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Based on interview and document review, the hospital failed to provide care in a safe setting for 2 of 10 patients (P1, P2). P1 when staff gave P1 a long piece of dental floss and she used it to attempt to injure herself, and P2 when he refused food and fluids, but staff did not monitor his intake, and he was hospitalized with dehydration.

Findings include:

P1's discharge summary dated 7/4/19, revealed P1 was admitted to the hospital on 5/2/19, with diagnoses that included borderline personality disorder.

P1's psychiatric assessment dated 5/2/19, revealed P1 attempted suicide prior to admission by taking two bottles of Tylenol, 30 gabapentin, and a week's worth of Zoloft, Xanax and other medications. She was civilly committed to the hospital related to mental illness. Initially P1 was placed on frequent observations (at least every 15 minutes) by her treatment team, but those observations were decreased to routine (random, at least hourly) on 5/13/19, related to her ability to keep herself safe, or talk to staff if she felt unsafe. P1 had a long history of self-injurious behavior including cutting her wrists and neck.

An incident report dated 6/15/19, revealed at approximately 6:40 p.m. on 6/15/19, P1 became upset at a staff member for giving a peer a shirt that P1 wanted. P1 became verbally and physically aggressive throwing items, and punching walls. P1 calmed and watched a portion of a movie with peers. P1 ate popcorn, and at approximately 7:05 p.m. P1 requested dental floss for her teeth. P1 went to the bathroom with the dental floss. P1 was in the bathroom for about 20 minutes, with staff attempting to get P1 to come out of the bathroom for an unknown period of time. Staff entered the bathroom at about 7:25 p.m. and found P1 had used the dental floss to attempt to cut her neck. P1 had two superficial scratches to her neck.

On 8/19/19, at 1:00 p.m. registered nurse (RN)-G was interviewed and stated on 6/15/19, P1 was having a bad day. P1 thought a staff member favored one of P1's peers and became angry, agitated and yelling. P1 calmed down later and came up to the desk to ask for dental floss. The hospital keeps floss for patients at the desk and staff give out the floss. Staff were supposed to give patients short pieces, but that day P1 grabbed a longer piece from the container herself. RN-G stated she did not know if there was a facility policy for the use of floss, if staff were supposed to cut the floss for patients, and stated there was no policy for staff to watch patients when they use floss. Staff checked on P1 later, and she refused to come out of the bathroom. When staff were able to check on P1, she had two superficial abrasions to her neck from the floss. After the incident P1 stated she was suicidal.

On 8/20/19, at 7:40 a.m. licensed pratical nurse (LPN)-P was interviewed and stated she worked on 6/15/19, when P1 attempted to injure herself with the floss. LPN-P stated she was told that RN-G gave P1 the floss cartridge and let her pull off as much floss as she wanted. This concerned LPN-P because it was her understanding that staff were to cut the floss for patients, and the length should not be more that about 6 inches due to the risk to patients like P1 with a history of self-injurious behavior. LPN-P stated she found P1 in the bathroom and had no idea how long she had been in there alone. She asked P1 to come out of the bathroom with the floss and P1 refused. P1 started to cry and said she needed help but refused to open the door. LPN-P opened the bathroom door and found P1 with 2 superficial abrasions to her neck. P1 had put the floss to her neck and "sawed" it back and forth across her neck. Eventually P1 threw the floss at staff and stomped out of the bathroom. P1 continued to make suicidal threats and gestures, and eventually staff restrained P1.

On 8/20/19 at 8:30 a.m. the nursing supervisor (NS)-A stated the hospital has no policy related to the use of floss by patients. NS-A stated the practice has been that staff should give an appropriate amount to patients to floss their teeth, but not too long of a piece. Staff should give patients floss verses having them take their own length of floss. If patients are on routine observations, there is no need to observe them using the floss.

Although a policy for the use of dental floss was requested, none was provided.

P2's medical record review revealed P2 was admitted to the hospital on 6/24/19, with diagnoses that included bipolar disorder.

P2's psychiatric assessment dated 6/26/19, revealed P2 was civilly committed for mental illness. P2 had a history of refusal to eat and drink, not understanding that this could do harm to himself. P2 had a history of refusal to take medications and making suicidal threats. P2 was obese. On 7/6/19, staff sent P2 to a local acute care hospital (Hospital 2) related to refusal to eat or drink, refusal to get up, and right foot pain and redness.

Records of P2's weight monitoring and intake and output monitoring were requested but none were provided.

On 8/19/19, at 2:55 p.m. psychiatric nurse practitioner (NP)-M was interviewed and stated she saw P2 three times a week during his stay. P2 had a history of being resistant to care for himself. NP-M's recommendation was for staff to set firm boundaries with P2. NP-M stated she was aware that staff were struggling to get P2 to eat and drink.

An incident report dated 7/4/19, revealed P2 had a fall by the bathroom in the west hall. Staff assessed P2's condition at the time of the fall. P2's blood pressure was 50/35. P2 stated he hit his head and had pain everywhere. Staff called the on-call provider and monitored P2's neurological status. P2 was able to move all extremities.

On 8/20/19, at 7:00 a.m. LPN-N stated P2 was refusing food and fluids most of his time at the hospital. Some days P2 would not even leave his room. Staff brought drinks to him in his room, but he declined to drink. LPN-N stated she did not think staff were monitoring P2's intake and output.

On 8/19/19, at 11:20 a.m. human services technician (HST)-E stated P2 was refusing food and fluids frequently. P2 was often in almost a catatonic state, just walking and staring. She was not aware if staff were monitoring P2's weight, but she thought staff monitored every patient's intake.

On 8/19/19, social worker (SW)-J was interviewed and stated P2 was sent to Hospital 2 on 7/6/19. The nurse manager from Hospital 2 told SW-J that P2 was diagnosed with dehydration and a pelvic fracture.

On 8/19/19, at 1:20 p.m. NP-I was interviewed and stated staff were having difficulty getting P2 to eat or drink. She did not know if staff were monitoring P2's intake and output related to that refusal. P2 had a fall on 7/4/19, in the evening. NP-I assessed him after the fall. P2 complained of rib pain, and she examined the area and noted no obvious injury. During the physical examination he did not grimace in pain. Later P2 refused to get out of bed, which was not unusual for P2. On 7/6/19, P2 was sent to Hospital 2 for evaluation. NP-I checked on P2 at Hospital 2 a few days later, and P2 was doing well.

On 8/19/,19 at 11:45 a.m. NS-A stated the hospital has no specific policy related to monitoring patients who are refusing food and fluids, as that would fall under the nurse practioner responsibility. NS-A stated nurses just monitor patients according to the general assessment policy. Nurses can initiate increased weight monitoring and intake and output monitoring in an effort to have objective data about a patient's nutritional status.

The policy titled Assessments dated effective 2/5/19, directed under the section: Procedures

D: Completed assessments are appropriately related to the patient's age and specific clinical needs related (but not limited) to the following areas:
1. Physical
2. Emotional
3. Behavioral

G. Assessments are ongoing with reassessment conducted as the patient's condition warrants.