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Based on observation, interview and record review, the facility failed to protect the rights of 1 of 34 sampled patients (1) on the adolescent/youth unit, by not conducting 15 minute rounds to ensure the patient was safe. As a result, Patient 1 was not observed or contacted during a 40 minute period and was found unresponsive, with a bed sheet around her neck after the bathroom door was opened by staff. Patient 1 did not respond to CPR and expired at the facility.

Findings:

The facility failed to ensure Patient 1's right to care in a safe environment was protected. (Refer to A144.)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutorily mandated compliance with Federal regulations for Patient Rights.

Based on observation, interview and record review, the facility failed to protect the rights of 1 of 34 sampled patients (1) on the youth unit, by not conducting 15 minute rounds to ensure the patient was safe. As a result, Patient 1 was not observed or contacted during a 40 minute period and was found unresponsive, with a bed sheet around her neck, after the bathroom door was opened by staff. Patient 1 did not respond to cardiopulmonary resuscitation (CPR) and expired at the facility.


Findings:

On 11/21/12, the facility reported to the California Department of Public Health (entity reported incident # CA00333809) the death by suicide of a 13-year old female in the facility on 11/19/12. The cause of death was presumed to be self-strangulation by the use of a bed sheet. The mechanics of death are currently unknown, as the forensic investigation has yet to be completed. The county medical examiner took possession of the body on 11/19/12.

Patient 1's medical record was reviewed on 11/21/12. Patient 1 was admitted to the facility's youth unit 11/8/12, on a 72 hour legal hold (5150), which cited the patient was a "Danger to herself."

Documentation on the initial nursing assessment dated 11/8/12 at 4:30 PM, indicated Patient 1 had thoughts of suicide, described a plan for harming herself, and had a history of harming herself. According to the documentation, the patient said she heard voices, had thoughts of suicide, and had anxiety, which caused her to cut herself. The nurse assessed the patient with fresh cuts on the right hand and left lower arm that were self-inflicted. In addition, the patient had scarring on both arms, both thighs, and both ankles from cutting herself in the past. Plans of care were developed on the day of admission to address interventions related to depressed mood, anxiety, and self harm.

According to the physician's admitting history and physical dated 11/9/12, the admission diagnoses were major depression and severe intermittent explosive disorder. (According to the Mayo Clinic (www.mayoclinic.com), intermittent explosive disorder involves repeated episodes of impulsive, aggressive, violent behavior or angry verbal outbursts in which people react grossly out of proportion to the situation. People with intermittent explosive disorder may attack others and their possessions, causing bodily injury and property damage. They may also injure themselves during an outburst. Road rage, domestic abuse, throwing or breaking objects, or other temper tantrums may be signs of intermittent explosive disorder.)

According to the physician's admission orders dated 11/8/12, Patient 1 was to be observed at an SP 3 level. Levels of observation/supervision were defined by the facility policy and procedure, dated 6/12 and titled, Levels of Observation (#300.22). SP 3 was defined as suicide or assault precautions. The policy mandated that staff make rounds every 15 minutes and document the patient's location and safety status on the Rounds Record Sheet.

The interdisciplinary team (IDT), consisting of a physician and nursing representative, met on 11/11/12 to discuss Patient 1's plan of treatment. According to the IDT notes, the plan of treatment continued with the same problem areas and indicated the rationale was, "Danger to self, severe depression, anxiety, and conduct requires 24 hour supervision." Patient 1 continued with the SP 3 level of observation per the physician's order, which stayed in place until 11/17/12.

On 11/17/12 at 11:15 AM, documentation in the nurses notes indicated broken pieces of glass were discovered in Patient 1's room. The IDT met to discuss Patient 1 and concluded she was still a, "Danger to self and others, severely depressed, and a discharge may exacerbate illness." Patient 1 was placed on SP 2 observations. SP 2 observations were defined as having the patient in direct line of sight, according to the facility policy and procedure, dated 6/12 and titled, Levels of Observation (#300.22).

On 11/17/12 at 9:20 PM, documentation in the nursing notes indicated Patient 1 was placed in seclusion (isolation) due to episodes of acting out, as demonstrated by, "Cursing at staff, disruptive in milieu (group)." Patient 1 was released from seclusion after approximately 25 minutes.

On 11/18/12, documentation in the physician's progress notes indicated Patient 1 had no suicidal ideas, plans or intent; no agitation; fair insight/judgment; and was again ordered SP 3 level of observation due to, "Unpredictable behavior."

On 11/19/12 at 8:00 AM, documentation in the physician's progress notes indicated Patient 1 had no suicidal ideas, plans or intent; no agitation; and fair insight/judgment. Documentation in the nursing assessment for the day shift (7 AM to 3 PM) on 11/19/12, indicated the absence of any suicidal ideation and without any plan or intent to harm herself. Routine observations were initiated based on the assessment and a physician's order. Routine observations were defined as patients that have been assessed to have no safety risks and can be managed with routine observations, every 15 minutes, according to the facility policy and procedure, dated 6/12 and titled, Levels of Observation (#300.22).

On 11/19/12, MHW 1 documented on the Patient Rounds/Observation record that Patient 1 was lying in bed at 7:00 PM, and was in the bathroom at 7:15 and 7:30 PM.

On 11/19/12 at approximately 7:47 PM, Patient 1 was found by the facility staff inside the bathroom. Documentation on the code sheet indicated the patient, "Hung self over bathroom door- not off ground knees were supported." CPR (mechanical breathing and chest compressions) was initiated and the paramedics were called to the scene. Patient 1 expired in the facility at 8:27 PM per the code sheet documentation.

On 11/21/12 at 2:35 PM, Mental Health Worker (MHW) 1 was interviewed He acknowledged his presence on the adolescent unit on 11/19/12, and his responsibility for performance of the 15 minutes checks on the patients. MHW 1 stated he heard water running, but made no verbal or visual contact with Patient 1 during this time. MHW 1 explained his reluctance to observe the 13 year old female during bathroom time. MHW 1 stated he did not seek out the services of any of the female staff members to check and/or visualize Patient 1 for approximately 40 minutes. MHW 1 described the various levels of observations related to the rounding on patients every 15 minutes. He stated Patient 1 was on routine observations, which did not require visualization every 15 minutes.

MHW 1's statement contradicted the facility policy and the competency document signed by him on 10/13/12, which included, "...15 minute checks will be completed on all patients both on and off their home unit. Checks will be completed by observing the patient at close enough range to allow for checking circulation, breathing, changes in behavior or mood environmental safety issues and to insure that the patient has not performed any self harm. Checks will be completed on time. I will ask for assistance if I for any reason cannot complete the check task. I will not fill in the check sheet prior to completing the checks. I will not falsify that checks have been completed..." MHW 1 signed and dated the competency document on 7/27/10 and again on 10/13/12.

On 12/5/12 at 9:50 AM, the facility closed circuit television (CCTV) from 11/19/12 was reviewed with the Director of Clinical Services. The recordings demonstrated the comings and goings of a common hallway on the facility's adolescent unit on 11/19/12, the night Patient 1 expired. The CCTV demonstrated all activity related to the entering or exiting of persons at Patient 1's room.

As explained by the Director of Clinical Services, there was a 16 minute differential on the CCTV time marker versus real time. For example, the CCTV showed the date of 11/19/12 at 7 PM, but real time was at 6:44 PM. For the purpose of this review all time will be as the CCTV recorded the events.

Patient 1 was shown entering her room with RN 1 at 7:06 PM, and RN 1 exiting the room 7:08 PM. The video footage the shows no one entering the room until MHW 1 entered at 7:39:31 and exited at 7:39:37 PM (six seconds).

The video footage does not support the documentation of MHW 1 making the required contact with Patient 1 at 7:00 PM, 7:15 PM, or 7:30 PM. The video footage also demonstrated the presence of a female staff member on duty in the hallway directly across from Patient 1's room. The Director of Clinical Services explained the female staff member was engaged in a 1:1 patient watch, and was available at the request of MHW 1 to check on the welfare of Patient 1.

At 8:03:30 PM, the CCTV captured MHW 1 and two female staff members entering Patient 1's room. Patient 1 was discovered in distress when the bathroom door was opened.

Documentation on the emergency documentation record (code sheet) indicated CPR was initiated at 7:47 PM (real time) and was subsequently discontinued at 8:27 PM by paramedics.

Documentation in a written statement by MHW 1, dated 11/19/12 at 11:30 PM, indicated that Patient 1 was found, "With a bed sheet wrapped around her neck and attached to the top of the door and door frame."

Inspections of the facility bathrooms were done on 11/21/12 and 12/11/12, and failed to yield any mechanical structures in place to allow the attachment of bed linens.

On 11/29/12 at 3:10 PM, RN 1 stated an understanding of the same process, with "eyes on" (visualizing) the patient if the first 15 minute observation was limited to verbal contact. RN 1 was the charge nurse on the night of the incident and accounted for his actions during the interview. RN 1 stated he observed Patient 1 talking on the phone and crying. RN 1 intervened by asking Patient 1 to end the phone call and walked her to her room. RN 1 stated he assessed the emotional condition of Patient 1, and discovered the source of her crying was a conversation with her mother. RN 1 went and retrieved a beverage for Patient 1. This concluded the last physical contact of Patient 1 until she was discovered in the bathroom, approximately 40 minutes later. The physical actions of RN 1 were corroborated by the viewing of the closed circuit television monitoring on 12/5/12.

On 11/29/12 at 4:15 PM, MHW 3 stated an understanding of "eyes on the patient " (visualizing) every 15 minutes and would seek the assistance of another staff for gender appropriateness (i.e. a male staff member checking on a male patient and a female staff member checking on a female patient that was in the bathroom or unclothed).

Additional interviews were conducted, with multiple facility staff on all the units, during the survey period, 12/11/12 through 12/13/12. All staff spoke to the process of "routine observations" consisted of "eyes on" (directly observing) the patients and documenting the activity on the rounding record every 15 minutes.

The facility had a similar case on 7/19/10, in which a patient eloped undetected from the facility and committed suicide on a local freeway. The elements of the plan of correction received from the facility, effective 7/31/10, included, "As a plan of correction all clinical staff, including RN's (Registered Nurses) were retrained on the 15min check procedure. Specifically, they are to personally visualize the patient and document their activity at that time. Licensed Nurses are to supervise staff completing checks and assure they are done per policy."

On 12/12/12 at 1:15 PM, the Director of Clinical Services provided a document citing MHW 1 failed to make 15 minute rounds in a timely manner, and make visual or verbal contact with Patient 1. MHW 1 was terminated from employment on 12/3/12.