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The hospital failed to maintain a safe setting for all patients on the ED 3 Psychiatric holding unit as evidenced by looping devices in nine (9) of nine (9) patient cubicle areas and four (4) of four (4) patient common areas. The hospital failed to ensure all patients remained free of harm by allowing patient #1 with suicidal ideations to close his patient curtain and failed to complete one (1) fifteen (15) minute check on the patient that resulted in his death by hanging (refer to Tag A 144).

A. Based on observation and staff interview it was determined the hospital failed to provide a safe setting for all patients as evidenced by looping devices in nine (9) of nine (9) patient rooms and in four (4) of four (4) patient common areas. This failure resulted in the death of patient #1 by hanging and has the potential for all patients admitted to the ED 3 unit to cause self-harm or suicide by hanging.

Findings include:

1. A tour of the unit ED 3 psychiatric " holding " unit on 10/3/16 at 10:25 a.m. with the Nurse Manager of the ED 3 unit, the Engineering Manager of the hospital and a life safety surveyor revealed patient rooms from twenty-one (21) through twenty-nine (29), for a total of nine (9) patient rooms, identified as containing looping devices that resulted in the death of patient #1 by hanging, and in the future could result in death by hanging. The rooms contained hospital beds (at the time of the tour only one (1) hospital bed remained on the closed unit). Patient rooms twenty-five (25), twenty-six (26), twenty-seven (27) and twenty-eight (28) contained air supply vents which are looping devices. Patient room twenty-nine (29) contained an air grill which is a looping device. In the patient common area the television is wall mounted and is a looping device. The closure, hinges and door knob on the entrance to the common room, medication room door knob and the exit door knob are looping devices.

2. An interview was conducted during the tour of the ED 3 psychiatric holding unit with the Clinical Nurse Manager of ED 3. He stated, in part: "All rooms in this area were hospital beds and because we self-reported we left this bed in the patient's cubicle so that you could see it." He concurred with the above finding of looping devices found during the tour.

3. An interview was conducted during the tour with the Engineering Manager and he concurred with the above findings.

B. Based on record review, document review and staff interview it was determined the hospital failed to follow hospital policies for Level one (1) suicide patient safety checks every fifteen (15) minutes on one (1) of six (6) records reviewed with patients on Level one (1) suicide precautions (patient #1). This failure resulted in the death by hanging of patient #1 and has the potential for all patients to have the ability to commit self-harm or commit suicide by hanging.

Findings include:

1. Review of the medical record for patient #1 revealed he was admitted to the ED 3 psychiatric holding unit on 9/23/16 at 9:30 p.m. with a diagnosis of suicidal ideation with previous suicidal attempts. Upon arrival to the unit the patient was placed on Level one (1) suicide watch and was admitted to a private cubicle. The patient signed a contract for safety. On 9/24/16 at approximately 6:50 p.m. the patient went to the nursing station and requested a cup of coffee and no coffee was available at the time. At 7:15 p.m. the patient's fifteen (15) minute safety check was completed and documented as patient resting with eyes closed, respiration even and unlabored. The 7:30 p.m. fifteen (15) minute safety check was not completed. At 7:40 p.m. Registered Nurse (RN) #1 opened the patient's curtain and noticed him sitting on the floor with blood on his face and coming out of his nose and called a rapid response. Upon moving to the patient's body he realized the patient had made a noose and was hanging from his bed rail and was unresponsive and a code blue was called. The patient was cut loose from the noose and moved into the hallway onto the floor and Cardiopulmonary Resuscitation (CPR) was started. The Rapid Response team and the CPR team arrived and took over CPR. The patient was pronounced dead at 8:08 p.m.

2. Review of the policy titled, "Rounds", effective date 7/1/04, states, in part: "Rounds for all other nursing staff (minimum every fifteen minutes during the shift)... Evaluate the condition of patients...assess physical environment."

3. Review of the policy titled, "Suicidal Precautions", effective date 11/3/08, states, in part: "Interventions for patients placed on Level 1 Suicide Risk...Will not be placed in a private room...they will be admitted to a room with another patient."

4. An interview was conducted on 10/3/16 at 11:25 a.m. with the Chief Executive Officer and when asked what his expectation for a patient on a Level one (1) suicide watch on the ED 3 unit would be, he stated in part: "The curtain should remain open."

5. An interview conducted on 10/3/16 at 1:45 p.m. with RN #1 revealed he was in report until about 7:30 p.m. When he came out of report, two (2) patients were in the common area and he stopped for five (5) to ten (10) minutes to talk to them to assess their behavior and then he continued to room twenty-one (21), opened the patient's curtain and found him sitting on the floor with blood on his face and coming out of his nose. He called a rapid response and upon moving to the patient's body he realized he had a pillow case around his neck. He cut him down and called a code blue and then moved the patient into the hall and started CPR. When asked what position the bed was in he stated, in part: "The head of the bed was in the high position and the pillow case was tied to the highest part of the bed rail."

6. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 10/3/16 at 3:38 p.m. and she stated, in part: "The patient came out of the room at about 7:05 p.m. and asked for coffee and at 7:15 p.m. he was laying in the bed and I asked him if he was ok and he said he was." When asked if the patient's curtain was closed, she stated, "Yes, he wanted it closed for privacy and we let our patients do that because it's a small unit." She further stated she left work at 7:25 p.m. with the nurse she worked with during day shift.

7. An interview was conducted with LPN #2 on 10/4/16 at 7:49 a.m. and she stated, in part: "I remember the patient and when RN #1 opened the patient's curtain, I was going in behind him to get the patient's vital signs at around 7:35 p.m. and saw the patient sitting on the floor with the head of the bed in high position and we then realized the patient was tethered to the bed and we cut him down and dragged him into the hallway and started CPR."

8. An interview was conducted with the Clinical Nurse Manager on 10/4/16 at 8:30 a.m. and he concurred with the above findings.

The Director of Nursing failed to be responsible to ensure supervision of nursing care related to a suicide by hanging and the failure to ensure completion of fifteen (15) minute patient safety checks were completed on patient #1 (refer to Tag A 395).

Based on record review, document review and staff interview it was determined the hospital failed to follow hospital policies for Level one (1) suicide patient safety checks every fifteen (15) minutes on one (1) of six (6) records reviewed with patients on Level one (1) suicide precautions (patient #1). This failure resulted in a death by hanging of patient #1 and has the potential for all patients to have the ability to commit self-harm or commit suicide by hanging.

Findings include:

1. Review of the medical record for patient #1 revealed he was admitted to the ED 3 psychiatric holding unit on 9/23/16 at 9:30 p.m. with a diagnosis of suicidal ideation with previous suicidal attempts. Upon arrival to the unit the patient was placed on Level one (1) suicide watch and was admitted to a private cubicle. The patient signed a contract for safety. On 9/24/16 at approximately 6:50 p.m. the patient went to the nursing station and requested a cup of coffee and no coffee was available at the time. At 7:15 p.m. the patient's fifteen (15) minute safety check was completed and documented as patient resting with eyes closed, respiration even and unlabored. The 7:30 p.m. fifteen (15) minute safety check was not completed. At 7:40 p.m. Registered Nurse (RN) #1 opened the patient's curtain and noticed him sitting on the floor with blood on his face and coming out of his nose and called a rapid response. Upon moving to the patient's body he realized the patient had made a noose and was hanging from his bed rail and was unresponsive and a code blue was called. The patient was cut loose from the noose and moved into the hallway onto the floor and Cardiopulmonary Resuscitation (CPR) was started. The Rapid Response team and the CPR team arrived and took over CPR. The patient was pronounced dead at 8:08 p.m.

2. Review of the policy titled, "Rounds", effective date 7/1/04, states, in part: "Rounds for all other nursing staff (minimum every fifteen minutes during the shift)... Evaluate the condition of patients...assess physical environment."

3. Review of the policy titled, "Suicidal Precautions", effective date 11/3/08, states, in part: "Interventions for patients placed on Level 1 Suicide Risk...Will not be placed in a private room...they will be admitted to a room with another patient."

4. An interview was conducted on 10/3/16 at 11:25 a.m. with the Chief Executive Officer and when asked what his expectation for a patient on a Level one (1) suicide watch on the ED 3 unit would be he stated, in part: "The curtain should remain open."

5. An interview conducted on 10/3/16 at 1:45 p.m. with RN #1 revealed he was in report until about 7:30 p.m. When he came out of report, two (2) patients were in the common area and he stopped for five (5) to ten (10) minutes to talk to them to assess their behavior and then he continued to room twenty-one (21), opened the patient's curtain and found him sitting on the floor with blood on his face and coming out of his nose. He called a rapid response and upon moving to the patient's body he realized he had a pillow case around his neck. He cut him down and called a code blue and then moved the patient into the hall and started CPR. When asked what position the bed was in he stated, in part: "The head of the bed was in the high position and the pillow case was tied to the highest part of the bed rail."

6. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 10/3/16 at 3:38 p.m. and she stated, in part: "The patient came out of the room at about 7:05 p.m. and asked for coffee and at 7:15 p.m. he was laying in the bed and I asked him if he was ok and he said he was." When asked if the patient's curtain was closed, she stated, "Yes, he wanted it closed for privacy and we let our patients do that because it's a small unit." She further stated she left work at 7:25 p.m. with the nurse she worked with during day shift.

7. An interview was conducted with LPN #2 on 10/4/16 at 7:49 a.m. and she stated, in part: "I remember the patient and when RN #1 opened the patient's curtain, I was going in behind him to get the patient's vital signs at around 7:35 p.m. and saw the patient sitting on the floor with the head of the bed in high position and we then realized the patient was tethered to the bed and we cut him down and dragged him into the hallway and started CPR." When asked if she completed the 7:30 p.m. fifteen (15) minute check she stated, in part: "I was a little late getting to it."

8. An interview was conducted with the Clinical Nurse Manager on 10/4/16 at 8:30 a.m. and he concurred with the above findings.

In accordance with the 2010 Guidelines for Construction, 2.5-2.2 General Psychiatric Nursing Unit and 2.5-2.2.2.2(1) Space Requirements, patient rooms shall have a minimum clear floor area of one hundred (100) square feet for single bed rooms and eighty (80) square feet per bed for multiple-bed rooms.

This Condition is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain the physical environment in a safe condition for nine (9) of nine (9) rooms (Room Numbers 21, 22, 23, 24, 25, 26, 27, 28 and 29).

Findings include:

1. An observation on 10/03/16 at approximately 10:45 a.m. revealed Room 21 contained a patient bed, which had a looping device.

2. An observation on 10/03/16 at approximately 10:45 a.m. revealed that nine (9) of nine (9) rooms (Room Numbers 21, 22, 23, 24, 25, 26, 27, 28 and 29) did not meet the space requirements (as noted above) for a typical psychiatric patient room. The square footage of each room is as follows: Room 21 - 76.65 square feet; Room 22 - 75.68 square feet; Room 23 - 76.56 square feet; Room 24 - 77 square feet; Room 25 - 50.3 square feet; Room 26 - 47.4 square feet; Room 27 - 45.3 square feet; Room 28 - 57.8 square feet; and, Room 29 - 56.25 square feet.

3. An observation on 10/03/16 at approximately 10:45 a.m. revealed that nine (9) of nine (9) rooms (Room Numbers 21, 22, 23, 24, 25, 26, 27, 28 and 29) did not contain a window in accordance with the design of a typical psychiatric patient room.

4. An observation on 10/03/16 at approximately 10:45 a.m. revealed that nine (9) of nine (9) rooms (Room Numbers 21, 22, 23, 24, 25, 26, 27, 28 and 29) did not contain a desk or writing surface in accordance with the design of a typical psychiatric patient room.

5. An observation on 10/03/16 at approximately 10:45 a.m. revealed that nine (9) of nine (9) rooms (Room Numbers 21, 22, 23, 24, 25, 26, 27, 28 and 29) did not contain a separate wardrobe, locker, or closet suitable for hanging full-length garments and for storing personal effects in accordance with the design of a typical psychiatric patient room.

6. The above findings were discussed with the Chief Executive Officer on 10/03/16 at approximately 3:30 p.m. and he concurred with the findings.