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482.13 Condition of Participation: Patient Rights is Not Met as evidenced by the following:


Based on medical record review, staff interviews, patient interview, review of policies and procedures, incident reports and review of video surveillance, the facility failed to ensure that 3 of 3 patients (#1, 3 and 4), who attempted suicide while hospitalized in 2010, were provided a safe environment, protected from abuse in the form of neglect and the assurance that staff are knowledgeable relating to nonphysical behavioral interventions.

This facility has a capacity of 160 and on 10/31/10, census was 125.

Findings include:

The hospital staff failed to provide 3 of 3 patients (#1, 3, and 4) who attempted suicide while in this hospital in 2010, ongoing monitoring after stating an intent and a plan to commit suicide.

Please see 42 CFR 482.13(c)(2); tag A 144 for details relating to a lack of provision of a safe environment.

The hospital failed to ensure all staff were knowledgeable of facility behavioral polices and procedures.

Please see 42 CFR 482.13(f)(2)(ii); tag A200 for details relating to the failure to ensure each staff member demonstrates knowledge of nonphysical behavioral interventions such as line of sight observation.

This deficiency substantiates an allegation contained in Complaint OH00058221.

Based on review of patient medical records, review of policies and procedures, incident/accident reports and staff interviews, 3 of 3 patients (#1, 3, and 4), who attempted suicide while in this hospital in 2010, did not receive ongoing monitoring after notifying staff of their intent and plan to commit suicide.

This facility has a capacity of 160 and on 10/31/10, census was 125.

Findings include:

1. Per medical record review on 11/04/10, Patient #1 was admitted to the hospital on 10/23/10 at 12:35 AM, for an overdose of Ativan and with suicidal ideation including a plan. Patient #1 was admitted to unit 1400 (the stabilization unit), and remained there until 10:00 AM on 10/25/10, when he/she was admitted to the step down unit (1500). Per review of the integrated progress notes, the following was written on 10/28/10 at 12:45 PM, "Patient's mood depressed and suicidal. Reports feeling the same as admission. Reports wanting to hang self with pajama pants. Referral for ECT (electroconvulsive therapy) in place. Will continue safety rounds."

Per review of the safety observation form documentation from 10/23/10 at 12:35 AM to 7:00 PM on 10/31/10, Patient #1 was observed every 15 minutes and his/her location, activity and the staff member making the observation was documented. On 10/30/10 from 4:30 PM until 11:30 PM and 4:45 PM until 7:00 PM on 10/31/10, Patient #1 was informally determined to require line of sight observation. From 11:30 PM on 10/30/10 until 7:30 AM on 10/31/10, Patient #1 was placed on the stabilization unit and assigned to sleep in a seclusion room with a staff member remaining by the open door. The informal line of sight observation status and the 1:1 in the seclusion room were initiated by nursing without the input from the physician. This finding was verified by Staff I, risk manager, on 11/04/10 at 4:45 PM.

On 10/31/10 at 4:45 PM, Staff Q, a registered nurse (RN), documented in the integrated progress notes that the patient had a sad affect, hopeless, had suicidal ideation and that Patient #1 stated he/she felt no better than the previous day and that his/her mood is very depressed. Staff Q further documented "increased observation by staff for patient safety and continue to monitor."

At 6:15 PM on 10/31/10, the integrated progress notes documented that Patient #1 reported increased anxiety and suicidal ideation. According to documentation, Patient #1 was instructed to remain in the hallway for the remainder of the evening until he/she was ready to sleep. Patient #1 was documented as stating that he/she will hang himself/herself from the sink with his/her sweatshirt. The note further documented "Continue to monitor."

The hospital's surveillance video was viewed on 11/04/10 at 11:50 AM in the presence of Staff I. The video included surveillance of the hallway including Patient #1's room, from 6:15 PM-7:05 PM on 10/31/10. Per the findings of the video, Patient #1 was seated in the hallway on 10/31/10 at 6:29 PM. At 6:41 PM, Patient #1 entered his/her bedroom which was located at the end of the 1500 unit. At 6:47 PM Staff M, the only mental health technician on the floor, walked past Patient #1's room where the door was open and Staff M documented the patient was in the bedroom. Further review of the video revealed Staff Q returned to the 1500 unit at 7:00 PM and walked quickly down the hall to Patient #1's room. Immediately after that, Staff M ran down the hall from the nurses station to Patient #1's room and then ran back to the nurses station and returned along with six other staff members.

Per interview with Staff Q on 11/04/10 at 9:00 AM, there was an overhead page for assistance to another unit in the hospital on 10/31/10 at 6:30 PM and four of the six staff members, including Staff Q, responded to the page leaving two female staff, one nurse and one mental health technician, to monitor 26 patients, including Patient #1.

Per interview with Staff Q on 11/04/10 between 9:00 AM-10:00 AM, he/she placed Patient #1 on "informal line of sight" observation status on 10/30/10 from 4:30 PM-11:30 PM and on 10/31/10 from 4:45 PM-7:00 PM. Staff Q did not make the patient's psychiatrist aware of the continued suicidal ideation with a specific plan on 10/30/10 nor on 10/31/10, until after Patient #1 attempted suicide by hanging at 7:00 PM on 10/31/10. When questioned during the interview, Staff Q was not aware of the hospital's policy that notification of the Patient's physician was required to implement this level of observation.

Per review of the hospital's policy, "Safety Observation Levels and Procedures" Number NSG 54.0, "Line of sight observation is implemented per physician order for patients who need constant attendance because of high risk of self-destructive tendencies, acting out behavior, acute psychotic state, or other unpredictable behaviors. Physician orders a patient to be placed on line of sight observation. The patient will be in staff view at all times. Physician orders the discontinuance of line of sight observation."

When Staff Q and three others left the unit on 10/31/10 at 6:30 PM, no remaining staff were aware of the need to keep Patient #1 in line of sight observation per interview with Staff M on 11/05/10 at 10:52 AM. Video review revealed Patient #1 was not observed on 10/31/10 from 6:47 PM-7:02 PM when found in the act of attempting suicide by hanging. This was confirmed on 11/04/10 at 11:50 AM by Staff I.

Per interview with Patient #1 on 11/03/10 from 4:00 PM-4:35 PM, " I was supposed to be sitting in the hallway. I waited til staff was busy and slipped into my room. If (Staff Q) had been a minute later I would have been done." As verified by Staff I on 11/04/10 at 12:10 PM, leaving Patient #1 to enter his/her room at 6:41 PM placed Patient #1 at risk to suicide by hanging.

Per review of an incident report written by Staff Q on 10/31/10 at 8:30 PM, "I entered patient's room. The patient was standing on the countertop next to the bathroom door. Patient had clothing wrapped around her neck and tucked into the bathroom door. I approached, held patient in place with one hand, the other hand felt at the neck to unloose the clothing. The clothing was not tight at all. Patient was prompted to get down. Patient got down safely." No physical assessment of the patient's condition was documented on the incident report nor in the medical record by nursing or the physician.

Per review of policy Number NSG 10.0 on 11/04/10, "At the beginning of the shift, the unit RN will designate one staff to be the responder to a "team support" page. This person should be skilled in de-escalation techniques." The policy goes on to say that when a "code three" page is heard that "all available staff will respond to the area where assistance is needed."

Per interviews with Staff L, Staff M, and Staff O, all mental health technicians and Staff N and Staff Q, both RNs, Staff L, O and Q stated the code paged overhead on 10/31/10 at 6:30 PM was "team support", Staff M stated he/she did not hear a code and Staff N stated he/she heard "Code three" paged. Per interview with Staff N, the RN who described his/her role on the 1500 unit as the charge nurse, stated he/she had not designated a staff member to respond in the event of a "team support" page and only began that practice as of 11/04/10. Staff Q, per interview on 11/04/10, stated when asked who is to respond to a behavior code, "There is no set staff who go." Leaving two staff to monitor and ensure safety for 26 patients placed Patient #1 and others at risk for harm.

Per video review and medical record review, after the suicide attempt, Patient #1 was ambulatory and was escorted to the stabilization unit on 10/31/10 at 7:05 PM where he/she has remained on one to one monitoring since then.

2. Patient #3 was admitted to the hospital on 05/26/10, with diagnoses of suicidal ideation and poly substance abuse. Patient #3 was on the unit known as the recovery unit (1600) which has 26 beds. Review of the patient's medical record on 11/04/10, revealed that on 06/07/10 the patient attempted to commit suicide by slitting one of his/her wrists. Further review of the medical record revealed that there was a nursing note dated 06/07/10 at 3:35 AM, that documented the patient had stated to staff that he/she was worried about where the patient and patient's parent were going to live upon discharge because the patient's parent had stated to patient #3 that they could not go back home upon discharge.

In an un-timed nursing note in Patient #3's medical record on 06/07/10, it was documented that the patient had "anxious look on face. Brightens on approach - contracts 1:1 for safety. No prn's requested, Goes to groups and interacts with peers and staff". This note was written after the 3:35 AM note. Following this note was one dated 06/07/10 at 10:30 PM. At this time the nurse went into the patient's room to administer nightly medications and met the patient coming out of his/her bathroom. The patient was noted to have cut his/her right wrist.

According to documentation in the medical record the nurse washed the wound, called the supervisor, called the physician and sent the patient to the emergency room for stitches. When Patient #3 was asked why he/she had done this the patient stated nobody wanted them and that his/her parent had told Patient #3 they could no longer live at his/her house.

Review of other nursing notes revealed that Patient #3 had stated on 06/01/10 to staff that he/she still had thoughts of "cutting when I get home". Again on 06/02/10 in discussion with the case manager Patient #3 stated that he/she still had feelings of being anxious, hopeless and despairing feeling powerless over his/her addiction and that he/she still felt the desire to use medication for his/her despair and sees overdosing or self-mutilation as an option. On 06/03/10 the patient stated to the case manager that they still had the desire to use and that they felt unstable and could not contract for safety or sobriety if discharged.

Further review of documentation in the medical record revealed that on 06/03/10, the social worker documented in his/her note at 11:00 AM, that the patient stated he/she has been having urges to cut or pick his/her skin or smash his/her head against the wall. On 06/05/10, in a note written by the case manager, the case manager stated that the Patient #3 was still anxious and stated that he/she still had a desire to "use". On 06/06/10, the patient again stated to the case manager that he/she wished to medicate his/her depressive symptoms.

Upon Patient #3's return from the emergency room it was noted Patient #3 had to have 10 stiches to close the wrist wound. It was not until the patient returned from the emergency room for treatment to his/her right wrist laceration that Patient #3 was placed on a one to one observation.

3. Patient #4 was hospitalized from 03/13/10 thru 03/22/10. The patient was brought into the hospital after an attempt to hang himself/herself from a bridge. Patient #4 was admitted to 2600 which is the adolescent ward.

During a review of Patient #4's medical record on 11/03/10, it was noted in the nursing and progress notes that the patient had continued to state a desire to commit suicide. On 03/14/10, the patient stated to one of the nurses that he/she had been thinking about killing him/herself for years and rated his/her depression as an 8 out of 10. On 03/15/10, it was documented in a progress note that Patient #4 was having "fleeting thoughts of self harm" and rated his/her depression as an 8 out of 10. On 03/16/10, a family meeting was held and the patient's parent was able to give more information about the patient's behaviors at home. The note further documented that the patient rated his/her depression as an 8 out of 10 at that time. On 03/17/10, at 1:15 PM a note written by the nurse stated that the patient still rated his/her depression an 8 out of 10 and did not feel that he/she could keep him/herself safe while in the hospital or at home. The note further stated that the patient remained hopeless and helpless.

On 03/18/10, a note by a licensed chemical dependency counselor at 3:50 PM revealed that another family meeting was held and Patient #4 was confronted about her/his behavior at home and about the things that needed to be changed upon discharge. On 03/19/10, a progress note written at 10:45 AM, revealed Patient #4 stated that he/she could not contract for safety after discharge and refused to discuss what was bothering him/her with the writer of the note (an RN). On 03/19/10, in a note written by the licensed chemical dependency counselor, another family meeting was held. At 3:50 PM a note by this same individual stated that the patient's parent had called and stated that they were not really feeling safe for the patient's discharge even if it was postponed a few more days. The parent stated he/she did not feel that he/she could keep the patient safe upon discharge. In a note, written by an RN on 03/19/10 at 12:00 PM, Patient #4 stated that he/she was still depressed and having thoughts of suicide. The patient stated " I don't have a plan, I just want to die, my life is not worth living".

On 03/20/10 at 10:00 PM, the first progress note of the day, the RN wrote that the patient needed constant re-direction all shift, had been rude, disrespectful and argumentative with staff. Patient #4 was reprimanded by another RN for his/her behavior. The patient began yelling and stating that he/she was suicidal and that he/she was not getting help. Patient #4 was asked to stay away from other patients until he/she calmed down.

At 10:55 PM Patient #4 was found hanging with a gown around his/her neck behind the bathroom door. During an every 15 minute safety round, one of the mental health workers found the patient who, when the bathroom door was opened, fell to the ground. The patient's vital signs were checked, oxygenation level was checked, pulse and swallowing ability were checked by the nurse. The patient was able to walk normally, was oriented to self, time and place. The RN did call the patient's mother and left a message for the physician in regard to the event. It was not until after this suicidal attempt that the patient was placed in a 1:1 setting.

Although both incidents involving Patients #3 and #4 had written incident reports filed, there was no investigation into what led up to either attempt, what occurred right before, during or after the attempts in order to determine what systems failed to work to prevent these attempts. Discussion with Staff I on all days of the survey from 11/03/10 thru 11/05/10 confirmed there were no formal investigations completed, no debriefing of staff or auditing of the documentation in the patients' records.

This deficiency substantiates an allegation contained in OH00058221.


03193

Based on review of medical records, staff interviews and policy review, Staff N and Staff Q did not demonstrate knowledge of behavioral interventions relating to nonphysical interventions which placed Patient #1 at risk for harm on 10/31/10. Both staff are registered nurses (RN) and were not aware of the policies which require a physician order for "line of sight" observation and a requirement to designate one staff member at the beginning of the shift to respond to a behavioral code.

This facility has a capacity of 160 and on 10/31/10, census was 125.

Findings include:

Per policy review, "Safety Observation Levels and Procedures" Number NSG 54.0, " Line of sight observation is implemented per physician order for patients who need constant attendance because of high risk of self-destructive tendencies, acting out behavior, acute psychotic state, or other unpredictable behaviors. Physician orders a patient to be placed on line of sight observation. The patient will be in staff view at all times. Physician orders the discontinuance of line of sight observation."

Per interview with Staff Q on 11/04/10 between 9:00 AM-10:00 AM, he/she was not aware of the requirement to notify the physician to implement this level of observation. When Staff Q and three other staff left the unit on 10/31/10 at 6:30 PM to respond to an overhead page, no remaining staff were aware of the need to keep Patient #1 in "line of sight" observation per interview with Staff M on 11/05/10 at 10:52 AM. Video surveillance review revealed Patient #1 was not observed on 10/31/10 from 6:47 PM-7:02 PM when found in the act of attempting suicide by hanging. This was confirmed on 11/04/10 at 11:50 AM by Staff I.

Per review of policy Number NSG 10.0 on 11/04/10, "At the beginning of the shift, the unit RN will designate one staff to be the responder to a "team support" page. This person should be skilled in de-escalation techniques." The policy goes on to say that when a "code three" page is heard that "all available staff will respond to the area where assistance is needed." Per interviews with Staff L, M, N, O and Q, Staff L, O and Q stated the code paged overhead on 10/31/10 at 6:30 PM was a "team support", Staff M stated he/she did not hear a code and Staff N stated he/she heard "Code three" paged. Per interview with Staff N, the RN who described his/her role on the 1500 unit as the charge nurse, stated he/she had not designated a staff member to respond in the event of a "team support" page and only began that practice as of 11/04/10. Staff Q, per interview on 11/04/10, stated when asked who is to respond to a behavior code, "There is no set staff who go." Leaving two staff to monitor and ensure safety for 26 patients placed Patient #1 and others at risk for harm.

Per interview with Staff Q on 11/04/10 at 9:00 AM, the reason he/she responded to the 6:30 PM overhead page for "team support" is "because it's good etiquette and the other staff appreciates it " He/She also stated "Typically males go to behavior codes." Per interview with Staff Q, he/she has worked at the facility every Saturday and Sunday since 02/16/09 and he/she floats to whatever unit needed.

When Staff N was interviewed by telephone on 11/05/10 between 10:16 AM-10:50 AM, he/she state that he/she serves as the official charge nurse of the step down unit (1500) and has for the past 1-1.5 years. He/She knew he/she "was supposed to assign one staff member to attend codes, but didn't always assign one." Per Staff N on 11/04/10 in the telephone interview, "Line of sight observation doesn't require a physician order but it would be a good idea to contact the physician." Staff N continued talking about the 10/31/10 code which occurred at 6:30 PM in the adolescent unit by saying, " I didn't think about the number of staff left on 1500, but rather the safety of the adolescent patient involved in the code." As far as Staff N's awareness of Patient 1's suicidal ideation, he/she said, " Patient was very depressed but nothing he/she knew of led her/him to believe the patient was suicidal." Then Staff N stated as the charge nurse his/her responsibility is to make sure everyone is doing what they are supposed to.

Per interview with Staff C, the unit manager of 1500 on 11/04/10 between 1:08 PM-1:28 PM, he/she had met with Staff N on 11/02/10 along with the other RNs on 1400 and 1500 to reinforce the need to schedule one person to respond to behavioral codes off the unit.

This deficiency substantiates an allegation contained in Complaint OH00058221.

Based on policy review, job description and staff interview, the hospital failed to investigate the 10/31/10 suicide attempt by hanging as a "near miss" which required a thorough and credible root cause analysis to be completed.

This facility has a capacity of 160 and on 10/31/10, census was 125.

Findings include:

Per interview with Staff I, the risk manager and director of performance improvement on 11/03/10, 11/04/10 and 11/05/10, the following information was provided:

11/03/10 at 5:38 PM, Staff I indicated the incident involving Patient #1 was brought to his/her attention on 11/01/10, but did not recall at what time. He/she stated the incident involving the suicide attempt by Patient #1 did not meet the corporate definition of a sentinel event or a "near miss" as there was no harm to the patient. He/she verified the survey findings that there were no nurses notes addressing the incident or a medical assessment of potential injury sustained.

11/04/10 at 10:00 AM, Staff I verified that Staff A, the chief nursing officer and C, the unit manager of 1400 and 1500 have met to discuss Patient #1's suicide attempt. He/she confirmed there were meetings about this incident which he/she was not a part of. He confirmed he/she found out on 11/03/10 at the morning management meeting there was a behavior code called on 10/31/10 at 6:30 PM which impacted the number of staff available to monitor Patient #1. He/she admitted that he/she had not interviewed any of the staff involved in the incident. Staff I stated, when asked what his/her role as the risk manager and director of performance improvement entailed, that it is "a suggestive role, not a formal role. It changed in 2007 and I used to report directly to the chief executive officer, but now I report to the chief nursing officer."

At the time of this interview with Staff I, a copy of Staff I's job description was requested along with a copy of the summary of the investigation of the 10/31/10 incident which involved the attempted suicide of Patient #1 by hanging. The incident report written by Staff Q was brought to the surveyor for review. Upon review of the incident report on 11/04/10, there was no documentation that physical assessment had been completed of Patient #1 after the incident at 7:00 PM on 10/31/10. The nursing supervisor section on the report was signed, timed and dated, but was not complete in regard to interventions, if injury occurred, if urgent care was needed, if incident resulted in a fracture or if incident reported to an outside agency. All of these responses required a "yes or no" answer on this preprinted form. Per interview with Staff I on 11/04/10 at 8:55 AM, the patient's family was not notified and the findings regarding the incompleteness of the incident report and patient record were validated.

On 11/04/10 at 11:50 AM, Staff I was present for the review of the surveillance video from 10/31/10 between 6:12 PM-7:06 PM. Staff I stated he/she reviewed Patient #1's medical record on 11/01/10 and reported the findings to Staff A. He/she then began to watch the video surveillance tapes at the point when the 4 of 6 staff left the 1500 unit to respond to the behavior code. Only after finding the specific time frame was Staff I able to determine what monitoring took place of Patient #1 while the staff were off the unit.

11/04/10 from 1:28 PM-1:57 PM, Staff I stated he had been told by Staff C that the "code" called on 10/31/10 at 6:30 PM was for "All available male staff". When Staff I was asked whether or not the week-end psychiatrist rounded on Patient #1 on 10/30/10 or 10/31/10, he/she was unable to answer. Prior to this question, no physician progress notes by a psychiatrist were found during the medical record review on 11/03/10 and 11/04/10. Staff I went on to say that "documentation of interviews conducted with staff relating to Patient #1's suicide attempt was not an expectation." He/She also stated that an e-mail received by Staff R, the chief executive officer, on 11/03/10 from a family member of Patient #1 was considered a formal complaint and that his/her job was to use corporate guidelines to use the appropriate severity index which is "used to monitor the potential liability for the facility" when an incident occurs.

11/04/10 from 2:29 PM-2:45 PM, Staff I stated the 10/31/10 suicide attempt by Patient #1 was "not considered a 'near miss' because there was no significant injury." Staff I went on to say, "From a quality point of view, (Patient #1) should have been considered a 'near miss' and it did come to this conclusion when (the family member) sent the e-mail on 11/02/10 at 1:57 PM."

Per job description reviewed on 11/04/10 at 2:15 PM, the director of performance improvement /risk manager is responsible for identifying and correcting potential risk related issues and reporting risk violations to and through the appropriate channels.

Per review on 11/04/10 of the facility's "Near Miss Events", Policy Number PSO-004 last revised May 2010, the definition of a near miss event is an "unplanned event or situation that did not result in a serious injury, illness or damage to the patient, but had the potential to do so. An example would be a serious suicide attempt in a staffed, round-the-clock, care setting. The facility's risk manager will focus on gathering as much information as possible about what occurred leading up to, during and immediately after the near miss.
Interviews with those individuals directly involved in the event should be conducted, separately and the interviewer will record notes regarding each individual's description of the event. The risk manager shall assemble the facts and document the sequence of events leading up to the occurrence in preparation for a root cause analysis being performed." None of these interventions were completed as Staff I concluded the event did not meet the level of a "Near Miss Event." On 11/05/10 at 11:30 AM, Staff I admitted he/she was in error when he/she did not classify the 10/31/10 suicide attempt by Patient #1 as a "Near Miss Event."

482.23 Condition of Participation: Nursing Services is Not Met as evidenced by the following:

Based on medical record review, policy review, staff interviews and patient interview, the hospital failed to ensure that supervision by the registered nurse was adequate to protect three patients (#1, 3, and 4) from making a suicide attempt.

This facility has a capacity of 160 and on 10/31/10, census was 125.

The hospital failed to ensure that nursing supervision was adequate to protect three patients (#1, 3, and 4) from self harm.

Please see 42 CFR 482.23(B)(3); tag A395 for details relating to the lack of nursing supervision to prevent suicide attempts.

Based on medical record review, policy review, and staff and patient interview, the hospital failed to ensure adequate nursing supervision to safeguard 3 of 3 patients (Patient #1, 3, and 4) who voiced suicidal ideation from attempting suicide while in the hospital.

This facility has a capacity of 160 and on 10/31/10, census was 125.

Findings include:

1. Per interview with Staff Q on 11/04/10 between 9:00 AM-10:00 AM, he/she stated his/her assignment on 10/30/10 and 10/31/10 from 3:00 PM-11:30 PM included Patient #1 along with eight other patients on unit 1500 which had a census of 26 patients. Also assigned were two RNs, Staff N and Staff S, and three mental health technicians (MHT), Staff L, M and O. Per Staff Q, Patient #1 had expressed suicidal ideation with a plan on 10/30/10 at 4:30 PM and at 4:45 PM on 10/31/10. On both occasions, Staff Q "increased observation by staff" throughout the second shift. On 10/30/10 at 11:30 PM, the decision had been made by the nursing supervisor to move Patient #1 from the 1500 unit to the seclusion area on 1400 where Patient #1 slept in a seclusion room with the door open and a staff member directly outside the open door until 7:30 AM when Patient #1 was returned to the stepdown unit (1500).

Per medical record review, Patient #1's psychiatrist did not visit the patient on 10/30/10 or 10/31/10 and the week-end psychiatrist did not visit Patient #1. Staff Q confirmed Patient #'s psychiatrist had not been notified of the continued suicidal ideation with a plan either on 10/30/10 or until after Patient #1's suicide attempt by hanging on 10/31/10. When notified by telephone on 10/31/10 at 7:00 PM, the psychiatrist directed the staff to transfer Patient #1 to the 1400 stabilization unit permanently where a 1:1 was to be maintained.

Per interview on 11/04/10 at 9:00 AM, Staff Q stated the "line of sight" observation status is "the go to." When Staff Q was asked if implementing the "line of sight" status required notifying the physician, the response was "No". This is in direct conflict with the content of the policy entitled "Safety Observation Levels and Procedures" Number NSG 54.0. Per policy review on 11/04/10, " Line of sight observation is implemented per physician order for patients who need constant attendance because of high risk of self-destructive tendencies, acting out behavior, acute psychotic state, or other unpredictable behaviors. Physician orders a patient to be placed on line of sight observation. The patient will be in staff view at all times. Physician orders the discontinuance of line of sight observation."

Per interview with Staff Q on 11/04/10 at 9:00 AM, when he/she and three other staff responded to a behavior code on the second floor of the facility, two staff, one RN and one MHT were left to monitor 26 patients. Per Staff B, the medical director on 11/03/10 at 2:55 PM, "When staff have a line of sight patient, they can have more than one patient as long as the patient requiring line of sight monitoring remains in view at all times." On 10/31/10 at 6:30 PM when Staff Q left the unit to respond to the behavior code on the adolescent unit, he/she said he/she made Staff M aware of the need to keep Patient #1 in line of sight. Staff M stated in an interview on 11/05/10 at 10:52 AM that Staff Q did not tell him/her that he/she was leaving the unit and Staff M was not aware of the need to keep Patient #1 in the line of sight. So when Patient #1 went into the bedroom at 6:41 PM, per video surveillance, no attempt was made to have Patient #1 return to the hallway so line of sight observation could be maintained. At 7:02 PM, Staff Q returned from the off unit behavior code and found Patient #1 standing on the sink with a sweater tied around the neck which was pushed into the corner of the closed bathroom door. Per Patient #1 in an interview on 11/03/10 at 4:00 PM, "If (Staff Q) had come in a minute later I would have been done."

2. Patient #3 was admitted to the hospital on 05/26/10, with diagnoses of suicidal ideation and poly substance abuse. Patient #3 was on the unit known as the recovery unit (1600) which has 26 beds. Review of the patient's medical record on 11/04/10, revealed that on 06/07/10 the patient attempted to commit suicide by slitting one of his/her wrists. Further review of the medical record revealed that there was a nursing note dated 06/07/10 at 3:35 AM, that documented the patient had stated to staff that he/she was worried about where the patient and patient's parent were going to live upon discharge because the patient's parent had stated to patient #3 that they could not go back home upon discharge.

In an un-timed nursing note in Patient #3's medical record on 06/07/10, it was documented that the patient had "anxious look on face. Brightens on approach - contracts 1:1 for safety. No prn's requested, Goes to groups and interacts with peers and staff". This note was written after the 3:35 AM note. Following this note was one dated 06/07/10 at 10:30 PM. At this time the nurse went into the patient's room to administer nightly medications and met the patient coming out of his/her bathroom. The patient was noted to have cut his/her right wrist.

According to documentation in the medical record the nurse washed the wound, called the supervisor, called the physician and sent the patient to the emergency room for stitches. When Patient #3 was asked why he/she had done this the patient stated nobody wanted them and that his/her parent had told Patient #3 they could no longer live at his/her house.

Review of other nursing notes revealed that Patient #3 had stated on 06/01/10 to staff that he/she still had thoughts of "cutting when I get home". Again on 06/02/10 in discussion with the case manager Patient #3 stated that he/she still had feelings of being anxious, hopeless and despairing feeling powerless over his/her addiction and that he/she still felt the desire to use medication for his/her despair and sees overdosing or self-mutilation as an option. On 06/03/10 the patient stated to the case manager that they still had the desire to use and that they felt unstable and could not contract for safety or sobriety if discharged.

Further review of documentation in the medical record revealed that on 06/03/10, the social worker documented in his/her note at 11:00 AM, that the patient stated he/she has been having urges to cut or pick his/her skin or smash his/her head against the wall. On 06/05/10, in a note written by the case manager, the case manager stated that the Patient #3 was still anxious and stated that he/she still had a desire to "use". On 06/06/10, the patient again stated to the case manager that he/she wished to medicate his/her depressive symptoms.

Upon Patient #3's return from the emergency room it was noted Patient #3 had to have 10 stiches to close the wrist wound. It was not until the patient returned from the emergency room for treatment to his/her right wrist laceration that Patient #3 was placed on a one to one observation.

3. Patient #4 was hospitalized from 03/13/10 thru 03/22/10. The patient was brought into the hospital after an attempt to hang himself/herself from a bridge. Patient #4 was admitted to 2600 which is the adolescent ward.

During a review of Patient #4's medical record on 11/03/10, it was noted in the nursing and progress notes that the patient had continued to state a desire to commit suicide. On 03/14/10, the patient stated to one of the nurses that he/she had been thinking about killing him/herself for years and rated his/her depression as an 8 out of 10. On 03/15/10, it was documented in a progress note that Patient #4 was having "fleeting thoughts of self harm" and rated his/her depression as an 8 out of 10. On 03/16/10, a family meeting was held and the patient's parent was able to give more information about the patient's behaviors at home. The note further documented that the patient rated his/her depression as an 8 out of 10 at that time. On 03/17/10, at 1:15 PM a note written by the nurse stated that the patient still rated his/her depression an 8 out of 10 and did not feel that he/she could keep him/herself safe while in the hospital or at home. The note further stated that the patient remained hopeless and helpless.

On 03/18/10, a note by a licensed chemical dependency counselor at 3:50 PM revealed that another family meeting was held and Patient #4 was confronted about her/his behavior at home and about the things that needed to be changed upon discharge. On 03/19/10, a progress note written at 10:45 AM, revealed Patient #4 stated that he/she could not contract for safety after discharge and refused to discuss what was bothering him/her with the writer of the note (an RN). On 03/19/10, in a note written by the licensed chemical dependency counselor, another family meeting was held. At 3:50 PM a note by this same individual stated that the patient's parent had called and stated that they were not really feeling safe for the patient's discharge even if it was postponed a few more days. The parent stated he/she did not feel that he/she could keep the patient safe upon discharge. In a note, written by an RN on 03/19/10 at 12:00 PM, Patient #4 stated that he/she was still depressed and having thoughts of suicide. The patient stated " I don't have a plan, I just want to die, my life is not worth living".

On 03/20/10 at 10:00 PM, the first progress note of the day, the RN wrote that the patient needed constant re-direction all shift, had been rude, disrespectful and argumentative with staff. Patient #4 was reprimanded by another RN for his/her behavior. The patient began yelling and stating that he/she was suicidal and that he/she was not getting help. Patient #4 was asked to stay away from other patients until he/she calmed down.

At 10:55 PM Patient #4 was found hanging with a gown around his/her neck behind the bathroom door. During an every 15 minute safety round, one of the mental health workers found the patient who, when the bathroom door was opened, fell to the ground. The patient's vital signs were checked, oxygenation level was checked, pulse and swallowing ability were checked by the nurse. The patient was able to walk normally, was oriented to self, time and place. The RN did call the patient's mother and left a message for the physician in regard to the event. It was not until after this suicidal attempt that the patient was placed in a 1:1 setting.

Although both incidents involving Patients #3 and #4 had written incident reports filed, there was no investigation into what led up to either attempt, what occurred right before, during or after the attempts in order to determine what systems failed to work to prevent these attempts. Discussion with Staff I on all days of the survey from 11/03/10 thru 11/05/10 confirmed there were no formal investigations completed, no debriefing of staff or auditing of the documentation in the patients' records.

This deficiency substantiates an allegation contained in OH00058221.

Based on medical record review and staff interview, Patient #1's medical record did not contain all information relating to services provided and a suicide attempt on 10/31/10 at 7:00 PM. A total of 7 medical records were reviewed in this facility with a census on 11/03/10 of 125.

Findings include:

Per medical record review on 11/03/10 , Patient #1's suicide attempt on 10/31/10 at 7:02 PM was not mentioned in the nursing notes. This was confirmed by Staff Q, the registered nurse assigned to Patient #1, when interviewed on 11/04/10 at 9:00 AM. Per interview, when Staff Q was asked why there was no nursing note regarding the suicide attempt, Staff Q responded, "I'm not sure. I thought charting events and interventions would place myself in an unnecessarily poor light. I gave the minimum in terms of charting."

Per medical record review on 11/03/10, Patient #1 received a dose of Ambien 10 milligrams on 10/30/10 at 9:00 PM as ordered. A second dose of the medication was documented as given on 10/31/10 at 1:00 AM. A telephone order was received by Staff T, a registered nurse, for the second dose. However, no nursing note was found which described the patient's behavior and why the second sleeping pill was needed.
At 5:30 AM on 10/31/10, the registered nurse, Staff F, wrote" Patient sent over at 11:30 PM to sleep in quiet area (in seclusion area on 1400) from 1500. Patient unable to contract for safety. Patient up and down all night. Complained of head cold-given acetaminophen two tablets at 5:15 AM. ...Monitor for safety every 15 minutes. At 7:30 AM transferred back to 1500." It was confirmed that Staff F came in to work at 4:00 AM and was not the nurse who obtained the repeat order for the sleeping pill. This was confirmed on 11/04/10 by Staff I at 1:28 PM.

Based on patient and surveyor observation, patient and staff interview, the infection control officer failed to ensure a sanitary hospital environment relating to dried feces on the wall and floor of seclusion room 1402(a). This seclusion room is located on the stabilization unit (1400) which had a patient census of six patients on 11/03/10. Total facility census was 125.

Findings include:

Per interview with Patient #1 on 11/03/10 between 4:00 PM-4:35 PM, while Patient #1 spent time in the seclusion room he/she noticed dried splatters of a substance on the wall and floor of seclusion room 1402 (a).

Per review of safety observation flow sheets on 11/03/10, Patient #1 was in the "quiet room" on 10/30/10 from 11:30 PM-7:30 AM on 10/31/10, from 7:15 PM on 10/31/10 and 7:30 AM on 11/01/10, from 9:30 PM on 11/01/10-6:30 AM on 11/02/10 and from 10:16 PM on 11/02/10-7:30 AM on 11/03/10. Per interview with Staff D on 11/03/10 at 11:56 AM, seclusion room 1402( a) is also known as the "quiet room" or "quiet area".

Per observation on 11/03/10 at 4:38 PM, with Staff H, at least 20 splatters of a dark substance was observed on the wall and baseboard and 8 splatters of a dark substance on the floor in seclusion room 1402(a). Staff H obtained gloves and an antibacterial spray cleaner and used it to clean the wall and floor. Staff H used a towel to wipe the dried dark matter from the floor and when asked what he/she felt it was, the response was "Feces".

Per interview with Staff D on 11/03/10 at 11:56 AM, it is the responsibility of the unit staff to clean urine, feces and blood. This was confirmed by Staff H when interviewed at 4:38 PM. Staff H, a registered nurse, explained that unit staff must clean the initial blood, urine and feces from the surface and housekeeping staff clean after that. Staff H stated housekeeping staff are available until 3:30 PM only.

Per interview with Staff D on 11/03/10 at 12:00 PM, when asked if there are any patients who smear feces, Staff D immediately responded Patient #2. Per review of Patient #2's medical record on 11/04/10, Patient #2 was admitted on 10/23/10 and was placed in seclusion room 1402( a) from 7:46 PM on 10/24/10-10:15 PM on 10/25/10 during which time he/she was documented in the medical record to have engaged in "smearing feces on the walls" while in the quiet room. Staff I confirmed on 11/05/10 at 8:30 AM that the dried feces in seclusion room 1402( a) were probably present from 10/24/10 until cleaned by Staff H on 11/03/10 at 4:38 PM.

This deficiency substantiates an allegation contained in Complaint OH00058221.