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Based on review of 6 of 6 open medical records (patients #1-#6), personnel files, policies and procedures and interviews, the hospital failed to ensure all patients have the right to receive care in a safe setting as evidenced by not: 1) increasing the observation level of a patient who voiced suicidal ideations and afforded him (patient #1) an opportunity to attempt suicide, 2) contacting the psychiatrist, DON and administrator after patient #1 verbalized suicidal ideations and 3) reporting to the on-coming shift patient #1's verbalization of suicidal ideations. Findings:

1. Review of the ED medical record revealed patient #1 was a 15 year-old who presented on 1/26/2010 at 7:47 PM by ambulance to Hospital A with chief complaint of "suicide ideation". Review of the ED nurse's assessment at Hospital A revealed the ED nurse documented that patient #1's mother stated that she caught patient #1 with a belt around his neck and he was trying to hang himself. The ED doctor noted the patient was awake, alert and oriented. According to documentation in the ED record at Hospital A on 1/27/2010 at 2:46 AM, patient #1 was transferred to Liberty Healthcare-Bastrop for treatment of major depression and suicide attempt.

Review of the open medical record revealed patient #1 was admitted to Liberty Healthcare Systems-Bastrop on 1/27/2010 at 4:30 AM on a PEC (Physician Emergency Certificate) and stated his reason for admission was "I guess I tried suicide". Review of physician orders dated 1/27/2010 at 4:30 AM revealed a diagnosis of depression and an observation level of "strict line of sight".

Review of the Psychiatric Evaluation dated 1/28/2010 at 10:15 AM by S17 psychiatrist revealed patient #1 "had been diagnosed with depression and anxiety. It should be noted that (patient #1) reports a history of multiple suicide attempts, the contemplation of committing suicide while at school by hanging himself. He also noted that he now recognizes he had experienced some psychotic symptoms in the form of auditory hallucinations for quite some time, and that he "simply learned to ignore". Further review revealed that patient #1's Axis I admitting diagnoses were "Major depressive disorder, recurrent with psychotic features, Anxiety disorder, rule out panic disorder without agoraphobia. Rule out prodromal (early symptoms prior to) symptoms of schizophrenia. Rule out oppositional defiant disorder, by history. Parent-child relational problem".

Review of the 2/17/2010 nursing flow sheet signed by S11RN revealed at 8:30 PM patient #1 was "already in bed, but awake. Very depressed, sad. Encouraged pt (patient #1) to tell what was wrong. Pt. stated he would rather commit suicide than go back and live with his aunt and uncle (guardians). Pt's voice was clear and firm. Also stated he was to talk to MD (medical doctor) tomorrow (2/18/2010). Encouraged to sincerely express himself to MD tomorrow. Will monitor pt. closely due to state of depression". Further review of the nursing flow sheet failed to reveal nursing staff increased the observation level (previous order for LOS), notified the psychiatrist, DON or administrator on call. Review of the 2/17/2010 pre-printed close observation form revealed nursing staff failed to indicate which level of observation the patient was on. Further observation revealed from 8:30 PM on 2/27/2010 until 8:15 AM on 2/18/2010 patient #1 was monitored every 15 minutes.

Review of the 2/18/2010 at 8:15 AM nursing flow sheet documented by S9 RN revealed, "pt (patient #1) was found on the floor by MHT, (S3) with a shirt, towel, and pillow case wrapped around his neck. According to MHT, (S3) pt. asked to go to the bathroom. He stated he checked on him several times (and) when he did not respond by saying 'I am ok' as he did the other times he checked he then opened the bathroom door and found him on the floor with the shirt, towel (and) pillow case wrapped around his neck (and) the other end was tied to the hand rail that is located next to the toilet. Pt began to fight the staff as we transferred him to the bed from the bathroom floor. He screamed 'Leave me alone'. Vital signs were taken B/P 150/77, P 156 (no) resp (respiratory) distress. (Oxygen) sat (saturation) 100% on room air. Upon inspection (no) bruises, lacerations or any type of discoloration or edema was noted around his neck. He was escorted to the day room when he was questioned. He stated 'I will do anything not to go back (and) live with them. Y'all don't believe me anyway'. Pt is noted angry, hostile and with a blunted affect. He stated 'I was just pretending to be happy by taking all of those happy pills'. Pt is now on 1:1 observation. The observation level is explained to pt (and) MHT. The pt responded by saying 'I don't care'. He is angry and does not exhibit any remorse. (S17 psychiatrist) was notified (at) 0825 (8:25 AM). She stated to put patient on 1:1.

In an interview on 2/22/2010 at 10:10 AM S9 RN stated she had been a RN for 13 years, worked at Liberty Healthcare since 5/09 and had 5 years psychiatric nursing experience. When questioned by the survey team if she thought the hospital had adequate staff to care for the patients, S9 replied they go by a staffing grid and they can always add extra staff if needed. S9 said there is always 1 RN and 1 LPN and the census dictated the number of MHTs scheduled. S9 said she was working 7AM-7PM on 2/18/2010 when patient #1 attempted suicide. She said they had received the shift report and the night nurse (S11 RN) told the day shift that patient #1 had a good night, slept well, but did not mention to them that the patient had verbalized suicidal ideations to her. S9 said the patients had eaten breakfast at 7:30 AM and she was in morning report when S6 MHT came in saying they needed a nurse for patient #1. S9 said when she got to the patient ' s room; he was lying on the bathroom floor with his back against the wall. S9 said she saw a pillowcase, towel and pajamas tied together on the floor and patient #1 was saying, "Leave me alone, and don't bother me!"

S9 RN was questioned by the survey team what she thought went wrong and what the hospital could do to prevent it from happening again? S9 replied, "The patient should not have been left alone, and according to the evening notes by S11 RN he should have been on 1:1 observation level. If I had read the notes, I could have called in more staff and he would have been on 1:1 (observation). As far as what can we do to prevent it from happening again, staff should be trained on 1:1 and Line of Sight because that goes with psychiatric training. If a patient asks if they can go to the bathroom, we should answer 'yes if I can go with you'. This should start with orientation".

On 2/19/2010 at 8:55 AM an interview was held with S3 MHT who stated he had worked at Liberty Healthcare-Bastrop since 11/09 and did not have prior psychiatric training. When questioned by the survey team about his understanding of what Line of Sight observation meant to him S3 replied, "Keep the patient in sight as close as you can. If they have to go to the bathroom, this changes their status. It depends on how many patients you have. You must watch the patient go (to the bathroom) and I allow 1 minute for urination and 2-3 minutes for a bm (bowel movement) before I check on the patient". When questioned if he had been trained on what to do when a patient on Line of Sight needed to go to the bathroom, S3 responded, "I have some knowledge, but I have not been briefed all the way".

S3 MHT said on the morning of 2/18/2010 at approximately 8:00 AM all patients were in the dayroom when patient #1 told him that he needed to go to the bathroom. S3 said all patients use the bathroom in their rooms so he walked with patient #1 to the bathroom. S3 said after approximately 1 minute he knocked on the bathroom door and called out to patient #1 who said he was all right but needed to "take #2" (bowel movement). S3 said he ran back to check on his other patients in the dayroom (another tech was monitoring these patients and no one was on 1:1 observation) and when he returned the patient had been in the bathroom approximately 5 minutes. S3 stated he knocked on the bathroom door and when patient #1 did not respond, he went into the bathroom and found patient #1 with a towel, pillowcase and a pajama top knotted together and tied around his neck. S3 said the patient tried to pull harder on the noose he had constructed but he (S3) "knocked his hand away", loosened the articles and removed them from around the patient's neck. S3 MHT stated patient #1 was breathing, but seemed dazed. S3 further stated once he removed the noose, he laid the patient down and called for help.

S3 stated once help arrived, he and S10 LPN lifted the patient onto the bed and restrained his hands to keep him on the bed because he was trying to get up. S3 stated after the nurses assessed patient #1 they allowed him to sit for a few minutes and then the patient went to the dayroom with the other patients. S3 said after that incident, patient #1 went to 1:1 observation level.

When the survey team questioned S3 MHT if he was clear about bathroom privileges for patients on Line of Sight observation, he responded, "It's kinda like a judgment thing because it is a gray area. On 1:1 you go into the bathroom with the patient and you tell that patient that you have to go with him. If the patient is on Line of Sight and the patient goes to the bathroom I go in with the patient but not if the patient has a history of abuse. You must use your judgment".

In a telephone interview on 2/22/2010 at 11:10 AM S11 RN stated she had worked at Liberty Healthcare since 11/09 and she did not have previous psychiatric nursing experience. She said she worked the 7PM-7AM shift and on the evening of 2/17/2010 the patients were in the dayroom and she sat and visited with patient #1. S11 RN said she asked the patient how he was doing because he seemed depressed and sad. S11 said patient #1 said to her that he would rather commit suicide than go home with his aunt and uncle after discharge from the hospital. S11 RN said the patient would not make eye contact so she patted him on the shoulder and said to him, "they are still working on the arrangements and I'm going to check on you every hour during the night and the MHT will check on you every 15 minutes".

S11 RN said she did not call the patient's physician and looking back she wish she had contacted the psychiatrist and placed the patient on 1:1 observation. S11 stated "I did not know to do that". S11 RN said she checked patient #1 closely throughout the night and that he slept all night. S11 further stated she did report to the oncoming shift on 2/18/2010 what patient #1 said to her the evening before he attempted suicide, but could not recall the exact words she said to the nurses. She stated, "Up to this point (2/17/2010) the patient had not said anything about suicide and I didn't expect anything like this to happen".

In an interview on 2/22/2010 at 12:45 PM, S7 DON stated the hospital has a policy that if a patient is on Line of Sight, the observation at hour of sleep goes to every 15 minutes and within audible contact at all times until 7:00 AM. S7 said she felt that many times the patients need to go to every 15 minutes (even during the day) but this is only done at night and that she felt it was "a money thing" (to save money). S7 DON said when a patient is on Line of Sight and needs to go to the bathroom, the MHT that has that patient should ask another tech to watch his/her other patients and go to the bathroom with the patient. S7 added that was what a new MHT is taught to do. The survey team asked S7 DON what she considered MHT S3 did wrong and she stated, "The child should not have been left alone. He (S3) let the patient go to the bathroom alone, the patient shut the door and the MHT didn't stay with the patient and watch him". When questioned if anyone was delegated to make sure everyone adhered to Line of Sight observation, S7 did not identify anyone assigned to this task.

Review of the employee's personnel files maintained by Liberty Healthcare Systems revealed there were 4 RNs (S9, S18, S20 and S22) with psychiatric nursing experience prior to their employment at Liberty Healthcare-Bastrop and 4 RNs (S5, S11, S19 and S21) who did not have prior psychiatric nursing experience. It was also noted that the performance evaluations and competencies for all 8 RNs were not done until the nurse had worked 3 months. Review of the personnel file for S11 RN (the nurse who admitted patient #1 to Liberty Healthcare Systems and the nurse to whom patient #1 expressed suicidal ideations on 2/17/2010) revealed a hire date of 8/21/09. Further review revealed S11 did not have prior psychiatric nursing experience.

In an interview on 2/24/2010 at 1:30 PM S7 DON confirmed there failed to be documented evidence that nursing personnel had the training and competency to provide nursing care and services to patients with psychiatric diagnoses and exhibited high risk behaviors. During the interview S7 DON said she felt the staff at Liberty Healthcare is "adequately trained". She stated, "We give the nurses 2 weeks with a preceptor and I tell the nurse if they don't feel comfortable with taking a shift and need longer orientation, I'll come out and help them". S7 said the hospital did not have a formal orientation program and further stated each shift consists of 1 RN, 1 LPN, and 1 or more MHTs depending on the staffing grid and patient census. S7 said all RNs are charge nurses but she tries to schedule the RNs without prior psychiatric nursing experience "with a strong LPN with psychiatric experience".

In an interview on 2/23/2010 at 3:30 PM S17 attending psychiatrist for patient #1 said when a patient is on Line of Sight, it means visual and peripheral sight at all times but she was not sure about bathroom privileges because the patient does need some privacy. S17 stated she did not know that patients on Line of Sight observation went to every 15 minutes observation at night because she had been in the hospital as late as 8:00-9:00 PM and would see several MHTs down the hallways outside patient rooms. S17 said patient #1 "is a hard case to work with because he is manipulative and his genetic and environmental makeup predisposed him to future problems".

2. Review of the open medical records for patients #2-#6 revealed diagnoses of either homicidal or suicidal attempts or ideations. Further review revealed that these patients were at risk for self-harm and the same staff provided direct care to them as for patient #1.

Based on record review, personnel files, policies and procedures and interviews, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1) Failure to have documented evidence that all nurses have the training and competencies and are determined competent to provide nursing care and services to patients with psychiatric diagnoses and to patients who exhibited high risk behavior, (See findings A0395 and A0397)

2) Failure to increase the observation level and contact the psychiatrist or physician and DON after a patient verbalized suicidal ideations which resulted in a 15 year-old attempting to hang himself, (See findings A0395)

3) Failure to ensure all patients with suicidal ideations are reassessed for potential for self-harm, (See findings A0395)

4) Failure to identify patients at risk for self-harm (i.e. suicide) as a primary problem on the treatment plan that was not individualized for each patient, (See findings under A0396 and B118), and

5) Failure to implement policies and procedures to notify the psychiatrist and the director of nursing services when patients voiced or exhibited behaviors indicative of suicidal ideations (See findings A0395).

The culmination of the deficient practices identified for Nursing Services resulted in an Immediate Jeopardy situation which was identified on 2/25/2010 at 10:30 AM and reported to the Administrator. The Immediate Jeopardy was a result of the hospital's failure to ensure a process was in place to ensure all RNs who provided direct patient care had the training and competency to provide nursing care and services to psychiatric patients. As a result of the hospital's acceptable plan of action, the Immediate Jeopardy situation was removed on 2/25/2010 at 3:50 PM with an acceptable plan of correction.

The hospital submitted the following corrective action plan and the Immediate Jeopardy situation was removed on 2/25/2010 at 3:50 PM.

1) Policy #8001 New Employee Orientation was approved by the Governing Body in a meeting held on 2/25/2010. This policy indicated all nurses hired are required to complete 30 contact hours of specific psychiatric nursing training and complete training on the "Management of the Suicide Patient with pre/post tests",

2) Policy #2010 "Assessment for Suicide and Homicide was approved during the Governing Body meeting on 2/25/2010 which was revised to include contacting the Psychiatrist, Administrator on call, and DON when a newly admitted patient or current patient exhibits suicidal/homicidal threats. The patient will immediately be placed on 1:1 observation,

3) The nursing flow sheet was revised and approved by the Governing Body to include suicidal and homicidal criteria,

4) Policy #2012 "Assessment for Suicide" was revised, approved by the Governing Body on 2/25/2010, posted at the nurses station and staff was in-serviced on the changes. These processes will be monitored by the DON and Performance Improvement Coordinator.

The deficient practice remains at condition level.

Based on review of 1 of 1 open medical records of patients who attempted suicide (#1) in a total sample of 6, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for patient #1 who verbalized suicidal ideations to an RN on 2/17/2010. The nurse failed to increase the patient's observation level, reassess the patient, or contact the physician. Additionally, the hospital failed to implement a policy to notify the psychiatrist and the director of nursing services when a patient voiced or exhibited behaviors indicative of suicidal ideations. As a result, patient #1 attempted suicide on 2/18/2010. Findings:

Review of the open medical record revealed patient #1 was a 15 year-old who attempted suicide by hanging while at his mother's home. Patient #1 was admitted to Liberty Healthcare-Bastrop on 1/27/2010 at 4:30 AM and the psychiatrist ordered the patient to be on "strict line of sight".


Review of the Psychiatric Evaluation dated 1/28/2010 at 10:15 AM by S17 psychiatrist revealed, "It should be noted that (patient #1) reports a history of multiple suicide attempts, the contemplation of committing suicide while at school by hanging himself". Further review revealed that patient #1's Axis I admitting diagnoses were "Major depressive disorder, recurrent with psychotic features, Anxiety disorder, Parent-child relational problem". S17 further documented: 1) Axis IV- Severe as evidenced by the patient's recent suicide attempt that was nearly successful, as evidenced by the patient's loss of consciousness, lack of respirations, and weak pulse, as well as his required hospitalization for 2-1/2 days and 4) GAF (Global Assessment Function is) score is 5-10" (a numerical scale from 0-100 that represents the severity of the patient's psychiatric condition, the lower the number the most severe the condition).


Review of nursing progress notes dated 2/17/2010 at 8:30 PM revealed S11 RN documented that patient #1 was "already in bed, but awake. Very depressed, sad. Encouraged patient to tell what was wrong. Pt. stated he would rather commit suicide than go back and live with his aunt and uncle. (guardians). Pt's voice was clear and firm. Also stated he was to talk to MD (medical doctor) tomorrow (2/16/2010). Encouraged to sincerely express himself to MD tomorrow. Will monitor pt. closely due to state of depression".

Further review of the nursing flow sheet failed to reveal the nursing staff increased the patient's level of observation (previous order for strict Line of Sight), notified the psychiatrist, DON or administrator on-call, or reassessed the patient throughout the night. Review of the 2/17/2010 pre-printed close observation form (form staff uses to document the patient's location and behavior every 15 minutes) revealed nursing staff failed to indicate the level of observation (1:1, Line of Sight or every 15 minutes) the patient was on during the night of 2/17/2010. Further review of the observation form revealed from 8:30 PM on 2/17/2010 until 8:15 AM on 2/18/2010 patient #1 was monitored every 15 minutes.

Review of the 2/18/2010 at 8:15 AM nursing flow sheet documented by S9 RN revealed, "pt (patient #1) was found on the floor by MHT (S3) with a shirt, towel, and pillow case wrapped around his neck. According to MHT pt. asked to go to the bathroom. He stated he checked on him several times (and) when he did not respond by saying 'I am ok' as he did the other times he checked he then opened the bathroom door and found him on the floor with the shirt, towel (and) pillow case wrapped around his neck (and) the other end was tied to the hand rail that is located next to the toilet. Pt began to fight the staff as we transferred him to the bed from the bathroom floor. He screamed, 'Leave me alone'. Vital signs were taken B/P 150/77, P 156 (no) resp (respiratory) distress. (Oxygen) sat (saturation) 100% on room air. Upon inspection (no) bruises, lacerations or any type of discoloration or edema was noted around his neck. He was escorted to the day room when he was questioned. He stated 'I will do anything not to go back (and) live with them (guardians). Yall don't believe me anyway'. Pt is noted angry, hostile and with a blunted affect. He stated, 'I was just pretending to be happy by taking all of those happy pills'. Pt is now on 1:1 observation".


In an interview on 2/22/2010 at 12:45 PM, S7 DON stated that the hospital has a policy if a patient is on Line of Sight, the observation level at hour of sleep (9:00 PM) goes to every 15 minutes and staff remains within audible contact at all times until 7:00 AM. S7 said she felt that many times the patients need to go to every 15 minutes (even during the day) but this is only done at night and that she felt it was "a money thing" (to save money). S7 DON said when a patient is on Line of Sight and needs to go to the bathroom, the MHT responsible for the patient should ask another tech to watch his/her other patients and go to the bathroom with the patient. S7 DON stated she talked to S11 RN, to whom patient #1 verbalized suicidal ideations, and told her she should have documented she made hourly rounds on patient #1 on 2/17/2010 after he verbalized suicidal ideations to her, and that she should have called the patient's doctor and asked for an increase in observation.

In a telephone interview on 2/22/2010 at 11:10 AM S11 RN stated she had worked at Liberty Healthcare-Bastrop since 11/09 and did not have any prior psychiatric nursing experience or training. She said she worked the 7PM-7AM shift and on the evening of 2/17/2010 she asked patient #1 how he was doing because he seemed depressed and sad. S11 said patient #1 said to her that he would rather commit suicide than go home with his guardians after discharge from the hospital. S11 RN said the patient would not make eye contact so she patted him on the shoulder and said to him, "they are still working on the arrangements and I'm going to check on you every hour during the night and the MHT will check on you every 15 minutes".

Further interview at that time with S11RN revealed she did not call the patient's physician and looking back she "wish she had contacted the psychiatrist and placed the patient on 1:1 observation". S11 stated "I did not know to do that". S11 RN said she checked patient #1 closely throughout the night and that he slept all night, but she failed to document it.

During the interview S11 RN stated, "It brings to front if a kid says something like he (patient #1) did, I need to call the doctor. I knew he didn't want to go home and I don't recall getting this type of information in orientation. I thought he was getting better and getting his troubles worked out. Up to this point (2/17/2010) the patient had not said anything about suicide and I didn't expect anything like this to happen".

Review of the personnel files maintained by the hospital revealed there were 9 RNs including S7 DON. Further review of the files revealed there were 4 nurses with psychiatric nursing experience prior to their employment at Liberty Healthcare-Bastrop (S9, S18, S20, and S22) and 4 nurses who did not have prior psychiatric nursing experience or training (S5, S11, S19, and S21). It was also noted that the performance evaluations and competencies for all 8 RNs were not done until the nurses had worked 3 months. There failed to be documented evidence the nurses' received psychiatric training or that their competencies were assessed prior to providing direct patient care.

Further review of personnel files revealed S11 RN did not have a preceptor check-off sheet in her file and the DON did not document a performance evaluation until 11/09 (no day documented). S7 DON documented, "Knowledge increases daily in psychiatric nursing". In an interview on 2/24/2010 at 1:30 PM S7 DON confirmed there failed to be documented evidence that all nurses had been determined qualified and competent in all aspects of nursing care prior to assignment of patient care.

During the interview S7 DON said she felt the staff at Liberty Healthcare is "adequately trained". She stated, "We give the nurses 2 weeks with a preceptor and I tell the nurse if they don't feel comfortable with taking a shift and need longer orientation, I'll come out and help them". S7 said the hospital did not have a formal orientation program and further stated each shift consists of 1 RN, 1 LPN, and 1 or more MHTs depending on the staffing grid and patient census. S7 said all RNs are charge nurses but she tries to schedule the RNs without prior psychiatric nursing experience "with a strong LPN with psychiatric experience".

Review of the Suicide Precautions Policy, (Reference #2009, Revised 10/2008) revealed "suicide precautions will be ordered by the physician, but nursing personnel will implement suicide precautions while awaiting the order. All patients placed on suicide precautions will be assigned an acuity level (every 15 minutes, Line of Sight, or 1:1 observation levels) based upon the severity of the suicidal thoughts, plan, or behavior. Liberty Healthcare Systems' observation for hs (hour of sleep) is q (every) 15 minutes and within audible contact at all times until 0700 (7:00 AM)". Review of the Administrator On-call Policy (Reference #7007, Revised 1/2009) revealed the "charge nurse will notify the administrator on-call" for patients who commit "suicide or serious attempt".

In an interview on 2/23/2010 at 3:30 PM S17 psychiatrist said she believed the major problem at Liberty healthcare was the lack of staff education. She stated when she came to work at this hospital she assumed the nurses were trained in psychiatric nursing but the incident with patient #1 made her aware of the need for more training.

Based on review of 5 of 6 open medical records, policies and procedures, and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient by: 1) failing to identify patients at risk for self-harm (i.e. suicide) as a primary problem on the care plan for patients #1, #2, #4, #5, and #6, 2) failing to review and revise care plans, and 3) failing to attend weekly treatment team meetings to review and discuss the treatment plan. Findings:
1. Review of the open medical record revealed patient #1 was admitted on 1/27/2010 on a PEC (physician emergency certificate) for suicidal ideation with a suicide attempt on 1/26/2010. According to the psychiatric evaluation by S17 Psychiatrist dated 1/28/2010 at 10:15 AM revealed patient's Axis I admitting diagnoses were "Major depressive disorder, recurrent with psychotic features, Anxiety disorder, rule out panic disorder without agoraphobia. Rule out prodromal symptoms of schizophrenia. Rule out oppositional defiant disorder, by history, Axis IV- Severe as evidenced by the patient's recent suicide attempt that was nearly successful, as evidenced by the patient's loss of consciousness, lack of respirations, and weak pulse, as well as his required hospitalization for 2-1/2 days". According to the information by S17 Psychiatrist, patient #1 had a prior history of suicide attempts.

Review of patient #1's master treatment plan on 2/19/2010, which was initiated on 1/27/2010 by S11 RN, revealed the patient's primary diagnosis was "Depression" and the secondary diagnosis of "Risk for Suicide" with 2/05/2010 documented as the short-term target dates for the treatment plan interventions. Further review of the care plan revealed there was no documentation to indicate if the goals or the target date were met for the patient. It was further noted that although patient #1 presented with suicidal ideations with a recent suicide attempt and unable to contract for safety, the nurse made "Risk for Suicide" as the patient's secondary problem and not the patient's primary problem. Further review of the master treatment plan failed to reveal approaches and interventions for a change of status which reflected patient #1's suicide attempt on 2/18/2010.

2. Review of the open medical record on 2/23/2010 revealed patient #2 was admitted to the hospital on 2/10/2010 on a PEC due to suicidal ideations. Review of the information in the 2/11/2010 psychiatric evaluation revealed the patient had an Axis I diagnosis of Major Depression without Psychosis versus with Psychosis.

Review of the psychiatrist's documentation revealed that on 2/18/2010 patient #2 had "endorsed significant symptoms of suicide ideation with at least 3 plans to harm herself while in hospital". As a result, patient #2 was placed on a 1:1 observation level.

Review of the master treatment plan revealed the nurse identified patient #2's primary problem as "Depressed Mood" and the secondary problem as "Risk of Suicide and Elopement". It was further noted that the treatment plan did not contain revisions nor was it completed or signed by an RN.

3. Review of the open medical record revealed patient #4 was admitted to the hospital on 2/06/2010 with diagnoses "Axis I- Psychosis not otherwise specified; Substance induced psychosis; Major depression with psychosis. Further review of the record revealed the master treatment plan was imitated on 2/06/2010 and the nurse identified the patient's primary diagnosis as "Depressed Mood" with the secondary problem listed as "Risk for Suicide". Further review of the master treatment plan revealed that two weekly treatment plan meetings did not indicate an RN attended the meetings or signed the updates.

4. Review of the open medical record revealed patient #5 was admitted to the hospital on 2/06/2010 at 7:00 PM on a PEC for suicidal and homicidal ideation. Review of the admission diagnosis revealed: "Axis I- Oppositional defiant disorder, History of Psychosis, Psychosis Not otherwise specified. Review of the master treatment plan revealed the plan was initiated on 2/06/2010 by an RN and the patient's short term goals for the interventions the nurse identified had a target date of 2/13/2010. Further review of the plan revealed it had not been revised or updated to indicate whether target dates were/not met. Further review of the master treatment plan revealed the patient's primary problem was "Disturbed Sensory Perception" and the secondary problem was listed as "Risk for Suicide".

5. Review of the open medical revealed patient #6 was admitted to the hospital on 2/17/2010 on a PEC due to suicidal ideations. Review of the patient's diagnoses revealed "Axis I-Depressive disorder, not otherwise specified. Review of the master treatment plan revealed the RN documented the patient's primary problem as "Depressed Mood" and the secondary problem was identified as "Risk for Suicide".
Review of policy titled "Master Treatment Plan" (reference #2037A) revealed the RN would initiate the patient care plans and list the problems with interventions and documented short and long term goals. Further review revealed the policy indicated staff would check the care plan "every shift for revisions or goals met".

In an interview on 2/22/2010 at 10:30 AM, S1 Performance Improvement Coordinator and S7 DON confirmed that the master treatment plans for patients #1, #2, and #4-#6 were individualized and the weekly summaries were incomplete. According to S7 DON, the 7PM-7AM RN is responsible for ensuring the weekly reviews are completed. S7 further confirmed that all care plans are to be reviewed weekly and revised as often as needed.
















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Based on record review and interviews the hospital failed to ensure a registered nurse assigned the nursing care and services to staff according to the needs of the patient and according to specialized qualifications and competence of the staff member. The DON failed to ensure that 4 of 4 RNs (S5, S11, S19 and S21) in a total sample of 8 and 4 of 4 MHTs (S3, S6, S13 and S15) with no prior mental health experience or training were deemed competent to provide nursing care for patients with diagnosed psychiatric disorders. Finding:


Review of the ED (emergency department) record revealed patient #1 was a 15 year-old male who presented to Hospital A by ambulance on 1/26/2010 at 7:47 PM with a chief complaint of "suicide ideation". Review of the 1/26/2010 at 7:53 pediatric assessment performed by the ED nurse revealed "Pt (patient) would only shake his head yes when asked by (ED doctor) if he tried to hurt himself. The mother states that she caught him with a belt around his neck and was trying to hang himself". Documentation by the ED physician revealed the clinical impression for patient #1 was major depression, acute exacerbation and suicide attempt. The physician progress notes dated 1/27/07/2010 at 2:33 AM revealed patient #1 was transported on 1/27/2010 at 2:46 AM by Emergency Medical System (EMS) to Liberty Healthcare Systems-Bastrop on suicide precautions. Review of the medical record revealed patient #1 was admitted to Liberty Healthcare Systems-Bastrop on 1/27/2010 at 4:30 AM with a Physician Certificate for a Minor. Review of the information on the form revealed the physician documented, patient #1 had a "history of suicidal ideations".

Review of 1/27/2010 at 4:30 AM admission assessment form signed by S11RN revealed patient #1 said in his "own words" that the reason for his admission was "I guess I tried suicide". These assessments also indicated patient #1 had auditory hallucination because he "stated today he felt like several voices telling him 'They won't miss you".

Review of the 1/27/2010 at 4:30 AM physician orders revealed a diagnosis of depression and an observation level of "strict line of sight" (LOS). Review of the History and Physical dated 1/27/2010 at 1:30 PM and signed by the Family Nurse Practitioner, revealed patient #1 reported that he was "found unconscious in bathroom (after) S/A (suicide attempt) by hanging" and his "prev. (previous) attempted (at) school".

According to hospital policy "Suicide Precautions" (reference #2009, effective 7/2005, revised 10/2008) LOS "is very restrictive toward the patient and involves continuous visual monitoring at all times. Staff must be within visual contact at all times with the exception of toileting and showering during which times staff shall be present outside a door left ajar but remain in audible contact with the patient. A staff member may observe more than one patient on line of sight observation only while those patients remain in an area for scheduled activity (i.e. group therapy, during dining, outside break or activity). If a staff member is observing more than one patient and one or more of the patients go to separate areas, the staff must transfer responsibility for line of sight to other staff member(s) so that there is continuous observation for all patients on line of sight. Nursing personnel must maintain a continuous log which indicates the patient's location every 15 minutes and documents the patient's thought and behaviors throughout each shift. Patient's on this level are considered high risk and documentation must reflect the need for continued line of sight or improvement in behaviors and thoughts, which allows the patient to be categorized to a level II". According to policy Staffing-Nursing Levels of Observation (reference #7004, revised 1/2009), " if a patient's condition requires special precautions, (i.e. suicide precautions), the physician will write and order identifying the specific precautions required."

Review of documentation on the 2/17/2010 nursing flow sheet signed by S11RN revealed at 8:30 PM patient #1 was "already in bed, but awake. Very depressed, sad. Encouraged pt (patient #1) to tell what was wrong. Pt. stated he would rather commit suicide than go back and live with his aunt and uncle. Pt's voice was clear and firm. Also stated he was to talk to MD (medical doctor) tomorrow (2/18/2010). Encouraged to sincerely express himself to MD tomorrow. Will monitor pt. closely due to state of depression". Further review of the nursing flow sheet failed to reveal nursing staff increased the patient's level of observation (previous order for LOS), notified the psychiatrist, the MD on call, DON, or administrator on call that the patient voiced suicidal ideations. Review of the 2/17/2010 pre-printed close observation form revealed nursing staff failed to indicate which level of observation the patient was on (strict line of site was ordered on admission). Further observation revealed from 8:30 PM on 2/17/2010 until 8:15 AM on 2/18/2010 patient #1 was monitored every 15 minutes.

Review of the 2/18/2010 at 8:15 AM nursing flow sheet documented by S9 RN revealed "Pt (patient #1) was found on the floor by MHT, (S3) with a shirt, towel, and pillow case wrapped around his neck. According to MHT, (S3) pt. asked to go to the bathroom. He stated he checked on him several times (and) when he did not respond by saying 'I am ok' as he did the other times he checked he then opened the bathroom door and found him on the floor with the shirt, towel (and) pillow case wrapped around his neck (and) the other end was tied to the hand rail that is located next to the toilet. Pt began to fight the staff as we transferred him to the bed from the bathroom floor. He screamed 'Leave me alone'. Vital signs were taken B/P (blood pressure) 150/77, P (heart rate) 156 (no) resp (respiratory) distress. (Oxygen) sat (saturation) 100% on room air. Upon inspection (no) bruises, lacerations or any type of discoloration or edema was noted around his neck. He was escorted to the day room when he was questioned. He stated 'I will do anything not to go back (and) live with them. Yall' all don't believe me anyway'. Pt is noted angry, hostile and with a blunted affect. He stated 'I was just pretending to be happy by taking all of those happy pills."

In an interview on 2/19/2010 at 8:55 AM S3 MHT stated he was employed by Liberty Healthcare Systems-Bastrop in 11/09 and did not have prior psychiatric training or experience. When questioned by the survey team about his understanding of what Line of Sight observation meant to him S3 replied, "Keep the patient in sight as close as you can. If they have to go to the bathroom, this changes their status. It depends on how many patients you have. You must watch the patient go (to the bathroom) and I allow 1 minute for urination and 2-3 minutes for a bm (bowel movement) before I check on the patient".

The survey team asked S3 MHT if he was clear about bathroom privileges for patients on Line of Sight observation, he responded, "It's kinda like a judgment thing because it is a gray area. On 1:1 you go into the bathroom with the patient and you tell that patient that you have to go with him. If the patient is on Line of Sight and the patient goes to the bathroom I go in with the patient but not if the patient has a history of abuse. You must use your judgment".

On 2/19/2010 at 1:35 PM an interview was held with S6 MHT who said she had worked at Liberty Healthcare since 2005 and until recently had been the MHT supervisor (they eliminated the position). S6 MHT said on 2/18/2010 she was working with S3 MHT and she asked him had he done his room checks and he told her no. When patient #1 said he had to go the bathroom, she told S3 she would watch his other patients while he took patient #1 to the bathroom and to go ahead and do the room checks. S6 said she watched S3 walk with patient #1 half way down the hall and then allowed the patient to enter his room alone. S6 said S3 MHT went into room 13 first and then went into patient #1's room, walked out and came back to the dayroom to check on his other patients. S6 said after that, S3 MHT went back to patient #1's room and a few seconds later the housekeeper called her name so she ran to patient #1's room. S3 said when she arrived at the room, S3 MHT was removing something from around patient #1's neck so she ran for the nurses and then she went back to the dayroom to monitor the other patients.

An interview on 2/19/2010 at 2:05 PM with S5 RN revealed she has been an RN for 35 years but did not have psychiatric nursing experience. S5 stated she has worked at Liberty Healthcare for two weeks and this was her last week in orientation. When the survey team asked S5 RN what she had learned during her orientation, she answered "the routine of the unit, charting, admissions, discharges, the MHTs job, observing interactions between the MHTs and the patients, morning rounds, and patient goals for the day". S5 said she did not know the different levels of observation until she asked about them because the different levels are on the nursing flow sheets. S5 added during her orientation her preceptor time was spent with several different nurses.

S13 MHT said in an interview on 2/24/2010 at 9:03 AM that she had worked at Liberty Healthcare for the past 5 months. She said she works the 11:00 PM shift and did not have prior experience. The survey team questioned S13 about what she learned during her orientation and she said, "They talked to us about how to handle patients when they act out". S13 said Line of Sight to her meant "when you have to watch a patient close. I don't think it's 1:1"

On 2/24/2010 at 9:40 AM an interview was held with S15 MHT who stated she had worked at Liberty Healthcare for 3 years and did not have prior healthcare experience. S15 said she usually works the 3PM-11PM shift. S15 said when a patient is on Line of Sight and the patient needs to go to the bathroom, she walks with the patient halfway down the hall to the patient's room and the patient goes into the bathroom alone. S15 said the only time she goes with the patient into the bathroom is when he/she is on 1:1 observation. S15 stated if a patient is on 1:1 at night, the MHT sits in the doorway to the patient's room and if the patient is on Line of Sight observation, the MHT sits in the hallway and checks on the patient every 15 minutes. S15 stated when she trains another MHT, she teaches that individual to watch the patient closely and how to chart on the observation flow sheet.

In an interview on 2/22/2010 at 12:45 PM, S7 DON stated she assumed her position 2 years ago and she has 10 years psychiatric nursing experience, which included eight years with geriatric patients. S7 DON said she felt the staff at Liberty Healthcare is "adequately trained". She stated, "We give the nurses 2 weeks with a preceptor and I tell the nurse if they don't feel comfortable with taking a shift and need longer orientation, I'll come out and help them". S7 further stated, we should put each new admit on at least Line of Sight or 1:1 observation if they have a history of, or threatened to harm themselves. S7 DON added she thought it was a "miscommunication between the night and day shifts on 2/18/2010" but added the hospital did not have a policy/procedure to follow when a patient voiced suicidal ideations. She also stated that the hospital did not have a policy which defined "strict Line of Sight" or the procedure for the observation level.

Review of employee personnel files maintained by Liberty Healthcare Systems revealed there were 4 RNs (S9, S18, S20 and S22) with psychiatric nursing experience prior to their employment at Liberty Healthcare-Bastrop and 4 RNs (S5, S11, S19 and S21) who did not have prior psychiatric nursing experience. It was also noted that the performance evaluations and competencies for all 8 RNs were not done until the nurse had worked 3 months.

Review of the personnel file for S11 RN (the nurse who admitted patient #1 on 1/27/2010 to Liberty Healthcare Systems and the nurse to whom patient #1 expressed suicidal ideations on 2/17/2010) revealed a hire date of 8/21/09. Further review revealed S11 had no prior psychiatric nursing experience. The administrator stated in an interview on 2/24/2010 at 2:30 PM that there was no documented evidence that competencies for S11 RN were evaluated before allowing her to be charge nurse and before allowing her to provide care and services to patients at Liberty Healthcare-Bastrop (psychiatric hospital).

Review of the orientation packet for MHTs, provided by S7 DON, failed to reveal observation levels were addressed during orientation and prior to the MHTs' working on the unit. In an interview on 2/22/2010 at 12:45 PM, S7 DON confirmed there was no documentation that observation levels are addressed in MHT orientation. S7 added the MHTs have one day of classroom orientation and then they work two weeks with a preceptor.

S7 DON indicated that she addressed observation flow sheets during MHT orientation because she "knows they (MHTs) will be responsible" for the forms. Review of this form failed to reveal observation levels were identified or explained. Additionally, suicide precautions or suicide ideations were not addressed on the observation form.

In an interview on 2/23/2010 at 2:30 PM S17 Psychiatrist stated she believed the major problem at Liberty healthcare was the lack of staff education. She stated when she came to this hospital she assumed the nurses were trained in psychiatric nursing but the incident with patient #1 made her aware of the need for more training.

Based on review of 6 of 6 open medical records, policies and procedures, and interviews, the hospital failed to ensure each patient had an individual comprehensive treatment plan by failing to ensure: 1)the treatment plans for patients #1, #2, #3, #4, #5 and #6 were individualized and based on patient needs, and 2) weekly treatment team reviews were conducted with all relevant team members attending and participating in reviewing, discussing, and updating the plans of care. Findings:
1. Review of the open medical record revealed patient #1 was admitted on 1/27/2010 on a PEC (physician emergency certificate) for suicidal ideation with a suicide attempt on 1/26/2010. According to the psychiatric evaluation by S17 Psychiatrist dated 1/28/2010 at 10:15 AM revealed patient's Axis I admitting diagnoses were "Major depressive disorder, recurrent with psychotic features, Anxiety disorder, rule out panic disorder without agoraphobia. Rule out prodromal symptoms of schizophrenia. Rule out oppositional defiant disorder, by history, Axis IV- Severe as evidenced by the patient's recent suicide attempt that was nearly successful, as evidenced by the patient's loss of consciousness, lack of respirations, and weak pulse, as well as his required hospitalization for 2-1/2 days".
Review of patient #1's master treatment plan on 2/19/2010, which was initiated on 1/27/2010 by S11 RN, revealed a primary diagnosis of "Depression" and a secondary diagnosis of "Risk for Suicide" with 2/05/2010 documented as the short-term target dates for the treatment plan interventions. Further review of the plan revealed there was no documentation to indicate if the goals or the target date were met for the patient. It was further noted that although patient #1 presented with suicidal ideations with a recent suicide attempt and unable to contract for safety, the nurse made "Risk for Suicide" as the patient's secondary problem and not the patient's primary problem.

Further review of the master treatment plan revealed that the interventions section was incomplete and did not specify which staff was responsible for each intervention to ensure they were completed. Review of the multidisciplinary master treatment plan weekly summary for patient #1 revealed the plans were incomplete and documentation was not done on a consistent basis as evidenced by not having all disciplines sign the summary. On the weekly summary for 2/04/2010, only the psychiatrist documented a note. Only the psychiatrist and the activity director made an entry on the 2/11/2010 weekly summary and there failed to be a weekly summary done for the week of 2/18/2010. Additionally, there failed to be approaches and interventions for a change of status which reflected patient #1's suicide attempt on 2/18/2010.

2. Review of the open medical record on 2/23/2010 revealed patient #2 was admitted to the hospital on 2/10/2010 on a PEC due to suicidal ideations and that the psychiatric evaluation was completed 2/11/2010. Review of the information in the psychiatric evaluation revealed the patient had an Axis I diagnosis of Major Depression without Psychosis versus with Psychosis, Axis IV- Severe; and Axis V- 30.

Review of the psychiatrist's documentation for patient #2 revealed that on 2/18/2010 patient #2 had "endorsed significant symptoms of suicide ideation with at least 3 plans to harm herself while in hospital". As a result, patient #2 was placed on a 1:1 observation level.

Review of the master treatment plan for patient #2 revealed the staff identified the patient's primary problem as "Depressed Mood" and the secondary problem as "Risk of Suicide and Elopement". It was further noted that the treatment plan did not contain revisions nor was it completed or signed by the attending psychiatrist or an RN.

3. Review of the open medical record revealed patient #3 was admitted on a physician emergency certificate for "assaulting police". Review of the psychiatric evaluation revealed admitting diagnoses which included Axis I- Anxiety disorder, not otherwise specified; rule out substance abuse mood disorder; Polysubstance abuse; Oppositional defiant disorder. Axis II- Cluster B personality traits; Axis IV- Severe; Axis V- 15-20.

Further review of the record for patient #3 revealed the master treatment plan was completed on 2/18/2010 and listed the patient's primary problem as "Depressed Mood" and the secondary problem as "Risk for Suicide and Elopement". Further review revealed the master treatment plan failed to address care plan approaches for substance abuse, anxiety, or elopement. Further review of the medical record revealed the weekly treatment plan summary dated 2/16/2010 was not signed by the physician or an RN.

4. Review of the open medical record revealed patient #4 was admitted to the hospital on 2/06/2010 with diagnoses "Axis I- Psychosis not otherwise specified; Substance induced psychosis; Major depression with psychosis, Axis IV- severe; and Axis V 25-30". Further review of the record revealed the master treatment plan was imitated on 2/06/2010 and the nurse identified the patient's primary as "Depressed Mood" with the secondary problem listed as "Risk for Suicide". The treatment plan did not address the Axis I diagnosis of Psychosis nor the diagnosis of Substance induced psychosis. Further review of the master treatment plan revealed that two weekly treatment plan updates were in the medical record and the forms were incomplete and did not contain a note by the RN or the therapist.

5. Review of the open medical record revealed patient #5 was admitted to the hospital on 2/06/2010 at 7:00 PM on a PEC for suicidal and homicidal ideation. Review of the admission diagnosis revealed: "Axis I- Oppositional defiant disorder, History of Psychosis, Psychosis Not otherwise specified; Axis IV- severe; Axis V- 25". Review of the master treatment plan revealed the plan was initiated on 2/06/2010 and the patient's short term goals for the interventions the team identified had a target date of 2/13/2010. Further review of the plan revealed it had not been revised or updated to indicate the target dates were/not met.

Further review of the master treatment plan revealed the patient's primary problem was "Disturbed Sensory Perception" and the secondary problem was listed as "Risk for Suicide". Further review revealed the treatment plan was a preprinted form with a designated area to check interventions to the identified problems listed for the patient and the form was not individualized to meet patient #5's needs. Additionally, none of the patient's weekly updates were complete.

6. Review of the open medical revealed patient #6 was admitted to the hospital on 2/17/2010 on a physician's emergency certificate due to suicidal ideations. Review of the patient's diagnoses revealed "Axis I-Depressive disorder, not otherwise specified; PTSD, Rule out Bipolar Disorder Type I; Acute II- Cluster B and C traits; and Axis V- 10-15". Review of the master treatment plan revealed the patient's primary problem was identified as "Depressed Mood" and the secondary problem was identified as "Risk for Suicide". Further review of the treatment plan revealed the disciplines responsible for the the interventions were not documented.

In an interview on 2/22/2010 at 10:30 AM, S1 Performance Improvement Coordinator and S7 DON confirmed that the master treatment plans for patients #1 through #6 were incomplete, the care plans were not individualized and the weekly summaries were incomplete. According to S7 DON, the 7PM-7AM RN is responsible for ensuring the weekly reviews are completed. S7 further confirmed that all treatment plans are to be reviewed weekly and revised as often as needed.

Review of the hospital's policy titled "Treatment Planning" (reference #3010) revealed, "The initial treatment team shall be scheduled within 7 days of the patient's admission. The team will review progress and revise the plan as necessary on a weekly basis. Further review of the policy revealed that the treatment planning meetings will be attended by the primary physician, RN, Mental Health Clinician/Therapist. The mental health clinician/therapist will facilitate the treatment planning meeting process and when possible, the nurse on duty will serve as documenter. The RN will request signatures of each team member to signify their agreement with the plan of care. All unit care staff will be apprised of the treatment plan formulation and are expected to review the plan and utilize the interventions. Progress or lack of progress in relation to the plan will be reflected in the documentation completed by each clinical discipline on the patient ' s progress notes. Review of the ongoing treatment review policy revealed representatives from each discipline will complete their respective section of the Weekly Summary Progress report prior to the treatment planning session when possible. The representatives will meet weekly in treatment team to discuss, review and update the plan. This will include presentation of their update summary, a review and discussion of goals, objectives and interventions on each problem-specific plan of care. All disciplines will be responsible for a weekly Summary Progress report. The policy further indicated that all disciplines will be responsible to revise and or update the problem specific plans of care for their discipline. This will include all changes in goals, objectives and interventions, revised target dates or closure of a problem. All disciplines will be responsible for adding new problems and closing resolved problems of their discipline. All unit staff should be apprised of revisions and review the plan of care prior to making a care intervention with the patient".