 12/05/10 the following information:
-The patient had been released from another psychiatric facility for about a day and a half prior to presenting his/herself to the emergency room;
-The patient expressed he/she had increasing auditory hallucinations and thoughts about harming himself/herself;
-The patient has a history of psychiatric admissions;
-The patient was homeless, living at a homeless shelter;
-The patient was estranged from his/her family and was unemployed; and
-The patient was admitted to the psychiatric unit for treatment of Major Depression, recurrent.

Medical record review of Patient #1 showed on 12/5/10 he/she was verbalizing plans for Christmas and was looking forward to positive things. Patient #1 was last observed by staff at 4:20 PM. Per video tape patient #1 was seen sticking his/her head out of the room looking out into the hallway at 4:23 PM. Patient #1's roommate entered his/her room at approximately 5:10 PM, and found patient #1 with a sheet tied around his/her neck and looped over the door. The roommate began screaming and upon hearing these screams facility staff entered the room and initiated CPR. Patient #1 was found with ligature marks around his/her neck, with no pulse or respirations. Patient #1 successfully committed suicide by hanging in his/her room on 12/05/10.

2. Policy review of "Psychiatric Services Policy", Precautions: Adult I and II, Standard #: Treatment I, revised and approval on 08/2010, stated in part the following information:

Definitions of Levels of Precautions:

-On page 3 (of 4), of this policy included the definition of levels of precautions. Close Observation is defined as, "Patient is observed a minimum of every fifteen minutes by psychiatric staff."
-The same policy included a Documentation section on Page 2 (of 4) that stated: 15 Minute Checks Flowsheet: "This form will be initiated and maintained by psychiatric staff when a patient is placed on physician ordered precautions. It is discontinued at the time of precaution discontinuation."

Review of the "15 Minute Check Flowsheet" dated 12/5/2010 for patient #1, showed the following documentation:
-1600 (4:00 PM), by Psychiatric Technician (PT), Staff C, who also documented the patient's behavior as "2" (per the legend/key on the form identified "2" as appropriate behavior);
-1615 (4:15 PM), by PT, Staff C, and documented the patient's behavior as "2."
-1630 (4:30 PM), by PT, Staff C, and documented the patient's behavior as "2."
-1645 (4:45 PM), by LPN (licensed practical nurse), Staff D and documented the patient's behavior as "2."

Observation showed the total patient census for Cox North Psychiatric Units was 52, with 45 of 52 patient's at risk for safety hazard, and on Close Observation status. Note: All patients admitted to the psychiatric units are placed on Close Observation status.

3. During a phone interview with Psychiatric Technician (PT), Staff I, on 12/13/10 at 2:12 PM, showed: Staff I stated that he/she worked from 7 AM to 3 PM on 12/5/10, and was already off work when Patient #1 committed suicide. Staff I confirmed he/she was on administrative leave because when the video from 12/5/10 was reviewed it did not show him/her making the 10:00 AM check that he/she documented for Patient #1. Staff I stated there was not a good system for doing the 15-minute checks, and no structure for the assignment of the 15-minute checks. Staff I stated that if any staff walked by the check-book they would pick it up and document the checks, but they were not assigned. Staff I stated that he/she is aware of other times the PT's would document 15-minute checks as being done when they were not. Staff I stated that he/she was never given any training on what to do if a check was not done, staff were told the checks must be done, and he/she did not want to bring it to anyone's attention that the checks were not being done. Staff I stated that at times the PT's will be in situations when there is a "Code" and everyone's attention is elsewhere and patient checks were not done, but charted as done. Staff I confirmed that the camera/video was correct that he/she failed to complete the 15-minute checks for Patient #1 at 10:00 AM, and failed to document the check.

4. During a phone interview with PT, Staff J, on 12/13/10 at 2:38 PM, showed: Staff J stated that he/she worked 12/5/10, from 7:00 AM to 3:00 PM, and was off work by 3:00 PM, prior to Patient #1 committing suicide. Staff J stated that the PT's were not assigned to check on the patients. Staff J stated that the 15-minute checks were done by communication between the PT's as there was no one specifically assigned to do them. Staff J stated that he/she was aware of PT's not doing the 15-minute checks, but charting that they were done. Staff J stated that if something is going on, distracting the PT's from doing the 15-minute checks the PT's documented the checks as being done when the PT's were really doing something else. Staff J stated it did not happen often, but it did happen. Staff J stated that he/she would take over the 15-minute checks and there would be blank spaces when they should have been documented as done.

5. During an interview on 12/13/10 at 3:05 PM, with RN, Staff K, and RN, Staff L, who work in the Office of Patient Safety for the facility showed the following information:
-Both Staff K and Staff L reviewed the video tape of Patient #1 between the hours of 9:00 AM to 2:00 PM for the 15-minute checks;
-Staff K and Staff L matched the video taped 15-minute checks to the documented 15-minute checks and found discrepencies;
- Checks for Patient #1 included staff charting from 10:00 AM to 11:00 AM, that Patient #1 was in his/her room, but the video tape showed patient #1 was actually out of his/her room from 9:47 AM to 11:00 AM;
-Staff K and Staff L reviewed the video tape for the 3:00 PM to 11:00 PM shift, and it showed at 4:20 PM PT staff did check on Patient #1, and at 4:23 PM patient #1 peeked out of his/her room door;
-At 5:15 PM the video tape showed Patient #1's roommate going into his/her room;
-The video tape does not support that Staff C or Staff D made any 15-minute checks between 4:20 PM and 5:15 PM.

6. During a phone interview on 12/13/10 at 3:35 PM, with Staff C showed: Staff C stated he/she worked from 3:00 PM to 11:00 PM on 12/5/10 on F 300 hall, there were no other PT's working on the F 300 hall, and staffing was down to one PT. Staff C stated that he/she was on administrative leave due to charting 15-minute checks when they were not actually done. Staff C stated that he/she saw Staff D closing the 15-minute check-book and thought Staff D had done the 5:00 PM check for Patient #1. Staff C stated that it was not clear who was to do the 5:00 PM and 5:15 PM, 15-minute checks as he/she was pulled off of doing them to assist with a new admission. Staff C stated that he/she was not trained on the appropriate thing to do if a 15-minute check was missed. Staff C stated that he/she followed by the example of others to chart 15-minute checks were done when they were not done. Staff C stated that other PT's did the same thing. Staff C confirmed he/she did not check on Patient #1 as documented on 12/5/10, at 5:00 PM, and another time earlier in the shift.

7. During a phone interview on 12/14/10 at 9:30 AM, with Staff D showed: Staff D confirmed he/she worked the F 300 hall from 3:00 PM to 11:00 PM, on 12/5/10 as a medication nurse. Staff D confirmed he/she did not go down the hall to Patient #1's room to check on him/her, but documented that he/she checked patient #1 at 4:45 PM. Staff D stated that he/she was aware that other staff charted doing the 15-minute checks when they were not done. Staff D stated it was not clear to the staff what to do when a 15-minute check time had already passed, so the staff would document that they were done when they were not done.

8. During an interview on 12/9/10 at 11:40 AM, with Director of Psychiatric Services, RN, Staff H, showed: Staff H stated that prior to Patient #1's death it was not clearly assigned as to what staff would be responsible for 15-minute checks. Staff H stated that 15-minute checks were not assigned to any one employee for a specified amount of time. Staff H stated that it was discovered while watching the video of 12/5/10, for F 300 hall that Staff C had been pulled off the task of making 15-minute checks to assist with a new admission.

9. Record review for Patient #1 showed: On 12/5/10 at 5:17 PM, Charge Nurse (RN), Staff M, documented the following information: This recorder took over chest compressions on patient who was found on the floor in the doorway of room 304. The patient had no carotid pulse and was not showing respirations. Comment: was pale and warm to touch; he/she was not responding to verbal or physical touch. Chest Compressions were continued by this recorder; the Code Blue had been called and staff were calling Cox North ER (emergency room) CAT (Critical Assessment Team) to respond to the code situation. Ambu (a self-reinflating bag used during resuscitation) airway was being administered with chest compressions. The AED (automated external defibrillator) was applied and no conversions would take place. No carotid (carotid pulse: pulse of the carotid artery located in the neck) or radial pulse (radial pulse: pulse of the radial artery felt in the wrist) found. No response from patient. The CAT team arrived at approximately 5:20 PM and assumed emergency care of patient. The patient was transported to Cox North ER per cart with ER staff and this recorder accompanied the patient.

10. During a documented interview obtained on 12/5/10 between Staff H and Staff G showed the following information: At 5:15 PM, the Code Blue was paged. Staff G stated that he/she thought it might have been over the intercom and not over the switchboard. Staff G reported upon his/her arrival to the scene of Patient #1, he/she plugged in the AED and hit activate and it read " No shock required " , did 3 rounds of 30 compressions (CPR) stopped and took pulse, but could not find one so resumed CPR. Did 2 more rounds of 30 (CPR) and the AED was again read with " No shock required " . Did maybe one more set of 30 (CPR) and asked for the second time if anyone had called the CAT team. The 3rd time Staff G reported he/she stated to call the CAT team. Before the call could be made the CAT team arrived. The emergency department staff brought in a gurney. Staff G reported seeing a ligature mark on the neck of Patient #1.

11. Based on review of Patient #1's medical record, and interview with Staff G, both confirmed a CAT Code was called when a Code Blue should have been called since the patient failed to have a heart rate and no respirations. The Code Blue that had been called was limited to the intercom of the Psychiatric Units only, and was not announced in the Emergency Room. Staff G failed to use the facility switchboard, which would have notified all emergency room staff to respond to a Code Blue.

12. Review of Patient #1's Emergency Room (ER) record showed that ER Physician, Staff N documented the following information: Patient found unresponsive. Ligature mark around neck. ED team called to floor and brought back to ED. Intubated under my supervision by paramedic. Patient hooked up to monitor - asystole. IV (Intravenous therapy, or IV therapy, is the giving of substances directly into a vein) started by RN and 3 rounds of Epi (Epinephrine -a drug to improve breathing and stimulate the heart) and Atropine (a drug to treat cardiac arrest) given with pulse checks negative with asystole the entire time in ED (emergency department). Skin color is cyanotic.

Review of the ER record confirmed Patient #1 did not receive advanced life support from the CAT team on-site where the patient was found. This record confirmed advanced life support did not begin until Patient #1's arrival in the ER.

13. Review of the "Resuscitation Policy" for Cox North effective 10/14/2009 showed the following information:
Definitions:
1. Code Blue - The resuscitation effort shall be referred to as a "Code Blue";
2. BLS - Basic Life Support;
3. CPR - Cardiopulmonary Resuscitation;
4. ACLS - Advanced Cardiac Life Support; and
5. AED - Automatic External Defibrillator.
.
Section II, Resuscitation Process, Item C, "Duties of Personnel Discovering the Arrest",
included: Item #3, "Activate the Code Blue Team by"
b. dialing #333 from Cox North.
b(1).Tell the operator "Code Blue",
b(3). Give the room number or patient location, making sure to identify the building and campus location.
Section II, Item #5, included: "Floor Personnel" (not performing CPR): Move the Code Blue cart and defibrillator/AED with Code Blue Board, IV pole and suction to the bedside.
Section II, Item #6, included: Defibrillator and the ED emergency bag with emergency supplies will be brought to the Code Blue by assigned area or ED personnel.
Section III, "Code Blue Team Responsibilities" include:
1. The respiratory Care staff will:
a. Provide and maintain a patient airway
b. Ventilate;
c. Cardiac Compressions and
d. Obtain ABG ( a blood draw for arterial blood gases to evaluate the gas exchange levels of the patient) sample when requested.
2. Emergency Department Personnel - will do CPR and will suction
airway if needed and will proceed to the ER unless an ER doctor
responds with the team and directs otherwise.
a. May start the Code Blue Flow Sheet on the unit or once in the ER and will complete it in the ER.

14. Review of "Resuscitation Policy" for Cox South effective 10/14/2009 showed the following information:
Section III, "Code Blue Team Responsibilities" included:
A (1) - The respiratory care staff will:
a. Provide and maintain a patient airway;
b. Ventilate;
c. Cardiac Compressions; and
d. Obtain ABG sample when requested.

A (2) Anesthesia and/or qualified Emergency/Urgent/Care Department Personnel - Anesthesia qualified Emergency Department personnel, a physician/family practice resident attending the Code Blue, or a qualified Respiratory Therapist will intubate the patient after ascertaining the patient's intubation status and allow respirator care to maintain ventilation.
A (4) Critical Care Nurse[s] or ACLS trained staff will direct the specific resuscitation protocol and assess over-all responses per ACLS standards until a physician is available.
A (6) EKG or Cardiopulmonary Technician will bring an EKG machine to the code site and report to the team leader for further directions. A 12 Lead EKG (electrocardiogram - provides a reading of the heart's electrical function) and Rhythm documentation may be requested.
A (7) Physician - The attending physician is responsible for the management of the patient including resuscitation.
A (8) Laboratory Phlebotomist (a technician that performs blood draws) will report to the code blue site and prepare to draw blood as directed.

15. Based on the reviews of the Cox North Resuscitation policy and the Cox South Resuscitation policy differences were found for how patients were resuscitated between the two hospitals. The Cox North Resuscitation policy failed to include that the Code Blue team is to respond to the patient arrest per ACLS standards until a physician is available. The Cox South Resuscitation policy does include the Code Blue team is to respond to the patient arrest per ACLS standards until a physician is available.

16. Review of Adult Psychiatry, "Guidelines for Evaluating Staffing Needs", for the 3 PM to 11 PM shift showed the following information: 2-3 PT's are the recommended guidelines for 11-15 patients. On 12/5/10 the staffing schedule showed F 300 hall with only one PT staff working the 3:00 PM to 11:00 PM shift, with a census of 13 patients. Only one PT staff was working on F 300 hall during the time Patient #1's death.

17. During an interview on 12/13/10 at 4:00 PM, with Staff H, he/she confirmed the Adult Psychiatric Unit, F 300 hall was short one PT staff on 12/5/10 for the 3 PM to 11 PM shift.

18. During an interview on 12/13/10 at 9:13 AM, with Staff E, Administrative Director, Office of Patient Safety showed the following information: Staff E stated that he/she watched the video recording for F 300 hall on 12/5/10 to determine if Patient #1 received the 15-minute checks from Staff C or Staff D as documented in Patient #1's clinical record. Staff E stated at 4:20 PM Staff C is seen entering Patient #1's room. Staff E stated that Staff C documented entering patient #1's room at 4:15 PM and again at 4:30 PM, but the video confirmed Staff C entered patient's #1's room at 4:20 PM). Staff E stated at 4:23 PM, Patient #1 is seen looking out into the hallway from his/her room. Staff E stated at 4:24 PM, a shadow is seen as if Patient #1's door is closing. Staff E stated at 5:15 PM, Patient #1's roommate goes down the hallway to his/her room and is seen screaming in the hall.

19. Staff E and the psychiatric team confirmed: The video camera showed F 300 hall activity, but did not show what was happening in Patient #1's room. Staff C and Staff F, both from G 300 hall, responded to hearing the roommates screams and started Basic Life Support (CPR, Cardiopulmonary Resuscitation) for Patient #1 at 5:15 PM. Staff G from G 300 hall responded and brought the AED and the Code Cart to Patient #1's room. Staff E reported that Staff G placed AED patches on Patient #1 to assess his/her need for a shock from the AED and two times the AED advised "No Shock Required." This message means: asystole (no heart rhythm) or the patient has a heart rhythm that is stable enough that no shock is required. In the case of Patient #1, Staff E reported patient #1 had no heart beat (asystole) and was not breathing. The CAT team arrived at 5:22 PM, and placed Patient #1 on a gurney and continued Basic CPR while transporting him/her to the emergency room.

Staff E stated from a process standpoint the facility's process was broken because Staff C and Staff D both documented checking on Patient #1 when the video recording verified that neither of these employees checked Patient #1 between the times of 4:20 PM and 5:10 PM.

22. All patient rooms observed on F 300 hall were found to have accordion folding doors in the bathrooms of each patient room. The census for F 300 hall was 11. The top folding portion of the bathroom doors presents as a looping hazard. This surveyor was able to put an ink pen through the top folding area confirming that a patient could loop items through this area and therefore presents as a looping hazard. This surveyor tested the accordion doors for the ability to support the weight of a patient by holding the top of the accordion doors and bearing a significant amount of body weight on the door, and the door stood the added pressure of excess weight with ease. All patient bathrooms on F 300 hall had heavy, vinyl shower curtains that could be used by patient's to commit suicide by suffocation, and presents as a safety hazard. The accordian folding doors and heavy, vinyl shower curtains placed 10 patient's at risk for safety hazard.

23. Observation on 12/9/10 at 12:24 PM, on G 300 hall patient rooms showed the following information:
In room G-327 was a Bariatric Bed with one 6 foot electrical cord and one 15 foot electrical cord attached, which presents a potential as a looping hazard for all at risk patients. The census on G 300 hall was 6, with 6 patient's at risk for safety hazard.

24. Observation on 12/9/10 at 2:10 PM, on G 100 hall (Adolescent Unit), classrooms and office areas showed the following:
-An electric shredder machine sitting out in the hall with an electrical cord approximately 5 feet in length attached;
-A copy machine sitting out in the hall with an electrical cord approximately 5 to 6 feet in length attached;
-Observed that all patients have open access to the hallway where these machines with long electrical cords are located.

26. Review of "Environmental Inspection Reports" for March 2010 and October 2010 for the Psychiatric Units showed the following information: These reports include inspection of Life Safety Code regulations, but failed to include inspections of Psychiatric patient hazards such as inspecting for looping and hanging hazards, presence of electrical cords within patient access, or suffocation hazards from heavy, vinyl shower curtains.

Based on observations, interview, record review, review of facility policies and procedures, staffing review and environmental inspection review, the facility failed to ensure psychiatric nursing care and supervision was provided to ensure the safety of suicidal patients on the Adult Psychiatric Unit. One of 52 patients in the Cox North Psychiatric Units (Patient #1) was not provided with adequate nursing supervision to ensure his/her safety. Nursing staff failed to perform safety monitoring checks for Patient #1, prescribed by the physician to be done every 15 minutes. Patient #1 had attempted suicide as part of the reason for admission, including depression and suicidal ideation. Review of videotaped rounds on 12/5/10 showed the staff on the Adult Psychiatric Unit failed to make rounds on Patient #1 for 50 minutes. Patient #1 successfully committed suicide by hanging in his/her room on Adult Psychiatric Unit on 12/5/10. Due to the serious nature of these findings, the Condition of Participation for Nursing Services was not met. The facility census was 445. The facility census for Cox North Psychiatric Units was 52.

Based on observations, interview, record review, review of facility policies and procedures, and staffing review, the facility failed to ensure nursing care and supervision was provided to ensure the safety of sucidal patients on the Adult Psychiatric Unit. One of 52 patients in the Cox North Psychiatric Units (Patient #1) was not provided with adequate nursing supervision to ensure his/her safety. Nursing staff failed to perform safety monitoring checks for Patient #1, prescribed by the physician to be done every 15 minutes. Patient #1's admission diagnoses included major depression, suicidal ideation and a history of attempting suicide. Review of videotaped rounds done on 12/5/10 showed the staff on the Adult Psychiatric Unit failed to make rounds on Patient #1 for 50 minutes. Patient #1 successfully committed suicide by hanging in his/her room on the Adult Psychiatric Unit on 12/5/10. The facility census was 445. The facility census for Cox North Psychiatric Units was 52, with 45 of the 52 patients at risk for safety hazard and on Close Observation status.

Findings Included:

1. Medical record review showed patient #1 was admitted on 12/4/2010 after being seen in the emergency room for major depression, borderline functioning, problems with support systems and previous suicide attempts. Patient #1 had been living in homeless shelter.

Patient #1's History and Physical (H & P) dated 12/4/10, showed:
-The patient was having suicidal thoughts;
-The patient had a plan to jump in front of a truck or slice his/her wrists;
-The patient stated he/she did have a history of overdose; and
- Diagnosis of Major Depression.

Review of the Adult Inpatient Psychiatry Admitting Orders dated 12/4/10 showed:
-Precautions: Close Observation for risk of harm. (Check/Observe patient every 15 minutes.)

Patient #1's psychiatrist documented in the H & P on 12/5/10 the following information:
-The patient had been released from another psychiatric facility for about a day and a half prior to presenting his/herself to the emergency room;
-The patient expressed he/she had increasing auditory hallucinations and thoughts about harming himself/herself;
-The patient has a history of psychiatric admissions;
-The patient was homeless, living at a homeless shelter;
-The patient was estranged from his/her family and was unemployed; and
-The patient was admitted to the psychiatric unit for treatment of Major Depression, recurrent.

Medical record review of Patient #1 showed on 12/5/10 he/she was verbalizing plans for Christmas and was looking forward to positive things. Patient #1 was last observed by staff at 4:20 PM. Per video tape patient #1 was seen sticking his/her head out of the room looking out into the hallway at 4:23 PM. Patient #1's roommate entered his/her room at approximately 5:10 PM, and found patient #1 with a sheet tied around his/her neck and looped over the door. The roommate began screaming and upon hearing these screams facility staff entered the room and initiated CPR. Patient #1 was found with ligature marks around his/her neck, with no pulse or respirations. Patient #1 successfully committed suicide by hanging in his/her room on 12/5/10.

2. Policy review of "Psychiatric Services Policy", Precautions: Adult I and II, Standard #: Treatment I, revised and approval on 08/2010, stated in part the following information:

Definitions of Levels of Precautions:

-On page 3 (of 4), of this policy included the definition of levels of precautions. Close Observation is defined as, "Patient is observed a minimum of every fifteen minutes by psychiatric staff."
-The same policy included a Documentation section on Page 2 (of 4) that stated: 15 Minute Checks Flowsheet: "This form will be initiated and maintained by psychiatric staff when a patient is placed on physician ordered precautions. It is discontinued at the time of precaution discontinuation."

Review of the "15 Minute Check Flowsheet" dated 12/5/2010 for patient #1, showed the following documentation:
-1600 (4:00 PM), by Psychiatric Technician (PT), Staff C, who also documented the patient's behavior as "2" (per the legend/key on the form identified "2" as appropriate behavior);
-1615 (4:15 PM), by PT, Staff C, and documented the patient's behavior as "2."
-1630 (4:30 PM), by PT, Staff C, and documented the patient's behavior as "2."
-1645 (4:45 PM), by LPN (licensed practical nurse), Staff D and documented the patient's behavior as "2."

3. During a phone interview with Psychiatric Technician (PT), Staff I, on 12/13/10 at 2:12 PM, showed: Staff I stated that he/she worked from 7:00 AM to 3:00 PM on 12/5/10, and was already off work when Patient #1 committed suicide. Staff I confirmed he/she was on administrative leave because when the video from 12/5/10 was reviewed it did not show him/her making the 10 AM check that he/she documented for Patient #1. Staff I stated there was not a good system for doing the 15-minute checks, and no structure for the assignment of the 15-minute checks. Staff I stated that if any staff walked by the check-book they would pick it up and document the checks, but they were not assigned. Staff I stated that he/she is aware of other times the PT's would document 15-minute checks as being done when they were not. Staff I stated that he/she was never given any training on what to do if a check was not done, staff were told the checks must be done, and he/she did not want to bring it to anyone's attention that the checks were not being done. Staff I stated that at times the PT's will be in situations when there is a "Code" and everyone's attention is elsewhere and patient checks were not done, but charted as done. Staff I confirmed that the camera/video was correct that he/she failed to complete the 15-minute checks for Patient #1 at 10 AM:00, and failed to document the check.

4. During a phone interview with PT, Staff J, on 12/13/10 at 2:38 PM, showed: Staff J stated that he/she worked 12/5/10, from 7:00 AM to 3:00 PM, and was off work by 3:00 PM, prior to Patient #1 committing suicide. Staff J stated that the PT's were not assigned to check on the patients. Staff J stated that the 15-minute checks were done by communication between the PT's as there was no one specifically assigned to do them. Staff J stated that he/she was aware of PT's not doing the 15-minute checks, but charting that they were done. Staff J stated that if something is going on, distracting the PT's from doing the 15-minute checks the PT's documented the checks as being done when the PT's were really doing something else. Staff J stated it did not happen often, but it did happen. Staff J stated that he/she would take over the 15-minute checks and there would be blank spaces when they should have been documented as done.

5. During an interview on 12/13/10 at 3:05 PM, with RN, Staff K, and RN, Staff L, who work in the Office of Patient Safety for the facility showed the following information:
-Both Staff K and Staff L reviewed the video tape of Patient #1 between the hours of 9:00 AM to 2:00 PM for the 15-minute checks;
-Staff K and Staff L matched the video taped 15-minute checks to the documented 15-minute checks and found discrepencies;
- Checks for Patient #1 included staff charting from 10:00 AM to 11:00 AM, that Patient #1 was in his/her room, but the video tape showed patient #1 was actually out of his/her room from 9:47 AM to 11:00 AM;
-Staff K and Staff L reviewed the video tape for the 3:00 PM to 11:00 PM shift, and it showed at 4:20 PM PT staff did check on Patient #1, and at 1623 (4:23 PM), patient #1 peaked out of his/her room door;
-At 1715 (5:15 PM) the video tape showed Patient #1's roommate going into his/her room;
-The video tape does not support that Staff C or Staff D made any 15-minute checks between 4:20 PM and 5:15 PM.

6. During a phone interview on 12/13/10 at 3:35 PM, with Staff C showed: Staff C stated he/she worked from 3:00 PM to 11:00 PM on 12/5/10 on F 300 hall, there were no other PT's working on the F 300 hall, and staffing was down to one PT. Staff C stated that he/she was on administrative leave due to charting 15-minute checks when they were not actually done. Staff C stated that he/she saw Staff D closing the 15-minute check-book and thought Staff D had done the 5:00 PM check for Patient #1. Staff C stated that it was not clear who was to do the 5:00 PM and 5:15 PM, 15-minute checks as he/she was pulled off of doing them to assist with a new admission. Staff C stated that he/she was not trained on the appropriate thing to do if a 15-minute check was missed. Staff C stated that he/she followed by the example of others to chart 15-minute checks were done when they were not done. Staff C stated that other PT's did the same thing. Staff C confirmed he/she did not check on Patient #1 as documented on 12/5/10, at 5:00 PM, and another time earlier in the shift.

7. During a phone interview on 12/14/10 at 9:30 AM, with Staff D showed: Staff D confirmed he/she worked the F 300 hall from 3:00 PM to 11:00 PM, on 12/5/10 as a medication nurse. Staff D confirmed he/she did not go down the hall to Patient #1's room to check on him/her, but documented that he/she checked patient #1 at 4:45 PM. Staff D stated that he/she was aware that other staff charted doing the 15-minute checks when they were not done. Staff D stated it was not clear to the staff what to do when a 15-minute check time had already passed, so the staff would document that they were done when they were not done.

8. During an interview on 12/9/10 at 11:40 AM, with Director of Psychiatric Services, RN, Staff H, showed: Staff H stated that prior to Patient #1's death it was not clearly assigned as to what staff would be responsible for 15-minute checks. Staff H stated that 15-minute checks were not assigned to any one employee for a specified amount of time. Staff H stated that it was discovered while watching the video of 12/5/10, for F 300 hall that Staff C had been pulled off the task of making 15-minute checks to assist with a new admission.

9. Review of Adult Psychiatry, "Guidelines for Evaluating Staffing Needs", for the 3:00 PM to 11:00 PM shift showed the following information: 2-3 PT's are the recommended guidelines for 11-15 patients. On 12/5/10 the staffing schedule showed F 300 hall with only one PT staff working the 3:00 PM to 11:00 PM shift, with a census of 13 patients. Only one PT staff was working on F 300 hall during the time Patient #1's death.

10. During an interview on 12/13/10 at 4:00 PM, with Staff H, he/she confirmed the Adult Psychiatric Unit, F 300 hall was short one PT staff on 12/5/10 for the 3:00 PM to 11:00 PM shift.

11. During an interview on 12/13/10 at 9:13 AM, with Staff E, Administrative Director, Office of Patient Safety showed the following information: Staff E stated that he/she watched the video recording for F 300 hall on 12/5/10 to determine if Patient #1 received the 15-minute checks from Staff C or Staff D as documented in Patient #1's clinical record. Staff E stated at 4:20 PM, Staff C is seen entering Patient #1's room. Staff E stated that Staff C documented entering patient #1's room at 4:15 PM, and again at 4:30 PM, but the video confirmed Staff C entered patient's #1's room at 4:20 PM. Staff E stated at 4:23 PM, Patient #1 is seen on the videotape looking out into the hallway from his/her room. Staff E stated at 4:24 PM, a shadow is seen on the videotape as if Patient #1's door is closing. Staff E stated at 5:10 PM, thae videotape shows Patient #1's roommate going down the hallway to his/her room and is seen screaming in the hall. Staff E stated from a process standpoint the facility's process was broken because Staff C and Staff D both documented checking on Patient #1 when the video recording verified that neither of these employees checked Patient #1 between the times of 4:20 PM and 5:10 PM.