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Based on staff interviews, medical record reviews, and facility policy review, the facility failed to ensure a safe environment for patients ordered on suicide precautions and failed to document re-assessment of the suicide risk per policy on two of eight medical records reviewed of patients on suicide precautions. (Patients #1 and #12).

Findings include:

Review of Patient #1's medical record on 04/18/13 revealed the patient arrived by EMS to the emergency room after being found by family with lacerations to the neck and arms on 4/13/13, per the patient's family this was a suicide attempt. The medics report revealed the patient was combative and tried to run out of the back of the ambulance. The record revealed the patient was taken straight to OR from the trauma bay.
Physician orders for suicide precautions and a one to one sitter were written on 04/13/13 at 3:15 PM while Pt #1 was in ICU. The ICU record revealed the patient was extubated at 5:58 PM, family at bedside and a one to one sitter was present. According to the medical record a (SAD) persons screening tool for suicide risk was completed several times on 04/13/13 with the last documented (SAD PERSONS) screening assessment on the nursing flowsheet at 9:02 PM. The screening includes the following risk factor categories: (Sex, Age Depression, Previous suicide attempt, Ethanol abuse, Rational thinking loss, Social support deficit, Organized suicide plan, No spouse and Sickness). The patient's risk score was rated as high (greater than 7) with every assessment. The record lacked documentation the SAD PERSONS screening tool/assessment was completed every 4 hours for the remaining patient stay. This was verified by Staff F on 04/14/13 at approximately 9:00 AM.

On 4/14/13 at 3:00 PM the patient was transferred from ICU to Room 500 on the fifth floor. The nurses note revealed at 3:12 PM the patient arrived to the floor from ICU, assessment complete, sitter present at bedside, and the patient denies any needs or anxiety at this time.

Interview of Staff A, patient support assistant/sitter, on 4/19/13 at 11:20AM revealed the room was cleared of any potential hazardous materials including trash bags and cords. The suicide precaution policy numer P-137-G page 4 of 5 reveals the following objects are removed from the room; sharp objects, cord like objects, glass and metal objects, plastic bags etc. The next bullet on page 4 reads: Windows are secured (Contact Facilites Engineering for assistance). The record lacked evidence the suicide precaution list was followed in regards to staff contacting facility engineering to secure windows before the transfer of the patient to the 5th floor.

Review of the facility policy titled: Identification and Management of Patients at Risk for Suicide, category " Suicide Precautions stated windows are secured (contact facilities engineering for assistance)." There is no documented evidence that the facility's engineering was contacted before the patient was admitted to the 5th floor. Interview with Staff H on 04/18/13 at 1:30 PM stated "the windows on the hospital will only open inward and have a block in the casing to prevent them from opening all the way."

Interview of Staff B, registered nurse, on 4/18/13 at 3:05 PM revealed the patient was on the 5th floor for approximately 28 minutes before the patient forced the window open with his body and went feet first jumping out of the window. Per interview on 4/19/13 at 11:20AM Staff A, the sitter, screamed for help, heard the patient's gown rip and was unable to hold on to the patient as he/she jumped.

Review of the medical record for Patient #12 completed on 04/19/13 revealed an admission date of 04/07/13. Suicide precautions were initiated by nursing staff on 04/07/13 at approximately 11:05. A physician order was obtained to continue suicide precautions and one to one sitter on 04/07/13 at 1630. A SAD assessment (score evaluated as high risk or greater than 7) was completed on 04/07/13 at 1105 by the registered nurse. No additional SAD assessments were documented in the record. The record revealed the suicide precautions were discontinued on 04/08/13. This was verified by Staff G on 04/19/13 at approximately 12:00 P.M.

Review of the standard policy titled "Identification and management of patients at risk of Suicide" completed on 04/18/13 revealed if potential patient risk is identified after admission, the SAD PERSONS tool will be completed at that time. According to the policy the patient will be reassessed at an interval that is determined by the results of the suicide assessment. Every four hours for high risk patients and every shift for moderate risk patients and any change for patients that score low.