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Based on observation, medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1) a safe environment for patients on suicide precautions by performing a proper safe environment check of the patients rooms, in accordance with the Safe Room Environment Checklist; 2) that nurses perform and document assessments every four hours of presence or absence of injurious behavior and patient's coping skills in accordance with facility policy three of four medical records reviewed (P1, P2, and P4).

Findings include:

1. Reference: Facility policy titled, "One to One Criteria" states, " ... II Definition One to One (1:1) - A specifically designated staff member will maintain constant observation of the patient at all times. ... a. The staff member will intervene to prevent patient from harm ... Type of Patient - Suicidal/Homicidal - Observation Criteria 1:1 at arm's length, Protection for Patient - Remove all personal items from room ... F. ... Conduct room search at the time the patient is placed on Observation to check for a safe environment. (See Observation Record) ..."

On 10/13/22 at approximately 11:00 AM, a review of the Observation Record forms for P1 was conducted in the presence of Staff #3. A statement on the Observation Record stated, "Completed SAFE ROOM ENVIRONMENT Checklist if suicidal" was noted on the top of the form, a check box for Yes or No was also noted. Upon review of the SAFE ROOM ENVIRONMENT, it was revealed that there was no safe room checklist for each shift on 7/16, 7/17, and 7/18/22.

At 12:50 PM, review of the Safe Room Environment checklist for P2 revealed that there was no safe room checklist for 10/9/22 and 10/12/22.

At 2:05 PM, during a tour of the third floor the Medical Progressive Care Unit (MPCU), in the presence of Staff #3 and Staff #10. The following was revealed:

In Room 360, P3 was placed on suicide precautions on 10/12/22 because the patient took unknown pills from home. Upon observation of the patient's room, it was observed that the bedside table was in the room with a boxed fan sitting on top and a round mirror. The bedside table was across the patient with multiple items including a water pitcher. The 1:1 sitter was sitting by the door using a blue high back chair with metal legs.

In Room 361, P2 was observed on a 1:1 observation for suicide precautions. The patient was observed standing, talking on the phone with a long cord. The 1:1 sitter was positioned sitting by the door using a blue high back chair with metal legs. On the bed, was an uncapped black pen. There was a used plastic food tray stored on top of the cabinet.

Review of the Safe Room Environment Checklist revealed a statement on the bottom of the page that stated, "Complete checklist daily each shift with observer and nurse together."

Upon interview, Staff #3 stated that the staff should be completing the safe room checklist each shift, and that meal trays should be served on a paper tray, not a hard plastic tray.

2. Reference: Facility policy titled, "Suicide Precautions/Self-Injury Precautions" states, "... III. Procedure ... B. Implementation: ... 4. An RN assessment of the patient's behavior will be documented every four (4) hours. ... IV. Documentation A. Observation Record: Patient observed continuously. Document every fifteen (15) minutes. Assessment every four hours (4) by the RN to include presence or absence of injurious behavior and patient's coping skills. ..."

On 10/13/22 at 1:05 PM, during a review of the nursing assessment, the following was revealed:
P1 was placed on 1:1 observation for suicide precautions on 7/14/22. There was no documented assessment of the patient's behavior every four hours by an RN.
P2 was placed on 1:1 observation for suicide precautions on 10/06/22. There was no documented assessment of the patient's behavior every four hours by an RN.
P4 was placed on 1:1 observation for suicide precautions on 10/11/22. There was no documented assessment of the patient's behavior every four hours by an RN.

During an interview with Staff #3, he/she confirmed that nursing assessment every four hours should have been documented.