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Based on document review, observation, interview and video surveillance review, it was determined that for 1 of 1 (Pt. #1) patient admitted with suicidal ideation (with a plan to overdose and cut his throat), the Hospital failed to appropriately montor the patient with suicidal ideation to prevent the patient's strangulation, thus putting all potential patients with suicidal ideation at a serious safety threat for self-harm. Refer to deficiencies at A-144. As a result, it was determined that the Condition of Participation for Patient Rights 482.13 was not in compliance.

1.The Hospital failed to ensure that the patient's privacy was protected. See the deficiency at A-143.

2.The Hospital failed to appropriately monitor the patient with suicidal ideation to prevent strangulation. See the deficiency at A-144.

3.The Hospital failed to ensure that the order for suicidal precautions (1:1 observation-staff within arm's reach of the patient) was renewed. See the deficiency at A-144 B.

The immediate jeopardy (IJ) began on 4/7/2017 when patient (Pt. #1) presented to the Hospital with complaints of sucical ideation with a plan to overdose or cut his throat, followed by not appropriately montoring Pt #1 on sucical precautions on 04/09/2017 and proceeding with a suicidal gesture (strangled self with patient gown) on 04/09/2017.

An IJ was announced on 04/21/17 at 3:30 PM, during a meeting with the Chief Executive Officer, Administrator/Risk Manager/PI (Performance Improvement), Nurse Educator, and the Chief Medical Officer. The immediate jeopardy was not removed by survey exit date 4/26/17.

Based on document review, observation and interview, it was determined that for 1 of 1 patient (Pt. #1), the Hospital failed to ensure that the patient's privacy was protected.

Findings include:

1. On 4/25/17 the Hosptial policy entitled "Video Surveillance" (approved 2/2013) was reviewed and indicated, "Silent video security will be utilized in common areas of patient care units as well as exit and entry areas in the facility. Silent video security will be utilized in patient's rooms. Security surveillance will not be utilized in patients' restrooms at any time. Procedure: Silent video security will be viewed by the Safety Officer to assure correct positioning and functioning of camera equipment. Silent video surveillance will be reviewed by designated clinical staff for patient safety purpose."

2. On 4/25/17 the Hospital policy entitled "Denial (Restriction) of Rights" (reviewed 12/2016) was reviewed and indicated, "Denial of patients' rights requires a physician's order. The order must delineate the clinical justification for the denial of rights. The order must specify which right(s) are to be denied. 1. The rights that are restricted must be explained to the patient ... 3. If at any time patient's rights are violated, a Restriction of Rights (ROR) form will be completed and copies distributed as follows: 3:1 One to the patient ..."

3. On 4/20/17 at approximately 2:30 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 35 year old male admitted on 4/7/17 with a diagnosis of Schizophrenia Spectrum and Psychotic Disorder. Pt. #1 presented with suicidal ideation, and with a plan to "overdose or cut his throat." Pt. #1's clinical record contained a form titled "Video Surveillance, Video Teleconferencing and Photography Consent" dated 4/7/17 and signed by Pt. #1. This form indicated "I have been informed upon my admission that (the Hospital) utilizes silent video surveillance in patient care areas for the safety of the patients, staff and visitors, as well as general public. Security surveillance is not used in the restrooms at any time." Pt. #1's clinical record did not contain a Restriction of Rights form when placed in a room with a surveillance camera.

4. On 4/20/17 at approximately 4:50 PM, an observational tour was conducted on 3 East/West Behavioral Health Units. The room assigned to Pt. #1 during his admission had a surveillance camera. On 4/20/17 at approximately 5:10 PM, the IT (Information Technician) Coordinator (E #7) stated that the surveillance cameras are continuously on; however, they only record when motion is detected.

5. On 4/20/17 at approximately 6:20 PM, the Administrator (E #1) stated that all patients are required to be monitored at night. E #1 stated that the incident reports are reviewed daily and the surveillance is reviewed if deemed necessary.

A. Based on document review, observation, video surveillance review, and interview, it was determined for 1 of 1 (Pt #1) patient with suicidal ideation (with a plan to overdose or cut throat), that the Hospital failed to appropriately monitor the patient on suicide precautions (1 to 1 precautions-staff within arm's reach of the patient).

Findings include:

1. The hospital policy entitled, "Levels of Observation," (revision date 11/16) was reviewed on 4/20/2017 at approximately 2:15 PM and required, "Procedure...One-to-One Observation (1:1): A specified and dedicated staff member will stay within approximately one arm's length of the patient on 1:1 observation..."

2. The clinical record of Pt #1 was reviewed on 4/20/17 at approximately 2:30 PM. Pt. #1 was admitted on 4/7/17 with the diagnoses of schizophrenia spectrum and psychotic disorder. Admission orders dated 4/7/17 at 9:00 AM indicated, "level of care inpatient ...Precautions: Suicide, Assault and self-injury. ... Level observation: 1:1 for 24 hours."

The initial Psychiatric evaluation dated 4/8/17 indicated, "Patient (Pt. #1) is on 1:1 as he has been having acute suicidal thoughts ...Mental Health Exam: ...He has 1:1 because of his active suicidal ideation ...Mood- he is kind of irritable...Thought content- patient has been suicidal ...Initial treatment plan: Precautions Suicide ...

The "Observation Rounds" dated 4/9/17 (the day Pt. #1strangulated himself) indicated, Pt #1 was of 1:1 observations (within arm's reach). Pt. #1's Observation sheet dated 4/9/17, from 7:30 AM to 8:30 AM indicated, Pt #1 was "sleeping in his room."

3. The Hospital's Healthcare Peer Review Report dated 4/9/17 at 9:00 AM, reviewed on 4/20/17 at approximately 2:40 PM indicated, "...B. Incident type: Suicidal attempt C. Pre Incident Mental Status: Suicidal D. Type of Injury: Bruises and redness E. Category/DSM Diagnosis: Schizophrenia Spectrum Psychotic. Injury caused by self-inflicted I. Treatment or intervention given: First Aid Non physician, placed on precautions J. Notification of Physician: on 4/9/17 at 10:15 AM. Reviewed by supervisor on 4/9/17 and Risk Manager 4/10/17."

4. Nursing Progress Notes dated 4/9/17 at 9:00 AM indicated, "Staff ran out of room yelling 'code green, code green'. This RN (Registered Nurse) immediately called a code green then ran into the patients room ...pt lying on his back with 3 staff around him trying to pull gown around his neck that he was chocking himself with. The staff tried to pull the gown away the patient tried to make the gown tighter around his neck. This RN ran to get the shears and ran back to the patient's room ...This RN cut the gown. Pts (Pt. #1) neck was very red but did not turn blue or loss consciousness. After gown was removed from patient neck patient lied in bed. This RN took pt's (Pt. #1 vital signs BP (blood pressure) 117/60, P (pulse) 106, Resp (respirations) 18 and Sat% (96%) ....When asking pt what happened, pt stated ...he was able to do that is because the ...staff was not watching him. He stated that the staff had his chair in the hallway the whole night with his back facing pt (Pt. #1) while he talked to another staff. Pt stated that he got up and grabbed the paper gowns from the table. Pt (Pt. #1) stated he had been trying to choke himself since 4:30 AM."

5. On 4/21/17 between 9:00 AM and 10:00 AM, an observational tour was conducted on the 3 East unit (Behavioral Health Unit). The Patient Observation Rounds Reports were reviewed. The reports were current and no omissions noted. There were no patients currently on 1:1 precautions.

6. On 4/21/17 at approximately 10:30 AM, the video surveillance of 3 West, for 4/9/17 from 6:00 AM to 9:00 AM, was reviewed. This was the unit were Pt. #1 was admitted. The video surveillance captures the hallway and Pt. #1's assigned rooma and included:

-6:30 AM the BHT (E #6) is sitting outside of Pt. #1's room.
-7:05 AM E #6 is observed talking to patients in the hallway.
-7:08 AM Pt. #1 was moving in the bed and the camera is activated.
-7:15 AM BHT (E #5) is in the hallway conducting the patient observation [every 15 minutes]on the unit.
-8:17 AM E #5 relieves the BHT (E #6) and E #5 sits in the chair. E #5 does not go into Pt. #1's room.
-8:18 AM E #5 walks away from the chair and Pt. #1 has the gown in his hands.
- 8:28 AM E #5 is in the chair with his back toward Pt. #1's room.
-8:31 AM Pt. #1 is awake.
-8:44 AM E #5 is walking in the hallway.
-8:45 AM Pt. #1 sat up in the bed.
-8:47 AM Pt. #1 tightens the gown around his neck again. E #5 is in the hallway. The staff assigned to perform a 1:1 observation (within arm's reach of the patient) did not enter the patient's room to check on the patient.
-8:52 AM E #5 gets up from the chair. E #3 (BHT) takes over the 1 to 1 observation of Pt. #1 in the hallway and E #5 walks away. E #3 placed the chair that was in the hallway in Pt. #1's room.
8:53 AM E #3 walks toward Pt. #1's bed and E #3 runs out and immediately enters the room again. Pt. #1 attempted to tighten the gown around his neck.

7. On 4/20/17 at approximately 6:00 PM, the Behavioral Health Technician (BHT) (E #3) was interviewed. E #3 was the BHT that found Pt #1 attempting to strangle himself with the paper gown. E #3 stated that Pt. #1was "very suicidal and at times would have inappropriate sexual comments." E #3 stated that he arrived to the unit at approximately 9:00 AM and found E #5 (Behavioral Health Technician) sitting in the hallway. E #3 stated he asked E #5 if Pt. #1 continued on 1 to 1 observation and E #5 told him yes. E #3 also stated that E #5 told him that he was in the hallway because the patient was asleep.

8. On 4/21/17 at approximately 11:30 AM, the Child Unit RN Manager (E #2) stated, "...the staff assigned to monitor the patient 1:1 was in the hall all night instead of the patient's room and he never went into the room."

9. On 4/21/17 at approximately 1:30 PM, an Administrator (E #1) stated, "The 1:1 was not provided as it should have been."




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B. Based on document review and interview, it was determined for 1 of 1 patient (Pt. #1) with suicidal ideation, that the Hospital failed to ensure an order was renewed for suicidal precautions (1:1 observations-staff within arm's reach of the patient).

Findings include:

1. The Hospital policy entitled "Levels of Observation" (approved 11/2016) was reviewed on 4/20/17 and indicated, "Policy: All patients will be routinely observed in compliance with physician orders and prescribed protocols. Procedure: 1. The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change: ...One-to-one (requires a precaution) ...2. The physician will order a specific precaution for: Suicide, Assault ...Self Injury ...4. The RN may not decrease the level of observation. A decrease in the level of observation or change in precaution level requires a physician order ...7. One-to one Observation (1:1): A specified and dedicated staff member will stay within approximately one arm's reach of the patient on 1:1 observation. This continuous direct visual observation will continue even when the patients shower, changes clothes or uses the bathroom...."

3. On 4/20/17, the clinical record of Pt. #1 was reviewed at approximately 2:30 PM. Pt. #1 was a 35 year old male admitted on 4/7/17 with a diagnosis of Schizophrenia Spectrum and Psychotic Disorder. Pt. #1 presented with suicidal ideation, and with a plan to "overdose or cut his throat." Pt. #'1 s clinical record contained a Physician Order (admission) dated 4/7/17 at 9: 00AM and indicated, "Precautions: Suicide, Assault and self-injury. Level of Observations: 1:1 for 24 hours. Pt. #1's clinical chart did not contain a discontinue or renewal order on 4/8/17 for the suicide precautions (1:1 observation-staff within arm's reach of the patient). On 4/9/17 at 10:15 AM, an order was written for 1 to 1 observation level for 24 hours (after the incident where Pt. #1 strangled himself).

4. On 4/25/17 at approximately 2:10 PM, the findings were discussed with the Administrator (E #1) and a Nurse Manager (E #2). E #2 stated that the 1:1 observations are renewed every 24 hours if deemed necessary.