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Based on observation, interview and record review, on 6/1/2015-6/2/2015, the governing body failed to ensure that patient rights were protected, that a safe environment was maintained, and an effective nursing assessment and supervision of patient care were provided. The identified practices resulted in harm to a patient and present a likelihood for substantial harm to all current and potential patients on the Behavioral Health Unit.


Based on record review and interview the facility failed to assess, evaluate and supervise the care needs of a suicidal patient after she informed staff she had suicidal urges and a plan to commit suicide. This failure resulted in the patient hanging herself from her bathroom door. Refer to 482.23(b) (3).


Based on observation, interview and record review, the facility failed to ensure patient safety by removing grab bars, faucets, and door hinges without safety features from patient bathrooms after a patient hanged herself on 5/16/2015 in her bathroom by tying a noose on the hinges on the bathroom door. This failed practice presentes a likelihood for serious harm of all current and potential patients. Refer to (482.13 (c) (2).


Based on observation, interview and record review, the facility failed to identify grab bars, faucets, and door hinges without safety features in patient bathrooms as safety hazards after a patient hanged herself on 5/16/2015 in her bathroom by tying a noose on the hinges on the bathroom door. The facility's Quality Assurance Performance Improvement (QAPI) process failed to identify the hazard and failed to develop measures to prevent similar events. This failure presents a likelihood for other patients to hang themselves from bath room doors in their rooms. Citing 58 rooms in the behavioral Health Department. Refer to 482.21(a), (c)(2),(e)(3).

Based on observation, interview and record review, the facility failed to ensure patient safety by removing grab bars without safety features form patient bathrooms.


The facility failed to remove hinges on patient bathroom doors in the behavior health unit that served as hanging equipment for one patient on 5/16/2015. This failed practice presents a likelihood for serious harm to all current and potential patients.Random observations made on three (3) Behavior Health Units.

Refer to (482.13 (c) (2).

Based on observation, interview and record review, the facility failed to ensure patient safety by removing grab bars, faucets, and door hinges without safety features from patient bathrooms after a patient hanged herself on 5/16/2015 in her bathroom by tying a noose on the hinges on the bathroom door. This failed practice presents a likelihood of serious harm to all current and potential patients.

Citing random observations made on three (3) Behavior Health Units.

Findings:

During a survey at the facility on 6/1/2015-6/2/2015, interview and record review revealed that a patient hanged herself from the hinges of her bath room door on 5/16/2015.

When the patient was found she was described as cyanotic and was not breathing. The patient was revived after being resuscitated.

Observation on 6/1/2015, between the hours of 9:30 am and 11:30 am revealed that the Behavior Health Unit had three (3) floors and an intake unit. There were 20 patient care rooms on floors three (3) and four (4) and 18 rooms on floor two (2) making a total of 58 patient rooms.

During the observation, all the grab bars in the 20 bathrooms on the fourth floor had no safety features and had the capability for a noose to be tied. The hinges on the bathroom doors were sturdy and were spaced so that a noose could be tied from the top hinges.

Observation on the second and third floors revealed that the bathroom doors in those 38 rooms had similar unsafe features.

Observation on 6/1/2015, at 11:56am in the Intake Unit revealed that the patient's toilet had similar unsafe hinges on the door and there was no call light to summon help in the toilet.

Review of the facility's Root cause documentation dated 5/17/2015, revealed the plan documented that no controllable environmental factors was identified as associated to the patient hanging event.

During an interview on 6/1/2015, at 12:45 pm, with the Chief Executive Officer, he stated that he was not aware there was a required design for bathroom door hinges

During an interview on 6/1/2015, at 11:50 am, with the RN Director of the Behavior Health Unit, she stated a review of environment safety for the unit was scheduled. She stated that the staff did not monitor the patient as ordered by the physician.

Review of patient's Rights information given to the patients at time of admission revealed the following information:

"Rights to a clean, safe, secure, and pleasant environment that preserves your dignity and contributes to a positive self-image."

Based on observation, interview and record review, the facility failed to identify grab bars, faucets, and door hinges without safety features in patient bathrooms as safety hazards after a patient hanged herself on 5/16/2015, in her bathroom by tying a noose on the hinges of the bathroom door.

The facility's Quality Assurance Performance Improvement (QAPI) process failed to identify the hazards and develop measures to prevent similar events.

This failed practice presents a likelihood of serious harm to all current and potential patients. Citing 58 rooms in the behavioral Health Department.

Findings:

During a survey at the facility on 6/1/2015-6/2/2015, interview and record review revealed that a patient hanged herself from the hinges of her bathroom door on 5/16/2015.

When the patient was found she was described as cyanotic and was not breathing. The patient was revived after being resuscitated.

Observation on 6/1/2015, between the hours of 9:30 am and 11:30 am, revealed that the Behavior Health Unit had three floors and an intake unit. There were 20 patient care rooms on floors 3 and 4, and 18 rooms on floor 2, making a total of 58 patient rooms. Each floor had two private rooms. Patient # 1 who hanged herself was in a private room on floor 2.

During the observation, all the grab bars in the 20 bathrooms on the fourth floor had no safety features and had the capability for a noose to be tied. The hinges on the bathroom doors were sturdy and were spaced so that a noose could be tied from the top hinges.

Observation on the second and third floors revealed the bathroom doors in those 38 rooms had similar unsafe features.

Review of the facility's Root cause documentation dated 5/17/2015, revealed the plan documented that no controllable environmental factors was identified as associated to the patient hanging event.

The root cause analysis focused on the fact that adequate monitoring of patients was not done, but failed to identify unsafe features in the patient care areas.

During an interview on 6/1/2015, at 12:45 pm, with the Chief Executive Officer, he stated that he was not aware there was a required design for bathroom door hinges.

During an interview on 6/1/2015, at 11:50 am, with the RN Director of the Behavior Health Unit, she stated that a review of environment safety for the unit was scheduled. She stated that the staff did not monitor the patient as ordered by the physician.

Based on record review and interview, the facility failed to assess, evaluate and supervise the care needs of a suicidal patient after she informed staff she had suicidal urges and a plan to commit suicide.


This failure resulted in the patient hanging herself from her bathroom door. Refer to 482.23(b) (3).

Based on record review and interview, the facility failed to evaluate, supervise and implement safety precautions for a suicidal patient after she informed staff that she had suicidal urges with a plan to commit suicide. This failed practice resulted in the patient hanging herself from her bathroom door.

Findings:

Review of Emergency Room Physician notes and Psychiatrist notes dated 5/12/2015, revealed the following information:
Patient (#1) had history of alcoholism; she was brought into the ER by law enforcement officers for severe intoxication and depression.
The patient gave a history of being sober for more than a year but had been binge drinking for two weeks and relapsed after she had news that her mother had stage four cancer. She became depressed with suicidal ideation. The notes documented Patient (#1) had suicidal ideation in the past.
Patient (#1) was diagnosed with Depression and Suicidal Ideation and was admitted 5/12/2015, to the Behavior Health Unit for Detoxification, medication stabilization and Group therapy.
Review of Nursing admission assessment notes revealed that the patient was placed on 15-minute observation for suicide and detox precautions.
Review of the facility's observation policy revealed that a two hourly observation is to be done by the Registered Nurse with documentation that the observation was done.
Review of the observation record for 5/16/2015, revealed the patient was being monitored every 30 minutes. There was no documentation on the observation record that a nurse observed the patient on the morning or night shift. There was documentation by a Mental Health technician at 2345 that the patient was in her room asleep in bed.
Review of surveillance tapes for the unit revealed that the night nurse never went into the patient treatment areas until the patient was found hanging at 2353.
The surveillance tapes also revealed that the Mental Health Technician did not go into the patient's room on 5/16/2015, at 2345, as documented on the observation record.
Review of group notes dated 5/15/2015, revealed between 9:15 and 10:15 am, Patient (#1) was attentive in group, her thinking was vague/guarded her mood/ affect was depressed.

Review of physician's progress notes dated 5/15/2015, (no time documented), revealed information that Patient (#1) was doing better, her tremors had decreased. The physician made an order to discontinue suicide and detox precautions.Schedule patient for discharge on 5/18/2015.

Review of observation record revealed suicide and detox precautions were discontinued on 5/15/2015, at 1600.

Review of group notes dated 5/16/2015, at 10:15 am, revealed that the patient shared her feelings in the group, her thinking was disorganized/confused her mood/ affect was depressed.

Review of physician's progress notes dated 5/16/2015, (no time documented), revealed information that Patient (#1) complained of depression, suicide urges, despondency and hopelessness. Wants to attempt suicide by facing an oncoming truck or overdosing.
There was no documentation that the patient was evaluated for safety after this change in her condition. There was documentation on the nurses notes dated 5/16/2015 at 2353, that the patient was found hanging in her room.

During an interview on 6/2/2015, at 12:15 pm, on the Behavior Health unit with the physician that he had been assigned the patient's care since admission and saw her daily. He stated that the patient did say she was suicidal with a plan but did not have the same intensity as previous days. He said he did not think she would do it so he did not change his orders.

Review of the facility's Root cause analysis documentation dated 5/17/2015, revealed the plan documented that patient rounds were not consistently made every 15-30 minutes as ordered by the physician.

During an interview on 6/1/2015, at 10:15 am, on the Behavior Health Unit, and with the physician on 6/2/2015, at 12:30 pm, they both stated post hanging Patient (#1) told them she had been planning to hang herself for a while.
During an interview on 6/1/2015, at 11:50 am, with the RN Director of the behavior Health Unit, she stated a review of environment safety for the unit was scheduled. She stated that the staff did not monitor the patient as ordered by the physician.

Review of the facility's Assessment policy revealed the following information:
The purpose of the assessment for suicide, homicide and self-harm is to provide guidelines for the safe management of patients with suicidal ideation and to minimize self-harming acts by all patient admitted to SJMC Center for Behavior Health.
An order for suicide precautions is written by a physician, or by a registered nurse as an independent nursing intervention. A physician's order must be obtained within 24 hours of the nursing order. The order must include reason and duration."