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Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.13 Tag A-0144

The information reviewed during the survey provided evidence the facility failed to ensure suicidal patients were under direct supervision while on a 1:1 resulting in a suicidal patient attempting suicide.

A discussion took place with the survey team and the facility's administrative staff (EMP1), regarding the survey team's concerns related to Patient's Rights on November 2, 2020 at 5:11 PM.


Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting

Based on review of facility documents, policies and procedures, and medical records (MR), and staff interview (EMP), it was determined the facility failed to provide direct visual observation for a patient placed on suicide precautions as ordered by the physician; and the facility failed to ensure the one to one sitter was provided with a nursing [RN] or an on-going observation staff handoff prior to providing the patient with one to one care for one of one medical record reviewed (MR1).

Findings include:

Review on November 3, 2020, of facility documentation dated October 23, 2020, revealed "At 19:30 [7:30 PM] 1:1 alerted staff that pt [patient] was on bathroom floor with pillowcase tied around neck attempting to choke self. Staff intervened and cut pillowcase off. Vital signs as charted, within normal limits. Dr.... made aware. Pt placed in paper attire. Pt remains on 1:1 arms length. ..."

Review on November 2, 2020, of the facility's "Patient Rights and Responsibilities" policy, last approved March 19, 2018, revealed "... Patients have the right to receive care in a safe environment free from abuse, harrassment and neglect."

Review on November 2, 2020, of the facility's "Observation Guidelines for Assessment and Management of IP Behavioral Health Patients-Inpatient Behavioral Health"policy, last reviewed January 2018 revealed "II. Key Points: ... 10. Person responsible for observation will receive hand off communication from the RN assigned to the patient prior to assuming observation responsibility ... B. 2. RN will provide handoff communication to the assigned staff member prior to the assigned staff member prior to that staff member assuming observation responsibility. Off-going observation staff will also provide handoff communication to oncoming observation staff ... Purpose: To provide an optimal level of observation for an individual patient who has been assessed to demonstrate behaviors that may result in harm to self or others and promote healing.... To minimize Incidents of patient self-harm or harm to others. Policy: ... Definitions... Observation: Suicide Precautions: This level of observation is for a patient who expresses or demonstrates suicidal intent or actions requiring a greater level of precaution in order to maintain a safe environment.. This level of observation requires the assigned nursing staff member to be in direct, constant visual contact and within arms' length of the patient at all times enabling staff to intervene immediately ..."

Review of MR1 on November 2, 2020, revealed this patient was admitted to the crisis area of the Emergency department on a 201 (Voluntary psychiatric commitment) on October 19, 2020. MR1 documentation further revealed "patient was admitted voluntarily due to suicidal ideation and self-injurious behavior ... At this point patient is danger to self." Nursing completed a suicide risk assessment and determined MR1's level of suicide risk as high and initiated one to one observation for this patient's safety.

Review of MR1 nursing assessment dated October 20, 2020 revealed patient was admitted to the behavioral health unit "on a 201 commitment.... one to one arms length observation initated and explained (to patient)."

Review of MR1 revealed the physician ordered suicide precautions 1:1 on October 19, 2020, at 5:37 PM and discontinued on October 30, 2020 at 12:08 PM.

Review of MR1 dated October 22, 2020, revealed "1:1 alerted staff that pt [patient] was on the bathroom floor with pillowcase tied around neck attempting to choke self..."

Interview with EMP2 on November 2, 2020, at 3:12 PM, confirmed EMP2 assumed the role of patient one to one sitter start of 7 PM shift on October 22, 2020. EMP2 further confirmed EMP2 did not receive a nursing [RN] handoff, nor a handoff from the previous one to one sitter regarding patient observation status. EMP2 confirmed "looking in the room the chair was against the wall, not arms length, around 7:10 PM patient drinks ensure and goes to bed, no more than 30 minutes patient gets up and tells me [patient] is going to the bathroom ... I remained in the chair outside the bathroom, I am outside of the bathroom looking underneath the door and asking patient "is everything okay?" ...Patient responds, [patient is] okay ... One minute I see patient squatting on the ground." EMP2 confirmed announcing to the patient stating "I am coming in". EMP2 confirmed seeing patient on the floor with a cloth tied around [patient's] neck. EMP2 confirmed trying to slide fingers in between the patient neck and cloth, confirmed "cloth would not loosen". EMP2 confirmed running to the nurse station, banging on the window in dire need of help. EMP2 confirmed about three or four nurses came to the room and one cut the cloth off patient's neck. EMP2 confirmed "the sign off is minimal from previous sitter, not extensive as a RN sign-off". EMP2 confirmed EMP2 was not aware of the patient's observation level and further confirmed that she did not keep the patient at arms length distance. EMP2 further confirmed EMP2 was outside the bathroom door and looking underneath the door and then EMP2 opened the door and found the patient (MR1) on the floor with a cloth tied around [the patient's] neck.

Interview with EMP4 on November 2, 2020, at approximately 3:52 PM confirmed EMP4 was MR1's nurse with a working shift of 7 PM-7 AM. EMP4 confirmed " I arrived to the unit at around 7:20 PM from RN rounds and introduced myself to the patient". EMP4 confirmed "I believed I was told what type of observation type the patient was on, I am not too certain". EMP4 confirmed "shortly after that the patient sitter came running to the nurse station, banging on the window asking for help" EMP4 confirmed two nurses including EMP4 ran to MR1's room and found patient on the floor with a cloth tied around her neck. EMP4 confirmed she did not provide a nursing hand-off to MR1's 1:1 sitter at the start of the shift.

Interview with EMP5 on November 2, 2020, at 4:09 PM confirmed being the one to one sitter prior to the incident occuring. EMP5 confirmed being under the impression that "the sitter gets the report from RN", in reference to what observation status the patient is on. EMP5 confirmed being the one to one sitter prior to the suicide attempt by MR1. EMP5 further confirmed it was EMP5's understanding that the sitter gets the observation status report from the Nurse.



Cross reference
482.13 Patient Rights