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Based on observations, interviews with staff, and review of documentation, the Hospital failed to ensure that environmental risk hazards that were previously identified by Hospital staff were addressed in a manner to ensure the safety of patients, and failed to ensure that Patient #1's safety needs were addressed. The findings include:

Patient #1 was admitted on 11/24/10 with diagnoses that included schizoaffective and borderline personality disorders and had a history of multiple suicide attempts. Throughout the hospitalization, Patient #1 expressed or displayed suicidal and/or self injurious behaviors such as stating that he/she would kill self when the first possibility arose and attempting to wrap the bed's electrical cord around his/her neck. From 11/24/10 to 12/4/10, Patient #1 was on safety observations due to the risk for self injurious and/or suicidal behaviors. However, from 12/4/10 to 12/6/10, Patient #1's need for safety observations were not addressed. On 12/6/10 at approximately 6:08 PM, Patient #1 was found hanging from a bed sheet in his/her bedroom. Resuscitation efforts were unsuccessful, and Patient #1 was pronounced expired at a local acute care hospital.

The facility failed to ensure that the physical environment was safe (bed cords and surfaces that pose a hanging risk) and subsequent to the death of Patient #1, the Hospital failed to implement immediate safety interventions to correct all environmental safety issues that had been previously identified on Enviorment of Care Commitiee safety rounds dated 12/09/09.

Please refer to Deficiencies A49, A115, A144, A700, A701, and A724.

Based on clincal record review, review of Hospital documentation, observations, and interviews with staff for one patient (Patient #1) who was identified with self injurious and/or suicidal statements/gestures, the Hospital failed to ensure that the patient's safety needs were assessed prior to discontinuing safety monitoring, and/or ensure that the patient's environment was free from safety hazards. The findings include:

Patient #1 was admitted on 11/24/10 with diagnoses that included schizoaffective and borderline personality disorders and had a history of multiple suicide attempts. Between 11/24/10 and 12/4/10, Patient #1 expressed or displayed suicidal and/or self injurious behaviors such as stating that he/she would kill self when the first possibility arose (11/27/10), wrote a last will and testament, threw his/herself off the bed to the floor, and attempted to wrap the bed's electrical cord around his/her neck (11/28/10), barracaded self in bedroom (12/3/10), and repeatedly banged his/her head against a window and door (12/4/10). Physician's orders dated from 11/24/10 to 12/2/10 directed staff to conduct one-to-one and/or constant observations of Patient #1 due to the risk for self injurious and/or suicidal behaviors. On 12/2/10, a physician's order directed staff to discontinue constant observations and place Patient #1 on frequent observations (every 15 minute observations) due to the risk for self injurious and/or suicidal behaviors. The patient remained on frequent observations due to the risk for self injurious and/or suicidal behaviors from 12/2/10 to 12/4/10. On 12/4/10, Patient #1 was transferred to an acute care hospital following seizure-like activity. On return to the facility, Patient #1 was placed on constant observations (per physician's order) for medical reasons (seizure-like activity). The clinical record failed to address continued observations for self injurious and/or suicidal behaviors. On 12/6/10, a physician discontinued Patient #1's constant observations for medical reasons and directed staff to place the patient on frequent observations for medical reasons. On 12/6/10, Patient #1 was last seen at approximately 6 PM. At approximately 6:08 PM, Patient #1 was found hanging from a bed sheet in his/her bedroom. Resuscitation efforts were unsuccessful, and Patient #1 was pronounced expired at a local acute care hospital.
The clinical record was reviewed with MD #1 on 12/8/10 at 2:10 PM. Between 12/4/10 and 12/6/10, the clinical record failed to address Patient #1's observational needs due to the risk of self injurious and/or suicidal behaviors.

Based on clinical record reviews, interviews with staff, and review of Hospital documentation, the Hospital failed to ensure that Patient #1 remained safe during hospitalization. The findings include:

Patient #1 was admitted on 11/24/10 with diagnoses that included schizoaffective and borderline personality disorders and had a history of multiple suicide attempts. Between 11/24/10 and 12/4/10, Patient #1 expressed or displayed suicidal and/or self injurious behaviors such as stating that he/she would kill self when the first possibility arose and attempting to wrap the bed's electrical cord around his/her neck. From 11/24/10 to 12/4/10, the patient was on various levels of observation due to the risk for self injurious and/or suicidal behaviors. Between 12/4/10 and 12/6/10, Patient #1 was on various levels of observation for medical reasons. However, the clinical record failed to address Patient #1's need for continuing observations due to the risk for self injurious and/or suicidal behaviors. On 12/6/10 at approximately 6:08 PM, Patient #1 was found hanging from a bed sheet in his/her bedroom. Resuscitation efforts were unsuccessful, and Patient #1 was pronounced expired at a local acute care hospital.

A tour of Patient #1's unit (Battell 3 North) was conducted on 12/7/10 at 11:30 AM. Observations of the patient care area and interviews with staff identified that environmental hazards that could enable a person to strangle/hang one's self were identified. These items included the hasp locks on file/storage cabinets (which Patient #1 used to hang his/her self) and electrical cords on beds. Subsequently, hospital staff identified a total of 74 beds throughout the hospital's campus with similar electrical cords. The hospital reported that all bed cords were secured to their bed frames on 12/8/10 by 8 PM. and that efforts would continue to identify and address environmental safety hazards throughout the campus. In addition, a policy was revised to require a physician to complete and document a patient assessment when a patient's level of observation was decreased or discontinued.

Please refer to Deficiencies A43, A49, A144, A700, A701, and A724.

Based on clincal record review, review of Hospital documentation, and interviews with staff for one patient (Patient #1) who was identified with self injurious and/or suicidal statements/gestures, the Hospital failed to ensure that Patient #1's environment was safe from hazards, failed to ensure that the patient's safety needs were assessed prior to discontinuing safety monitoring, and failed to ensure that safety checks were documented. The findings include:

Patient #1 was admitted on 11/24/10 with diagnoses that included schizoaffective and borderline personality disorders and had a history of multiple suicide attempts. Between 11/24/10 and 12/4/10, Patient #1 expressed or displayed suicidal and/or self injurious behaviors such as stating that he/she would kill self when the first possibility arose (11/27/10), wrote a last will and testament, threw his/herself off the bed to the floor, attempted to wrap the bed's electrical cord around his/her neck (11/28/10), barracaded self in bedroom (12/3/10), and repeatedly banged his/her head against a window and door (12/4/10). Physician's orders dated from 11/24/10 to 12/2/10 directed staff to conduct one-to-one and/or constant observations of Patient #1 due to the risk for self injurous and/or suicidal behaviors. Review of clinical documentation for 12/1/10 failed to reflect that safety checks were conducted and/or documented as ordered. On 12/2/10, a physician's order directed staff to discontinue constant observations and place Patient #1 on frequent observations (every 15 minute observations) due to the risk for self injurious and/or suicidal behaviors. The patient remained on frequent observations due to the risk for self injurious and/or suicidal behaviors from 12/2/10 to 12/4/10. On 12/4/10, Patient #1 was transferred to an acute care hospital following seizure-like activity. On return to the facility, Patient #1 was placed on constant observations (per physician's order) for medical reasons (seizure-like activity). On 12/6/10, a physician discontinued Patient #1's constant observations for medical reasons and directed staff to place the patient on frequent observations for medical reasons. On 12/6/10, Patient #1 was last seen at approximately 6 PM. At approximately 6:08 PM, Patient #1 was found hanging from a bed sheet in his/her bedroom. Resuscitation efforts were unsuccessful, and Patient #1 was pronounced expired at a local acute care hospital.

The clinical record was reviewed with MD #1 on 12/8/10 at 2:10 PM. Between 12/4/10 and 12/6/10, the clinical record failed to address Patient #1's observational needs due to the risk of self injurious and/or suicidal behaviors.

A tour of Patient #1's unit (Battell 3 North) was conducted on 12/7/10 at 11:30 AM. Observations of the patient care area and interviews with staff identified that 2 metal file/storage cabinets with hasp locks were located at the end of the hallway, out of direct view, and placed against Patient #1's outer bedroom wall. The wall of the bedroom was a permanent structure that did not rise to the level of the ceiling. Patient #1 had taken a bed sheet, tied one end to a hasp lock on one of the file/storage cabinets, placed the remaining sheet over the bedroom wall, and used the sheet to hang his/her self inside the bedroom. Staff responded to the screams of another patient, found Patient #1 hanging, off-loaded the patient's weight, removed the sheet from around the neck, initiated emergency medical treatment, and transferred Patient #1 to an acute care hospital.

Review of the Management of Environment of Care Committee minutes identified that in December 2009, the Director of Environmental Services reported that electrical cords needed to be covered in the Merritt building. On 12/8/10 at 12:15 PM, patient beds on Battell 3 North were observed. Four (4) electric beds were noted to have 2 cords, an electrical cord 10 feet in length and a bed control cord 8 feet in length. The cords were not secured in a manner to reduce the potential for strangulation/hanging. Hospital staff identified a total of 74 beds throughout the hospital's campus with similar cords. The hospital reported that all bed cords were secured to their bed frames on 12/8/10 by 8 PM. and that hospital staff would continue to identify and address environmental safety hazards throughout the campus. In addition, a policy was revised to require a physician to complete and document a patient assessment when a patient's level of observation was decreased or discontinued.

Based on clincal record review, review of Hospital documentation, and interviews with staff for one patient (Patient #1) who was identified with self injurious and/or suicidal statements/gestures, the Hospital failed to ensure that Patient #1's safety needs were assessed prior to discontinuing safety monitoring. The findings include:

Patient #1 was admitted on 11/24/10 with diagnoses that included schizoaffective and borderline personality disorders and had a history of multiple suicide attempts. Between 11/24/10 and 12/4/10, Patient #1 expressed or displayed suicidal and/or self injurious behaviors such as stating that he/she would kill self when the first possibility arose (11/27/10), wrote a last will and testament, threw his/herself off the bed to the floor, and attempted to wrap the bed's electrical cord around his/her neck (11/28/10), barracaded self in bedroom (12/3/10), and repeatedly banged his/her head against a window and door (12/4/10). On 12/6/10, a physician discontinued Patient #1's constant observations for medical reasons and directed staff to place the patient on frequent observations for medical reasons. On 12/6/10, Patient #1 was last seen at approximately 6 PM. At approximately 6:08 PM, Patient #1 was found hanging from a bed sheet in his/her bedroom. Resuscitation efforts were unsuccessful, and Patient #1 was pronounced expired at a local acute care hospital. The clinical record failed to reflect that a physician addressed/documented Patient #1's observational needs related to his/her risk of self injurious and/or suicidal behaviors. As a result, a policy was revised to require a physician to complete and document a patient assessment when a patient's level of observation was decreased or discontinued. See A 0347

Based on clincal record review, review of Hospital documentation, and interviews with staff for one patient (Patient #1) who was identified with self injurious and/or suicidal statements/gestures, the Hospital failed to ensure that Patient #1's safety needs were assessed prior to discontinuing safety monitoring. The findings include:

Patient #1 was admitted on 11/24/10 with diagnoses that included schizoaffective and borderline personality disorders and had a history of multiple suicide attempts. Between 11/24/10 and 12/4/10, Patient #1 expressed or displayed suicidal and/or self injurious behaviors such as stating that he/she would kill self when the first possibility arose (11/27/10), wrote a last will and testament, threw his/herself off the bed to the floor, and attempted to wrap the bed's electrical cord around his/her neck (11/28/10), barracaded self in bedroom (12/3/10), and repeatedly banged his/her head against a window and door (12/4/10). Physician's orders dated from 11/24/10 to 12/2/10 directed staff to conduct one-to-one and/or constant observations of Patient #1 due to the risk for self injurous and/or suicidal behaviors. On 12/2/10, a physician's order directed staff to discontinue constant observations and place Patient #1 on frequent observations (every 15 minute observations) due to the risk for self injurious and/or suicidal behaviors. The patient remained on frequent observations due to the risk for self injurious and/or suicidal behaviors from 12/2/10 to 12/4/10. On 12/4/10, Patient #1 was transferred to an acute care hospital following seizure-like activity. On returned to the facility, Patient #1 was placed on constant observations (per physician's order) for medical reasons (seizure-like activity). On 12/6/10, a physician discontinued Patient #1's constant observations for medical reasons and directed staff to place the patient on frequent observations for medical reasons. On 12/6/10, Patient #1 was last seen at approximately 6 PM. At approximately 6:08 PM, Patient #1 was found hanging from a bed sheet in his/her bedroom. Resuscitation efforts were unsuccessful, and Patient #1 was pronounced expired at a local acute care hospital.

The clinical record was reviewed with MD #1 on 12/8/10 at 2:10 PM. Between 12/4/10 and 12/6/10, the clinical record failed to reflect that a physician addressed/documented Patient #1's observational needs related to his/her risk of self injurious and/or suicidal behaviors. As a result, a policy was revised to require a physician to complete and document a patient assessment when a patient's level of observation was decreased or discontinued.

Based on clincal record review, review of Hospital documentation, and interviews with staff for two patients (Patient #1 and Patient #18) who were identified with self injurious and/or suicidal statements/gestures, the Hospital failed to ensure that nursing staff assessed the patient's safety needs when monitoring checks for safety were discontinued and/or the patient(s)verbalized intent for self-harm. The findings include:

a. Patient #1 was admitted on 11/24/10 with diagnoses that included schizoaffective and borderline personality disorders and had a history of multiple suicide attempts. Between 11/24/10 and 12/4/10, Patient #1 expressed or displayed suicidal and/or self injurious behaviors such as stating that he/she would kill self when the first possibility arose (11/27/10), wrote a last will and testament, threw his/herself off the bed to the floor, and attempted to wrap the bed's electrical cord around his/her neck (11/28/10), barracaded self in bedroom (12/3/10), and repeatedly banged his/her head against a window and door (12/4/10). Physician's orders dated from 11/24/10 to 12/2/10 directed staff to conduct one-to-one and/or constant observations of Patient #1 due to the risk for self injurous and/or suicidal behaviors. Review of clinical documentation for 12/1/10 failed to reflect that safety checks were conducted and/or documented as ordered. On 12/6/10, a physician discontinued Patient #1's constant observations for medical reasons and directed staff to place the patient on frequent observations for medical reasons (due to recent seizure activity). On 12/6/10, Patient #1 was last seen at approximately 6 PM. At approximately 6:08 PM, Patient #1 was found hanging from a bed sheet in his/her bedroom. Resuscitation efforts were unsuccessful, and Patient #1 was pronounced expired at a local acute care hospital. Between 12/4/10 and 12/6/10, nursing documentation in the clinical record failed to address Patient #1's observational needs due to the risk of self injurious and/or suicidal behaviors.

b. Patient #18 had diagnoses that included Schizophrenia with a history of suicidal gestures. On 12/1/10 progress notes and physician orders identified that the patient was maintained on constant observation from 7:15 a.m. to 5:30 p.m. and was then a "level two" from 5:30 p.m. to 7:15 a.m. with frequent (every 15 minutes) observations throughout the night. Progress notes dated 12/1/10 on the evening shift, identified the patient as verbalizing self-harm. No further assessment or change in observational status was identified until 12/2/10 at 5:45 a.m. See A 395; A 396

Based on clincal record review, review of Hospital documentation, and interviews with staff for two patients (Patient #1 and Patient #18) who were identified with self injurious and/or suicidal statements/gestures, the Hospital failed to ensure that nursing staff assessed the patient's safety needs when monitoring checks for safety were discontinued and/or the patient(s) verbalized intent for self-harm. The findings include:

a. Patient #1 was admitted on 11/24/10 with diagnoses that included schizoaffective and borderline personality disorders and had a history of multiple suicide attempts. Between 11/24/10 and 12/4/10, Patient #1 expressed or displayed suicidal and/or self injurious behaviors such as stating that he/she would kill self when the first possibility arose (11/27/10), wrote a last will and testament, threw his/herself off the bed to the floor, and attempted to wrap the bed's electrical cord around his/her neck (11/28/10), barracaded self in bedroom (12/3/10), and repeatedly banged his/her head against a window and door (12/4/10). Physician's orders dated from 11/24/10 to 12/2/10 directed staff to conduct one-to-one and/or constant observations of Patient #1 due to the risk for self injurous and/or suicidal behaviors. Review of clinical documentation for 12/1/10 failed to reflect that safety checks were conducted and/or documented as ordered. On 12/2/10, a physician's order directed staff to discontinue constant observations and place Patient #1 on frequent observations (every 15 minute observations) due to the risk for self injurious and/or suicidal behaviors. The patient remained on frequent observations due to the risk for self injurious and/or suicidal behaviors from 12/2/10 to 12/4/10. On 12/4/10, Patient #1 was transferred to an acute care hospital following seizure-like activity. On returned to the facility, Patient #1 was placed on constant observations (per physician's order) for medical reasons (seizure-like activity). On 12/6/10, a physician discontinued Patient #1's constant observations for medical reasons and directed staff to place the patient on frequent observations for medical reasons. On 12/6/10, Patient #1 was last seen at approximately 6 PM. At approximately 6:08 PM, Patient #1 was found hanging from a bed sheet in his/her bedroom. Resuscitation efforts were unsuccessful, and Patient #1 was pronounced expired at a local acute care hospital. Between 12/4/10 and 12/6/10, nursing documentation in the clinical record failed to address Patient #1's observational needs due to the risk of self injurious and/or suicidal behaviors.

b. Patient #18 had diagnoses that included Schizophrenia with a history of suicidal gestures. On 12/1/10 progress notes and physician orders identified that the patient was maintained on constant observation from 7:15 a.m. to 5:30 p.m. and was then a "level two" from 5:30 p.m. to 7:15 a.m. with frequent observations throughout the night. Progress notes dated 12/1/10 on the evening shift, identified the patient as verbalizing anxiety, having poor effect from as-needed medication and "verbalizing to hurt self." The progress note further identified that medication was administered and that the patient was quiet in his/her room and refused dinner. Although a plan to "follow-up" was identified, the progress notes failed to identify a comprehensive assessment of the patient's intent for self-harm and/or the potential need for increased observation. No further assessment was identified until 12/2/10 at 5:45 a.m. at which time the patient was noted to have slept through the night on fifteen-minute observations.





15482

Based on review of the clinical record and interview for two patients (Patient #15 and Patient #14), the facility failed to ensure that the clinical record reflected the patients choking risk status and/or that facility practice was based on facility policy/procedures (choking assessments) and/or for one patient (Patient #13) that staff followed the standard of practice in an emergency situation. The findings include the following:

a. Review of Patient #15's clinical record indicated that the patient was admitted on 4/19/10. Review of the Nursing Dietary Tracking form posted on the unit indicated that the patient was a choking risk, and noted under the comments section that the patient "eats fast and doesn't chew well. " Interview with the Head Nurse on 10/14/10 at 10:30 AM indicated that in September all the patients on the unit were screened for choking risk and if criteria were met a full evaluation would be completed. Review of facility documentation dated 9/20/10 indicated that all patients would be screened for risk of choking. Review of Patient #15's clinical record failed to identify that the patient had been screened and/or evaluated by Speech Therapy. The clinical record failed to identify the rationale for the patient being identified on the Nursing Dietary Tracking form as a choking risk. Interview with the Director of Quality Improvement indicated that Patient #15 should have had a choking screening completed and, if needed, an evaluation completed, but she was unable to locate the documentation of the screening or evaluation. The Director of Quality identified that the patient was not a choking risk and she was not sure why staff had identified the patient as a choking risk. Additionally, interview with the Director of Quality Improvement indicated that the Nursing Dietary Tracking form being utilized and posted in the kitchen area is not a form she has seen and that the form that is being utilized in the rest of the facility does not have an area for choking risk.
b. Review of Patient #14's clinical record indicated that the patient had been admitted on 12/30/08. Review of the Nursing Dietary Tracking form indicated that the patient was a choking risk. Review of the treatment plan (TP) dated 12/2/10 indicated that the patient was edentulous and that Patient #14's current diet was regular tender. Review of facility documentation dated 9/20/10 indicated that all patients would be screened for risk of choking. Interview with the Head Nurse on 10/14/10 at 10:30 AM indicated that in September all the patients on the unit were screened for choking and if criteria were met a full evaluation would be completed. Review of Patient #14's clinical record with the Manager failed to identify that the patient had been screened and/or evaluated by Speech Therapy. On 12/16/10 the facility provided a Speech-Language Pathology Assessment for Patient #14 dated 11/21/10 that identified that Patient #14 was not a choking risk. Interview with the Director of Quality Improvement indicated that Patient #14 had an evaluation completed that identified the patient was not a choking risk and she was not sure why staff had identified the patient as a choking risk. Interview with the Director of Quality Improvement indicated that the nursing dietary tracking form being utilized and posted in the kitchen area is not a form she has seen and that the form that should be utilized does not have an area for choking risk.
c. Review of Patient #13's clinical record identified that the patient had been admitted on 4/19/10. Review of the Medical Risk survey dated 4/19/10 indicated that under the choking section that the patient ate too quickly and had no teeth. Review of the progress note dated 9/13/10 at 7:00 PM indicated that Patient #13 fell on the floor while eating dinner and was unresponsive. The note indicated that the patient was unresponsive, cyanotic, pulse less and without respirations and CPR was initiated. Interview with RN #3 on 12/15/10 indicated that on arrival to the dining room Patient #13 was on the floor and was unresponsive. RN #3 indicated that she checked the patient's breathing and Patient #13 was not breathing. RN #3 indicated that she tilted that patient's chin, checked the patient's airway, utilized the Ambu bag and then started chest compressions. The RN failed to to follow facility policy that directed to sweep the patient's mouth for potential food that had dislodged after compressions had been initiated and prior to utilizing the Ambu bag. Review of the ambulance run sheet indicated that on arrival the patient's airway was examined there was negative visibility, the patient was suctioned and chunks of a meat type substance were visualized and removed with forceps. Patient #13 was transferred to the hospital where he/she subsequently expired.

Based on review of the clinical record, interview and review of facility policy the facility failed to ensure that a comprehensive treatment plan had been completed for two patients (Patients #13 and #15) to address the patients dental/nutritional needs. The findings include the following:

a. Review of Patient #13's clinical record identified that the patient had been admitted on 4/19/10. Review of the Medical Risk survey dated 4/19/10 indicated that under the choking section that the patient ate too quickly and had no teeth. Although the TP dated 7/20/10 indicated that Patient #13 was edentulous, the identified interventions were that the RN would encourage the patient to wear her dentures. The clinical record indicated that the dentures were broken since May 2010. The TP failed to identify the patient's dentition, potential choking risk and/or interventions associated with the patients dental/nutritional issues.
b. Review of Patient #15's clinical record indicated that the patient was admitted on 4/19/10. Review of the nursing dietary tracking form indicated that the patient was a choking risk, ate fast and did chew well. The nutrition note dated 6/16/10 indicated that the patient had very poor dentition. The clinical record indicated that the patient's diet was low fat, low cholesterol, tender, no concentrated sweets and lactose free. Review of the TP dated 11/29/10 failed to identify the patients dentition issues.

Based on review of the clinical record the facility failed to ensure that drugs and biologicals were prepared and administered appropriately for one patient (Patient #13). The findings include the following:

Review of Patient #13's clinical record identified that the patient had been admitted on 4/19/10. Review of the Medical Risk survey dated 4/19/10 indicated that under the choking section that the patient ate too quickly and had no teeth. Review of the progress note dated 9/13/10 at 7:00 PM indicated that Patient #13 fell on the floor while eating dinner and was unresponsive. The note indicated that CPR was initiated, and the patient was transferred to the hospital where he/she subsequently expired. Review of the Medication Administration Record indicated that on 9/13/10 the patient's 8:00PM medications had been administered.

The facility failed to ensure that the Condition of Physical Environment was met.
Based on a tour of the inpatient psychiatric units, review of hospital documentation and interviews with staff, the Hospital failed to identify and ensure that the physical environment was safe and subsequent to the death of a patient, the Hospital failed to implement immediate safety interventions to correct all environmental safety issues that had been previously identified on Enviorment of Care Commitiee safety rounds dated 12/09/09:

See CMS form 2567 tags A 701 & A 724

Based on a tour of the hospital, staff interview and record review the facility failed to ensure that physical environment was designed and maintained in such a manner as to promote the safety and well being of patients.

On 12/07/10 at 10:55 AM, during a tour of Battell Hall inpatient units while accompanied by the Director of Fiscal Services and Plant Operations, and a Facility Plant Engineer 3 who is responsible for the physical environment and chairman of the environment of care committee the following was observed:
That the facility had screw mounted to the exterior of the room dividers, metal double door storage lockers secured with a lock and hasp for resident belongings in all resident dorms. Subsequent to a patient # 1 hanging herself on 12/06/10 the facility removed the lockers from the exterior room dividers and was removing all lockers from the facility. The facility plant engineer stated that these had not been identified as a hazard or risk as a ligature point for someone to hang themselves. During the tour and interview, the Director of Fiscal Services and Plant Operations, and Facility Plant Engineer 3 stated it that the lockers had been secured due to residents toppling the lockers on themselves and the decision had been made to secure them to the room dividers that are approximately seven feet tall. During this interview it was learned that patient #1 took a sheet from her bed tied it to the locker/hasp and threw the remainder of the sheet over the room divider for Room 305 H and subsequently tied the sheet around her neck and hung herself. The rooms for these dorms are made up of dividers approximately 7 feet tall with doors and pressure strips along the top that alarm at the nurses station if pressure is applied to prevent suicides. The pressure strip alarm for Room 305 H was examined and found to stop approximately 24 inches beyond the door opening and when interviewed the Director of Fiscal Services and Plant Operations and Facility Plant Engineer 3 stated that the door way was identified after risk analysis as being the possible ligature point and in hindsight the facility is ordering strip material to continue the full length of the rooms for all dorms. The last environment of care rounds checklist available for Battell 3 N on the day of this investigation was 05/03/10 and the findings of environment and suicide risks identified were not reflected and not addressed in the master report to administration dated 05/12/2010

Based on a tour of the hospital, staff interview and record review the facility failed to ensure that physical environment was maintained in such a manner as to promote the safety and well being of patients.

a. Patient #1's clinical record identified that on 11/28/10, the patient was placed in mechanical restraints after gesturing suicide with the electric cord of the hospital bed. On 12/08/10 at 08:15 AM it was identified that a few electrical beds were found that with cords that were unsecure and that the facility instituted a directed plan of correction to identify and inventory all electric beds and to safe/secure all electrical cords. The Director of Fiscal Services and Plant Operations, and the Facility Plant Engineer 3 furnished an inventory of all electrical beds and that the cords had been secured. Subsequent to the documentation review the Battell Hall rooms and electric beds were randomly sampled and found to have had the cords temporarily secured with nylon zip ties. Observation also identified that the facility would have to more permanently secure these cords and/or replace the beds with a hand crank style to abate the suicide risk.

b. On 12/08/10 at 11:30 AM, during a tour of Battell Hall inpatient units while accompanied by the Director of Fiscal Services and Plant Operations, and a Facility Plant Engineer 3 it was observed that the facility was utilizing oxygen concentrators with cords approximately 10 feet long and oxygen nasal cannulas with tubing approximately 10 to 12 feet long. The Facility Plant Engineer 3 stated they were medically necessary and when asked if a risk based assessment had been done he had no answer. Prior to this interview documentation reviewed that was supplied by the facility identified that on 12/09/10 the management of the Environment of Care Committee found that unsecured electrical cords were a suicide risk with no further mention of this risk from 12/09/10 to present and on 05/03/10 the facility environmental rounds checklist for Battell B3N found loose bed cords with no mention or follow up reported by the Environment of Care Committee.

Based on clinical record review, interviews, and review of facility policies for one patient (Patient #2), the facility failed to itemize and safeguard the patient's eyeglasses. The findings include:

Review of Occupational Therapy assessment dated 8/10/2010 indicated that P#2 had glasses for reading and "to see good from far". Review of the clinical record did not indicate P#2 was restricted from wearing glasses. The Property and Clothing Record completed on admission date 6/28/2010 listed numerous clothing items but no listing of glasses. Subsequent Property and Clothing Records also had no listing of glasses. Interview with Unit Director for Batell 3 North on 12/8/2010 at 4:15 PM indicated that he/she had never seen P#2 with glasses, but on subsequent interview on 12/9/2010 at 3:30 PM stated that P#2 may have had glasses. Interview with RN#7 on 12/29/2010 at 11:20 AM indicated he/she had never seen P#2 with glasses. Interview with MHA#10 on 12/22/2010 at 5:30 PM indicated that despite caring for P#2 almost every work day, he/she did not recall seeing the patient wearing glasses normally, maybe on one or two occasions. Request for optometry consult was entered on 7/13/2010, with an exam completed the same day. Interview with the Director of Accreditation and Regulatory Compliance on 12/29/2010 at 3:00 PM indicated that P#2 was seen by the optometrist on 7/13/2010 and was issued glasses approximately a week later, on 7/20/2010. Upon surveyor inquiry, no documention could be found in clinical record documenting the reciept of glasses. The Property and Clothing Record dated 7/22/2010 was not updated to include the glasses received two days prior. Review of facility policy "Guidelines for the Safe Management of Patient Personal Property" indicated that it is the MHA/FTS responsibility to work with their assigned patients to ensure that an up to date personal property listing is maintained on form CVH-23 Property/Clothing Record in their Patient Medical Records Chart. In addition, the Director of Accreditation and Regulatory Compliance indicated RN#1 reported that on 12/6/2010, P#2 approached nursing staff that he/she had lost the glasses. Review of nursing notes dated 12/6/2010 do not reflect documentation of glasses being lost.

Based on clincal record review, review of Hospital documentation, and interviews with staff for two patients (Patient #1 and Patient #18) who were identified with self injurious and/or suicidal statements/gestures, the Hospital failed to ensure that nursing staff assessed the patient's safety needs when monitoring checks for safety were discontinued and/or the patient(s) verbalized intent for self-harm. The findings include:

a. Patient #1 was admitted on 11/24/10 with diagnoses that included schizoaffective and borderline personality disorders and had a history of multiple suicide attempts. Between 11/24/10 and 12/4/10, Patient #1 expressed or displayed suicidal and/or self injurious behaviors such as stating that he/she would kill self when the first possibility arose (11/27/10), wrote a last will and testament, threw his/herself off the bed to the floor, and attempted to wrap the bed's electrical cord around his/her neck (11/28/10), barracaded self in bedroom (12/3/10), and repeatedly banged his/her head against a window and door (12/4/10). Physician's orders dated from 11/24/10 to 12/2/10 directed staff to conduct one-to-one and/or constant observations of Patient #1 due to the risk for self injurous and/or suicidal behaviors. Review of clinical documentation for 12/1/10 failed to reflect that safety checks were conducted and/or documented as ordered. On 12/2/10, a physician's order directed staff to discontinue constant observations and place Patient #1 on frequent observations (every 15 minute observations) due to the risk for self injurious and/or suicidal behaviors. The patient remained on frequent observations due to the risk for self injurious and/or suicidal behaviors from 12/2/10 to 12/4/10. On 12/4/10, Patient #1 was transferred to an acute care hospital following seizure-like activity. On returned to the facility, Patient #1 was placed on constant observations (per physician's order) for medical reasons (seizure-like activity). On 12/6/10, a physician discontinued Patient #1's constant observations for medical reasons and directed staff to place the patient on frequent observations for medical reasons. On 12/6/10, Patient #1 was last seen at approximately 6 PM. At approximately 6:08 PM, Patient #1 was found hanging from a bed sheet in his/her bedroom. Resuscitation efforts were unsuccessful, and Patient #1 was pronounced expired at a local acute care hospital. Between 12/4/10 and 12/6/10, nursing documentation in the clinical record failed to address Patient #1's observational needs due to the risk of self injurious and/or suicidal behaviors.

b. Patient #18 had diagnoses that included Schizophrenia with a history of suicidal gestures. On 12/1/10 progress notes and physician orders identified that the patient was maintained on constant observation from 7:15 a.m. to 5:30 p.m. and was then a "level two" from 5:30 p.m. to 7:15 a.m. with frequent observations throughout the night. Progress notes dated 12/1/10 on the evening shift, identified the patient as verbalizing anxiety, having poor effect from as-needed medication and "verbalizing to hurt self." The progress note further identified that medication was administered and that the patient was quiet in his/her room and refused dinner. Although a plan to "follow-up" was identified, the progress notes failed to identify a comprehensive assessment of the patient's intent for self-harm and/or the potential need for increased observation. No further assessment was identified until 12/2/10 at 5:45 a.m. at which time the patient was noted to have slept through the night on fifteen-minute observations.





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Based on review of the clinical record and interview for two patients (Patient #15 and Patient #14), the facility failed to ensure that the clinical record reflected the patients choking risk status and/or that facility practice was based on facility policy/procedures (choking assessments) and/or for one patient (Patient #13) that staff followed the standard of practice in an emergency situation. The findings include the following:

a. Review of Patient #15's clinical record indicated that the patient was admitted on 4/19/10. Review of the Nursing Dietary Tracking form posted on the unit indicated that the patient was a choking risk, and noted under the comments section that the patient "eats fast and doesn't chew well. " Interview with the Head Nurse on 10/14/10 at 10:30 AM indicated that in September all the patients on the unit were screened for choking risk and if criteria were met a full evaluation would be completed. Review of facility documentation dated 9/20/10 indicated that all patients would be screened for risk of choking. Review of Patient #15's clinical record failed to identify that the patient had been screened and/or evaluated by Speech Therapy. The clinical record failed to identify the rationale for the patient being identified on the Nursing Dietary Tracking form as a choking risk. Interview with the Director of Quality Improvement indicated that Patient #15 should have had a choking screening completed and, if needed, an evaluation completed, but she was unable to locate the documentation of the screening or evaluation. The Director of Quality identified that the patient was not a choking risk and she was not sure why staff had identified the patient as a choking risk. Additionally, interview with the Director of Quality Improvement indicated that the Nursing Dietary Tracking form being utilized and posted in the kitchen area is not a form she has seen and that the form that is being utilized in the rest of the facility does not have an area for choking risk.
b. Review of Patient #14's clinical record indicated that the patient had been admitted on 12/30/08. Review of the Nursing Dietary Tracking form indicated that the patient was a choking risk. Review of the treatment plan (TP) dated 12/2/10 indicated that the patient was edentulous and that Patient #14's current diet was regular tender. Review of facility documentation dated 9/20/10 indicated that all patients would be screened for risk of choking. Interview with the Head Nurse on 10/14/10 at 10:30 AM indicated that in September all the patients on the unit were screened for choking and if criteria were met a full evaluation would be completed. Review of Patient #14's clinical record with the Manager failed to identify that the patient had been screened and/or evaluated by Speech Therapy. On 12/16/10 the facility provided a Speech-Language Pathology Assessment for Patient #14 dated 11/21/10 that identified that Patient #14 was not a choking risk. Interview with the Director of Quality Improvement indicated that Patient #14 had an evaluation completed that identified the patient was not a choking risk and she was not sure why staff had identified the patient as a choking risk. Interview with the Director of Quality Improvement indicated that the nursing dietary tracking form being utilized and posted in the kitchen area is not a form she has seen and that the form that should be utilized does not have an area for choking risk.
c. Review of Patient #13's clinical record identified that the patient had been admitted on 4/19/10. Review of the Medical Risk survey dated 4/19/10 indicated that under the choking section that the patient ate too quickly and had no teeth. Review of the progress note dated 9/13/10 at 7:00 PM indicated that Patient #13 fell on the floor while eating dinner and was unresponsive. The note indicated that the patient was unresponsive, cyanotic, pulse less and without respirations and CPR was initiated. Interview with RN #3 on 12/15/10 indicated that on arrival to the dining room Patient #13 was on the floor and was unresponsive. RN #3 indicated that she checked the patient's breathing and Patient #13 was not breathing. RN #3 indicated that she tilted that patient's chin, checked the patient's airway, utilized the Ambu bag and then started chest compressions. The RN failed to to follow facility policy that directed to sweep the patient's mouth for potential food that had dislodged after compressions had been

Based on review of the clinical record the facility failed to ensure that drugs and biologicals were prepared and administered appropriately for one patient (Patient #13). The findings include the following:

Review of Patient #13's clinical record identified that the patient had been admitted on 4/19/10. Review of the Medical Risk survey dated 4/19/10 indicated that under the choking section that the patient ate too quickly and had no teeth. Review of the progress note dated 9/13/10 at 7:00 PM indicated that Patient #13 fell on the floor while eating dinner and was unresponsive. The note indicated that CPR was initiated, and the patient was transferred to the hospital where he/she subsequently expired. Review of the Medication Administration Record indicated that on 9/13/10 the patient's 8:00PM medications had been administered.