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I. Based on document review and staff interview, the hospital's administrative staff failed to ensure 3 of 3 reviewed patients (Patient #1, Patient #2, and Patient #3) received care in a safe setting when:

1. the nursing staff failed followed the hospital's policies for performing visual safety checks on the patients on the inpatient behavioral health unit and prevented patients from attempting to commit suicide in the inpatient behavioral health unit. Please refer to A-0144 for additional information.

2. the hospital failed to ensure a safe environment for all patients at risk of committing suicide in the hospital's inpatient behavioral health unit. Please refer to A-0144 for additional information.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure staff provided patient care occurred in a safe setting.




II. During the course of the investigation of self-reported incident 90892-I, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis that placed the health and safety of patients at risk) related to Condition of Participation for Patient's Rights (42 CFR 482.13). The hospital staff failed to prevent Patient #1 from committing suicide.

1. Prior to an event on 05/04/2020, the Administration staff failed to develop and implement a corrective action plan to ensure the nursing staff physically observed all patients during the 15 minute safety rounds and did not rely on camera video monitors to substitute for the nursing staff physically observing the patients.

2. While on-site, the survey team identified an Immediate Jeopardy situation and notified the administrative staff on 05/08/2020 at 4:00 PM. The administrative staff promptly took action to remove the immediacy of the situation. The hospital staff removed the Immediate Jeopardy prior to the exit date of the self-reported incident investigation. A condition level deficiency remained for the Condition for Patient's Rights (42 CFR 482.13).

The corrective action plan included:

a. The Vice President/Chief Nursing Officer, Behavioral Health/Emergency Care Director and Behavioral Health Unit Manager created a "Behavioral Health Video Monitor Tech" (BH VMT) staff position, which was implemented on 05/08/2020. The BH VMT will be assigned to observe the patient video camera monitors on a 24/7 basis. The BH VMT would be positioned in front of the monitor station to observe the monitors on a continuous basis with minimal potential for distractions. The BH VMT would be expected to promptly notify BH staff of any concerning patient safety behaviors. If a BH staff member is not immediately available, the BH VMT would activate an alarm that can be audibly heard throughout the BH Unit. Prior to assuming the role, the BH VMT would receive the expectations outlining the role and education including types of concerning behaviors to be reported. The BH VMT would demonstrate competency before performing the role independently. Competency would be evaluated on an ongoing basis through the audit process and during performance reviews. The performance of the BH VMT would be monitored and evaluated by BH Unit Leadership or designee. Random performance monitoring would occur, ensuring the BH VMT was devoting their undivided time and attention to the role. These performance observations would be evaluated using a blend of direct observations by BH Leadership and/or designee and by random observations by off unit security monitors, 1-2 randomly timed observations during each shift and logged on an audit sheet by those conducting the observation. During the observation, the BH VMT would demonstrate 100% compliance with the outlined expectations.

b. The Vice President/Chief Nursing Officer reviewed the "Suicide Screening Risk Assessment and Interventions" with no changes made to the policy. Included in this policy, rounding would occur at a minimum of every 15 minutes for patients at low or moderate risk for suicide. 1:1 monitoring is expected for patients that score high suicide risk. Camera monitoring would not replace rounding and was not to be a supplement to the rounding process. The "Patient Rounds" policy was reviewed and revised to include more clearly defined timing of the rounding completion, not to exceed 15 minutes between rounds and the charge nurse would ensure rounding is completed.


The following Condition level deficiency remained for the Condition of Patient's Rights (42 CFR 482.13).

I. Based on document review and staff interviews, the hospital's administrative staff failed to ensure staff provided adequate supervision to prevent 3 of 3 patients reviewed from attempting suicide while on the inpatient Behavioral Health Unit (Patient #1, Patient #2, and Patient #3) and 1 of the 3 patients (Patient #1) from committing suicide. Failure to provide adequate supervision for the patients resulted in the patients attempting to kill themselves and Patient #1 killing themselves, while on a secured behavioral health unit. The hospital's administrative staff identified a census of 14 patients at the beginning of the survey on the inpatient behavioral health unit.

Findings include:

1. Review of the policy "Suicide screening, risk assessment, and interventions," revised 12/2019, revealed in part, "following a positive suicide risk screening and assessment, a nurse needs to complete the Suicide Risk Re-assessment/Stratification form ... every shift or with [changes in a patient's condition] ..." "Initiate interventions based on Risk Stratification ..." Further review revealed the "Risk Stratification" for High Suicide Risk patients (including patients with suicidal behavior in the past 3 months) instructed the hospital staff to initiate 1:1 observation of the patient. "Video Monitoring may be used as a secondary safety measure, but CANNOT be used as the only means to observe the patient."

2. Review of the policy "Patient Rounds," revised 5/2018, revealed in part, "Visually account for the location, condition, and safety of patients. This is completed and documented every 15 minutes on all patients."

3. Review of Patient #3's medical record revealed the hospital staff admitted Patient #3 to the hospital's inpatient behavioral health unit on 2/28/20. The History and Physical, completed on 2/18/20 at 11:41 by Psychiatrist O, revealed Patient #3 was admitted after attempting suicide by taking an overdose of medication. Patient #3 admitted they unsuccessfully tried to hang themselves with an electrical cord 1.5 years prior. Registered Nurse (RN) P documented that Patient #3 tied a blanket around their neck (attempted suicide) on 2/18/20 at 5:05 PM (~5.5 hours after admission). Patient #3's medical record lacked evidence the hospital staff placed any additional interventions to address Patient #3's suicide attempt, including placing Patient #3 on 1:1 observation with a staff member, as required by the hospital's policy.

4. Review of Patient #2's medical record revealed the hospital staff admitted Patient #2 to the hospital's inpatient behavioral health unit on 3/28/20. The Psychiatric History and Physical, completed on 3/29/20 at 11:38 AM by Psychiatrist Q, revealed they admitted Patient #2 to the inpatient behavioral health unit after Patient #2 overdosed on alcohol and medication. RN R documented on 3/29/20 at 8:43 PM that hospital staff let Patient #1 use the bathroom. Shortly afterwards, the staff found Patient #2 hanging in the bathroom, with a sheet around their neck. Patient #2 was gasping for air and still conscious. The hospital staff later transferred Patient #2 to the ICU. Patient #2's medical record lacked evidence the hospital staff placed any additional interventions to address Patient #2's suicide attempt, including placing Patient #2 on 1:1 observation with a staff member, as required by the hospital's policy.

5. Review of Patient #1's medical record revealed the hospital staff admitted Patient #1 to the hospital's inpatient behavioral health unit on 5/1/20 at 8:08 AM for treatment of suicidal ideation under a court order for treatment from Hospital A. The ED nursing staff assessed Patient #1 as "High Risk" for attempting suicide. The other nursing staff assessed Patient #1 as low to moderate risk for attempting suicide. Patient #1 died on 5/4/20 at 5:47 AM, after hanging themselves with a sheet in the bathroom of their inpatient behavioral health unit.


6. Review of a timeline of Patient #1's activities, created by the Security Director after viewing archived video footage from the cameras in Patient #1's inpatient behavioral health room, revealed the following:

a. on 5/1/20 at 7:58 AM, the hospital staff admitted Patient #1 to the inpatient behavioral health unit, room Observation #2.

b. on 5/1/20 at 5:55 PM (10 hours after admission), Patient #1 took a bed sheet, twisted the sheet into a rope, walked to the sink area between the inner and outer doors, placed the rope around their neck, placed the end of the sheet (with a knot at the end) over the top of the inner door, closed the inner door, and laid down on the floor. The sheet fell off the top of the inner door and the inner door closed. Patient #1 stood up, with the sheet around their neck, and returned to their bed.

c. on 5/1/20 at 6:04 PM, Patient #1 got out of bed, walked to the sink area, and looked for hospital staff. Patient #1 placed the sheet around their neck and placed the knotted end of the sheet over the top of the inner door. Patient #1 disappeared from camera view and approximately 5 minutes later, stood up, and removed the sheet from their neck and the door (Patient #1 practiced the suicide attempt for ~14 minutes).

d. on 5/1/20 at 6:34 PM, Patient #1 got out of bed, walked to the sink area, and looked for hospital staff. Patient #1 placed the sheet around their neck and the knotted end of the sheet over the top of the inner door. Patient #1 disappeared from camera view and approximately 2 minutes later, removed the sheet from the door. At 6:36 PM, Patient #1 stood up, placed the knotted end of the sheet over the inner door, with the sheet still around Patient #1's neck. Patient #1 disappeared from view, with Patient #1 visible a minute later near the ground. At 7:02 PM, Patient #1 stood up from the ground, removed the sheet from the inner door, and began examining parts of the room (Patient #1 practiced the suicide attempt for ~28 minutes).

e. on 5/1/20 at 7:15 PM, Patient #1 stood on their bed and opened a panel in the ceiling. Patient #1 took their mattress, folded it in half, secured the folded mattress with a sheet, and stands on the mattress to look into the ceiling. Patient #1 stands on the mattress and looks in the ceiling 3 more times. At 7:25 PM, Patient #1 replaced the mattress on the bed, and attempted to shut the panel in the ceiling. At 7:30 PM, Patient #1 left their room (15 minutes after Patient #1 first attempted to open the ceiling panel).

f. on 5/1/20 at 8:02 PM, Patient #1 stood on their bed and began pulling cables out from the ceiling panel. Patient #1 wrapped the sheet around the cable from the ceiling. Patient #1 closed the inner door, stood on the bed, removed the sheet from the cable, tries to place the cable back in the ceiling panel, and attempted to shut the ceiling panel. At 8:10 PM, Patient #1 tied the sheet back to the cable from the ceiling panel. Patient #1 got off the bed and left the sheet hanging from the cable. At 8:15 PM, Patient #1 untied the sheet from the cable. Patient #1 then covered the camera in the room with a paper plate and tape Patient #1 removed from the ceiling. At 8:21 PM (19 minutes after Patient #1 began pulling cables out of the ceiling), Patient Care Technician (PCT) G knocked on the outer door and spoke with Patient #1. PCT G returned at 8:26 PM with a drink for Patient #1. Patient #1 removed the plate from the camera in the room at 8:28 PM (12 minutes after Patient #1 covered the camera with the plate and 7 minutes after PCT G first entered the room).

g. on 5/1/20 at 8:29 PM, Patient #1 took the plate they previously used to cover the camera in the room and attempted to pour milk into the electrical socket. Patient #1 then attempted to pour milk, using the plate, into 2 other electrical sockets. Patient #1 replaced the plate over the camera in the room at 8:31 PM.

h. on 5/1/20 at 11:08 PM, Patient #1 spoke with Safety Tech F in Patient #1's room. Safety Tech F provided Patient #1 a drink and left the room. The plate Patient #1 placed over the camera remained over the camera.

i. on 5/1/20 at 11:32 PM, RN E, PCT A, and Safety Tech F entered Patient #1's room. RN E removed the plate over the camera in Patient #1's room (3 hours after Patient #1 placed the plate over the camera). PCT A closed the ceiling panel that Patient #1 opened. The hospital staff left Patient #1's room at 11:41 PM.

j. on 5/2/20 at 6:45 PM, Patient #1 walked to the bedroom sink, knelt on the sink, and examined the ceiling panel. Patient #1 then stood on the sink and jumped off the sink 3 minutes later.

k. on 5/4/20 at 4:23 AM, Patient #1 walked into their room and closed the inner door. The room went dark. At 4:34 AM, Patient #1 opened the inner door, with the sheet tied around Patient #1's neck. Patient #1 placed the sheet over the top of the inner door and closed the inner door. The room went dark and Patient #1 went out of camera view. At 4:40 AM, Patient #1 appears in the camera view as a dark spot close to ground level. At 4:41 AM, Patient #1's outline appeared in the door crack and did not move again (18 minutes after Patient #1 closed the inner door and 13 minutes after Patient #1 placed the sheet tied around their neck over the inner door).

l. on 5/4/20 at 5:15 AM, RN E entered Patient #1's room and noticed Patient #1 committed suicide (26 minutes after Patient #1 last moved and 39 minutes after Patient #1 tied the sheet around their neck and placed the sheet over the door).


7. Review of the "Behavioral Health Precaution Sheets," (where the nursing staff document a patient's activities) from 5/1/20 at 9:15 AM to 5/4/20 at 5:00 AM, revealed the nursing staff documented they observed Patient #1 every 15 minutes.

8. Further review of Patient #1's medical record revealed the nursing staff identified Patient #1 covered the camera in the room and opened the ceiling panel on 5/1/20 at 11:50 PM. The nursing staff failed to identify or document any of the other 7 times Patient #1 attempted suicide in their room in the inpatient behavioral health unit.

9. During an interview on 5/27/20 at 1:00 PM, PCT A revealed they primarily relied on the video camera in Patient #1's room to observe Patient #1. When PCT A would check on Patient #1's location, PCT A would walk by the nurses' station and look at the monitor. Even though the room was dark, PCT A would look for motion in Patient #1's room to verify Patient #1 was present in the room. On the morning of 5/4/20 at 5:00 AM, PCT A observed Patient #1 move in the room and assumed Patient #1 would come out to the nurses' station (camera footage revealed Patient #1 last moved at 4:41 AM on 5/4/20). PCT A became distracted and did not notice Patient #1 failed to come out to the nurses' station as PCT A expected. At 5:15 AM, as PCT A prepared to start the 5:15 AM rounds, RN E emerged from Patient #1's room and informed the staff that Patient #1 had hung themselves.

10. During an interview on 5/12/20 at 3:02 PM, PCT A G revealed the staff did not physically go into the observation rooms (Patient #1's room was Observation Room 2) to check on patients during the 15 minute rounds. Instead, the nursing staff would observe the patients in the observation rooms through cameras and only go into the observation rooms 2-3 times per shift, always with a second staff member present.

11. During an interview on 5/12/20 at 3:17 PM, PCT H revealed the staff did not physically go into the observation rooms to check on patients during the 15 minute rounds. Instead, the nursing staff would observe the patients in the observation rooms through cameras and only go into the observation rooms with a second staff member present.

12. During an interview on 5/8/20 at 9:50 AM, RN E revealed the nursing staff did not physically go into the observation rooms to check on the patients during the 15 minute rounds. Instead, the nursing staff would use the cameras in the observation rooms to check on the patients, as the patients may become aggressive or violent.

13. During an interview on 5/8/20 at 10:30 AM, RN I revealed the nursing staff did not physically go into the observation rooms to check on the patients during the 15 minute rounds. Instead, the nursing staff would use the cameras in the observation rooms to check on the patients, especially if the patient had a history of becoming aggressive towards the staff.

14. Observations on 5/7/20 at 12:40 PM, during a tour of the inpatient behavioral health unit, revealed the nursing staff did not observe the camera monitors at the nursing station for greater than 15 minutes.

15. Observations on 5/7/20 at 2:30 PM revealed the nursing staff did not observe the camera monitors at the nursing station for greater than 15 minutes.

16. During an interview on 5/18/20 at 2:40 PM, the Behavioral Health Nurse Manager revealed they expected the nursing staff to physically observe each patient at least every 15 minutes. Even if the nursing staff used the camera monitors to visualize a patient, the nursing staff needed to physically go into the patient's room to visualize the patient. If the staff had concerns about their safety, the staff member could ask a second staff member to accompany them into the patient's room. However, the video footage from the cameras in Patient #1's room revealed the nursing staff failed to enter Patient #1's room every 15 minutes to physically check on Patient #1 (which would have detected Patient #1's suicide attempts).



II. Based on document review, observation, and staff interview, the hospital's administrative staff failed to ensure the hospital staff provided care in a safe environment when 2 of 3 reviewed patients (Patient #1 and Patient #2) attempted suicide by hanging themselves while receiving care in the hospital's inpatient behavioral health unit. Failure to provide a safe environment for patients on the inpatient behavioral health unit resulted in Patient #2 attempting to hang themselves in their bathroom and Patient #1 attempting to hang themselves multiple times in their room, ultimately succeeding in hanging themselves in the bathroom of their inpatient behavioral health room. The hospital's administrative staff identified a census of 14 patients at the beginning of the survey on the inpatient behavioral health unit.

Findings include:

1. Review of the policy "Patient Rights & Responsibilities," revised 5/2019, revealed in part, "As a patient at MercyOne, you have the right ... to ... receive considerate and respectful care ... in a ... safe and secure environment."

2. Review of Patient #2's medical record revealed the hospital staff admitted Patient #2 to Observation Room #2 on the hospital's inpatient behavioral health unit on 3/28/20. The Psychiatric History and Physical, completed on 3/29/20 at 11:38 AM by Psychiatrist Q, revealed they admitted Patient #2 to the inpatient behavioral health unit after Patient #2 attempted suicide by overdosing on alcohol and medication. RN R documented on 3/29/20 at 8:43 PM that hospital staff let Patient #1 use the bathroom. Shortly afterwards, the staff found Patient #2 hanging in the bathroom, with a sheet around their neck. Patient #2 was gasping for air and still conscious when staff found Patient #2.

3. Review of Patient #1's medical record revealed the hospital staff admitted Patient #1 to the hospital's inpatient behavioral health unit on 5/1/20 at 8:08 AM for treatment of suicidal ideation under a court order for treatment from Hospital A. The ED nursing staff assessed Patient #1 as "High Risk" for attempting suicide. The nursing staff assigned Patient #1 to Observation Room #2 (the same room as Patient #2). The other nursing staff assessed Patient #1 as low to moderate risk for attempting suicide. Patient #1 died on 5/4/20 at 5:47 AM, after hanging themselves with a sheet in the bathroom of their inpatient behavioral health unit.

4. Review of a timeline of Patient #1's activities, created by the Security Director after viewing archived video footage from the cameras in Patient #1's inpatient behavioral health room, revealed the following:

a. on 5/1/20 at 7:58 AM, the hospital staff admitted Patient #1 to the inpatient behavioral health unit, room Observation #2.

b. on 5/1/20 at 5:55 PM (10 hours after admission), Patient #1 took a bed sheet, twisted the sheet into a rope, walked to the sink area between the inner and outer doors, placed the rope around their neck, placed the end of the sheet (with a knot at the end) over the top of the inner door, closed the inner door, and laid down on the floor. The sheet fell off the top of the inner door and the inner door closed. Patient #1 stood up, with the sheet around their neck, and returned to their bed.

c. on 5/1/20 at 6:04 PM, Patient #1 got out of bed, walked to the sink area, and looked for hospital staff. Patient #1 placed the sheet around their neck and placed the knotted end of the sheet over the top of the inner door. Patient #1 disappeared from camera view and approximately 5 minutes later, stood up, and removed the sheet from their neck and the door.

d. on 5/1/20 at 6:34 PM, Patient #1 got out of bed, walked to the sink area, and looked for hospital staff. Patient #1 placed the sheet around their neck and the knotted end of the sheet over the top of the inner door. Patient #1 disappeared from camera view and approximately 2 minutes later, removed the sheet from the door. At 6:36 PM, Patient #1 stood up, placed the knotted end of the sheet over the inner door, with the sheet still around Patient #1's neck. Patient #1 disappeared from view, with Patient #1 visible a minute later near the ground. At 7:02 PM, Patient #1 stood up from the ground, removed the sheet from the inner door, and began examining parts of the room.

e. on 5/1/20 at 7:15 PM, Patient #1 stood on their bed and opened a panel in the ceiling. Patient #1 took their mattress, folded it in half, secured the folded mattress with a sheet, and stands on the mattress to look into the ceiling. Patient #1 stands on the mattress and looks in the ceiling 3 more times. At 7:25 PM, Patient #1 replaced the mattress on the bed, and attempted to shut the panel in the ceiling.

f. on 5/1/20 at 8:02 PM, Patient #1 stood on their bed and began pulling cables out from the ceiling panel. Patient #1 wrapped the sheet around the cable from the ceiling. Patient #1 closed the inner door, stood on the bed, removed the sheet from the cable, tries to place the cable back in the ceiling panel, and attempted to shut the ceiling panel. At 8:10 PM, Patient #1 tied the sheet back to the cable from the ceiling panel. Patient #1 got off the bed and left the sheet hanging from the cable. At 8:15 PM, Patient #1 untied the sheet from the cable. Patient #1 then covered the camera in the room with a paper plate and tape Patient #1 removed from the ceiling. Patient #1 removed the plate from the camera in the room at 8:28 PM.

g. on 5/1/20 at 8:29 PM, Patient #1 took the plate they previously used to cover the camera in the room and attempted to pour milk into the electrical socket. Patient #1 then attempted to pour milk, using the plate, into 2 other electrical sockets. Patient #1 replaced the plate over the camera in the room at 8:31 PM.

h. on 5/1/20 at 11:32 PM, RN E, PCT A, and Safety Tech F entered Patient #1's room. RN E removed the plate over the camera in Patient #1's room (3 hours after Patient #1 placed the plate over the camera). PCT A closed the ceiling panel that Patient #1 opened. The hospital staff left Patient #1's room at 11:41 PM.

i. on 5/2/20 at 6:45 PM, Patient #1 walked to the bedroom sink, knelt on the sink, and examined the ceiling panel. Patient #1 then stood on the sink and jumped off the sink 3 minutes later.

j. on 5/4/20 at 4:23 AM, Patient #1 walked into their room and closed the inner door. The room went dark. At 4:34 AM, Patient #1 opened the inner door, with the sheet tied around Patient #1's neck. Patient #1 placed the sheet over the top of the inner door and closed the inner door. The room went dark and Patient #1 went out of camera view. At 4:40 AM, Patient #1 appears in the camera view as a dark spot close to ground level. At 4:41 AM, Patient #1's outline appeared in the door crack and did not move again.

k. on 5/4/20 at 5:15 AM, RN E entered Patient #1's room and noticed Patient #1 committed suicide .


5. Observations on 5/7/20 at 2:30 PM, during a tour of the inpatient behavioral health unit, revealed the hospital utilized doors to control access to the bathrooms in the patient rooms and provide patient privacy. The doors lacked a mechanism to either prevent a patient from attempting or committing suicide by placing a sheet over the door and allowing a patient to hang themselves from the door. Further observations also revealed a ceiling panel located in the patient bedroom of Observation Room #2 and a sink (which withstood Patient #1 standing on it several times) located in a vestibule between the inner and outer doors to Observation Room #2.

6. During an interview on 5/21/20 at 10:15 AM, the Director of Behavioral Health and Emergency Services and the Behavioral Health Nurse Manager revealed that after Patient #2 attempted to hang themself, the nursing staff explored an option to prevent patients from hanging themselves on the bathroom doors in Observation Room #2, but the staff could not fix the doors, due to the steel door construction.

After Patient #2 attempted to hang themself in the bathroom of Observation Room #2, the Behavioral Health Nurse Manager drafted a memo to the behavioral health nursing staff to lock the doors to the bathroom in Observation Room #2 and for the staff to remain in the area while patients are using the bathroom. However, the Behavioral Health Nurse Manager failed to save the document they drafted about locking the bathroom doors and staying with patients using the bathroom. The Behavioral Health Nurse Manager acknowledged they could not provide evidence they educated the nurses to lock the bathroom door in Observation Room #2 and acknowledged the nursing staff did not lock the bathroom door to prevent Patient #1 from hanging themselves.

Based on document review and staff interviews, the hospital's administrative staff failed to ensure the nursing staff adequately assessed 1 of 3 patients reviewed (Patient #1) to identify the patient engaged in multiple suicide attempts during their hospitalization in the inpatient behavioral health unit. Please refer to A-0395 for additional information. The cumulative effect of these failures and deficient practices resulted in the hospital staff's inability to ensure patients received safe nursing services.

Based on document review and staff interviews, the hospital's administrative staff failed to ensure the nursing staff adequately assessed 1 of 3 patients reviewed (Patient #1) to identify the patient engaged in multiple suicide attempts during their hospitalization in the inpatient behavioral health unit. Failure of the nursing staff to adequately assess Patient #1 and identify Patient #1 attempted suicide during their hospitalization resulted in the nursing staff failing to identify Patient #1 required additional nursing care, including 1:1 supervision, to prevent Patient #1 from successfully committing suicide in the hospital's inpatient behavioral health unit. The hospital's administrative staff identified 14 inpatients in the hospital's behavioral health unit at the beginning of the survey.

Findings include:

1. Review of the policy "Assessment of Patient," revised 6/2019, revealed in part, "Assessment includes systematic collection of date and occurs continuously so as to maintain awareness of [the] patient's needs and effectiveness of interventions. Assessments include subjective and objective data ... to make care decisions." "Assessment and reassessment is appropriate throughout the entire patient stay." "The registered nurse uses nursing judgement to determine the appropriate frequency and components of reassessment. Ongoing/Focused assessments occur: ... When the patient condition/diagnosis changes ..." "Based on information obtained during any additional assessments performed, appropriate interventions will be implemented. These may include ... continuous monitoring for patients that are at risk ... and 1:1 observation ..."

2. Review of the policy "Suicide Screening, Risk Assessment, and Interventions," revised 12/2019, revealed in part, "Following a positive suicide risk screening and assessment, a nurse needs to to complete the Suicide Risk Re-Assessment/Stratification form at a minimum of every shift or with [a patient] condition change ... Implement interventions and observation level based on [the] patient's assessed risk level." "Management of a patient who attempts self-harm/suicide: If a patient is found with what appears to be an attempted suicide, evaluate the patient's condition and take appropriate action ... Reassesses the patients (sic) Suicide Risk Level and implement observation and interventions." "High Suicide Risk ... Suicidal behavior within past 3 months ... Initiate 1:1 observation of the patient. Video monitoring may be used as a secondary safety measure, but CANNOT be used as the only means to observe the patient." "One-to-one (1:1) monitoring: [a staff member] is at arm's length from the patient, with continuous, unobstructed view of the patient and the ability to intervene immediately."

3. Review of Patient #1's medical record revealed the hospital staff admitted Patient #1 to the hospital's inpatient behavioral health unit on 5/1/20 at 8:08 AM for treatment of suicidal ideation under a court order for treatment from Hospital A. Patient #1 died on 5/4/20 at 5:47 AM, after hanging themselves with a sheet in the bathroom of their inpatient behavioral health unit.


4. Review of a timeline of Patient #1's activities, created by the Security Director after viewing archived video footage from the cameras in Patient #1's inpatient behavioral health room, revealed the following:

a. on 5/1/20 at 7:58 AM, the hospital staff admitted Patient #1 to the inpatient behavioral health unit, room Observation #2.

b. on 5/1/20 at 5:55 PM (10 hours after admission), Patient #1 took a bed sheet, twisted the sheet into a rope, walked to the sink area between the inner and outer doors, placed the rope around their neck, placed the end of the sheet (with a knot at the end) over the top of the inner door, closed the inner door, and laid down on the floor. The sheet fell off the top of the inner door and the inner door closed. Patient #1 stood up, with the sheet around their neck, and returned to their bed.

c. on 5/1/20 at 6:04 PM, Patient #1 got out of bed, walked to the sink area, and looked for hospital staff. Patient #1 placed the sheet around their neck and placed the knotted end of the sheet over the top of the inner door. Patient #1 disappeared from camera view and approximately 5 minutes later, stood up, and removed the sheet from their neck and the door (Patient #1 practiced the suicide attempt for ~14 minutes).

d. on 5/1/20 at 6:34 PM, Patient #1 got out of bed, walked to the sink area, and looked for hospital staff. Patient #1 placed the sheet around their neck and the knotted end of the sheet over the top of the inner door. Patient #1 disappeared from camera view and approximately 2 minutes later, removed the sheet from the door. At 6:36 PM, Patient #1 stood up, placed the knotted end of the sheet over the inner door, with the sheet still around Patient #1's neck. Patient #1 disappeared from view, with Patient #1 visible a minute later near the ground. At 7:02 PM, Patient #1 stood up from the ground, removed the sheet from the inner door, and began examining parts of the room (Patient #1 practiced the suicide attempt for ~28 minutes).

e. on 5/1/20 at 7:15 PM, Patient #1 stood on their bed and opened a panel in the ceiling. Patient #1 took their mattress, folded it in half, secured the folded mattress with a sheet, and stands on the mattress to look into the ceiling. Patient #1 stands on the mattress and looked in the ceiling 3 more times. At 7:25 PM, Patient #1 replaced the mattress on the bed, and attempted to shut the panel in the ceiling. At 7:30 PM, Patient #1 left their room (15 minutes after Patient #1 first attempted to open the ceiling panel).

f. on 5/1/20 at 8:02 PM, Patient #1 stood on their bed and began pulling cables out from the ceiling panel. Patient #1 wrapped the sheet around the cable from the ceiling. Patient #1 closed the inner door, stood on the bed, removed the sheet from the cable, tries to place the cable back in the ceiling panel, and attempted to shut the ceiling panel. At 8:10 PM, Patient #1 tied the sheet back to the cable from the ceiling panel. Patient #1 got off the bed and left the sheet hanging from the cable. At 8:15 PM, Patient #1 untied the sheet from the cable. Patient #1 then covered the camera in the room with a paper plate and tape Patient #1 removed from the ceiling. At 8:21 PM (19 minutes after Patient #1 began pulling cables out of the ceiling), Patient Care Technician (PCT) G knocked on the outer door and spoke with Patient #1. PCT G returned at 8:26 PM with a drink for Patient #1. Patient #1 removed the plate from the camera in the room at 8:28 PM (12 minutes after Patient #1 covered the camera with the plate and 7 minutes after PCT G first entered the room).

g. on 5/1/20 at 8:29 PM, Patient #1 took the plate they previously used to cover the camera in the room and attempted to pour milk into the electrical socket. Patient #1 then attempted to pour milk, using the plate, into 2 other electrical sockets. Patient #1 replaced the plate over the camera in the room at 8:31 PM.

h. on 5/1/20 at 11:08 PM, Patient #1 spoke with Safety Tech F in Patient #1's room. Safety Tech F provided Patient #1 a drink and left the room. The plate Patient #1 placed over the camera remained over the camera.

i. on 5/1/20 at 11:32 PM, Registered Nurse (RN) E, PCT A, and Safety Tech F entered Patient #1's room. RN E removed the plate over the camera in Patient #1's room (3 hours after Patient #1 placed the plate over the camera). PCT A closed the ceiling panel that Patient #1 opened. The hospital staff left Patient #1's room at 11:41 PM.

j. on 5/2/20 at 6:45 PM, Patient #1 walked to the bedroom sink, knelt on the sink, and examined the ceiling panel. Patient #1 then stood on the sink and jumped off the sink 3 minutes later.

k. on 5/4/20 at 4:23 AM, Patient #1 walked into their room and closed the inner door. The room went dark. At 4:34 AM, Patient #1 opened the inner door, with the sheet tied around Patient #1's neck. Patient #1 placed the sheet over the top of the inner door and closed the inner door. The room went dark and Patient #1 went out of camera view. At 4:40 AM, Patient #1 appears in the camera view as a dark spot close to ground level. At 4:41 AM, Patient #1's outline appeared in the door crack and did not move again (18 minutes after Patient #1 closed the inner door and 13 minutes after Patient #1 placed the sheet tied around their neck over the inner door).

l. on 5/4/20 at 5:15 AM, RN E entered Patient #1's room and noticed Patient #1 committed suicide (26 minutes after Patient #1 last moved and 39 minutes after Patient #1 tied the sheet around their neck and placed the sheet over the door).


5. Further review of Patient #1's medical record revealed, on the Suicide Risk Re-Assessment/Stratification forms:

a. on 5/1/20 at 8:00 AM, RN T documented Patient #1 acknowledged suicidal thoughts, denied a specific plan to commit suicide, denied any intention of acting on the suicidal thoughts, and denied attempting to end Patient #1's life. RN T assessed Patient #1 at a low risk of attempting suicide.

b. on 5/1/20 at 6:00 PM (approximately the same time as Patient #1 first attempted suicide in the hospital), RN P documented Patient #1 acknowledged suicidal thoughts, denied a specific plan to commit suicide, denied any intention of acting on the suicidal thoughts, and denied attempting to end Patient #1's life. RN P failed to identify Patient #1's suicide attempt in the hospital and assessed Patient #1 at a low risk of attempting suicide, instead of a high suicide risk, which warranted 1:1 observation, due to Patient #1's suicide attempt.

c. on 5/2/20 at 1:00 AM (approximately 3 hours after Patient #1 made the first of 6 additional suicide attempts in the hospital), RN E documented Patient #1 denied suicidal thoughts and had not attempting to end their life. RN E failed to identify Patient #1's suicide attempts in the hospital and assessed Patient #1 at a low risk of attempting suicide, instead of a high suicide risk, which warranted 1:1 observation, due to Patient #1's suicide attempt.

d. on 5/2/20 at 9:00 AM (after Patient #1 made 7 suicide attempts in the hospital), a staff member (who did not document their identify) documented Patient #1 acknowledged suicidal thoughts, acknowledged a specific plan to commit suicide, denied any intention of acting on the suicidal thoughts, and denied attempting to end Patient #1's life. The staff member failed to identify Patient #1's suicide attempts in the hospital and assessed Patient #1 at a low risk of attempting suicide, instead of a high suicide risk, which warranted 1:1 observation, due to Patient #1's suicide attempt.

e. on 5/2/20 at 6:00 PM (after Patient #1 made 7 suicide attempts in the hospital), RN P documented Patient #1 acknowledged suicidal thoughts, acknowledged a specific plan to commit suicide, denied any intention of acting on the suicidal thoughts, and denied attempting to end Patient #1's life. RN P failed to identify Patient #1's suicide attempts in the hospital and assessed Patient #1 at a low risk of attempting suicide, instead of a high suicide risk, which warranted 1:1 observation, due to Patient #1's suicide attempt.

f. on 5/3/20 at 1:00 AM (after Patient #1 made 7 suicide attempts in the hospital), RN Q documented Patient #1 denied suicidal thoughts and denied attempting to end Patient #1's life. RN Q failed to identify Patient #1's suicide attempts in the hospital and assessed Patient #1 at a low risk of attempting suicide, instead of a high suicide risk, which warranted 1:1 observation, due to Patient #1's suicide attempt.

g. on 5/3/20 at 9:00 AM (after Patient #1 made 7 suicide attempts in the hospital), RN C documented Patient #1 denied suicidal thoughts, acknowledged a specific plan to commit suicide, denied any intention of acting on the suicidal thoughts, and denied attempting to end Patient #1's life. RN C failed to identify Patient #1's suicide attempts in the hospital and assessed Patient #1 at a low risk of attempting suicide, instead of a high suicide risk which, warranted 1:1 observation, due to Patient #1's suicide attempt.

h. on 5/3/20 at 5:30 PM (after Patient #1 made 7 suicide attempts in the hospital), RN S documented Patient #1 denied suicidal thoughts and denied attempting to end Patient #1's life. RN S failed to identify Patient #1's suicide attempts in the hospital and assessed Patient #1 at a low risk of attempting suicide, instead of a high suicide risk, which warranted 1:1 observation, due to Patient #1's suicide attempt.

i. on 5/4/20 at 1:00 AM (after Patient #1 made 7 suicide attempts in the hospital and 3 hours before Patient #1 committed suicide in the hospital), RN E documented Patient #1 denied suicidal thoughts and denied attempting to end Patient #1's life. RN E failed to identify Patient #1's suicide attempts in the hospital and assessed Patient #1 at a low risk of attempting suicide, instead of a high suicide risk, which warranted 1:1 observation, due to Patient #1's suicide attempt.


6. During an interview on 5/18/20 at 1:20 PM, the Director of Behavioral Health and Emergency Care acknowledged the nursing staff failed to identify Patient #1 had attempted suicide 7 times in the hospital, prior to committing suicide on 5/4/20 at 4:41 AM.