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Based on interviews, record reviews and policy review, it was determined the facility failed to ensure one (1) of nine (9) sampled patients received care in a safe setting (Patient #1). Patient #1 came to the Emergency Department (ED) after ingesting 15 to 20 Depakote pills on 08/21/12 in a suicidal attempt. The ED physician admitted the patient to the Critical Care Unit (CCU) on a 72 hour hold and suicidal precautions. Patient #1 was monitored one to one until 11:00 PM when the sitter was pulled to monitor another patient on the unit. Registered Nurse (RN) #1 was supposed to monitor the patient from the nursing desk along with the other nurse on the CCU. The staff on the unit went about doing their assigned duties and revealed there was always somebody at the nursing desk watching for the patient. Patient #1 awoke early on 08/22/12. At the time the patient awoke he/she returned to bed after using the bathroom, staff did not return to provide continuous monitoring. RN #1 reported to RN #3 at the change of shift there was no sitter for the patient; however the patient had been calm and cooperative throughout the night. The sitter assigned to Patient #1 on 08/22/12 was sent to monitor another patient on the unit and the staff failed to provide continuous monitoring from 11:00 PM until the time he/she left the CCU without staff's knowledge. These failures placed patients at risk for serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist related to Patient Rights.

Refer to A-144.

Based on interview, record review and policy review, it was determined the facility failed to ensure care was given in a safe environment. The facility failed to ensure one (1) of nine (9) sampled patients received care in a safe setting (Patient #1). Patient #1, was admitted with suicidal ideation and attempting to overdose on Depakote (anti-convulsant). Patient #1 was transferred to the Critical Care Unit (CCU) of the hospital on a 72 hour hold and suicidal precautions. During the night the Clinical Nurse Supervisor and the Registered Nurse agreed to remove the sitter on one to one with Patient #1 and left him/her unmonitored for 11:00 PM on 08/21/12 until sometime between 9:10 and 9:30 AM on 08/22/12, when the resident eloped from the CCU without staff's knowledge.

The findings include:

A review of the policy entitled "Suicide Risk Assessment & Precautions" with an effective of 07/01/12, revealed all patients presenting to the Emergency Department (ED) shall be screened at triage for suicide risk. Patients will be determined at risk for suicide if they answer "yes" to the question "are you having thoughts of suicide or of hurting yourself now or have you recently had those thoughts?" When a patient is determined to be at risk of suicide, he/she will be placed on suicide precautions, with one-on-one continuous observation, which can be initiated by either nursing or medical staff.

A review of the policy entitled "Involuntary Admission" with an effective date of 12/01/11, revealed a person met criteria for an involuntary hospitalization when "1)a person who is mentally ill AND 2) presents a danger or threat of danger to self, family, or others as a result of mental illness AND 3) for whom hospitalization is the least restrictive alternative mode of treatment presently available. The determination of 1, 2, and 3 must be made by an authorized member of the medical staff. If the physician is not a psychiatrist, a Behavioral Health consult is recommended, but not required".

Review of the clinical record revealed the facility admitted Patient #1 on 08/21/12 for expressing suicidal ideations and an overdose on Depakote (anti-convulsant). The patient was admitted on a 72 hour hold. Continued record review revealed Patient #1 had a diagnosis of Depression.

Interview with the admitting doctor on 09/07/12 at 11:03 AM, revealed the 72 hour hold meant the staff were to watch him/her continuously and make sure they didn't do anything to harm themselves. The patient was suppose to be on suicide precautions.

Interview with the Clinical Supervisor for ICU/CCU for 7:00 PM until 7:00 AM shift on 09/07/12 at 8:27 AM, revealed at 11:00 PM the decision was made to move the sitter with Patient #1 to another patient on the unit. Patient #1 denied suicidal thoughts and the curtains were kept open in his/her room so nursing staff could have direct view of him/her at all times from the nursing desk. The Clinical Supervisor stated there were three staff at the nursing desk at all times during the night and one of us was there until the shift changed. Patient #1 was an intentional overdose and while on a one to one we had to keep him/her in view and the exits at all times. The patient was on suicidal precautions. The other patient on the unit became combative and a "code green" was called related to the patient's behaviors. The supervisor for the hospital responded and she was in agreement with moving the sitter from Patient #1.

Interview with Registered Nurse (RN) #1, on 09/07/12 at 9:01 AM, revealed she was the nurse assigned to care for Patient #1 on 08/21/12 from 7:00 PM until 7:00 AM. The patient was on a 72 hour hold and suicidal precautions and he/she had a sitter. The patient denied suicidal thoughts during the assessment and after midnight he/she did not have a sitter. The other nurses at the desk were told to keep a check on the patient because he/she was on a 72 hour hold and suicidal precautions. During the night somebody was always at the desk to keep an eye on the patient. On 08/22/12, RN #3 came in and was given report the patient had a good night, no suicidal thoughts and the sitter had been pulled to another patient. Patient #1 was awake and he/she had voiced he/she wanted to go home, but we continued to report on the patients and nobody was in the room to monitor the patient.


Interview with RN #2, on 09/05/12 at 3:05 PM, revealed he was one of the day shift charge nurses for the CCU/Intensive Care Unit (ICU) on 08/22/12. He revealed during the shift to shift round at 6:30 AM on 08/22/12, Patient #1 was lying in bed asleep and no staff was at the bedside monitoring the patient. He stated according to the facility policy, if a patient was on suicidal precautions then they were on one to one monitoring. He questioned the night supervisor about the sitter and he was informed during the night another patient on the unit had become combative and required a sitter. The night shift supervisor made the decision to pull the sitter from Patient #1 who had calm and cooperative, and place him/her with the other patient that was combative. Patient #1 was left unmonitored.

Interview with RN #3, on 09/06/12 at 9:25 AM, revealed she admitted Patient #1 on 08/21/12 and was the assigned nurse to the patient on 08/22/12. She knew the patient was on a 72 hour hold and suicidal precautions. On 08/22/12, she assessed the patient and he/she denied suicidal thoughts. Somewhere between 7:30 AM and 8:30 AM she exited another patient room and noticed Patient #1 did not have a rhythm on the monitor. RN #2 checked the patient room and discovered he/she was missing then she alerted security. When she checked Patient #1 after coming on duty on 08/22/12, there was no sitter in the room monitoring the patient. When a patient was on suicidal precautions, staff checked their belongings to make sure they did not have any dangerous items, remove clothing from the room and assigned them a sitter. The morning of 08/22/12 was super busy and she did not think to make sure the patient had a sitter because she assumed the "charge people" made the calls to get the sitters.

Interview with Certified Nursing Assistant (CNA) #1, on 09/06/12 at 2:11 PM, revealed she was the sitter with Patient #1 on 08/21/12 from 7:00 PM until 11:00 PM. She revealed at the end of her shift the nurse on duty informed her it was "ok" for her to leave. She stated nobody came to relieve her from sitting with the patient. When she left Patient #1's room, no staff was monitoring him/her one to one.

Interview with Critical Care Manager, on 09/07/12 at 2:30 PM, revealed she became aware of the patient leaving the unit between 9:00 AM and 9:30 AM on 08/22/12. During the night the supervisor had pulled the sitter with Patient #1 to sit with another patient on the unit. Once the sitter was moved from Patient #1 there was the potential for him/her to do something to themselves or leave. The supervisor of the unit had requested three sitters for the day shift and nursing could only provide two sitters. The two sitters arrived and they were placed with the two other residents requiring a sitter and not with Patient #1. The communication broke down after the second sitter arrived to sit with the other suicidal patient. The staff did not communicate to the sitter they were to monitor the two patients in the rooms side by side. RN #3 was familiar with the patient and she understood someone needed to physically be observing Patient #1 continually.

Interview with the Manager of Accreditation, on 09/07/12 at 12:20 PM, revealed Patient #1 was on suicidal precautions and 72 hour hold. The patient should have had a sitter that morning and we realized we messed up. We now realize the policies we have in place for involuntary admission and suicide precautions go together.

Interview with Patient #1, on 09/06/12 at 9:08 AM, revealed he/she was in the hospital for taking the pills. Patient #1 stated the physician came in the morning of 08/22/12 and wanted him/her to stay another day. Patient #1 did not want to stay in the hospital. He/she put his/her clothes back on and walked out of the CCU. The patient revealed there was no staff at the nursing desk when he/she walked out and only saw a housekeeper when he/she left. He/she reported there was no staff sitting with him/her when he/she walked out of the hospital.

Based on interviews, record reviews and policy review, it was determined the facility failed to ensure one (1) of nine (9) sampled patients received care in a safe setting (Patient #1). Patient #1 came to the Emergency Department (ED) after ingesting 15 to 20 Depakote pills on 08/21/12 in a suicidal attempt. The patient was admitted to the Critical Care Unit (CCU) on a 72 hour hold and suicidal precautions. Patient #1 was monitored one to one until 11:00 PM when the sitter was pulled to monitor another patient on the unit. The staff were aware the patient was on suicidal precautions and the 72 hour hold but failed to provide continuous monitoring from 11:00 PM until the time he/she left the CCU without staff's knowledge. Additionally, a second sitter arrived to the CCU the morning of 08/22/12, but was not informed to monitor the two residents in the rooms beside each other. The sitter went to the other patient's room and monitored them and Patient #1 remained unmonitored. The Registered Nurse (RN) assigned to care for the patient did not notice the patient had left until she notice there was no telemetry on the monitor at the nursing desk. RN #3 went to Patient #1's room and found the patient had re-dressed and left. These failures placed patients at risk for serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist related to Nursing Services.

Refer to A-395.

Based on interview, record review and policy review, it was determined the facility failed to ensure supervision and evaluation of the nursing care for one (1) of nine (9) sampled patients (Patient #1). Patient #1, who was admitted for suicidal ideations and an attempted to overdose on Depakote (anti-convulsant).

The findings include:

A review of the policy entitled "Suicide Risk Assessment & Precautions" with an effective of 07/01/12, revealed all patients presenting to the Emergency Department (ED) shall be screened at triage for suicide risk. Patients will be determined at risk for suicide if they answer "yes" to the question "are you having thoughts of suicide or of hurting yourself now or have you recently had those thoughts?" When a patient is determined to be at risk of suicide, he/she will be placed on suicide precautions, with one-on-one continuous observation, which can be initiated by either nursing or medical staff.

Review of the clinical record revealed the facility admitted Patient #1 on 08/21/12 on a 72 hour hold for expressing suicidal ideations. Continued record review revealed Patient #1's diagnosis included Depression.


Interview with the admitting doctor on 09/07/12 at 11:03 AM, revealed the 72 hour hold meant the staff were to watch him/her continuously and make sure they didn't do anything to harm themselves. The patient was suppose to be on suicide precautions.

Interview with the Clinical Supervisor for ICU/CCU for 7:00 PM until 7:00 AM shift on 09/07/12 at 8:27 AM, revealed at 11:00 PM the decision was made to move the sitter with Patient #1 to another patient on the unit. Patient #1 denied suicidal thoughts and the curtains were kept open in his/her room so nursing staff could have direct view of him/her at all times from the nursing desk. The Clinical Supervisor stated there were three staff at the nursing desk at all times during the night and one of us was there until the shift changed. Patient #1 was an intentional overdose and per the policy we had to keep him/her in view and the exits while on a one to one at all times. The patient was on suicidal precautions. The supervisor for the hospital was in agreement with moving the sitter from Patient #1.

Interview with Registered Nurse (RN) #1, on 09/07/12 at 9:01 AM, revealed she was the nurse assigned to care for Patient #1 on 08/21/12 from 7:00 PM until 7:00 AM. The patient was on a 72 hour hold and suicidal precautions and she had a sitter earlier during the shift. Suicidal precautions meant once they were stable and report they did not want to hurt themselves they we would do hourly checks on them. They usually had a sitter but if one was not available then someone was at the desk to see them at all times.


Interview with RN #2, on 09/05/12 at 3:05 PM, revealed he was one of the day shift charge nurses for the CCU/Intensive Care Unit (ICU) on 08/22/12. He revealed during the shift to shift round at 6:30 AM on 08/22/12, Patient #1 was lying in bed asleep and no staff was at the bedside monitoring the patient. He stated according to the facility policy, if a patient was on suicidal precautions then they were on one to one monitoring. He questioned the night supervisor about the sitter and he was informed during the night another patient on the unit had become combative and the sitter assigned to the patient has been pulled to sit with the other patient that now required a sitter. Patient #1 was left unmonitored.

Interview with RN #3, on 09/06/12 at 9:25 AM, revealed she admitted Patient #1 on 08/21/12 and was the assigned nurse to the patient on 08/22/12. She knew the patient was on a 72 hour hold and suicidal precautions. When she checked Patient #1 after coming on duty on 08/22/12, there was no sitter in the room monitoring the patient. Somewhere between 7:30 AM and 8:30 AM she exited another patient room and noticed Patient #1 did not have a rhythm on the monitor. RN #2 checked the patient room and discovered he/she was missing then she alerted security. The morning of 08/22/12 was super busy and she did not think to make sure the patient had a sitter because she assumed the "charge people" made the calls to get the sitters.

Interview with Certified Nursing Assistant (CNA) #1, on 09/06/12 at 2:11 PM, revealed she was the sitter with Patient #1 on 08/21/12 from 7:00 PM until 11:00 PM. She revealed at the end of her shift the nurse on duty informed her it was "ok" for her to leave. She stated nobody came to relieve her from sitting with the patient. When she left Patient #1's room, no staff was monitoring him/her one to one.

Interview with Critical Care Manager, on 09/07/12 at 2:30 PM, revealed she became aware of the patient leaving the unit between 9:00 AM and 9:30 AM on 08/22/12. During the night the supervisor had pulled the sitter with Patient #1 to sit with another patient on the unit. Once the sitter was moved from Patient #1 there was the potential for him/her to do something to themselves or leave. The supervisor of the unit had requested three sitters for the day shift and nursing could only provide two sitters. The two sitters arrived and they were placed with the two other residents requiring a sitter and not with Patient #1. The communication broke down after the second sitter arrived to sit with the other suicidal patient. The staff did not communicate to the sitter they were to monitor the two patients in the rooms side by side. RN #3 was familiar with the patient and she understood someone needed to physically be observing Patient #1 continually. Following the incident, a department meeting was held with the staff and re-educated the stafff on the suicide policy as well as what we learned from the improper things we did with the patient leaving.

Interview with the Manager of Accreditation, on 09/07/12 at 12:20 PM, revealed "Patient #1 was on suicidal precautions and a 72 hour hold. The patient should have had a sitter that morning and we realized we messed up. We now realize the policies we have in place for involuntary admission and suicide precautions go together. On 08/30/12, we started reviewing the policies in place for changes and have a team of people looking at them".

Based on interview, record review and policy review, it was determined the facility failed to ensure care was given in a safe environment. The facility failed to ensure one (1) of nine (9) sampled patients received care in a safe setting (Patient #1). Patient #1, was admitted with suicidal ideation and attempting to overdose on Depakote (anti-convulsant). Patient #1 was transferred to the Critical Care Unit (CCU) of the hospital on a 72 hour hold and suicidal precautions. During the night the Clinical Nurse Supervisor and the Registered Nurse agreed to remove the sitter on one to one with Patient #1 and left him/her unmonitored for 11:00 PM on 08/21/12 until sometime between 9:10 and 9:30 AM on 08/22/12, when the resident eloped from the CCU without staff's knowledge.

The findings include:

A review of the policy entitled "Suicide Risk Assessment & Precautions" with an effective of 07/01/12, revealed all patients presenting to the Emergency Department (ED) shall be screened at triage for suicide risk. Patients will be determined at risk for suicide if they answer "yes" to the question "are you having thoughts of suicide or of hurting yourself now or have you recently had those thoughts?" When a patient is determined to be at risk of suicide, he/she will be placed on suicide precautions, with one-on-one continuous observation, which can be initiated by either nursing or medical staff.

A review of the policy entitled "Involuntary Admission" with an effective date of 12/01/11, revealed a person met criteria for an involuntary hospitalization when "1)a person who is mentally ill AND 2) presents a danger or threat of danger to self, family, or others as a result of mental illness AND 3) for whom hospitalization is the least restrictive alternative mode of treatment presently available. The determination of 1, 2, and 3 must be made by an authorized member of the medical staff. If the physician is not a psychiatrist, a Behavioral Health consult is recommended, but not required".

Review of the clinical record revealed the facility admitted Patient #1 on 08/21/12 for expressing suicidal ideations and an overdose on Depakote (anti-convulsant). The patient was admitted on a 72 hour hold. Continued record review revealed Patient #1 had a diagnosis of Depression.

Interview with the admitting doctor on 09/07/12 at 11:03 AM, revealed the 72 hour hold meant the staff were to watch him/her continuously and make sure they didn't do anything to harm themselves. The patient was suppose to be on suicide precautions.

Interview with the Clinical Supervisor for ICU/CCU for 7:00 PM until 7:00 AM shift on 09/07/12 at 8:27 AM, revealed at 11:00 PM the decision was made to move the sitter with Patient #1 to another patient on the unit. Patient #1 denied suicidal thoughts and the curtains were kept open in his/her room so nursing staff could have direct view of him/her at all times from the nursing desk. The Clinical Supervisor stated there were three staff at the nursing desk at all times during the night and one of us was there until the shift changed. Patient #1 was an intentional overdose and while on a one to one we had to keep him/her in view and the exits at all times. The patient was on suicidal precautions. The other patient on the unit became combative and a "code green" was called related to the patient's behaviors. The supervisor for the hospital responded and she was in agreement with moving the sitter from Patient #1.

Interview with Registered Nurse (RN) #1, on 09/07/12 at 9:01 AM, revealed she was the nurse assigned to care for Patient #1 on 08/21/12 from 7:00 PM until 7:00 AM. The patient was on a 72 hour hold and suicidal precautions and he/she had a sitter. The patient denied suicidal thoughts during the assessment and after midnight he/she did not have a sitter. The other nurses at the desk were told to keep a check on the patient because he/she was on a 72 hour hold and suicidal precautions. During the night somebody was always at the desk to keep an eye on the patient. On 08/22/12, RN #3 came in and was given report the patient had a good night, no suicidal thoughts and the sitter had been pulled to another patient. Patient #1 was awake and he/she had voiced he/she wanted to go home, but we continued to report on the patients and nobody was in the room to monitor the patient.


Interview with RN #2, on 09/05/12 at 3:05 PM, revealed he was one of the day shift charge nurses for the CCU/Intensive Care Unit (ICU) on 08/22/12. He revealed during the shift to shift round at 6:30 AM on 08/22/12, Patient #1 was lying in bed asleep and no staff was at the bedside monitoring the patient. He stated according to the facility policy, if a patient was on suicidal precautions then they were on one to one monitoring. He questioned the night supervisor about the sitter and he was informed during the night another patient on the unit had become combative and required a sitter. The night shift supervisor made the decision to pull the sitter from Patient #1 who had calm and cooperative, and place him/her with the other patient that was combative. Patient #1 was left unmonitored.

Interview with RN #3, on 09/06/12 at 9:25 AM, revealed she admitted Patient #1 on 08/21/12 and was the assigned nurse to the patient on 08/22/12. She knew the patient was on a 72 hour hold and suicidal precautions. On 08/22/12, she assessed the patient and he/she denied suicidal thoughts. Somewhere between 7:30 AM and 8:30 AM she exited another patient room and noticed Patient #1 did not have a rhythm on the monitor. RN #2 checked the patient room and discovered he/she was missing then she alerted security. When she checked Patient #1 after coming on duty on 08/22/12, there was no sitter in the room monitoring the patient. When a patient was on suicidal precautions, staff checked their belongings to make sure they did not have any dangerous items, remove clothing from the room and assigned them a sitter. The morning of 08/22/12 was super busy and she did not think to make sure the patient had a sitter because she assumed the "charge people" made the calls to get the sitters.

Interview with Certified Nursing Assistant (CNA) #1, on 09/06/12 at 2:11 PM, revealed she was the sitter with Patient #1 on 08/21/12 from 7:00 PM until 11:00 PM. She revealed at the end of her shift the nurse on duty informed her it was "ok" for her to leave. She stated nobody came to relieve her from sitting with the patient. When she left Patient #1's room, no staff was monitoring him/her one to one.

Interview with Critical Care Manager, on 09/07/12 at 2:30 PM, revealed she became aware of the patient leaving the unit between 9:00 AM and 9:30 AM on 08/22/12. During the night the supervisor had pulled the sitter with Patient #1 to sit with another patient on the unit. Once the sitter was moved from Patient #1 there was the potential for him/her to do something to themselves or leave. The supervisor of the unit had requested three sitters for the day shift and nursing could only provide two sitters. The two sitters arrived and they were placed with the two other residents requiring a sitter and not with Patient #1. The communication broke down after the second sitter arrived to sit with the other suicidal patient. The staff did not communicate to the sitter they were to monitor the two patients in the rooms side by side. RN #3 was familiar with the patient and she understood someone needed to physically be observing Patient #1 continually.

Interview with the Manager of Accreditation, on 09/07/12 at 12:20 PM, revealed Patient #1 was on suicidal precautions and 72 hour hold. The patient should have had a sitter that morning and we realized we messed up. We now realize the policies we have in place for involuntary admission and suicide precautions go together.

Interview with Patient #1, on 09/06/12 at 9:08 AM, revealed he/she was in the hospital for taking the pills. Patient #1 stated the physician came in the morning of 08/22/12 and wanted him/her to stay another day. Patient #1 did not want to stay in the hospital. He/she put his/her clothes back o