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Based on medical record review, staff interview, and policy review; the facility failed to ensure nursing care was delivered per the facility's policy regarding direct observation of a patient on suicide precautions every 15 minutes. This affected one of 17 patients present on psychiatric unit B on 04/08/11 (Patient 8).

Findings include:

The facility failed to ensure nursing care was delivered per the facility's policy regarding direct observation of a patient on suicide precautions every 15 minutes. Please see A 395.

Based on medical record review, staff interview, and policy review; the facility failed to ensure nursing care was delivered per the facility's policy regarding direct observation of a patient on suicide precautions every 15 minutes. This affected one of 17 patients present on psychiatric unit B on 04/08/11 (Patient 8).

Findings include:

The medical record for Patient 8 was reviewed on 04/19/11. The medical record contained documentation the patient had an involuntary admission on 04/06/11. The patient was referred to this facility for paranoid schizophrenia. The medical record documented the patient was assessed to be a low risk for suicide from 04/06/11 through 04/08/11, and the patient was reassessed by nursing on every staff shift. The Frequent Monitoring Flowsheet (the document used for staff to record patient safety checks or rounds) for 04/08/11 contained documentation by Staff E that the patient was in the bathroom during the check at 10:00 PM; at 10:24 PM the documentation stated the patient was found unresponsive, an emergency code was called, and the patient was transferred to the emergency department. The nursing note for 04/08/11 at 10:23 PM written by Staff F, who actually found the patient, stated the nurse caring for the patient and making every 15 minute rounds, could not locate the patient and all staff began a search of the unit. The patient was found unresponsive by Staff F after opening the bathroom door of unoccupied room 221. The nurses note stated only that the patient was found lying on the floor, unresponsive with no pulse, and a patient gown was around his/her neck. Chest compressions were initiated immediately and a code blue was called at 10:24 PM. The manager of the unit and the attending physician were notified. The patient was transferred to the emergency room where he/she was placed on a ventilator after a second code blue, then transferred to the intensive care unit. On 04/09/11 at 12:35 PM the patient was pronounced dead per the brain death protocol.

On 04/19/11 at 4:07 PM, Staff A, B, C, and D were interviewed regarding the facility's investigation of the incident on 04/08/11. The camera system was reviewed and it was noted that Patient 8 had entered room 221 at 9:49 PM. The video surveillance system is an extra tool available to the staff while at the nurses station, but no one is assigned to watch the monitors as direct observation is what is required. The nurse (Staff E) reported that he/she had not visualized the patient at the 15 minute check at 10:00 PM, and documented the patient was in the bathroom in his/her own assigned room because the door to that bathroom was closed and the light was on. However, Staff E failed to visualize or speak to the patient. The investigation showed Patient 8 used two patient gowns and a bathroom door in an unoccupied patient room to hang him/herself. The patient tied a large knot in one end of the gowns, threw it over the top of the door, and closed the door. The patient tied the other end of the gown around his/her neck and then sat down. Patient 8 was six feet two inches tall and weighed 200 pounds.

The Patient Monitoring/Frequent Monitoring Flowsheet policy was reviewed on 04/20/11. The policy stated that patients will be visually monitored for safety every 15 minutes and reviewing monitors does not count, as the patients must be directly observed. The Management of Patients at Risk for Suicide policy was reviewed on 04/20/11. The policy also stated that suicidal patients are to be monitored at a minimum of every 15 minutes.

This substantiates complaint OH00060458.