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Based on document review, observation and interview it was determined that for 1 of 1 (Pt #1) patient on suicide precautions, whose death subsequently followed, the Hospital failed to ensure the Behavioral Health Unit patients were visibly monitored every 15 minutes, as required to help maintain patient safety. This potentially placed all patients at risk for serious harm and injury. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights, was not in compliance. This potentially affects all 71 current and future Behavioral Health Unit patients.

Findings include:

1. The Hospital failed to ensure the patient was monitored every 15 minutes, as required for safety (A 144-A).

2. The Hospital failed to provide a safe environment free of contraband (A 144-B).

A. Based on document review, observation and interview, it was determined, that for 1 of 1 (Pt #1) clinical record reviewed for a patient who committed suicide, the Hospital failed to ensure the patient was monitored every 15 minutes, as required for safety. In addition, the Hospital failed to ensure consistent patient safety rounds for all patients on the Behavioral Health Unit. This placed all patients on the Behavioral Health Unit, at immediate risk for serious harm and injury.

Findings include:

1. The clinical record for Pt #1 was reviewed on 08/28/18 at approximately 9:10 AM. Pt #1, a 19 year old female who was transferred from Hospital B's Emergency Department after being seen for a suicidal attempt/drug-overdose. Pt #1 arrived via ambulance and admitted on 07/10/18 at 9:55 PM, directly to the Women's Behavioral Health Unit (15th Floor) with diagnoses of major depression, post-traumatic stress disorder (unknown), suicidal attempt, and drug overdose.

On 07/10/18 at 11:28 PM, MD #1 (Attending Psychiatrist) ordered suicide precautions and patient monitoring every 15 minutes, via telephone. On 07/11/18 at 5:50 AM, a Code Blue (emergency cardiac resuscitation) was called and Pt #1 was pronounced dead at 6:23 AM.

2. The document titled, "Report of Postmortem Examination" (08/12/18) included, "This 19-year-old white female ...died of combined drug (heroin [addictive], fentanyl [narcotic analgesic], and alprazolam [sedative]) toxicity. Manner of death: Suicide."

3. The Hospital's policy titled, "Patient Rounds" (01/01/16) included, " ...III. Procedure: 1.The staff member assigned to rounds is responsible for ...a. visibly locating ...every 15 minutes with visual observation."

4. On 08/28/18 at approximately 2:30 PM, a video surveillance observation for the date of 07/10/18 from 9:40 PM - 07/11/18 until 5:40 AM was conducted. As per the schedule, E #11 (Mental Health Counselor) was assigned for every 15 minutes safety checks from 11:30 PM - 2:00 AM. E #11 was sitting in a chair at the end of the hallway with a table and computer workstation for the entire time period. At 2:12 AM, E #11 walked away from the hallway, out of the line of video surveillance. The staff switch was observed at 2:13 AM. E #3 (Registered Nurse) conducted monitoring every 15 minutes by standing in the hallway and opening each patients' room door. Again, the staff switch was observed at 4:35 AM, where E #11 returned back to the chair at the end of the hallway. At 4:36 AM, E #11 walked away from the hallway. At 4:40 AM, E #11 walks back and sits down on the chair at the end of the hallway. From 4:43 AM - 5:15 AM, E #11 was sitting back in the chair at the end of the hallway. At 5:20 AM, E #3 (Registered Nurse) walked by the room with blood pressure machine, but does not visibly observe Pt #1. On 07/11/18 at 5:32 AM, E #3 went inside Pt #1's room and rushed out of the room calling E #5 (Registered Nurse) into Pt #1's room. At 5:35 AM, the Unit staff pulled the crash cart into Pt #1's room. In summary, the video surveillance clearly showed that Pt #1 was not visibly observed on 07/10/18 from 11: 30 PM until 2:13 AM and from 4:13 AM until 5:32 AM.

5. On 08/28/18 at approximately 3:21 PM, E #1 (Charge Nurse) was interviewed. E #1 stated, "I was in-charge that day. This was a night shift admission. I called the doctor and received the admitting orders for suicide precautions. No suicide screening was done at that time. We did the body check and admitted the patient to the unit, and the rest of the admission was continued by the upcoming nurse on the next shift. Yes, (Pt #1) was brought into the Hospital directly to our Unit via the ambulance crew on a stretcher. (Pt #1) had her Hospital gown on when (Pt #1) came from the other Hospital ED (Hospital B). The belongings check is done by the Mental Health Counselor (MHC). (Pt #1) was anxious and pacing walking up and down the hallway. No we don't do the orifice checks."

6. On 08/28/18 at approximately 3:56 PM, E #3 (Registered Nurse) was interviewed. E #3 stated, "I was assigned to do the every 15 minutes monitoring rounds on the patients on 07/11/18 from 2:00 AM - 4:30 AM, to relieve the MHC. I just open the door and see if they are lying on the bed. I don't go check closely on them, as they are sleeping. I opened the door to see if (Pt #1) is lying on the bed. Later when I went back to check the vital signs at around 5:10 AM, I called her (Pt #1) name and there was no response. So I immediately called the nurse and we pulled the crash cart into the room and called for Code Blue."

7. On 08/29/18 at approximately 7:45 AM, E #5 (Registered Nurse) was interviewed. E #5 stated, "When I do my every 15 minutes checks, I visibly go inside the room and check on patients. And, I make sure to check the chest rise and fall or the stomach for movements, sometimes I use my flash light. Yes, we would have saved this (Pt #1), if we closely monitored by doing visible checks going inside the room and using flash light for the observation of the patient."

B. Based on document review, observation and interview, it was determined that for 1 of 1 (Pt. #1) with suicidal ideation, where a death followed, the Hospital failed to provide a safe environment, free of contraband to prevent harm and injury.

Findings include:

1. The Hospital's policy titled, "Contraband Policy" (05/11/18) included, "1. Purpose:..to provide a safe and therapeutic environment for patients...G. Room Search - means visually inspecting...a patient room...likelihood that there is a Contraband within...1. Screening for Contraband...staff should review the immediate area...at regular intervals."

2. The document titled, "Valuable Checklist" (07/10/18) at 10:05 PM, documentation by E #2 ( Mental Health Counselor) checked off: "No phone, blouse, pants, shirt kept with patient; bra, shoes, handbag with water and cigarette kept in the lock box. However, one green hoody was included in the Valuables Checklist and not checked off to clarify if it was with the patient or kept in the lock box. The socks (worn by Pt #1 on the video surveillance) was left blank in the valuables checklist. The checklist also included that Pt #1 'refused to sign'.

3. On 08/28/18 at approximately 2:30 PM, a video surveillance observation for the date of 07/10/18 from 9:40 PM - 07/11/18 until 5:40 AM was conducted. The observation included, on 07/10/18 at 11: 37 PM, Pt #1 walked out of her room wearing hospital gown and socks, turns to the left side and walks down the hallway. At 11: 38 PM, Pt #1 walked to the nurses station and paced the hallway. At 11:41 PM, Pt #1 returned back to her room from the hallway. At 11:51 PM, Pt #1 walked out of her room down to the end of hallway talking to E #11 (MHC). At 11:52 PM, Pt #1 returned to her room.

4. On 08/28/18 at approximately 3:47 PM, E #2 (Mental Health Counselor) was interviewed. E #2 stated, "I was the one who checked her belongings, (Pt #1) came in a Hospital gown, I think (Pt #1) had socks on too. I checked (Pt #1) belongings and (Pt #1) was pacing on the unit. She (Pt #1) kept asking for a small blanket. It is very essential to check the contraband items if any are present with the patient."

5. On 08/31/18 at approximately 11:45 AM, E #17 (Chief Nursing Officer) was interviewed. E #17 stated, "We just saw the cause of death. We had not seen the report. I don't know how that happened. Yes, (Pt #1) was medically stabilized at (Hospital B) and transferred to our BHU. The nursing team checks for contraband. We don't do orifice checks. I am not sure if she (Pt #1) got the drugs while (Pt #1) was at Hospital B or here at our Hospital (Hospital A). We know (Pt #1) had visitors while (Pt #1) was at the other Hospital (Hospital B). (Pt #1) was brought by ambulance crew in her Hospital Gown. Not sure how she got drugs. We did not administer any medications to the (Pt #1) while she was here."