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Based on a review of facility documents, facility policy, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure a safe setting to prevent a suicide attempt in one of ten MR reviewed.

Findings include:

On March 16, 2022, review of facility policy Suicide Screening Assessment and Intervention effective March 14, 2022, "Appendix A: Environmental Safety Room Precautions- Room Safety: If patient requiring admission to a general acute inpatient setting has suicidal ideation and screened to be high risk (or for use with Low to Moderate Risk patients based upon nursing judgement): All objects that pose a risk for self-harm that can be removed without adversely affecting the ability to deliver medical care should be removed: Potential hazardous materials/equipment: Any item that can be used as an anchor for ligature.. Remove and secure the following items from the patient's room: Gait belt..."

On March 16, 2022, review of MR1 revealed "Plan of Care noted by EMP6 on February 24, 2022, at 3:43 AM Upon BIT assessment, patient is cooperative, calm, blunt, and oriented. Patient endorses suicidal ideations (SI) with a plan of hanging due to patient's current living situation. Patient (Pt) also endorsed homicidal ideations (HI) towards the staff working at OTH1 (different facility) specifically OTH2 (Employee at other facility) who pt claims is abusive toward patient and other residents. Pt stated 'wanted to murder the owner.' Pt contracted for safety in the hospital but not at OTH1 since patient claims the facility is verbally abusive toward patient and the other residents. Pt claims living at OTH1 is a stressor for patient claiming Patient will either 'murder OTH2 or myself, one or the other.'" Progress Notes by EMP5 noted on February 27, 2022, at 11:51 AM stated "Patient reports ongoing visual and auditory hallucinations, ongoing depression with suicidal thoughts and a plan to hang self. However on evaluation no evidence of response internal stimuli...Patient's suicidality also appears contingent 'if you send me back to that place I will kill myself.'" Consult note entered by EMP10 on February 28, 2022, at 11:05 AM stated "soon after discussing with pt about an option to return to Personal Care home, OTH1, pt attempted to harm self by wrapping a cord around patient's neck to hang self."
In MR1 last Columbia Suicide Severity Rating Scale (CSSR-S) screening completed was on February 24, 2022, at 13:23 PM with a score of 0.
Further review of MR1 Emergency Department (ED) Notes by EMP7 on February 28, 2022, at 10:45 AM revealed "EMP8 heard bed alarm and found pt with gait belt around neck and suspended from overhead light bar. EMP7 entered room when EMP8 yelled for help. Pt red in the face and suspended off ground at this time. Attempted to lift pt up in the air, prison guard next door heard commotion and came to room. Prison guard was able to lift pt in the air and EMP9 was able to cut the taut gait belt with trauma shears. Pt laid on litter, red mark noted to neck."
Interview with EMP9 on March 19, 2022, at 09:50 AM EMP9 stated, "I ran to room 7 because I heard the two nurses yelling for help, I saw the patient hanging and his feet was off the ground. I used trauma scissors to cut him down. Afterwards the patient seemed confused and was gasping for air, his neck was red and looked bruised."
During interview with EMP10 on March 16, 2022, at 10:03 AM EMP10 stated "I did not tell patient he was going back to OTH1, I told him we were looking into it." EMP10 stated the patient got very angry when discussing OTH1 to the point he threatened to harm EMP10. EMP10 confirmed being aware returning to OTH1 was a trigger for the patient and denied reassessing the patient's suicide status or removing all potential hazardous equipment from the room.