HospitalInspections.org

Based on interview, record review, policy review, and review of the facility's Digital Video Disc (DVD) recording, the facility failed to ensure:
- Nursing staff assessed, monitored and observed one (#1) of one patient who successfully committed suicide when he placed a paper towel down his throat that completely blocked off his airway while a patient on the Senior Adult (60 years of age or older) Behavioral Health Unit (BHU a unit for care of patients with mental health issues). (Refer to A-0395)
- An appropriate suicide risk assessment and interventions for the appropriate level of observation were initiated for one (#1) of one patient who successfully committed suicide while a patient on the Senior Adult Unit; (Refer to A-0395)
- Patient Observation Flow Sheets (flow sheets that recorded every 15 minute checks to ensure patient safety) were performed and documented in real time for one deceased patient (#1) and 12 current patients (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17) of 13 patient Observation Flow Sheets reviewed on the BHU; (Refer to A-0395) and
- Immediate Cardiopulmonary Resuscitation (CPR, Basic Life Support [BLS] lifesaving technique used in emergencies where breathing and heartbeat has stopped) was immediately initiated when unresponsiveness and lack of pulse (heartbeat) and breathing was assessed for one of one patient (#1) that was found unresponsive on the Senior Adult BHU. (Refer to A-0395)

Patient #1 was last observed on 10/02/16 at 2:33 AM by Staff T, Safety Coordinator. He was found to be unresponsive at 2:40 AM by Staff V, Mental Health Technician (MHT). The code cart (cart on wheels that contains emergency resuscitative equipment and supplies used for CPR but does not contain emergency drugs) arrived at 2:44 AM followed by Emergency Medical Services (EMS, paramedics) at 2:49 AM. The patient was taken to the Emergency Department (ED) at 3:07 AM. The patient was pronounced dead at 3:20 AM, 12 hours after the patient's admission to the facility.

The facility failures resulted in a patient's death and placed all patients within the BHU at risk for their safety. The BHU census was 64. The Senior Adult Unit census was 13. The facility census was 263.

The severity and cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 10/06/16, after the survey team informed the facility of the IJ, facility staff created educational tools and began educating staff and put into place interventions to protect patients within the entire facility.

As of 10/06/16, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Conducted a suicide risk assessment for all current inpatients who had been admitted with suicidal ideations to ensure the risk assessment was conducted correctly and interventions were in place according to policy.
- Education began to all BHU Nursing Personnel regarding completion of the suicide risk assessment and associated interventions based on the outcome of the assessment, staggering of rounds, BLS refresher including silent choking, Rapid Response Team (RRT, a team of health care providers that respond to patients with early signs of clinical deterioration to prevent respiratory or cardiac arrest) process that included the use of a panic button and documentation requirements and educational materials of suicide and the elderly population.
- Education began to all BHU MHT's regarding staggering of rounds and if they were unable to complete the round that they were to delegate to another MHT or Registered Nurse (RN), the RRT process that included a panic button and documentation requirements and educational materials of suicide and the elderly population.
- All education was given prior to the start of the staff members' next shift.
- BHU assignment sheet was changed to include which staff was assigned to what patient room, who received report and patient risk assessment status.
- Scheduled pastoral care to meet with unit staff to debrief around event.
- Mock RRT drills on each shift that assessed if staff followed the process as outlined in the policy.
- Conduct a 30 minute competency revalidation to all BLS certified staff on the BHU that included review of the event.
- Each Charge RN to monitor every Behavioral Health patient (house wide) every shift to ensure a suicide risk assessment was completed and interventions were outlined per policy.
- All new employee orientation and yearly education was reassessed and updated for evaluation on what information needed to be added or changed to reflect the above training/changes.
- The BHU House Supervisor or BHU Assistant Chief Nursing Officer were to evaluate immediately after a RRT event that the associated RRT event paperwork was complete.
- All nursing staff not working on a BHU received education of suicide assessments and interventions.
- All BHU's were to conduct video validations (visual review of video recording of patient rounding on the units) of 15 minute rounding. This was to be conducted by a member of the leadership team.
- Employee found not to have done patient rounding prior to the event was suspended on 10/05/16 and was terminated on 10/07/16. The additional staff member that was assigned to the patient was also suspended until a full investigation was completed.
- All action items were to be tracked daily to ensure that compliance was met. A daily report was to be provided to the Chief Executive Officer and monthly to the Board until all action plans were completed.
- All BHU Nursing personnel were to have a competency revalidation that 15 minute rounds were completed according to policy.
- On all BHU's the nurse and the MHT were to round together each hour to validate that the MHT rounded every 15 minutes. The nurse was to validate the round on the observation flow sheet and the charge nurse was to actively validate once a shift by visualizing each nurse and MHT completing this process.

Based on interview, record review, policy review, and review of the facility's Digital Video Disc (DVD) recording the facility failed to ensure:
- Nursing staff assessed, monitored, and observed one (#1) of one patient who successfully committed suicide while a patient on the Senior Adult (60 years of age or older) Behavioral Health Unit (BHU, a unit for care of patients with mental health issues);
- Patient rounding (every 15 minute patient safety checks) was performed and documented in real time on the Observation Flow Sheets for one deceased patient (#1) and 12 current patients (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17) of 13 patient Observation Flow Sheets reviewed; and
- Immediate Cardiopulmonary Resuscitation (CPR, Basic Life Support [BLS] lifesaving technique used in emergencies where breathing and heartbeat has stopped) was immediately initiated when unresponsiveness and lack of pulse (heartbeat) and breathing was assessed for one patient (#1) of one patient that was found unresponsive on the Senior Adult BHU.

Patient #1 was last observed on 10/02/16 at 2:33 AM by Staff T, Safety Coordinator that had entered the unit and stopped at Patient #1's door to see if he needed anything. Patient rounding by Staff V, Mental Health Technician, (MHT), was performed at 2:07 AM and was not performed again until 2:40 AM, and at that time the patient was found to be unresponsive. The code cart (cart on wheels that contains emergency resuscitative equipment and supplies used for CPR but does not contain emergency drugs) arrived at 2:44 AM followed by Emergency Medical Services (EMS, paramedics) at 2:49 AM. The patient was transported from the Senior Adult BHU to the Emergency Department (ED) at 3:07 AM. The patient was pronounced dead at 3:20 AM, 12 hours after his admission. Patient rounding was not performed on Patient #1 for a total of 33 minutes but was falsely documented on the Observation Flow Sheets that rounding had been done within that 33 minute time frame.
These failures resulted in a patient's death and placed all patients within the BHU at risk for their safety. The BHU census was 64. The Senior Adult BHU census was 13. The facility census was 263.

Findings included:

1. Record review of the facility's policy titled, "Behavioral Health: Levels of Observation," dated 08/2016 showed:
- Purpose was to delineate the levels of patient observation and associated procedures specific to each of the BHU's at the facility;
- The BHU's were committed to the care and improvement of human life and in recognition of this commitment the facility strived to promote a safe and secure environment for all patients.
- On admission, all patients were to be placed on a minimum of 15 minute safety checks unless otherwise ordered by physician due to increased risk to self or others or indicated by medical status.
- 1:1 Observation was ordered on a patient who was at immediate risk or harm to self and/or others (unable to contract for safety and actively seeking ways to harm self or others).
- The physician initiated the order for 1:1 observation and any change in assessment was to be reported by staff to the physician.
- For the protection of the patient or others, the Registered Nurse, (RN), could initiate 1:1 observation and the attending physician had to be called within one hour to communicate the behavior and status of the patient and an order was to be obtained at that time.
- 15 minute safety checks were to be conducted in a random manner on all patients to maintain a secure and safe environment unless more intensive monitoring was ordered;
- The staff member was to observe the patient within every delineated 15 minute increment of time and document their location and activity on the Observation Flow Sheet throughout their hospitalization.
- The staff member assigned to 15 minute patient safety checks was not to leave the unit or divert from their assignment in any matter without first securing another staff person to assume responsibility of assignment.
- The team Charge Nurse or Nurse Manager was to be notified in the event of rounding interruptions so that the 15 minute safety checks could be reassigned and continued.
Record review of the facility's policy titled, "BH-002 Assessment - Reassessment of the BHU Patients," dated 09/2014 showed:
- The purpose was to delineate the assessment processes and associated timeframes for assessment of patients on the BHU's.
- The policy was to provide a Medical Screening Exam (MSE), and a comprehensive psychiatric screening examination for all persons who presented for assessment in order to determine the need for care and if so the most appropriate level and to access any needed medical, psychiatric or other services for those clients at the most appropriate level of care.
- During the assessment process, the need for care considerations and for further assessment should be determined based on an analysis of the patient's diagnosis; the care they were seeking; the present level of care; the patient's response to previous care; and high risk screens that included the patient's nutritional and functional status.
- Additional screening assessments could include suicide risk assessments.
- The RN or RN House Supervisor was to use the information obtained to communicate the assessment of the patient to the on-call or referring psychiatrist for treatment, care and service decisions.
- For direct admissions the nursing staff was responsible for patient assessment.
- This assessment included harm assessment with nursing unit staff responsible for additional information regarding high risk screens for suicide risk.
- The suicide risk assessment assessed the patient's plan for self-harm, the likelihood of self-harm attempt including while in the facility and if so what would they use, access to means, triggers, current level of safety and education provided with regard to new coping skills.
- Suicide risk of low indicated time frame for completion during regular shift reassessment;
- Suicide risk of medium indicated reassessment with suicide risk monitoring every 24 hours; and
- Suicide risk of high indicated reassessment with suicide risk monitoring every shift.

2. Record review of Patient #1's admission questionnaire dated 10/01/16 at 12:00 PM, showed that he had not recently been seen by a psychiatrist or therapist for his depression and that he had current thoughts of ways to harm himself.

Record review of Patient #1's Behavioral Health Assessment dated 10/01/16 at 2:12 PM, showed Staff Z, Mental Health RN, Intake Assessor documented that:
- The patient said he was there, voluntarily, because he could not make decisions that included what to wear;
- The patient had asked his sister to speak for him;
- On 09/29/16 the patient informed his sister that he was so low that he had made a plan for suicide and his plan was specific but he had not proceeded with it due to his consideration for others;
- The patient admitted to suicidal thoughts and had purchased chemicals and was going to leave his sister a note. The patient didn't want his sister to come into the apartment and find him because he was worried he would vomit and chemicals would then get onto her;
- The patient had also planned to use knives to slit his wrists in a vacant lot next door to his apartment but was afraid it would affect the flow of surrounding businesses.
- The patient had active thoughts with plans;
- The patient had the potential for self-harm; and
- The patient was placed on 15 minute level of monitoring.

Record review of Patient #1's Admission Assessment dated 10/01/16 at 2:09 PM by Staff BB, RN, showed:
- Self-harm potential;
- The patient had specific plans for suicide;
- Patient stated he sought treatment because he wasn't able to function properly;
- Patient felt as if he was on a teeter totter;
- Patient had slow but appropriate thinking;
- Suicide assessment of active thoughts with plan;
- Precautions for suicide;
- Level of monitoring every 15 minutes;

Record review of Patient #1's Nurse Admit Assessment Summary dated 10/01/16 at 6:49 PM by Staff BB, RN, showed that the patient was admitted from home and was alert and oriented x4 (orientation of a person that showed they were aware of who they were, where they were, date and time and recent events). He was very depressed with poor eye contact. The patient was suicidal with a plan to drink a chemical " that was used in a car". The patient stated that he made a mistake and "it's just more than being depressed" and when asked for clarification the patient just shook his head. He was placed on 15 minute checks to ensure safety.

There was no History & Physical or Psychiatric Evaluation completed for Patient #1 as the patient had been admitted 12 hours prior to his death and had not had these two assessments completed.

3. Review of the facility's DVD recording titled, "Senior B," dated 10/02/16, showed the camera view of hallway B on the Senior Adult BHU. At the beginning of the hallway was the patient/shower room, then three patient rooms with Patient #1's room at the end of the hallway just before the door to enter and exit the unit. The review showed:
- 2:07:16 AM Staff V, Mental Health Technician, (MHT), was at the doorway of Patient
#1's room;
- 2:08:23 AM Staff V walked towards the camera and out of the camera's view;
- 2:09:07 AM Staff V back into camera view with a female patient in the hallway by the patient shower/bathroom;
- 2:09:34 AM Staff V walked towards the camera and out of camera view;
- 2:20:36 AM Staff V back into camera view walked half way down hallway and obtained her drink from a table and walked back towards camera and out of view.
- 2:28:11 AM Staff V back into camera view with a female patient in the hallway by the shower/bathroom door then out of camera view;
- 2:33:31 AM unit door opened and Staff T, Safety Coordinator walked onto the unit;
- 2:33:34 AM Staff T stopped at Patient #1's doorway and appeared to be talking with patient;
- 2:33:36 AM Staff T walked away from Patient #1's door towards the camera;
- 2:33:34 AM Staff V, MHT back into camera view and took a female patient into the bathroom;
- 2:39:38 AM Staff V out of bathroom with female patient;
- 2:40:28 AM Staff V entered Patient #1's room;
- 2:40:52 AM Staff V exited Patient #1's room and walked (at a normal pace) down the hallway towards the camera with her right arm pointing back towards Patient #1's room. She appeared to be talking in the direction of the nurses' station. She continued to walk up and down the hallway at a normal pace talking in the direction of the nurses' station;
- 2:41:29 AM Staff V walked back down the hallway and entered Patient #1's room by herself. No other staff had come into the camera's view;
- 2:41:35 AM Staff W, MHT walked down hallway towards Patient #1's room;
- 2:41:44 AM Staff W entered Patient #1's room;
- 2:42:44 AM Staff V, MHT exited Patient #1's room and walked down the hallway towards the nurses' station. Staff V stopped halfway down the hallway at a table and chair and picked up a pair of shoes (Staff V was wearing a pair of patient yellow non-skid socks with no shoes) then continued to walk toward the camera;
- 2:42:55 AM Staff X, RN Charge Nurse into camera view and walked towards Patient #1's room;
- 2:42:58 AM Staff Y, RN into camera view with blood pressure machine and followed Staff X down the hallway toward Patient #1's room. Staff V, MHT walked out of camera view at this time.
- 2:43:04 AM Staff Y, RN ran down the remainder of the hallway and entered Patient #1's room with Staff X, RN;
- 2:43:12 AM Staff V, MHT back into camera view and walked towards Patient #1's room;
- 2:43:16 AM Staff T, Safety Coordinator entered Patient #1's room;
- 2:43:35 AM Unit door opens and Staff D, RN, House Supervisor walked onto the unit;
- 2:43:49 AM Staff Y, RN exited Patient #1's room;
- 2:43:54 AM Staff X, RN Charge Nurse exited the patients room and walked then ran towards the nurses' station and out of camera view;
- 2:44:09 AM Staff Y, RN continued to walk toward nurses' station and out of camera view;
- 2:44:41 AM Staff EE entered patients room with the code cart and Staff Y, RN followed behind;
- 2:44:42 AM Staff X, RN Charge Nurse into camera view and ran down hallway towards patients' room;
- 2:44:55 AM Staff V, MHT exited Patient #1's room with blood pressure machine;
- 2:46:02 AM Staff V walked to a table and picked up what appeared to be a clipboard and stopped in front of patient room two doors down from Patient #1 and appeared to make patient rounds from the hallway;
- 2:49:06 AM Unit door opened and EMS staff member onto the unit;
- 2:49:32 AM Second EMS staff member onto unit and entered Patient #1's room;
- 2:49:46 AM EMS stretcher onto the unit outside Patient #1's room;
- 2:51:12 AM Staff X, RN, Charge Nurse exited patients room and then walked towards the camera and out of view;
- 2:51:24 AM Staff W, MHT exited Patient #1's room and walked down the hallways towards the camera and out of view;
- 2:52:08 AM Staff W back into camera view and walked back down hallway towards Patient #1's room;
- 3:03:56 AM EMS staff pushed stretcher into Patient #1's room;
- 3:06:52 AM stretcher out of patients room and out into hallway; and
- 3:07:01 AM EMS exited the BHU with Patient #1 on the stretcher.

Staff V, MHT assigned to do patient safety rounds on Patient #1, was visualized by DVD recording review to have made rounds at 2:07:56 AM and 2:40:28 AM on Patient #1 and only at 2:07:56 for Patients #7 and #10. Staff V did not complete her patient rounding for a total of 33 minutes and 12 seconds. Staff V left Patient #1 alone after she discovered him to be unresponsive for a total of one minute 17 seconds. She did not activate any type of alarm to alert staff that there was an emergency and she did not begin CPR.

4. Record review of the Senior Adult BHU Observation Flow Sheets dated 10/01/16 showed Staff V, MHT documented that three patients (#1, #7, and #10) had been seen on 10/02/16 at 2:07 AM, 2:22 AM, and at 2:37 AM in their bed and/or room. One additional time of 2:52 AM had been written in on Patient #1's Observation Flow Sheet but was not completed for his location or activity and was initialed by Staff V.

Per DVD review Staff V, MHT did not round on these three patients at the times she documented on the Observation Flow Sheets.

During an interview on 10/06/16 at 10:05 AM Staff V, MHT stated that:
- She was aware that she "did wrong" and missed some rounds then filled the times in later because she was with another patient;
- Observation Flow Sheets were to be handed off to another MHT or a nurse when she wasn't able to make the rounds;
- She had set the clipboard with the observation sheets on a table in the hallway and told Staff X, RN Charge Nurse, and Staff Y, RN that she was with another patient (that wasn't assigned to her);
- She had been on her feet all night and she was tired but knew she had done wrong;
- When she rounded on Patient #1 at 2:07 AM he was the only patient in that room and he was on his knees beside the bed with this hands folded together under his chin. The patient told her he was praying and "hurried" her out of the room. He told her that she had to give him his time to pray and that she had to leave.
- When she made her next round on Patient #1 at 2:40 AM she found the patient on the floor on his side;
- She turned the light on; checked for a pulse; there was none and he wasn't breathing.
- She went out into the hallway and yelled at the nurses at the desk to call 911.
- The first staff member to come to Patient #1's room was Staff W and he turned the patient over and started doing chest compressions.
- She panicked when she felt the patient had no pulse and did not want to move him for fear of a neck injury;
- She saw a small amount of blood on the patients nose so she thought he had fallen and this was why she didn't want to move him;
- She had been trained on CPR and knew what to do in the event a patient was unresponsive;
- If a patient had fallen then the staff was to use the call button inside the patient's room.
- Patients were unable to reach the call lights so it was unusual when a call light was activated;
- She was unaware of how to activate the strobe light ligature alarm (an alarm installed at the top of the patient doorways that caused a beam of light from one side of the door to the other
and when that beam was interrupted a loud alarm sounded with a strobe light visible in the hallway that indicated a patient may have attempted to hang themselves) at the top of the patient's doorways;
- Looking back at the event she knew she should have stayed with the patient after she found him unresponsive;
- Staff W, MHT did chest compressions until the code cart was brought into the room. Then the "bag" (Ambu-bag, a hand held manual resuscitator that provides breathing to patients) was used;
- During report at the start of her shift she remembered the day shift nurse reported that she was unsure of Patient #1's situation; that she had not admitted him;
- She knew he was depressed and that he had been admitted voluntarily but she was unsure of his actual level of observation (precautions);
- The MHT's were responsible for completing the observation sheets and circled the precautions at the top of the sheet that pertained to the patient; and
- Level of observations was either close observation which was within sight at all times or 1:1, which was that staff stayed with the patient all the times.

Staff V, MHT did not perform patient rounding every 15 minutes per policy to ensure patient safety. She falsified documentation that indicated she did perform the rounding. Staff V did not activate the call light button or the ligature alarm for Patient #1 that would have alerted staff of the emergency and enabled Staff V to remain with the patient and begin CPR.

Record review of Staff V's training transcript showed the following training:
- Heart Code BLS part 1 on 10/27/15;
- Suicidal Tendencies: Screening for Risk of Self-harm on 11/23/15;
- Heart Code BLS parts 2 and 3 on 12/01/15;
- Observation Rounds on 12/01/15; and
- Patient Safety Education on 12/01/15.

During a telephone interview on 10/06/16 at 1:45 PM, Staff W, MHT stated that:
- He heard Staff V, MHT yell out to call 911 that a patient had fallen and there was blood on the floor;
- Staff V did not inform the staff that the patient was unresponsive with no pulse or breathing,
just stated that the patient had fallen and to call 911;
- When he entered Patient #1's room (per DVD review 2:41:44 AM) the patient was lying on the floor between the two beds with his head up close to the wall;
- He stepped over the patient and saw blood on the floor and blood on the patient's nose;
- He pulled the patient away from the wall by his ankles and saw that his mouth was half way opened with his tongue sticking out;
- It appeared to him that the patient had agonal breathing (abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing accompanied by strange vocalizations and noises). It appeared that a breath came out of his mouth when he moved the patient;
- He then proceeded to tear off the patient's shirt to start CPR but was unable to remove it;
- Staff T, Safety Coordinator entered the room (per DVD review 2:43:16 AM) and gave him scissors to cut off the patient's shirt;
- He then started chest compressions immediately after the shirt was removed;
- The code cart arrived (per DVD review 2:44:41 AM) and Staff T began to do the breathing using the Ambu-bag while he continued chest compressions;
- Staff X, RN, Charge Nurse re-positioned the patient's head because the chest did not rise and fall with the Ambu-bag ventilations;
- He and Staff T continued CPR with chest compressions and ventilations until the EMS staff arrived and took over CPR.

During a telephone interview on 10/06/16 at 3:45 PM, Staff X, RN Charge Nurse, stated that:
- During report from day shift Staff AA, RN informed the staff that Patient #1 had been admitted that day and that he had wanted to jump in front of a car.
- Patient #1 had stood at the nurses' station most of the evening and had talked about his whole life.
- She did not have any concerns that he wanted to hurt himself or end his life.
- She was at the desk working on an admission when Staff V came out of a patient room yelling that a patient had fallen.
- Staff V was screaming to call 911 that the patient was down and without a pulse.
- She immediately called 911 and told Staff Y, RN to get the code cart.
- The 911 dispatcher asked her to get an assessment of the patient and that she would hold on while she went to the patient's room.
- When she got to the room Staff W, MHT was performing chest compressions and informed her that the patient had no pulse so she did not assess the patient herself;
- She returned to the 911 phone call and told them the patient had no pulse and to send EMS as soon as possible.
- She returned to Patient #1's room and repositioned his head and Staff T, Safety Coordinator was bagging the patient and Staff W was performing chest compressions.
- The code cart arrived to the room and the AED was placed on the patient and instructed, "No shock continue CPR."
- The patients hands were cold; she checked the carotid (artery located on each side of the neck) pulse and he had no pulse; there was no rise and fall of the chest and his stomach was distended.
- EMS arrived at this time so she left the room.
- She returned to the nurses' station and called the patients daughter then called the patients doctor and informed both of the event.
- As an RN it was her responsibility to have done the patients assessment but she did not because Staff W, MHT was already there and had determined the patient had no pulse and was not breathing.
- Nurses were to monitor the MHT's and what they do and what they were supposed to do and that the nurses were to do patient rounding once per hour and document that rounding in real time on the observation sheet.
- If nursing staff were concerned regarding a patient's safety they would initiate close observation (line of sight) and then call the physician for the order.
- She would know if a patient had suicidal ideations on their mind if they would have told the nursing staff.

During an interview on 10/05/16 at 3:15 PM, Staff D, RN House Supervisor, stated that:
- She was House Supervisor on the night the event occurred.
- She heard the Rapid Response on the overhead speaker and responded to the Senior Unit.
- She called the administrator on call.
- Prior to the event there was no actual Rapid Response Team designated that any staff that was available was to respond.
- When she arrived to Patient #1's room he was on the floor between the beds and staff members were shaking him calling out his name and checking for a pulse.
- Someone called out to get the code cart and that 911 had already been called by the Charge Nurse.
- She remembered Staff T, Safety Coordinator, Staff W, MHT and a couple of other nurses from other units were in the patients' room all assessing him. Chest compressions were began shortly after she entered the room, prior to the code cart arriving.
- There was no rise and fall of the patient's chest with bagging during CPR so she asked for his head to be repositioned,which it was but still no rise and fall of the chest was seen.
- She viewed the DVD recording with Senior Leadership after the event.

During an interview on 10/06/16 at 9:25 AM, Staff T, Safety Coordinator stated that:
- He responded to all Rapid Responses primarily to help de-escalate the situation.
- At approximately 2:30 AM he entered the Senior Adult BHU and stopped at Patient #1's doorway because he saw him knelt down at the side of the bed and wanted to make sure he was okay.
- He asked the patient if he was praying and the patient replied "yes" so he thought he would let him finish and he walked away from the patients doorway.
- He later heard the Rapid Response call and he responded.
- When he arrived to the Senior Unit he entered Patient #1's room and saw the patient on the floor in-between two beds.
- He remembered that there was a MHT there and he was opening up the patient's shirt but was having difficulty so he gave him his scissors to cut the shirt off.
- The patient was unresponsive, staff was checking his vital signs (pulse rate, respirations and blood pressure).
- Once the patients' shirt was removed the MHT started doing chest compressions and once the code cart arrived he gave the patient breaths with the Ambu-bag.
- The patient did not have a pulse.
- The AED was connected and instructed not to shock just to continue CPR.
- While he was bagging the patient he noticed that there was no rise and fall with his chest so the patients head was repositioned and they did look into the patient's throat but were unable to see anything, so he continued with bagging but never saw rise and fall of his chest.
- They did about three to four cycles of 30 compressions to two breaths until EMS arrived and took over.
- When EMS arrived they placed an apparatus in the patient's mouth to open his mouth and they removed what appeared to be a paper towel.

During a telephone interview on 10/12/16 at 11:35 AM, Staff Y, RN stated that:
- He was seated at the nurses' station when Staff V, MHT came out of Patient #1's room and yelled down the hall for someone to call 911.
- Staff X instructed him to call a Rapid Response.
- When he arrived to Patient #1's room Staff W, MHT was already doing chest compressions so he looked out into the hallway for the code cart but didn't see it so he started down the hall and heard someone was going to get the cart.
- Staff X was on the floor assessing Patient #1;
- He went back to the nurses' station and prepared the patient's paperwork to send with EMS.
- He didn't remember any information that was told in the shift report from the day staff that would have indicated that Patient #1 was at risk for self-harm. He just remembered that he was admitted for major depression and that he had made statements to his family prior to admission regarding suicidal ideations (thoughts of suicide).
- If a patient verbalized to him that they currently had suicidal thoughts then he would call the doctor for a higher level of observation like 1:1 or close observation.

During a telephone interview on 10/13/16 at 2:40 PM, Staff Z, RN Mental Health Nurse, Intake Assessor stated that:
- She worked as an intake assessor and part of the assessment for a potential admission was a suicide risk assessment.
- Mid morning she had received a call from Physician Staff FF, asking her to call Staff DD, Psychiatrist and ask if he would accept admission for Patient #1; that he was being directly admitted to the BHU;
- Staff DD accepted the patient;
- Patient #1 arrived at the facility at approximately 12:00 Noon;
- Prior to admission the patient had purchased items (chemicals) to drink and had planned to slit his wrists to commit suicide;
- She was not concerned with the potential for self-harm as an inpatient since he did not have access to the items that were in his previous suicide plan and just had a "gut" feeling that his safety was not a concern;
- She felt the 15 minute safety checks were an appropriate level of observation for Patient #1.
- If she would have felt Patient #1 or any other patient was at risk for self harm she would have called the physician and obtained an order for higher level of observation.

During a telephone interview on 10/12/16 at 3:10 PM, Staff BB, RN, stated that:
- He completed the admission assessment for Patient #1 on the Senior Adult BHU;
- Patient spoke in depth regarding his plans for suicide explaining that he had purchased a chemical to drink;
- Patient stated that there was "more to this"and sometimes didn't fully answer questions;
- He had received a "quick run-down" on the patient's suicidal ideations from the intake assessor Staff Z, RN;
- The patient stood at the nurses' desk for the admission and for the remainder of the day shift.
- The patient was talkative with the staff.
- He "felt better" after talking with the patient for a few hours in regards to his safety.
- The patient was not placed on close observation only on 15 minute safety checks;
- If during an assessment he was ever concerned about a patient's safety he called the physician and asked for an order for close observation.
- His practice was to do rounding once per hour and to make sure rounding sheets were being completed.
- In the past he had seen Observation Flow Sheets that were blank and when he asked the MHT why he was told that they would get them caught up.

During a telephone interview on 10/12/16 at 1:30 PM, Staff DD, Psychiatrist, stated that:
- On 10/01/16 at approximately 10:00 AM he received a phone call from Staff Z, RN Intake Assessor. She informed him of Patient #1's direct admission and asked if he would accept to treat him;
- He accepted the patient as he met admission criteria;
- He did not receive any further calls from Staff Z which told him that there was nothing new clinically after the patient had arrived at the facility;
- He didn't recall anything out of the ordinary for Patient #1 that would have suggested the need for a higher level of observation "over any of the 100 or so patients that were admitted monthly with suicidal ideations."
- If a patient verbalized to staff something that made them "actively" suicidal then they made need 1:1 observation but "we can't place all suicidal patients on a 1:1."
- He spoke to Staff X, RN, Charge Nurse, later that evening and she reported that Patient
#1 had been up and was talkative.
- He did not feel that Patient #1's talkative, happy mood with staff for most of the evening was any kind of concern;
- He would not have thought that the patient came to the facility to carry out a plan of suicide.

During an interview on 10/06/16 at 9:10 AM, Staff C, Chief Operating Officer, CEO BHU stated that:
- She was the administrator on call the night of the event and had received the phone call of the event from Staff D, House Supervisor.
- She arrived to the facility Sunday morning 10/02/16 at approximately 3:00 AM;
- She viewed the video recording timed from 2:29 until after the event and verified that Staff V, MHT had missed one 15 minute rounding;
- After she reviewed Patient #1's admission documentation and spoke to staff she would not have been concerned for his safety due to the fact that his plan for suicide had involved items that he could not get while in the facility.
- Staff V, MHT had informed her that she had written the rounding times in ahead of time so that it would remind her to do them;
- She asked Staff V if she was in any "shape" to continue her shift or if she needed to go home.
- She believed that Staff V worked the next two days following the event.

5. Record review of the facility document titled, "Kronos Timekeeper," dated 09/25/16 through 10/09/16 showed that Staff V, MHT worked a 12 hour shift on 10/03/16 the day after the event occurred.

6. Record review of Patient #1's ED record dated 10/02/16 at 3:22 AM showed that Patient
#1 arrived to the ED at 3:16 AM in cardiac arrest (sudden loss of heart function) as he had been found down (unresponsive) approximately 25 minutes prior to his arrival. Patient #1 had been admitted to the BHU at approximately 3:00 PM the previous day for suicidal ideations. EMS was called at 2:50 AM for an unresponsive patient on the BHU. When EMS arrived they found the patient in asystole (state of no electrical activity from the heart, also known as flat line) and Advanced Cardiac Life Support (advanced basic life support by trained healthcare professionals and EMS for the urgent treatment of cardiac arrest utilizing emergency medications) was initiated. The patient had been intubated (insertion of a tube into the windpipe to maintain an open airway) by EMS after they removed what appeared to have been a wadded up paper towel from the patient's throat. The patient had no signs of life with no audible heart tones, no palpable pulse and no spontaneous respirations. He had an additional round of epinephrine (primary emergency medication used for cardiac arrest) in the ED without change. Resuscitative efforts were discontinued and Patient #1 was pronounced dead at 3:20 AM.

7. Interview on 10/05/16 at 2:50 PM with concurrent record review of the Senior Adult Unit Observation Flow Sheets dated 10/05/16 showed staff documented that 12 patients (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16,