HospitalInspections.org

Based on hospital policy review, medical record review, staffing assignment review, video review, staff interviews and personnel file reviews, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights and an organized nursing service to ensure the safety of patients.

The findings include:

1. The hospital failed to promote and protect patients' rights by failing to supervise and monitor a behavioral health patient according to policy to ensure a safe environment and prevent a patient's death by hanging with a belt.

~cross refer to 482.13 Patient Rights' Condition: Tag 0115.

2. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and monitored a behavioral health patient according to policy to ensure a safe environment and prevent a patient's death by hanging with a belt.

~cross refer to 482.23 Nursing Services Condition: Tag 0385.

Based on hospital policy review, medical record review, video review, and staff interviews, the hospital failed to promote and protect patients' rights by failing to supervise and monitor a behavioral health patient according to policy to ensure a safe environment and prevent a patient's death by hanging with a belt.

The findings include:

The hospital staff failed to ensure a safe environment by failing to supervise and monitor a behavioral health patient according to policy to prevent 1 of 1 patient's death by hanging with a belt (Patient #2).

~cross refer to 482.13(c)(2) Patient Rights' Standard: Tag A0144

Based on policy review, medical record review, video review and staff interviews, the hospital staff failed to ensure a safe environment by failing to supervise and monitor a behavioral health patient according to policy to prevent 1 of 1 patient's death by hanging with a belt (Patient #2).

The findings include:

Review on April 4, 2017 of the hospital's policy, "ACCOUNTING FOR PATIENTS" effective October 2016 revealed, "Purpose: To provide accountability for patient location. Policy: It is the responsibility of the registered nurse in charge of the ward to assign staff the task of doing patient head counts. Nursing personnel assigned direct patient care are responsible for accounting for patient movement. ...Procedure: 1. ... 2. Assigned staff shall perform rounds according to patient's Level of Observation, and any time a patient moves from one space to another. Rounds must involve visual contact with the patient. If the patient is in bed, staff must walk to the bed to ensure the patient is in bed, instead of observing through the door or window. Staff will need to actually view the patient's face to verify identification. Additionally, when patients appear to be sleeping, staff must observe for signs of life (i.e. chest rise and fall, snoring). ..."

Review of "Patient Contraband List" updated 01/17/2014 revealed " ... Contraband - Any item or substance in the possession of a patient that is not specifically authorized by hospital policy or the treatment team. Contraband items may include but not exclusively the following: weapons including knives or firearms, ...and other prohibited items such as glass bottles, mirrors, nail clippers, products that contain alcohol, scissors and other sharp objects, any item that could be used as a weapon, or any other items that renders the patient a present danger to himself or others. ..."

Review of "FSU (Forensic Services Unit) Privilege Level" updated 07/11/2013 revealed "Level 4 Privileges" included " ... Eligible for unsupervised on-ground passes if permitted by court and approved by the treatment team. ..."

Closed medical record review on April 4, 2017 at 1300 revealed Patient #2, a 42 year-old male was admitted to the hospital on 07/26/2011 after being found Not Guilty by Reason of Insanity (NGRI) for the 2006 death of an individual. Review revealed the patient had no history of self-harm nor suicidal ideations. Review revealed in August 2015, the patient was moved to FMED (Forensic unit) with physician orders for every 30 minutes observations. While on FMED unit, the patient made progress and earned Level 4 privileges which included two hours of unsupervised campus time and supervised community outings. Review of the patient's "Personal Property Record" revealed the patient had 2-woven belts, 2-leather belts and 4-ties which were kept in the patient's room.

Review of the record revealed the patient had a re-commitment hearing on February 17, 2017 and was re-committed for 365 days and no additional privileges were granted. On February 23, 2017, the patient voiced frustration to the Social Worker about the court proceedings, in that, the patient was not allowed to tell his side of the story. Review revealed the patient believed he would "never be released". On February 24, 2017, the patient voiced frustration to the Psychiatrist pertaining to the court hearing.

On March 27, 2017 from 1600 to 1700, the patient had unsupervised campus time. At 1750, the 2nd shift Nurse received telephone notification from the Nurse Coordinator related to a telephone call from a car service driver. Review revealed the car service driver alleged a telephone call was received from the patient requesting to be picked-up at 1810 from a "remote location" to transport the patient to Virginia and payment would be made in cash. After being informed of an elopement attempt, the 2nd shift Nurse canceled the patient's 1800 unsupervised campus pass, then notified the Psychiatrist, Clinical Nurse Manager and the Psychiatrist On-Call. Further review revealed the 2nd shift Nurse informed the patient the 1800 pass was canceled; the patient did not respond aggressively and immediately went to his room. Review of the "Behavioral Observation Flow Sheet" revealed on March 27, 2017 from 2200 to March 28, 2017 at 0300 (5 hours), the patient was located in his room. At 0340, the patient was found, with a belt(s) around his neck, hanging from the inside of the bathroom door. Review revealed the patient had no signs of life, a medical emergency was alerted and life-saving measures were implemented. Review revealed Physician #1 pronounced the patient's time of death at 0440.

Video review on April 6, 2017 at 1041 revealed the following occurred on March 27, 2017 through March 28, 2017:
At 2328: Multiple staff enter patient's bedroom.
At 0012: TSS (Therapeutic Support Staff) #1 walked past the patient's room (no observation for signs of life done).
At 0029: TSS #1 walked past the patient's room (no observation for signs of life done).
Video review revealed every 30 minute observations were not completed between 2328 and 0100 (1 hour and 32 minutes).
At 0100: TSS #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0138: RN #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway. RN #1 was observed to walk away from the patient's room and returned within seconds to observe the patient again through the window in the door.
Video review revealed every 30 minute observations were not completed between 0138 and 0251 (1 hour and 13 minutes).
At 0251: RN #2 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0310: TSS #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0329: RN #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway. RN #1 was observed to walk away from the patient's room and returned within a minute to observe the patient again through the window in the door.
At 0332: TSS #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0334: TSS #2 partially entered the patient's bedroom. RN #1 and RN #2 observe the patient from the hallway.
At 0409: TSS #2, TSS #3 and TSS #4 enter the patient's bedroom. TSS #1 followed the others into the room.

Interview during video review with the Risk Manager revealed the Nurses and TSSs performed signs of life observations by shining a flashlight through the glass of the patients' room doors. Interview also revealed TSS #1 walked past the patient's room at 0012, 0029, 0200 and at 0230. Interview revealed RN #1 rounded on the patient twice at 0138 and at 0329. Interview revealed the signs of life observations were not performed according to policy or every 30 minutes as ordered.

Interview on April 5, 2017 at 1330 with RN #3 revealed RN #3 worked the evening of March 27, 2017 in the capacity of Charge Nurse. Interview revealed the Unit Director telephoned and due to information provided related to the elopement attempt, the nurse was requested and carried out a "search and seizure" on all FMED-B0 patients. Interview revealed the search failed to reveal anything substantial. Interview revealed at 2300 shift change, report was given to on-coming shift with emphasis placed on being vigilant of Patient #2's location without increasing the level of observation. Prior to end-of-shift report, the nurses went to the patient's room with the intent of retrieving a DVD player. Interview revealed Patient #2 refused to return the DVD player which was unusual for Patient #2. Patient #2 was known to return the DVD player prior to bed.

Interview on April 6, 2017 at 1040 with TSS #2 revealed on March 28, 2017 at about 0340, this staff was informed by RN #1 (Charge Nurse) the patient was not in his bed. So as support to the unit, TSS #2 and RN #1 went to the patient's room. Interview revealed TSS #2 stood about 3 feet from the head of the bed, called the patient's name and there was no response. The patient's face was not observed because it was covered. Interview alleged signs of life observation was confirmed by the bed covers moving up and down at the stomach area. Interview revealed RN #1 was concerned about the patient due to the patient not communicating; therefore, about 30 minutes later, RN #1 approached TSS #2 again with the intent of having the patient contract for safety. The contract for safety was the patient saying I'm okay. Interview revealed due to the patient's history of violence, this staff member requested/received additional support from other TSS staff; TSS staff entered the patient's room and the patient was not in bed. Interview revealed the bed had been stuffed with comforters and covers, with a toboggan at the top to make it look like Patient #2 was in the bed. Interview revealed half of a "plush" blue towel was hanging from the top of the bathroom door. The bathroom door was pulled open by TSS #2 and TSS #3 with the patient falling to the floor with a "black" belt around the patient's neck. Interview revealed Patient #2 was assessed and signs of life were not detected. Interview revealed a medical emergency was alerted and life-saving measures were implemented. Interview revealed Patient #2 showed signs of behavior changes including a lack of communication on March 27, 2017, failure to turn in the DVD player and the recent elopement attempt. TSS #2 stated the patient "should have been placed on a higher observation level."

Interview on April 5, 2017 at 1133 with RN #2 revealed from March 27, 2017 at 2300 to March 28, 2017 at 0730, the nurse was assigned to the Medication nurse position. Interview revealed the nurse alternated hourly signs of life observation rounds with RN #1. Interview revealed report was received from RN #3, the off-going charge nurse which included Patient #2s elopement attempt, the cancelled unsupervised pass Patient #2s refusal of his scheduled 2100 Seroquel (anti-psychotic medication). Before the conclusion of the shift report, the on-coming and off-going charge nurses went to the patient's room, with the intent of retrieving a video player, which was unsuccessful. Interview revealed report concluded at about 2330. Interview revealed RN #2 and RN #1, prospectively, performed hourly rounds at about 0230 and at about 0330. The interview revealed RN #1 was unable to visualize Patient #2 during the 0330 round, and requested support from TSS #2. TSS #2 reported to RN #1 the patient did not say anything (asleep); at which time, RN #1 requested and received support from FSU-A0 (Forensic Services) unit and the staff presented as a "show of force" to the patient's room and a medical emergency was alerted and life-saving measures were implemented. The code blue team arrived to the unit, continued life-saving measures implemented and at 0440, Physician #1 pronounced the patient's time of death. Interview revealed RN #2 was not trained according to the facility's policy and procedure on accessing patients for signs of life.

Interview on April 5, 2017 at 0945 with RN #1 revealed from March 27, 2017 at 2300 to March 28, 2017 at 0730, the nurse was assigned to the Charge Nurse position. Interview revealed with the recent elopement attempt by Patient #2, the staff requested increased observations and expected an immediate transfer, but nothing happened. In the past, when a patient made an elopement attempt, the patient was transferred to FMAX (Forensic Unit-Maximum). Interview revealed the nurse had previous correctional system employment and was unable to understand why the patient was allowed to have belts in his room. Interview revealed when the patient was found unresponsive, a medical emergency was alerted and treatment initiated. Observation of the patient revealed possibly "2-military-style, fabric belts-bluish tan in color were wrapped around the patient's neck about 3-4 times." Interview revealed the staff was unable to revive the patient and Physician #1 pronounced the patient's time of death at 0440. Interview revealed the nurse alternated hourly signs of life observation rounds with RN #2. Interview revealed RN #1 was not trained according to the facility's policy and procedure on accessing patients for signs of life.

Interview on April 6, 2017 at 0934 with TSS #1 revealed from March 27, 2017 at 2300 to March 28, 2017 at 0730, the staff was assigned to perform every 30 minutes signs of life observations for Patient #2. Interview revealed at about 0400, this staff member was in the treatment room performing a catheterization (urinary) on another patient. Interview revealed other TSS staff went to the patient's room and discovered the patient was not in bed; at which time, the bathroom door was opened, the patient fell to the floor with a belt around his neck. Interview revealed there was blood located at the back of the patient's head, possibly due to the fall to the floor. Interview revealed the staff was trained to perform signs of life observations by shining a flashlight through the glass in patient's room door. Interview revealed this staff was not trained to go inside a patient's room. Interview revealed TSS #1 was not trained according to policy and procedure on assessing patients for signs of life.

Interview on April 4, 2017 at 1505 with the Social Worker revealed the patient was upset because during the re-commitment hearing, he was not allowed to speak about the series of events that led up to the 2006 murder. Interview revealed the recommendations to the court were made by the Psychiatrist; in which, an increase in privileges were requested in February 2017 but were not granted by the court. As it relates to the March 2017 elopement attempt, it was "atypical" for the patient not to voice disapproval when his elopement plans were discovered.

A meeting with the Hospital's leadership team on April 4, 2017 at 1042 revealed patients were allowed to have belts on the unit: as a right to personal clothing, and as dignity/respect of personal clothing, belts and shoe laces were allowed at the hospital. From a nursing perspective, the staff were concerned about Patient #2 due to his history of becoming angry.

In summary, nursing staff failed to monitor and supervise Patient #2 to ensure a safe environment and the patient was found hanging with a belt resulting in death.

Based on hospital policy review, medical record review, staffing assignment review, video review, staff interviews and personnel file reviews, the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and monitored a behavioral health patient according to policy to ensure a safe environment and prevent a patient's death by hanging with a belt.

The findings include:

1. The hospital nursing staff failed to supervise and monitor a behavioral health patient according to policy to prevent 1 of 1 patient's death by hanging with a belt (Patient #2).

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

2. The nurses and TSS (Therapeutic Support Staff) failed to demonstrate competency with conducting signs of life observations according to policy and procedure to prevent 1 of 1 patient's death by hanging with a belt (Patient #2).

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0397

Based on policy review, medical record review, video review and staff interviews, the hospital nursing staff failed to supervise and monitor a behavioral health patient according to policy to prevent 1 of 1 patient's death by hanging with a belt (Patient #2).

The findings include:

Review on April 4, 2017 of the hospital's policy, "ACCOUNTING FOR PATIENTS" effective October 2016 revealed, "Purpose: To provide accountability for patient location. Policy: It is the responsibility of the registered nurse in charge of the ward to assign staff the task of doing patient head counts. Nursing personnel assigned direct patient care are responsible for accounting for patient movement. ...Procedure: 1. ... 2. Assigned staff shall perform rounds according to patient's Level of Observation, and any time a patient moves from one space to another. Rounds must involve visual contact with the patient. If the patient is in bed, staff must walk to the bed to ensure the patient is in bed, instead of observing through the door or window. Staff will need to actually view the patient's face to verify identification. Additionally, when patients appear to be sleeping, staff must observe for signs of life (i.e. chest rise and fall, snoring). ..."

Review of "Patient Contraband List" updated 01/17/2014 revealed " ... Contraband - Any item or substance in the possession of a patient that is not specifically authorized by hospital policy or the treatment team. Contraband items may include but not exclusively the following: weapons including knives or firearms, ...and other prohibited items such as glass bottles, mirrors, nail clippers, products that contain alcohol, scissors and other sharp objects, any item that could be used as a weapon, or any other items that renders the patient a present danger to himself or others. ..."

Review of "FSU (Forensic Services Unit) Privilege Level" updated 07/11/2013 revealed "Level 4 Privileges" included " ... Eligible for unsupervised on-ground passes if permitted by court and approved by the treatment team. ..."

Closed medical record review on April 4, 2017 at 1300 revealed Patient #2, a 42 year-old male was admitted to the hospital on 07/26/2011 after being found Not Guilty by Reason of Insanity (NGRI) for the 2006 death of an individual. Review revealed the patient had no history of self-harm nor suicidal ideations. Review revealed in August 2015, the patient was moved to FMED (Forensic unit) with physician orders for every 30 minutes observations. While on FMED unit, the patient made progress and earned Level 4 privileges which included two hours of unsupervised campus time and supervised community outings. Review of the patient's "Personal Property Record" revealed the patient had 2-woven belts, 2-leather belts and 4-ties which were kept in the patient's room.

Review of the record revealed the patient had a re-commitment hearing on February 17, 2017 and was re-committed for 365 days and no additional privileges were granted. On February 23, 2017, the patient voiced frustration to the Social Worker about the court proceedings, in that, the patient was not allowed to tell his side of the story. Review revealed the patient believed he would "never be released". On February 24, 2017, the patient voiced frustration to the Psychiatrist pertaining to the court hearing.

On March 27, 2017 from 1600 to 1700, the patient had unsupervised campus time. At 1750, the 2nd shift Nurse received telephone notification from the Nurse Coordinator related to a telephone call from a car service driver. Review revealed the car service driver alleged a telephone call was received from the patient requesting to be picked-up at 1810 from a "remote location" to transport the patient to Virginia and payment would be made in cash. After being informed of an elopement attempt, the 2nd shift Nurse canceled the patient's 1800 unsupervised campus pass, then notified the Psychiatrist, Clinical Nurse Manager and the Psychiatrist On-Call. Further review revealed the 2nd shift Nurse informed the patient the 1800 pass was canceled; the patient did not respond aggressively and immediately went to his room. Review of the "Behavioral Observation Flow Sheet" revealed on March 27, 2017 from 2200 to March 28, 2017 at 0300 (5 hours), the patient was located in his room. At 0340, the patient was found, with a belt(s) around his neck, hanging from the inside of the bathroom door. Review revealed the patient had no signs of life, a medical emergency was alerted and life-saving measures were implemented. Review revealed Physician #1 pronounced the patient's time of death at 0440.

Video review on April 6, 2017 at 1041 revealed the following occurred on March 27, 2017 through March 28, 2017:
At 2328: Multiple staff enter patient's bedroom.
At 0012: TSS (Therapeutic Support Staff) #1 walked past the patient's room (no observation for signs of life done).
At 0029: TSS #1 walked past the patient's room (no observation for signs of life done).
Video review revealed every 30 minute observations were not completed between 2328 and 0100 (1 hour and 32 minutes).
At 0100: TSS #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0138: RN #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway. RN #1 was observed to walk away from the patient's room and returned within seconds to observe the patient again through the window in the door.
Video review revealed every 30 minute observations were not completed between 0138 and 0251 (1 hour and 13 minutes).
At 0251: RN #2 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0310: TSS #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0329: RN #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway. RN #1 was observed to walk away from the patient's room and returned within a minute to observe the patient again through the window in the door.
At 0332: TSS #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0334: TSS #2 partially entered the patient's bedroom. RN #1 and RN #2 observe the patient from the hallway.
At 0409: TSS #2, TSS #3 and TSS #4 enter the patient's bedroom. TSS #1 followed the others into the room.

Interview during video review with the Risk Manager revealed the Nurses and TSSs performed signs of life observations by shining a flashlight through the glass of the patients' room doors. Interview also revealed TSS #1 walked past the patient's room at 0012, 0029, 0200 and at 0230. Interview revealed RN #1 rounded on the patient twice at 0138 and at 0329. Interview revealed the signs of life observations were not performed according to policy or every 30 minutes as ordered.

Interview on April 5, 2017 at 1330 with RN #3 revealed RN #3 worked the evening of March 27, 2017 in the capacity of Charge Nurse. Interview revealed the Unit Director telephoned and due to information provided related to the elopement attempt, the nurse was requested and carried out a "search and seizure" on all FMED-B0 patients. Interview revealed the search failed to reveal anything substantial. Interview revealed at 2300 shift change, report was given to on-coming shift with emphasis placed on being vigilant of Patient #2's location without increasing the level of observation. Prior to end-of-shift report, the nurses went to the patient's room with the intent of retrieving a DVD player. Interview revealed Patient #2 refused to return the DVD player which was unusual for Patient #2. Patient #2 was known to return the DVD player prior to bed.

Interview on April 6, 2017 at 1040 with TSS #2 revealed on March 28, 2017 at about 0340, this staff was informed by RN #1 (Charge Nurse) the patient was not in his bed. So as support to the unit, TSS #2 and RN #1 went to the patient's room. Interview revealed TSS #2 stood about 3 feet from the head of the bed, called the patient's name and there was no response. The patient's face was not observed because it was covered. Interview alleged signs of life observation was confirmed by the bed covers moving up and down at the stomach area. Interview revealed RN #1 was concerned about the patient due to the patient not communicating; therefore, about 30 minutes later, RN #1 approached TSS #2 again with the intent of having the patient contract for safety. The contract for safety was the patient saying I'm okay. Interview revealed due to the patient's history of violence, this staff member requested/received additional support from other TSS staff; TSS staff entered the patient's room and the patient was not in bed. Interview revealed the bed had been stuffed with comforters and covers, with a toboggan at the top to make it look like Patient #2 was in the bed. Interview revealed half of a "plush" blue towel was hanging from the top of the bathroom door. The bathroom door was pulled open by TSS #2 and TSS #3 with the patient falling to the floor with a "black" belt around the patient's neck. Interview revealed Patient #2 was assessed and signs of life were not detected. Interview revealed a medical emergency was alerted and life-saving measures were implemented. Interview revealed Patient #2 showed signs of behavior changes including a lack of communication on March 27, 2017, failure to turn in the DVD player and the recent elopement attempt. TSS #2 stated the patient "should have been placed on a higher observation level."

Interview on April 5, 2017 at 1133 with RN #2 revealed from March 27, 2017 at 2300 to March 28, 2017 at 0730, the nurse was assigned to the Medication nurse position. Interview revealed the nurse alternated hourly signs of life observation rounds with RN #1. Interview revealed report was received from RN #3, the off-going charge nurse which included Patient #2s elopement attempt, the cancelled unsupervised pass Patient #2s refusal of his scheduled 2100 Seroquel (anti-psychotic medication). Before the conclusion of the shift report, the on-coming and off-going charge nurses went to the patient's room, with the intent of retrieving a video player, which was unsuccessful. Interview revealed report concluded at about 2330. Interview revealed RN #2 and RN #1, prospectively, performed hourly rounds at about 0230 and at about 0330. The interview revealed RN #1 was unable to visualize Patient #2 during the 0330 round, and requested support from TSS #2. TSS #2 reported to RN #1 the patient did not say anything (asleep); at which time, RN #1 requested and received support from FSU-A0 (Forensic Services) unit and the staff presented as a "show of force" to the patient's room and a medical emergency was alerted and life-saving measures were implemented. The code blue team arrived to the unit, continued life-saving measures implemented and at 0440, Physician #1 pronounced the patient's time of death. Interview revealed RN #2 was not trained according to the facility's policy and procedure on accessing patients for signs of life.

Interview on April 5, 2017 at 0945 with RN #1 revealed from March 27, 2017 at 2300 to March 28, 2017 at 0730, the nurse was assigned to the Charge Nurse position. Interview revealed with the recent elopement attempt by Patient #2, the staff requested increased observations and expected an immediate transfer, but nothing happened. In the past, when a patient made an elopement attempt, the patient was transferred to FMAX (Forensic Unit-Maximum). Interview revealed the nurse had previous correctional system employment and was unable to understand why the patient was allowed to have belts in his room. Interview revealed when the patient was found unresponsive, a medical emergency was alerted and treatment initiated. Observation of the patient revealed possibly "2-military-style, fabric belts-bluish tan in color were wrapped around the patient's neck about 3-4 times." Interview revealed the staff was unable to revive the patient and Physician #1 pronounced the patient's time of death at 0440. Interview revealed the nurse alternated hourly signs of life observation rounds with RN #2. Interview revealed RN #1 was not trained according to the facility's policy and procedure on accessing patients for signs of life.

Interview on April 6, 2017 at 0934 with TSS #1 revealed from March 27, 2017 at 2300 to March 28, 2017 at 0730, the staff was assigned to perform every 30 minutes signs of life observations for Patient #2. Interview revealed at about 0400, this staff member was in the treatment room performing a catheterization (urinary) on another patient. Interview revealed other TSS staff went to the patient's room and discovered the patient was not in bed; at which time, the bathroom door was opened, the patient fell to the floor with a belt around his neck. Interview revealed there was blood located at the back of the patient's head, possibly due to the fall to the floor. Interview revealed the staff was trained to perform signs of life observations by shining a flashlight through the glass in patient's room door. Interview revealed this staff was not trained to go inside a patient's room. Interview revealed TSS #1 was not trained according to policy and procedure on assessing patients for signs of life.

Interview on April 4, 2017 at 1505 with the Social Worker revealed the patient was upset because during the re-commitment hearing, he was not allowed to speak about the series of events that led up to the 2006 murder. Interview revealed the recommendations to the court were made by the Psychiatrist; in which, an increase in privileges were requested in February 2017 but were not granted by the court. As it relates to the March 2017 elopement attempt, it was "atypical" for the patient not to voice disapproval when his elopement plans were discovered.

A meeting with the Hospital's leadership team on April 4, 2017 at 1042 revealed patients were allowed to have belts on the unit: as a right to personal clothing, and as dignity/respect of personal clothing, belts and shoe laces were allowed at the hospital. From a nursing perspective, the staff were concerned about Patient #2 due to his history of becoming angry.

In summary, nursing staff failed to monitor and supervise Patient #2 to ensure a safe environment and the patient was found hanging with a belt resulting in death.

Based on policy review, medical record review, staffing assignment review, video review, staff interviews and personnel file reviews, the nurses and TSS (Therapeutic Support Staff) failed to demonstrate competency with conducting signs of life observations according to policy and procedure to prevent 1 of 1 patient's death by hanging with a belt (Patient #2).

The findings include:

Review on April 4, 2017 of the hospital's policy, "ACCOUNTING FOR PATIENTS" effective October 2016 revealed, "Purpose: To provide accountability for patient location. Policy: It is the responsibility of the registered nurse in charge of the ward to assign staff the task of doing patient head counts. Nursing personnel assigned direct patient care are responsible for accounting for patient movement. ...Procedure: 1. ...2. Assigned staff shall perform rounds according to patient's Level of Observation, and any time a patient moves from one space to another. Rounds must involve visual contact with the patient. If the patient is in bed, staff must walk to the bed to ensure the patient is in bed, instead of observing through the door or window. Staff will need to actually view the patient's face to verify identification. Additionally, when patients appear to be sleeping, staff must observe for signs of life (i.e. chest rise and fall, snoring). ..."

Closed medical record review on April 4, 2017 at 1300 revealed Patient #2, a 42 year-old was admitted to the hospital on 07/26/2011 after being found Not Guilty by Reason of Insanity (NGRI) for the 2006 death of an individual. Review revealed the patient had no history of self-harm nor suicidal ideations. On August 3, 2015, the patient was ordered every 30 minutes observations. On March 27, 2017 from 2200 to 2300 (1 hours), observations revealed the patient was located on the unit. On March 28, 2017 from 0000 to about 0300 (3 hours), observations revealed the patient was located in his room. At 0340, the patient was found, with a belt(s) around his neck, hanging from the inside of the bathroom door. Review revealed the patient had no signs of life, a medical emergency was alerted and life-saving measures were implemented. Review revealed Physician #1 pronounced the patient's time of death at 0440.

Review on April 4, 2017 at 1430 of the 3rd shift assignment revealed on March 27-28, 2017 there were 2-nurses and 4-TSS (Therapeutic Support Staff) for 24 of 24 patients located on the unit. Review revealed the patient was 1 of 6 patients under the direct care of TSS #1.

Video review on April 6, 2017 at 1041 revealed the following occurred on March 27, 2017 through March 28, 2017:
At 2328: Multiple staff enter patient's bedroom.
At 0012: TSS (Therapeutic Support Staff) #1 walked past the patient's room (no observation for signs of life done).
At 0029: TSS #1 walked past the patient's room (no observation for signs of life done).
Video review revealed every 30 minute observations were not completed between 2328 and 0100 (1 hour and 32 minutes).
At 0100: TSS #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0138: RN #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway. RN #1 was observed to walk away from the patient's room and returned within seconds to observe the patient again through the window in the door.
Video review revealed every 30 minute observations were not completed between 0138 and 0251 (1 hour and 13 minutes).
At 0251: RN #2 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0310: TSS #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0329: RN #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway. RN #1 was observed to walk away from the patient's room and returned within a minute to observe the patient again through the window in the door.
At 0332: TSS #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0334: TSS #2 partially entered the patient's bedroom. RN #1 and RN #2 observe the patient from the hallway.
At 0409: TSS #2, TSS #3 and TSS #4 enter the patient's bedroom. TSS #1 followed the others into the room.

Interview during video review with the Risk Manager revealed the Nurses and TSSs performed signs of life observations by shining a flashlight through the glass of the patients' room doors. Interview also revealed TSS #1 walked past the patient's room at 0012, 0029, 0200 and at 0230. Interview revealed RN #1 rounded on the patient twice at 0138 and at 0329. Interview revealed the signs of life observations were not performed according to policy or every 30 minutes as ordered.

Interview on April 5, 2017 at 0945 with RN #1 revealed from March 27, 2017 at 2300 to March 28, 2017 at 0730, the nurse was assigned to the Charge Nurse position. Interview revealed this nurse made the 3rd shift staff assignment. Interview revealed the nurse alternated hourly signs of life observation rounds with RN #2. Interview revealed the nurse was trained to perform signs of life observations by shining a flashlight through the glass of the patient's room door, onto the patient's chest area to observe for the rise and fall of the chest (signs of life). Interview revealed RN#1 was not trained according to the facility's policy and procedure on assessing patients for signs of life.

Interview on April 5, 2017 at 1133 with RN #2 revealed from March 27, 2017 at 2300 to March 28, 2017 at 0730, the nurse was assigned to the Medication nurse position. Interview revealed the nurse alternated hourly signs of life observation rounds with RN #1. Interview revealed the nurse was trained to perform signs of life observations by shining a flashlight through the glass of the patient's room door, onto the patient's chest area to observe for the rise and fall of the chest (signs of life). Interview revealed RN #2 was not trained according to the facility's policy and procedure on assessing patients for signs of life.

Interview on April 6, 2017 at 0934 with TSS #1 revealed from March 27, 2017 at 2300 to March 28, 2017 at 0730, the staff was assigned to perform every 30 minutes signs of life observations for Patient #2. Interview revealed the staff was trained to perform signs of life observations by shining a flashlight through the glass in patient's room door. Interview revealed TSS #1 was not trained to go inside a patient's room. Interview revealed TSS #1 was not trained according to the facility's policy and procedure on assessing patients for signs of life.

Personnel file reviews on April 6, 2017 revealed signs of life training was completed by RN #1 on February 3, 2017, by RN #2 on February 5, 2017 and by TSS #1 on February 4, 2016. Review revealed the staff received signs of life observations training.

Based on policy reviews, medical record review, staff assignment review, video review, staff interviews and personnel file reviews, the hospital staff failed to accurately document patient care observations for 1 of 5 sampled patients. (Patient #2).

The findings include:

Review on April 4, 2017 of the hospital's policy, "ACCOUNTING FOR PATIENTS" effective October 2016 revealed, "Purpose: To provide accountability for patient location. Policy: ...Procedure: 1. ...2. Assigned staff shall perform rounds according to patient's Level of Observation, and any time a patient moves from one space to another. Rounds must involve visual contact with the patient. If the patient is in bed, staff must walk to the bed to ensure the patient is in bed, instead of observing through the door or window. Staff will need to actually view the patient's face to verify identification. Additionally, when patients appear to be sleeping, staff must observe for signs of life (i.e. chest rise and fall, snoring). ..."

Review on April 6, 2017 of the hospital's policy, "DOCUMENTATION - NURSING" effective October 2015 revealed, "Purpose: To document comprehensive, safe, and effective Nursing Care assuring that pertinent information included in the patient's medical record is timely and accurate. To ensure all nursing assessments and observations are performed in a manner consistent with regulatory standards. ...Policy: Definitions: ...Procedure: DOCUMENTATION 1. ...10. Documentation of care is never completed prior to the actual performance or when not performed as it is falsification of documentation. ..."

Closed medical record review on April 4, 2017 at 1300 revealed Patient #2, a 42 year-old was admitted to the hospital on 07/26/2011 after being found Not Guilty by Reason of Insanity (NGRI) for the 2006 death of an individual. Review revealed the patient had no history of self-harm nor suicidal ideations. On August 3, 2015, the patient was ordered every 30 minutes observations. On March 27, 2017 from 2200 to March 28, 2017 at 0330 (5.5 hours), observation documentation revealed the patient was located on the unit. Review of the "Behavior Observation Flow Sheet" revealed every 30 minute observations were conducted on for March 27, 2017 at 2330; on March 28, 2017 at 2400; 2430; 0100; 0130; 0200; 0230; 0300; and 0330. At 0340, the patient was found, with a belt(s) around his neck, hanging from the inside of the bathroom door. Review revealed the patient had no signs of life, a medical emergency was alerted and life-saving measures were implemented. Review revealed Physician #1 pronounced the patient's time of death at 0440.

Review on April 4, 2017 at 1430 of the 3rd shift assignment revealed on March 27-28, 2017 there were 2-nurses and 4-TSS (Therapeutic Support Staff) for 24 of 24 patients located on the unit. Review revealed Patient #2 was 1 of 6 patients under the direct care of TSS #1.

Video review on April 6, 2017 at 1041 revealed the following occurred on March 27, 2017 through March 28, 2017:
At 2328: Multiple staff enter patient's bedroom.
At 0012: TSS #1 walked by the patient's room thereby failing to observe for signs of life.
At 0029: TSS #1 walked by the patient's room thereby failing to observe for signs of life.
At 0100: TSS #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
Video review revealed every 30 minute observations were not completed between 2328 and 0100 (1 hour and 32 minutes).
At 0138: RN #1 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
At 0200: The patient was not observed for signs of life.
At 0230: The patient was not observed for signs of life.
At 0251: RN #2 completed monitoring check on the patient by shining a flashlight through a window in the closed door from the hallway.
Video review revealed every 30 minute observations were not completed between 0138 and 0251 (1 hour and 13 minutes).

Interview during video review with the Risk Manager revealed TSS #1 walked past the patient's room at 0012 and 0029. Video review revealed the patient was not observed at 0200 and at 0230. Interview revealed behavior observation documented on March 28, 2017 at 2400; 2430; 0200 and 0230 by TSS #1 was not performed as documented.

NC00126690 and NC00126512