HospitalInspections.org

Based on review of medical records (MR), facility policies and procedures, Department of Mental Health Incident Notification Form, Investigation Review Panel Minutes and interviews with the staff, it was determined the facility failed to ensure the patients at risk for suicide and suicide attempts were provided a safe environment.

This had the potential to negatively affect all patients served by the facility.

Refer to tag A 144 for findings.

Based on review of medical records (MR), facility policies and procedures, Department of Mental Health Incident Notification Form, Investigation Review Panel Minutes and interviews with the staff, it was determined the facility failed to ensure the patients at risk for suicide were provided a safe environment.

This deficient practice affected 1 of 4 MR's reviewed and did affect Patient Identifier (PI) # 1, and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Patient Accountability
Policy number: NP 10.4.0
Revised Date: Nov 2018

Purpose:

To account for each patient's location and condition while on the Living Area, and for each patient's location while off the Living Area, every quarter hour throughout a specified 24-hour period...

Procedure: Primary Patient Accountability Checklist

A. Primary forms will be initiated, beginning at 7:00 AM each morning and will extend through 2:45 PM, with the process beginning again on a new form at 3:00 PM until 10:45 PM and again at 11:00 PM through 6:45 AM.

B. Information to be included:

1. Hospital program and Living Area.
2. Date of specified 24-hour period.
3. Full names of each patient assigned to Living Area during a specified 24-hour period.
4. A code letter indication the patient's location will be entered by his/her name, in the block designated for the time the check is being made...
8. A supervisor will review the checklist every hour for accuracy and completeness...

Staff Responsibilities for Primary Patient Accountability checklist.

B. MHW II (Mental Health Worker) /designee on all shifts will:

2. Be responsible for seeing that patients are individually accounted for on a quarter hour basis and that assumptions are not made regarding patient's location...

C. Assigned MHW I/designee completing the checklist will:

1. Account for the location of each patient listed on form every quarter hour, then legibly document the appropriate Activity Code...

5. Report to MHW II/designee any physical symptoms, unusual behavior or circumstances immediately...

Policy: Special Observation Status
Policy Number: 10.12.0
Revised Date: 8/2018

Procedure:

I. Constant (1:1) Observation:

The patient shall be placed on constant observation status if the patient:

1. has considered suicide or made an attempt
2. is self-injurious or aggressive...

A. Constant Observation may be instituted by the psychiatrist, psychologist, social worker or RN (registered nurse)...The Physician/Psychiatrist must be called within one hour for orders...

B. A nursing employee will be assigned to the patient on a one-to-one (1:1) basis. The assigned employee will be within constant eyes view and within arm's length of the patient at all times unless otherwise ordered...

D. The patient must be assessed each shift by a Registered Nurse and every 24 hours by a psychologist/physician/psychiatrist...

E. The Special Observation Flow Sheet...will be initiated within 15 minutes, on all patients placed on special observation status...

F. The employee given their assignment of constant observation will be responsible for the following:

1. Accompanying the patient to the bathroom at all times...The employee will remain in the commode/bath/shower area while the patient is taking a bath, shower or using the commode.

11. Observe for changes in the patient's behavior that would possibly indicate suicidal thought and/or thoughts of self-harm...

12. Carry out any special restrictions and/or considerations as ordered by the psychiatrist, physician or RN...

1. PI # 1 was admitted to the facility on 11/19/19 with admitting diagnosis of Major Depressive Disorder.

Review of the physician order dated 2/12/2020 at 12:10 PM revealed the following order: 1:1 - within eye view and arm's length 24 hours due to suicidal and self-injurious behavior. No bras, no panties, oversized jumpsuit/escort to bathroom.

Review of the physician order dated 2/22/2020 at 8:50 AM revealed the following order:

1:1- within eye view and arms length from 11:00 AM to 7:00 AM due to suicidal and self injurious behavior. Special Instructions included No bras, No panties, oversized jumpsuit and escort to bathroom.

The surveyor asked Employee Identifier (EI) # 1, Facility Director, what was the intent of the order dated 2/22/2020. EI # 1 stated PI # 1 was removed from 1:1 observation during the hours of 7:00 AM to 11:00 AM each day and then back on 1:1 observations at 11:00 AM each day. EI # 1 stated it is a trial to see if PI # 1 is able to remain off of the 1:1 observations.

Review of the Patient Accountability checklist dated 2/25/2020 at 9:00 AM revealed documetation PI # 1 was in the day area. At 9:15 AM there was no code to indicate the patient's location. Further review revealed at 9:30 AM the patient was in the hallway and at 9:45 AM until 10:00 AM it was documented the patient was in the bathroom. Further review revealed the patient remained in the bathroom until a code blue was called for PI # 1 at 10:05 AM.

Review of the RN progress note dated 2/25/2020 at 10:00 AM revealed the nurse documented "it was reported to him/her the MHW (Mental Health Worker) stated PI # 1 left the group therapy room to use the restroom . The MHW scanned the room and hallway to account for all high risk patients on the sterile hall way. Staff immediately called PI # 1's name and PI # 1 responded by stating he/she was in the bathroom" (which is accross the hall from the group room).

Further review of the progress note date 2/25/2020 at 10:00 AM revealed the patient was off of 1:1 observation at this time until 11:00 AM. Further review revealed another patient in the group therapy room stated "Look she is on the floor." MHW responded immediately by running to the scene, and shouting for additional staff to call code blue.

Review of the Code Blue code sheet dated 2/25/2020 revealed the estimated time of arrest was 10:05 AM. CPR (Cardiopulmonary Resuscitation) began at 10:07 AM due to no respirations and rescue breaths given. Further review of the code sheet revealed the patient had gasping respirations at 10:09 AM and remained unresponsive. There was no further documentation on the Code Blue code sheet dated 2/25/2020.

Review of the transfer sheet dated 2/25/2020 revealed PI # 1 was transferred to DCH hospital at 10:11 AM per local Emergency Medical Services (EMS).

Review of the DMH (Department of Mental Health) Incident Notification Form revealed an incident occurred on 2/25/2020 at 10:00 AM on Recovery 4 Unit, bedroom involving PI # 1.

Review of the DMH Incident Notification Form revealed PI # 1 removed the zipper from the jumpsuit he/she was wearing and placed it around his/her neck in an attempt to harm his/her self. Further review of the DMH form revealed PI # 1 was lying on the floor unresponsive and not breathing and a code was called. Once breathing on his/her own PI # 1 was transferred to DCH hospital.

Review of the Code Blue Evaluation form dated 2/25/2020 at 10:25 AM revealed during the code the intercom system was not working and a code blue page could not be completed. A MHW from Unit # 4 was used as a runner to other units for assistance. Failure of the intercom system potentially resulted in a delay in response in the code blue.

Review of the MR revealed PI # 1 returned to Recovery Unit # 4 from the hospital on 2/25/2020 at 2:00 PM and was placed on 1:1 observation. PI # 1 was then again placed in a zippered jumpsuit there by placing PI # 1 in Immediate Jeopardy.

Review of the Treatment Team Risk Evaluation Meeting form dated 2/25/2020 at 3:51 PM revealed a meeting with the team and PI # 1 who stated he/she was having thoughts of suicide for the past two days. PI # 1 was placed on 1:1 full time (Patient to remain in one arms length of sitter and remain in eye contact). Patient to remain in jumpsuit. Treatment team to discuss other clothing options should the need arise. There was no documentation the treatment team assessed PI # 1's suicide risk and failed to place him/her in a suicide smock.

Review of the Care Plan Report dated 2/25/2020 revealed the following:

Problem: Self injurious behavior as evidenced by PI # 1 had recent self strangulation attempt, on 2/25/2020 and was found with zipper/cloth from clothes she removed, tied around her neck.

Review of the physician order dated 2/25/2020 at 4:00 PM revealed the following order: 1:1 - within eye view and arms length 24 hours. Reason for 1:1 observation: Serious suicide attempt today/suicidal and self injurious behavior. Special Instructions: stay in group therapy room protocol from 7:00 AM to 8:00 PM. No bras, no panties, oversized jumpsuit, escort to bathroom/one arms length at all times and eye contact at all times.

Review of the Special Observation Flow Sheet dated 2/27/2020 revealed PI # 1 was on 1:1 observation with documentation as follows:
12:00 PM indicating PI # 1 was in the hall
12:15 PM PI # 1 was located in the bathroom
12:30 PM PI # 1 was in the hallway
12:45 PM PI # 1 was in the bedroom
1:00 PM to 1:15 PM PI # 1 was located in the bedroom
1:30 PM to 1:45 PM PI # 1 was located in the group room.

Review of the DMH (Department of Mental Health) Incident Report Form dated 2/27/2020 at 12:30 PM revealed PI # 1 was using the restroom. Staff was standing at door while the patient was having a bowel movement (BM). While PI # 1 had a jumpsuit with a zipper on it pulled down PI # 1 ripped the left side of the zipper off. Staff was thinking PI # 1 was having a hard time having a BM. While fumbling with the jumpsuit and hair she somehow tied the zipper around his/her neck. The staff member immediately noticed it when he/she tried to rip the right side of the zipper off.

Review of the RN (Registered Nurse) progress note dated 2/27/2020 at 1:54 PM revealed the RN documented "while making rounds the RN went to see where PI # 1 was because he/she had been absent from group therapy room for longer than 20 minutes....As RN went towards PI # 1's room the RN met PI # 1 and the 1:1 sitter in the hallway in front of the med room. The MHW (1:1 sitter) told the RN PI # 1 had this around his/her neck and handed the RN the zipper from the jumpsuit. Red ligature marks and petechiae (red dots occurring from strangulation) were noted to PI # 1's face and neck. When the RN asked PI # 1 why he/she tried to hurt his/her self, PI # 1 started to smile and laughing, said "cause I want to kill myself." PI # 1 was instructed to remove the jumpsuit and was wrapped in a blanket until more appropriate clothing was obtained..."

Review of the Treatment Team Risk Evaluation Meeting documentation dated 2/27/2020 at 1:54 PM by the Psychiatrist revealed PI # 1 was at high risk for suicide. PI # 1 was placed in a suicide smock and PI # 1 can not have bras, panties, or other clothing items on his/her person or in His/her room. PI # 1 is to remain within arms reach and eye's view at all times, even when in the bathroom and shower...

Further review of the Treatment Team Risk Evaluation Meeting documentation on 2/27/2020 at 1:54 PM revealed under Suicide: Suicide Risk Level: Extreme. Explanation: Pt. (Patient) had two serious suicide attempts in two days, one on Feb. 25th, another one today (Feb 27th). First one needed resuscitation and sending him/her to the hospital.

Review of the ADMH (Alabama Department of Mental Health) Progress Note dated 2/27/2020 at 3:57 PM revealed the psychiatrist documented "was informed approximately at 1:15 PM PI # 1 had tried to harm his/her self again by tying a zipper around her neck at approximately 12:30 PM on 2/27/2020." Further review of the ADMH Progress note revealed PI # 1 was to be considered a serious risk for suicide due to his/her past behavior and the patient was currently on a 2:1 observation status and to remain on this status for his/her safety.

Review of the physician order dated 2/27/2020 at 5:05 PM revealed an order for 2:1 observation at all times during 24 hour/day. Remain within arm's reach and eye view at all times. Suicide smock only, hair braided, escort to bathroom. No bras, no panties, group therapy room from 7 AM to 7 PM.

Review of the Investigation Review Panel Minutes dated 3/10/2020 revealed in the conclusion section of the form Employee Identifier (EI) # 3, MHW I was responsible for conducting the Patient Accountability checks and even though she spoke with PI # 1 (while in the bathroom) EI # 3 did not make a visual assessment of PI # 1.

The following interviews were conducted on 3/11/2020 from 8:40 AM to 10:28 AM by the state surveyors:

An interview was conducted on 3/11/2020 at 9:25 AM with EI # 5, MHW assigned to PI # 1 from 12:00 PM to 1:00 PM.

The surveyor asked EI # 5, "what 1:1 and 2:1 observation means". EI # 5 responded, "Arms length of client". The surveyor asked EI # 5, "did this include while PI # 1 was in the bathroom" and EI # 5 stated, "yes, suppose too."

EI # 5 was asked if he/she recalled an incident which occurred on 2/27/2020 with PI # 1 EI # 5 stated yes he/she was 1:1 with PI # 1. EI # 5 continued by stating "I was giving a girl a break." EI # 5 stated PI # 1 had to use the restroom and she "acted like she was having a hard time using the bathroom. She kept fumbling with her hair and jumpsuit. Somehow, she got the zipper off and tried to wrap it around her neck, but I stopped her."

EI # 5 was asked if she was in eyes view of the patient and EI # 5 stated "I was standing at the door (open) while PI # 1 was in the bathroom. I was standing at the door and facing straight, and PI # 1 was beside me. I looked over when PI # 1 was fumbling and asked her what she was doing. PI # 1 said she was just using the restroom. He/She sat there for about 30 minutes trying to use the restroom."

EI # 5 was asked how was the zipper, which is on the back of the jumpsuit, undone for the patient to use the restroom? EI # 5 responded by stating "I unzipped the jumpsuit for PI # 1 so he/she could use the bathroom.."

An interview was conducted on 3/11/2020 at 3:30 PM with EI # 1, Facility Director, who confirmed the need for staff education due to the staff not following facility policy and procedure for the 1:1 Special Observations and Accountability checks, a suicide risk evaluation should have bee conducted after the first suicide attempt, PI # 1 should have been placed in a suicide smock, PI # 1 should have been within arms length and within eye view at all times and confirmed PI # 1 should have been provided a safe environment.

Based on review of medical records (MR), facility policies and procedures, Department of Mental Health Incident Notification Form, Investigation Review Panel Minutes and interviews with the staff, it was determined the facility failed to provide supervision and oversight for nursing services to ensure safe and effective care for patients in the hospital.

This had the potential to negatively affect all patients served by the facility.

Refer to Tag A 392 for findings.

Based on review of medical records (MR), facility policies and procedures, Department of Mental Health Incident Notification Form, Investigation Review Panel Minutes and interviews with the staff, it was determined the facility failed to:

1. Ensure staff followed the policy for 1:1 (one to one) observation and keep Patient Identifier (PI) # 1 in eyes view and arm's length at all times.

2. Provide patients at risk for suicide a safe environment.

This deficient practice affected 1 of 4 MR's reviewed and did affect PI # 1, and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Patient Accountability
Policy number: NP 10.4.0
Revised Date: Nov 2018

Purpose:

To account for each patient's location and condition while on the Living Area, and for each patient's location while off the Living Area, every quarter hour throughout a specified 24-hour period...

Procedure: Primary Patient Accountability Checklist

A. Primary forms will be initiated, beginning at 7:00 AM each morning and will extend through 2:45 PM, with the process beginning again on a new form at 3:00 PM until 10:45 PM and again at 11:00 PM through 6:45 AM.

B. Information to be included:

1. Hospital program and Living Area.
2. Date of specified 24-hour period.
3. Full names of each patient assigned to Living Area during a specified 24-hour period.
4. A code letter indication the patient's location will be entered by his/her name, in the block designated for the time the check is being made...
8. A supervisor will review the checklist every hour for accuracy and completeness...

Staff Responsibilities for Primary Patient Accountability checklist.

B. MHW II (Mental Health Worker) /designee on all shifts will:

2. Be responsible for seeing that patients are individually accounted for on a quarter hour basis and that assumptions are not made regarding patient's location...

C. Assigned MHW I/designee completing the checklist will:

1. Account for the location of each patient listed on form every quarter hour, then legibly document the appropriate Activity Code...

5. Report to MHW II/designee any physical symptoms, unusual behavior or circumstances immediately...

Policy: Special Observation Status
Policy Number: 10.12.0
Revised Date: 8/2018

Procedure:

I. Constant (1:1) Observation:

The patient shall be placed on constant observation status if the patient:

1. has considered suicide or made an attempt
2. is self-injurious or aggressive...

A. Constant Observation may be instituted by the psychiatrist, psychologist, social worker or RN (registered nurse)...The Physician/Psychiatrist must be called within one hour for orders...

B. A nursing employee will be assigned to the patient on a one-to-one (1:1) basis. The assigned employee will be within constant eyes view and within arm's length of the patient at all times unless otherwise ordered...

D. The patient must be assessed each shift by a Registered Nurse and every 24 hours by a psychologist/physician/psychiatrist...

E. The Special Observation Flow Sheet...will be initiated within 15 minutes, on all patients placed on special observation status...

F. The employee given their assignment of constant observation will be responsible for the following:

1. Accompanying the patient to the bathroom at all times...The employee will remain in the commode/bath/shower area while the patient is taking a bath, shower or using the commode.

11. Observe for changes in the patient's behavior that would possibly indicate suicidal thought and/or thoughts of self-harm...

12. Carry out any special restrictions and/or considerations as ordered by the psychiatrist, physician or RN...

1. PI # 1 was admitted to the facility on 11/19/19 with admitting diagnosis of Major Depressive Disorder.

Review of the physician order dated 2/12/2020 at 12:10 PM revealed the following order: 1:1 - within eye view and arm's length 24 hours due to suicidal and self-injurious behavior. No bras, no panties, oversized jumpsuit/escort to bathroom.

Review of the physician order dated 2/22/2020 at 8:50 AM revealed the following order:

1:1- within eye view and arms length from 11:00 AM to 7:00 AM due to suicidal and self injurious behavior. Special Instructions included No bras, No panties, oversized jumpsuit and escort to bathroom.

The surveyor asked Employee Identifier (EI) # 1, Facility Director, what was the intent of the order dated 2/22/2020. EI # 1 stated PI # 1 was removed from 1:1 observation during the hours of 7:00 AM to 11:00 AM each day and then back on 1:1 observations at 11:00 AM each day. EI # 1 stated it is a trial to see if PI # 1 is able to remain off of the 1:1 observations.

Review of the Patient Accountability checklist dated 2/25/2020 at 9:00 AM revealed documetation PI # 1 was in the day area. At 9:15 AM there was no code to indicate the patient's location. Further review revealed at 9:30 AM the patient was in the hallway and at 9:45 AM until 10:00 AM it was documented the patient was in the bathroom. Further review revealed the patient remained in the bathroom until a code blue was called for PI # 1 at 10:05 AM.

Review of the RN progress note dated 2/25/2020 at 10:00 AM revealed the nurse documented "it was reported to him/her the MHW (Mental Health Worker) stated PI # 1 left the group therapy room to use the restroom . The MHW scanned the room and hallway to account for all high risk patients on the sterile hall way. Staff immediately called PI # 1's name and PI # 1 responded by stating he/she was in the bathroom" (which is accross the hall from the group room).

Further review of the progress note date 2/25/2020 at 10:00 AM revealed the patient was off of 1:1 observation at this time until 11:00 AM. Further review revealed another patient in the group therapy room stated "Look she is on the floor." MHW responded immediately by running to the scene, and shouting for additional staff to call code blue.

Review of the Code Blue code sheet dated 2/25/2020 revealed the estimated time of arrest was 10:05 AM. CPR (Cardiopulmonary Resuscitation) began at 10:07 AM due to no respirations and rescue breaths given. Further review of the code sheet revealed the patient had gasping respirations at 10:09 AM and remained unresponsive. There was no further documentation on the Code Blue code sheet dated 2/25/2020.

Review of the transfer sheet dated 2/25/2020 revealed PI # 1 was transferred to DCH hospital at 10:11 AM per local Emergency Medical Services (EMS).

Review of the DMH (Department of Mental Health) Incident Notification Form revealed an incident occurred on 2/25/2020 at 10:00 AM on Recovery 4 Unit, bedroom involving PI # 1.

Review of the DMH Incident Notification Form revealed PI # 1 removed the zipper from the jumpsuit he/she was wearing and placed it around his/her neck in an attempt to harm his/her self. Further review of the DMH form revealed PI # 1 was lying on the floor unresponsive and not breathing and a code was called. Once breathing on his/her own PI # 1 was transferred to DCH hospital.

Review of the Code Blue Evaluation form dated 2/25/2020 at 10:25 AM revealed during the code the intercom system was not working and a code blue page could not be completed. A MHW from Unit # 4 was used as a runner to other units for assistance. Failure of the intercom system potentially resulted in a delay in response in the code blue.

Review of the MR revealed PI # 1 returned to Recovery Unit # 4 from the hospital on 2/25/2020 at 2:00 PM and was placed on 1:1 observation. PI # 1 was then again placed in a zippered jumpsuit there by placing PI # 1 in Immediate Jeopardy.

Review of the Treatment Team Risk Evaluation Meeting form dated 2/25/2020 at 3:51 PM revealed a meeting with the team and PI # 1 who stated he/she was having thoughts of suicide for the past two days. PI # 1 was placed on 1:1 full time (Patient to remain in one arms length of sitter and remain in eye contact). Patient to remain in jumpsuit. Treatment team to discuss other clothing options should the need arise. There was no documentation the treatment team assessed PI # 1's suicide risk and failed to place him/her in a suicide smock.

Review of the Care Plan Report dated 2/25/2020 revealed the following:

Problem: Self injurious behavior as evidenced by PI # 1 had recent self strangulation attempt, on 2/25/2020 and was found with zipper/cloth from clothes she removed, tied around her neck.

Review of the physician order dated 2/25/2020 at 4:00 PM revealed the following order: 1:1 - within eye view and arms length 24 hours. Reason for 1:1 observation: Serious suicide attempt today/suicidal and self injurious behavior. Special Instructions: stay in group therapy room protocol from 7:00 AM to 8:00 PM. No bras, no panties, oversized jumpsuit, escort to bathroom/one arms length at all times and eye contact at all times.

Review of the Special Observation Flow Sheet dated 2/27/2020 revealed PI # 1 was on 1:1 observation with documentation as follows:
12:00 PM indicating PI # 1 was in the hall
12:15 PM PI # 1 was located in the bathroom
12:30 PM PI # 1 was in the hallway
12:45 PM PI # 1 was in the bedroom
1:00 PM to 1:15 PM PI # 1 was located in the bedroom
1:30 PM to 1:45 PM PI # 1 was located in the group room.

Review of the DMH (Department of Mental Health) Incident Report Form dated 2/27/2020 at 12:30 PM revealed PI # 1 was using the restroom. Staff was standing at door while the patient was having a bowel movement (BM). While PI # 1 had a jumpsuit with a zipper on it pulled down PI # 1 ripped the left side of the zipper off. Staff was thinking PI # 1 was having a hard time having a BM. While fumbling with the jumpsuit and hair she somehow tied the zipper around his/her neck. The staff member immediately noticed it when he/she tried to rip the right side of the zipper off.

Review of the RN (Registered Nurse) progress note dated 2/27/2020 at 1:54 PM revealed the RN documented "while making rounds the RN went to see where PI # 1 was because he/she had been absent from group therapy room for longer than 20 minutes....As RN went towards PI # 1's room the RN met PI # 1 and the 1:1 sitter in the hallway in front of the med room. The MHW (1:1 sitter) told the RN PI # 1 had this around his/her neck and handed the RN the zipper from the jumpsuit. Red ligature marks and petechiae (red dots occurring from strangulation) were noted to PI # 1's face and neck. When the RN asked PI # 1 why he/she tried to hurt his/her self, PI # 1 started to smile and laughing, said "cause I want to kill myself." PI # 1 was instructed to remove the jumpsuit and was wrapped in a blanket until more appropriate clothing was obtained..."

Review of the Treatment Team Risk Evaluation Meeting documentation dated 2/27/2020 at 1:54 PM by the Psychiatrist revealed PI # 1 was at high risk for suicide. PI # 1 was placed in a suicide smock and PI # 1 can not have bras, panties, or other clothing items on his/her person or in His/her room. PI # 1 is to remain within arms reach and eye's view at all times, even when in the bathroom and shower...

Further review of the Treatment Team Risk Evaluation Meeting documentation on 2/27/2020 at 1:54 PM revealed under Suicide: Suicide Risk Level: Extreme. Explanation: Pt. (Patient) had two serious suicide attempts in two days, one on Feb. 25th, another one today (Feb 27th). First one needed resuscitation and sending him/her to the hospital.

Review of the ADMH (Alabama Department of Mental Health) Progress Note dated 2/27/2020 at 3:57 PM revealed the psychiatrist documented "was informed approximately at 1:15 PM PI # 1 had tried to harm his/her self again by tying a zipper around her neck at approximately 12:30 PM on 2/27/2020." Further review of the ADMH Progress note revealed PI # 1 was to be considered a serious risk for suicide due to his/her past behavior and the patient was currently on a 2:1 observation status and to remain on this status for his/her safety.

Review of the physician order dated 2/27/2020 at 5:05 PM revealed an order for 2:1 observation at all times during 24 hour/day. Remain within arm's reach and eye view at all times. Suicide smock only, hair braided, escort to bathroom. No bras, no panties, group therapy room from 7 AM to 7 PM.

Review of the Investigation Review Panel Minutes dated 3/10/2020 revealed in the conclusion section of the form Employee Identifier (EI) # 3, MHW I was responsible for conducting the Patient Accountability checks and even though she spoke with PI # 1 (while in the bathroom) EI # 3 did not make a visual assessment of PI # 1.

The following interviews were conducted on 3/11/2020 from 8:40 AM to 10:28 AM by the state surveyors:

An interview was conducted on 3/11/2020 at 9:25 AM with EI # 5, MHW assigned to PI # 1 from 12:00 PM to 1:00 PM.

The surveyor asked EI # 5, "what 1:1 and 2:1 observation means". EI # 5 responded, "Arms length of client". The surveyor asked EI # 5, "did this include while PI # 1 was in the bathroom" and EI # 5 stated, "yes, suppose too."

EI # 5 was asked if he/she recalled an incident which occurred on 2/27/2020 with PI # 1 EI # 5 stated yes he/she was 1:1 with PI # 1. EI # 5 continued by stating "I was giving a girl a break." EI # 5 stated PI # 1 had to use the restroom and she "acted like she was having a hard time using the bathroom. She kept fumbling with her hair and jumpsuit. Somehow, she got the zipper off and tried to wrap it around her neck, but I stopped her."

EI # 5 was asked if she was in eyes view of the patient and EI # 5 stated "I was standing at the door (open) while PI # 1 was in the bathroom. I was standing at the door and facing straight, and PI # 1 was beside me. I looked over when PI # 1 was fumbling and asked her what she was doing. PI # 1 said she was just using the restroom. He/She sat there for about 30 minutes trying to use the restroom."

EI # 5 was asked how was the zipper, which is on the back of the jumpsuit, undone for the patient to use the restroom? EI # 5 responded by stating "I unzipped the jumpsuit for PI # 1 so he/she could use the bathroom.."

An interview was conducted on 3/11/2020 at 3:30 PM with EI # 1, Facility Director, who confirmed the need for staff education due to the staff not following facility policy and procedure for the 1:1 Special Observations and Accountability checks, a suicide risk evaluation should have bee conducted after the first suicide attempt, PI # 1 should have been placed in a suicide smock, PI # 1 should have been within arms length and within eye view at all times and confirmed PI # 1 should have been provided a safe environment.