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Based on record review and interview the hospital failed to ensure patients received care in a safe setting as evidenced by the introduction of contraband, specifically a pair of shorts with a drawstring which was given to a staff member, into the hospital which resulted in the use of the contraband by Patient #3tying the drawstring around his neck needing acute medical care/evaluation.
Findings:

Review of the hospital policy titled "Patient Searches-Contraband/Personal", policy number RI-00-015, revised 11/09/10, and presented as a current policy by S1CEO (chief executive officer), revealed that it was

a) hospital policy to conduct patient searches upon admission, following visitation, and at any time during the patient's hospital stay if their behavior indicated the necessity for a search.

b) contraband was defined as any sharp objects such as razors, knives, or scissors; all medications and drugs; alcoholic beverages and cigarettes; electrical appliances; flammable materials including matches and lighters; weapons of any kind; anything in glass containers; and belts, shoe laces, ties, suspenders, ropes or cords, draw strings, thong underwear, and boots or shoes with metal buckles or ornaments.

c)All patients admitted to the hospital will have their person searched by at least 2 nursing staff members consisting of a RN (registered nurse), LPN (licensed practical nurse), and/or MHT (mental health tech), one of whom being the same sex as the patient, prior to being escorted to the unit.

d) in order to ensure safety for all patients and staff, post visitation searches will be conducted once the patient is returned to the patient care unit. If belts, ties, flammable materials, and medications are found at the time of admission, they should be sent home with family members if possible.

e) All patient belonging searches should be documented in the patient's medical record including if the search was conducted by the same sex staff and witnessed and the disposition of any contraband that is found.

f) Patient belongings brought to the hospital by a family member or significant other after the patient's admission to the unit will be left at the front desk until picked up, searched, and taken to the unit by a staff member.

Patient # 3
Review of the Nursing Mental Status Exam dated/timed 6/16/13 at 0940 by S11RN revealed the following: "...Physical Appearance: Appropriate clothes. Mood: Sad, Anxious, Depressed. Affect: Sad...Assessment for Potential Risk: Suicidal...Narrative Note: Pt was in restroom (review of the video tape revealed patient #3 was in the restroom for 27 minutes), and MHT (S9MHT) walked to door and found pt lying on R (right) side with a drawstring wrapped twice and tied around his neck. Immediately, MHT (S9MHT) called for help. I found pt lying on the ground and turning cyanotic. I called for emergency services. (S10RN) got scissors and cut the string off. Pt was still breathing and color returned and pt began responding to pain stimuli and then verbal..."

Review of a document titled "Crossroads Regional Hospital Quality/Risk Management Report of Event" revealed the following: "WHO?...Inpatient ...WHEN? 6/16/13 0940. WHERE? Adult Males ...DESCRIPTION OF OCCURRENCE/COMPLAINT. (Self-strangulation attempt) Pt was in restroom and MHT (S9MHT) walk to door and found pt lying on his R (right) side with a drawstring wrapped twice and tied around his neck. Immediately MHT called for help. I found pt lying on the ground turning cyanotic. I called for Emergency Services. (S10RN) got scissors and cut the string off. Pt was still breathing and color returned and pt began responding to verbal and tactile stimuli...Completed By: (S11RN). Reviewed by: (S3RN/Risk Management)

Review of a Louisiana Department of Health and Hospitals - Hospital Abuse/Neglect Initial Report revealed: "Type of Incident: Alleged Neglect...Incident Information. Date of Incident: 6-16-13. Time of Incident: 9:40 a.m...Specific Location of Incident: Adult Unit Room ("c"). Patient Information: Name: (patient #3)...Admit Date: 6-14-13...Admitting Diagnoses: Depression...On initial investigation it was noted that on 6-15-13 Mom brought in a pair of shorts that had a draw string in the waist band. The tech (S8MHT) failed to remove the draw string when logging in the shorts. It is also noted that on the morning of 6-15-13 (patient #3) voiced to (S5RN) that he was feeling suicidal and would cut his wrist or shoot himself. (S5RN) did not document that the physician was notified at that time and she did not initiate any special safety precautions. Completed investigation to follow." Typed names of S2DON and S3RN, Risk Management are on the line for Name and Title of person preparing report. The document is dated June 17, 2013.

In an interview on 8/1/13 at 8:10 a.m. with S1CEO he confirmed that there is no documented evidence that any of the Policy and Procedures were reviewed and/or revised or that Quality Assurance had developed and/or implemented any actions that should prevent the events of 6/16/13 from occurring again.





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Based on observation, record review, and interview the hospital failed to ensure performance improvement activities were developed and implemented to track adverse patient events. This was evidenced by the Quality Assurance/Performance Improvement program having no documentation evidence of implementation of a plan to measure, analyze, and/or track Mental Health Technician (MHT) monitoring of patients; after an incident on 6/16/13 whereas a patient (#3) with MD orders of line of sight monitoring was left unattended in the bathroom for 27 minutes and found on the floor with a string tied around his neck and turning blue. The lack of patient monitoring level according to MD orders and hospital policy continues to present for 8 of 8 current patents (#1, #2, #4, #5, #R3, #R4, #R5 and #R7).

Patient #1
Review of Patient #1's medical record revealed he was a 25 year old male admitted on 07/15/13 with a diagnosis of Depression. Review of his "Physician's Orders" revealed an order on 07/17/13 at 10:00 a.m. for observation Status A 1:1 with Off Unit Privileges.

Observation of the area across from the nursing station near the exit door of the Adult Male Psychiatric Unit on 07/30/13 at 9:26 a.m. revealed Patient #1 (who was ordered to be on 1:1 observation) was ambulating in the area. Further observation revealed S32MHT, who was assigned to observe Patient #1 one-to-one, did not keep Patient #1 within his arms' length while Patient #1 was ambulating in the area. Observation revealed S11RN made signs with his hands to S32MHT indicating to move closer to Patient #1.

In a face-to-face interview on 07/30/13 at 9:26 a.m., S11RN confirmed that S32MHT was not in arms' length of Patient #1 at all times as ordered by the physician and according to hospital policy.

Patient # 2
Review of Patients #2's medical record revealed that he was a 26 year old male admitted on 7/29/13 with a diagnosis of Bipolar Disorder. Review of his "Physician's Admit Orders" dated 7/29/13 with no documented evidence of the time the telephone order was received, revealed Patient #2's observation status ordered was Status B, line of sight during waking hours and every 5 minute checks during the house of sleep.

Patient #4
Review of Patient #4's medical record revealed he was a 21 year old male admitted on 07/28/13 with a diagnosis of Depression. Review of his "Physician's Orders" revealed he was ordered on 07/29/13 to be on Status B with off unit privileges.

Patient #5
Review of Patient R5's medical record revealed he was a 19 year old male admitted on 07/23/13 with a diagnosis of Psychosis. Review of His "Physician's Orders" revealed an order on 07/23/13 at 10:27 a.m. for Status B with off unit privileges.

Patient R3
Review of Patient R3's "Tech Observation Sheet" dated 07/29/13 from 11:00 p.m. to 07/30/13 at 11:00 p.m. revealed he was admitted on 07/24/13 and was on Status B observation.

Patient #R4
Review of Patient R4's medical record revealed he was a 30 year old male admitted on 07/22/13 with a diagnosis of Schizophrenia. Review of his "Physician's Admit Orders" dated 07/22/13, with no documented evidence of the time the telephone order was received, revealed Patient R4's observation status was Status B, line of sight during waking hours and every 5 minute checks during the hours of sleep.

Observation in the Day Room of the Adult Male Psychiatric Unit on 07/29/13 at 2:50 p.m. revealed Patients #2, R3, and R4, seated on the sofa with no observation of a MHT observing the 3 patients who had orders to be in a staff member's line of sight at all times during waking hours. Further observation revealed S38Lead MHT standing at the nursing station with his back to the Day Room (the sofa was not visible from the area where he was standing if he had turned around to face the Day Room).

In a face-to-face interview on 07/29/13 at 2:50 p.m., S38Lead MHT indicated that S32MHT was assigned to observe Patients R3, and R4, but left the area to go to the bathroom. S38Lead MHT confirmed that the three patients were not within any staff member's line of sight during the time that S32MHT was in the bathroom.

Patient #R5
Review of Patient R5's medical record revealed he was a 19 year old male admitted on 07/23/13 with a diagnosis of Psychosis. Review of his "Physician's Admit Orders" dated 07/23/13 at 3:00 p.m. revealed his observation status was Status B, line of sight during waking hours and every 5 minute checks during the hours of sleep.

Observation on 07/30/13 at 11:20 a.m. on the Adult Male Psychiatric Unit revealed Patient R5 ambulating to the bathroom with S28MHT in attendance. While observing from the nursing station which provided a full view of the hall where patient rooms were located, S28MHT was observed standing in the hall outside Room "e" while Patient R5 was in the bathroom.

In a face-to-face interview on 07/30/13 at 11:34 a.m., S11RN, while standing in the area where S28MHT stood to observe Patient R5 in the bathroom, confirmed that even with the bathroom door open, a patient could not be seen when standing at the toilet.

Patient R7
Review of Patient R7's medical record revealed he was a 25 year old male admitted on 07/26/13 with a diagnosis of Opiate Dependence. Review of his "Physician's Orders" revealed he was to ordered to be on Status B.

Observation of the Adult Male Psychiatric Unit on 07/29/13 at 11:20 a.m. revealed a hall extended from the nursing station that included the patients' rooms. Further observation revealed when standing with one's back to the nursing station the left side of the hall consisted of Rooms "b", "d", "f", and "h", and the right side of the hall consisted of Rooms "a", "c", "e", and "g".

Review of the "Patient Charting Assignment" for the 11:00 p.m. to 7:00 a.m. shift on 07/29/13 revealed S29MHT was assigned to observe Patients #4, #5, R3, R4, and R7 who were all to be monitored at least every 5 minutes with a 1 to 6 staff to patient ratio maintained at all times during the hours of sleep. Further review revealed S30MHT was assigned to observed Patient #1 one-to-one (staff must be within arms' length at all times).

Review of the "Alpha Census For 07/28/13 Sunday" presented on 07/29/13 at 12:50 p.m. by S23Human Resource staff member revealed that Patient 4 was in Room "e" in the bed by the door, Patient #5 was in Room "b" in the bed by the door, Patient R3 was in Room "a" in the bed by the window, Patient R4 was in Room "h" in the bed by the window, Patient R7 was in Room "d" in the bed by the door, and Patient #1 was in Room "c" in the bed by the window".

Observation of a video surveillance disc made by the hospital of the night shift from 1:00 a.m. to 5:00 a.m. on 07/30/13 on the Adult Male Psychiatric Unit revealed the following observations:
00:52 - S29MHT rose from a chair placed in the hall between Rooms "a", "b", "c", and "d" (position allowed S29MHT to see patients in Rooms "a", "b", "c", "d") and began to walk towards the nursing station;
00:54 - S29MHT began to walk from the nursing station toward the chair in the hall between Rooms "a", "b", "c", and "d" and then steps out of the view of the camera;
01:03 - S29MHT returns to sit in chair in hall outside Rooms "a", "b", "c", and "d".
Continued observation of the video surveillance revealed Patients #4, #5, R3, R4, and R7 were not observed by S29MHT every 5 minutes according to hospital policy and physician orders when he was away from the patients' rooms for 11 minutes. Further observation revealed that S29MHT could not visualize Patient #4 who was in Room "e" and Patient R4 who was in Room "h" from his seated position in the hall across from Rooms "a", "b", "c", and "d".
01:10 - S30MHT was seated in Room "c" in a chair at the door used to enter Room "c" (he was not within arms' length of the patient who was in the bed by the window); S30MHT got up from the chair and walked into the hall with his back to the room for 3 seconds;
01:14:58 - S30MHT walks into the hall from Room "c" with his back to the room;
01:15:21 - S30MHT returns to Room "c";
01:15:24 - S30MHT stands outside Room "c" in the hall looking at his cell phone with another MHT;
01:17:35 - S30MHT returns to Room "c".
Observation revealed Patient #1 was never within arms' length of S30MHT for the 25 minutes of video surveillance observations. Further observation revealed Patient #1 was not in S30MHT's sight for 2 minutes and 37 seconds.

Review of the "Tech Observation Sheet: for Patients #4, #5, R3, R4, and R7 revealed that S29MHT documented that these patients were asleep in their room laying on the bed/mattress and in his line of sight on )7/30/13 from 12:45 a.m. to 1:30 a.m. Review of the "Tech Observation Sheet: for Patient #1 revealed that S30MHT documented that Patient #1 was on 1:1 observation and asleep in his room laying on his bed/mattress.

In a face-to-face interview on 07/31/13 at 2:55 p.m., S2DON confirmed that S29MHT could not visibly see patients in Rooms "e" and "h" without walking from where he was seated in the hall between Rooms "a", "b", "c", and "d". She also confirmed that S29MHT did not visibly observe Patients #4, #5, R3, R4, and R7 every 5 minutes as required by the hospital's policy and physician orders. S2DON confirmed that S30MHT should have been seated within arms' length of Patient #1 and that he was not supposed to step out of the room at any time without being replaced.

Patient #3
Review of the Physician Admit Order for patient #3 revealed the following: "Order to Admit: Admit to: Adult Psych. Accepting Physician: (S17MD) to services of Attending Physician: (S18MD). 1:50P (p.m.). TO (telephone order) (S17MD)/S19LPN. 6/14/13 1830 pm ...Admission Orders: Date and Time: 6-14-13 1:50P. 1. Provisional Diagnosis: Depression. Level: Evaluation. 3. May have roommate. 4. Status B (Line of Sight during waking hours and every 5 minute checks during hours of Sleep) ..." Further review of the Physician's Orders revealed an order dated 6/14/13 at 1830 by S17MD that read as follows: "BOUP (status B with Off Unit Privileges)." There is no further documentation regarding the OUP status.

Review of the Nursing Mental Status Exam dated/timed 6/16/13 at 0940 by S11RN revealed the following: "...Physical Appearance: Appropriate clothes. Mood: Sad, Anxious, Depressed. Affect: Sad ...Assessment for Potential Risk: Suicidal...Narrative Note: Pt was in restroom (review of the video tape revealed patient #3 was in the restroom for 27 minutes), and MHT (S9MHT) walked to door and found pt lying on R (right) side with a drawstring wrapped twice and tied around his neck. Immediately, MHT (S9MHT) called for help. I found pt lying on the ground and turning cyanotic. I called for emergency services. (S10RN) got scissors and cut the string off. Pt was still breathing and color returned and pt began responding to pain stimuli and then verbal. (S4MD) was on site at nurse's station and walked to pt's room and stayed on site until EMS arrived. 0945: Contacted (S2DON) and notified of the incident. Pt at that time is awake and alert responding to verbal stimuli. No blood vessels ruptured in eyes OU (both eyes) visible at present. Noted small abrasions across the midline of his neck from nurse trying to put fingers underneath the strings to cut. 0950: (S17MD) was contacted and notified of the incident. 1005: (S18MD) contacted and notified of incident. Ordered to (Hosp "a") for eval and tx for possible neck injuries from self-strangulation attempt. 1015: (EMS) on site with (Police Department) and (Fire Department) 1st responders. Pt sitting upright on stretcher verbally responding. Photo taken of marks on neck. Report called to (name) at (hosp "a") ER (emergency room). (name) is the attending MD for pt."

Review of the Tech Observation Sheet for 6/16/13 at 8:30 a.m. and 8:45 a.m. revealed patient #3 was documented as BN (Line of Sight and Dayroom).

Review of the video tape revealed patient #3 was in room "c" at 8:16:52 a.m. and got in his bed at 8:17:03 a.m. Further review of the video tape revealed patient #3 exited room "c" at 8:36:52 a.m. and re-enters room "c" at 8:38:40 a.m. Patient #3 got into his bed 10 seconds later at 8:38:50 a.m.

Further review of the video tape revealed patient #3 entered the bathroom inside of room "c" at 8:44:18. The video displays that there is no MHT inside of patient #3's room performing Line of Sight Observation. Review of the video tape revealed that at 9:11:41 S9MHT entered room "c" and opened the bathroom door. (27 minutes and 23 seconds since patient #3 entered the bathroom) At 9:12:02 a.m. (20 seconds after entering the bathroom) S9MHT exits and appears to call for help.

Review of a document titled "Crossroads Regional Hospital Quality/Risk Management Report of Event" revealed the following: "WHO?...Inpatient ...WHEN? 6/16/13 0940. WHERE? Adult Males ...DESCRIPTION OF OCCURRENCE/COMPLAINT. (Self-strangulation attempt) Pt was in restroom and MHT (S9MHT) walk to door and found pt lying on his R (right) side with a drawstring wrapped twice and tied around his neck. Immediately MHT called for help. I found pt lying on the ground turning cyanotic. I called for Emergency Services. (S10RN) got scissors and cut the string off. Pt was still breathing and color returned and pt began responding to verbal and tactile stimuli...Completed By: (S11RN). Reviewed by: (S3RN/Risk Management)

Review of a Louisiana Department of Health and Hospitals - Hospital Abuse/Neglect Initial Report revealed: "Type of Incident: Alleged Neglect...Incident Information. Date of Incident: 6-16-13. Time of Incident: 9:40 a.m...Specific Location of Incident: Adult Unit Room ("c"). Patient Information: Name: (patient #3)...Admit Date: 6-14-13...Admitting Diagnoses: Depression...On initial investigation it was noted that on 6-15-13 Mom brought in a pair of shorts that had a draw string in the waist band. The tech (S8MHT) failed to remove the draw string when logging in the shorts. It is also noted that on the morning of 6-15-13 (patient #3) voiced to (S5RN) that he was feeling suicidal and would cut his wrist or shoot himself. (S5RN) did not document that the physician was notified at that time and she did not initiate any special safety precautions. Completed investigation to follow." Typed names of S2DON and S3RN, Risk Management are on the line for Name and Title of person preparing report. The document is dated June 17, 2013.

In an interview on 7/31/13 at 3:02 p.m. with S2DON she confirmed that Quality Assurance has not met to develop and/or implement a plan to prevent similar occurrences related to the incident of 6/16/13.

In an interview on 8/1/13 at 8:10 a.m. with S1CEO he confirmed that there is no documented evidence that any of the Policy and Procedures were reviewed and/or revised or that Quality Assurance had developed and/or implemented any actions that should prevent the events of 6/16/13 from occurring again.

Based on record reviews and interview, the hospital failed to ensure that the registered nurses (RN) had a valid and current nursing license as evidenced by having no current current verification of licensure obtained from the Louisiana State Board of Nurses for 3 of 3 RN's personnel files reviewed from a total of 14 employed RN's (S5, S11, S22). Findings:

Review of the hospital policy titled "Verification and Annual Review of Licenses, Certifications", policy number HR-00-022, revised 06/05/07, and presented as a current policy by S31RN Human Resource Director, revealed that all licensed professionals will present verification of licenses at the time of pre-employment interview or on hire date and annually thereafter.

S5RN
Review of S5RN's personnel file revealed she was hired on 11/15/10. Further review revealed no documented evidence that her RN license for 2013 had been verified as active with the Louisiana State Board of Nurses (LSBN).

S11RN
Review of S11RN's personnel file revealed he was hired on 04/18/11 as a MHT and began duties as a RN on 09/13/12. Further review revealed no documented evidence that S11RN's RN license was verified as active with the LSBN for 2013. Review of the "Licensure Verification" in his personnel file revealed that his license was "Active Probated Disciplinary Status: Submit a public records request for more information", and it expired on 01/31/13.

S22RN
Review of S22RN's personnel file revealed she was hired on 03/07/11. Further review revealed no documented evidence that S22RN's RN license was verified as active with the LSBN for 2013.

In a face-to-face interview on 08/01/13 at 3:25 p.m., S2DON (director of nurses) confirmed there was no verification of licenses in the personnel files of S5RN, S11RN, and S22RN.

Based on observations, record reviews, and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

1) The RN delegated complex nursing tasks (assessment of patients' risk for suicide, assault, and violence) to the LPN (licensed practical nurse) for 4 of 5 sampled patients (#1, #2, #3, #5) and 4 of 8 random patients' records reviewed for nursing assessment of suicide, assault, and violence risk (R4, R5, R7, R8). The Louisiana State Board of Nurses' Registered Nurse Practice Act does not allow the RN to delegate complex nursing tasks to an LPN.

2) The RN failed to assess a patient with a change in condition (burn to forearm and abrasions to scalp and forehead) for 1 of 5 sampled patients (#1); and

3) The RN failed to implement the hospital's policy and procedure for a patient who was assessed as an elopement risk by the RN for 1 of 5 sampled patients (#1).

Findings:

1) The RN delegated complex nursing tasks (assessment of patients' risk for suicide, assault, and violence) to the LPN:

Review of the Louisiana State Board of Nursing's "Delegation Decision-Making Process" revealed that the Louisiana State Board of Nursing has the legal responsibility to regulate the practice of nursing and to provide guidance regarding the delegation of nursing interventions by the registered nurse to other competent nursing personnel.
In Louisiana, R.S. (revised statute) 37:913(14)(f) provides that registered nursing includes delegating nursing interventions to qualified nursing personnel in accordance with criteria established by the Board of Nursing. LAC 46:XLVII.3703 sets the standards for implementation of the statutory mandate.
a) The term "delegating nursing interventions" is defined and criteria are provided for all delegatory activities, for delegation to licensed practical nurses.
b) The registered nurse who delegates nursing interventions retains the responsibility and accountability to assure that the delegated intervention is performed in accord with established standards of practice, policies and procedures.
c) Appropriate assessment, planning, implementation and evaluation are integral activities in the fulfillment of the registered nurse's responsibility and accountability.

Review of the "Administrative Rules Defining RN Practice LAC46:XLVII" revealed the registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Any situation where tasks are delegated should meet the following criteria:
1) the person has been adequately trained for the task;
2) the person has demonstrated that the task has been learned;
3) the person can perform the task safely in the given nursing situation;
4) the patient's status is safe for the person to carry out the task;
5) appropriate supervision is available during the task implementation; and
6) the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.

The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, that is, when the following three conditions prevail at the same time in a given situation:
1) nursing care ordered and directed by RN/M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable;
2) change in the patient's clinical conditions is predictable; and
3) medical and nursing orders are not subject to continuous change or complex modification.

Review of the hospital policy titled "Admission & (and) Assessment Process For Inpatient Psychiatric Treatment", policy number AS 00-017, revised 01/20/06, and presented by S2DON (director of nurses) as a current policy, revealed that it was hospital policy for a patient to be accepted for admission by a licensed psychiatrist who was properly credentialed and in good standing as a member of the hospital's Medical Staff following appropriate assessment and determination that criteria for admission was present.

Further review revealed that "Assessment and Referral Services or other designated staff" will review the Medical Screening Questionnaire and Medical History that was completed by the patient or their designated representative. After completing the "Initial Screening Evaluation", the "Assessment and Referral Services or other designated staff" will contact a physician to review the collected data. Review revealed that if the physician felt that the information collected didn't reflect that the proposed patient met admission criteria, an RN would be requested to review the screening evaluation and interview the patient for further information. Further review revealed that the screening evaluation was to be signed by the reviewing RN. and upon arrival of a patient being transferred from a clinical referral source or hospital, the "Assessment and Referral Services or other designated staff" will perform a physical evaluation including vital signs, review of skin for markings, and obvious distress which may be medically related prior to accepting the patient from the ambulance or police personnel. If any pertinent medical findings were identified, the accepting physician and the DON or designee would be notified to complete a more detailed assessment. Review of the entire policy revealed no documented evidence that the designated staff performing the admission assessments had to be a RN.

Review of the hospital policy titled "Suicide Assessment/Precautions", policy number TX-00-015, revised 12/14/12, and presented as the current policy for suicide risk assessments by S2DON, revealed that it was the hospital policy to perform an assessment for suicide risk on all patients at the time of admission and throughout hospitalization as determined by patient behavior. Further review revealed that at admission and assessment of risk must be performed by the admitting RN/LPN on all patients as part of the initial screening evaluation. Review of the entire policy revealed no documented evidence that only a RN could perform an assessment for suicide risk or could delegate this assessment to a qualified LPN.

Review of the hospital's "Assault And Violence Assessment Tool" revealed the directions included to assess each key factor, circle one of three descriptors for each factor best describing the patient, and add the circled items to determine the total score.
a) 9 or more scored resulted in high-risk precautions,
b) 3 to 8 points scored resulted in moderate risk precautions, and
c) 0 to 2 points scored resulted in no precautions.

The key factors included the following: history of violence, history of recent aggression, history of aggression in family of origin, substance abuse status, paranoia/hostility, impulsivity, agitation, sensorium. Further review revealed the bottom of the tool included a place for the total score, the patient's age, the name of the person who conducted the assessment with the date and time, the signature of the physician who reviewed the tool, and the signature of the RN who reviewed the assessment.

Review of the hospital's "Suicide/Self-Harm Assessment Tool" revealed the directions included to answer question 1, complete section II by circling one of the three descriptors for each key factor that best describes the patient, complete Section III, and add the points from each circled item to obtain the total score. Further review revealed
1) a score of 10 or more resulted in high risk precautions,
2) a score of 4 to 9 indicated moderate risk precautions, and
3) a score of 0 to 3 indicated low risk.
The key factors included the following: is the current admission precipitated by a suicide attempt, contract for safety, suicide plan, plan lethality, elopement risk, suicidal ideation, attempt history, symptoms (choices included hopelessness, helplessness, anhedonia, guilt/shame, anger/rage, impulsivity); RN's subjective appraisal of patient's reliability. Further review revealed the bottom of the tool included a choice for the suicide risk management plan of either Status A 1:1 Arms Length Unit Restricted or Status B Line of Sight, the total score, patient age, the signature of the person who performed the assessment with the date and time, the signature of the physician who reviewed the tool, and the signature of the RN who reviewed the tool.

Patient #1
Review of Patient #1's medical record revealed he was a 25 year old male admitted on 07/15/13 with a diagnosis of Depression. Further review revealed he had a Physician's Emergency Certificate (PEC) signed on 07/15/13 at 9:00 a.m. due to starting an alcohol binge on 07/11/13, stating he attempted suicide twice, maintaining suicide ideation impulses, and being a danger to himself. A Coroner's Emergency Certificate (CEC) was signed on 07/16/13 at 1:16 p.m. that revealed Patient #1 was suicidal and a danger to himself.

Review of Patient #1's "Initial Screening/Nursing Assessment" revealed the first 4 pages were completed by S19LPN, and S19LPN documented that she completed Patient #1's evaluation on 07/15/13 at 4:30 p.m. There was no documented evidence that a RN reviewed S19LPN's evaluation. Further review revealed Patient #1's "Assault and Violence Assessment Tool" and "Suicide/Self-Harm Assessment Tool" included documentation that Patient #1 was assessed by S19LPN on 07/25/13 at 4:30 p.m. and reviewed by S4Medical Director and S11RN with no documented evidence of the date and time that S4Medical Director and S11RN reviewed the assessment of S19LPN.

Patient #2
Review of Patient #2's medical record revealed that he was a 26 year old male admitted on 07/29/13 with a diagnosis of Bipolar Disorder. Patient #2 had a PEC signed on 07/29/13 at 7:55 a.m. due to being found wandering the highway with a hammer in his hand, being suicidal, dangerous to himself, and gravely disabled. Review of his "Assault and Violence Assessment Tool", "Suicide/Self-Harm Assessment Tool", and the first 4 pages of the "Initial Screening/Nursing Assessment" revealed his assessment was performed by S19LPN on 07/29/13 at 11:00 a.m. Further review revealed no documented evidence that S36Psychiatrist had reviewed the assessment. S11RN reviewed the assessment, and there was no documented evidence of the date or time that he reviewed S19LPN's assessment of Patient #2's risk for suicide, assault, and violence.

Patient #3
Review of Patient #3's medical record revealed he was a 21 year old male admitted on 06/14/13 with a diagnosis of Depression. Review of Patient #3's "Initial Screening/Nursing Assessment" revealed the first 4 pages of the assessment was completed by S19LPN on 06/14/13 at 1:50 p.m. Review of his "Assault and Violence Assessment Tool" and his "Suicide/Self-Harm Assessment Tool" revealed S19LPN performed the assessments on 06/14/13 at 1:50 p.m. Further review revealed the RN reviewed Patient #3's suicide, assault, and violence risk assessments performed by S19LPN, and there was no documented evidence of the date or time that the RN reviewed the assessment. S17Psychiatrist reviewed the assessment with no documented evidence of the date or time the assessment was reviewed by S17Psychiatrist.

Patient #5
Review of Patient #5's medical record revealed that he was 33 year old male admitted on 07/22/13 with diagnoses of PTSD (post traumatic stress disorder), Constipation, Hypercholesterolemia, Pain, and a history of Traumatic Brain Injury. Further review revealed he had a PEC signed on 07/22/13 at 12:40 p.m. due to being suicidal, dangerous to self, and gravely disabled. A CEC was signed on 07/23/13 at 3:30 p.m. due to Patient #5 being suicidal, homicidal, and dangerous to self and others. Review of Patient #5's "Initial Screening/Nursing Assessment" revealed the first 4 pages of the assessment was completed by S19LPN on 07/22/13 at 5:20 p.m. Review of his "Assault and Violence Assessment Tool" and his "Suicide/Self-Harm Assessment Tool" revealed S19LPN performed the assessments on 07/22/13 with no documented evidence of the time that the assessment was performed. Further review revealed no documented evidence that a RN reviewed Patient #5's suicide, assault, and violence risk assessments performed by S19LPN.

Random Patient R4
Review of Patient R4's medical record revealed he was a 30 year old male admitted on 07/22/13 with a diagnosis of Schizophrenia. Review of Patient #4's "Initial Screening/Nursing Assessment" revealed the first 4 pages of the assessment was completed by S19LPN on 07/22/13 at 5:10 p.m. Review of his "Assault and Violence Assessment Tool" and his "Suicide/Self-Harm Assessment Tool" revealed S19LPN performed the assessments on 07/22/13 at 5:10 p.m. Further review revealed the RN reviewed Patient #5's suicide, assault, and violence risk assessments performed by S19LPN, and there was no documented evidence of the date or time that the RN reviewed the assessment. S18Psychiatrist reviewed the assessment on 07/23/13 with no documented evidence of the time the assessment was reviewed by S18Psychiatrist.

Patient R5
Review of Patient R5's medical record revealed he was a 19 year old male admitted on 07/23/13 with a diagnosis of Psychosis. Review of his "Assault and Violence Assessment Tool" and his "Suicide/Self-Harm Assessment Tool" revealed S19LPN performed the assessments on 07/23/13 at 3:00 p.m. S18Psychiatrist reviewed the assessments on 07/23/13 with no documented evidence of the time the assessments were reviewed. There was no documented evidence that a RN reviewed the suicide, assault, and violence assessments performed by S19LPN as of 08/01/13 when Patient R5's medical record was reviewed.

Patient R7
Review of Patient R7's medical record revealed he was a 25 year old male admitted on 07/26/13 with a diagnosis of Opiate Dependence. Review of his "Assault and Violence Assessment Tool" and his "Suicide/Self-Harm Assessment Tool" revealed S19LPN performed the assessments on 07/26/13 at 4:25 p.m. Further review review revealed the RN reviewed the assessment with no documented evidence of the date or time that the assessment performed by S19LPN was reviewed. There was no documented evidence that the psychiatrist reviewed the suicide, assault, and violence risk assessments.

Patient R8
Review of Patient R8's medical record revealed he was a 26 year old male admitted on 07/26/13 with a diagnosis of Schizophrenia. Review of his "Assault and Violence Assessment Tool" and his "Suicide/Self-Harm Assessment Tool" revealed S19LPN performed the assessments on 07/26/13 at 6:00 p.m. Further review revealed S25RN House Supervisor reviewed the assessments of S19LPN with no documented evidence of the date or time of the review. Further review revealed S18Psychiatrist reviewed the suicide/self-harm assessment performed by S19LPN on 07/26/13 with no documented evidence of the time that he reviewed the assessment. There was no documented evidence that a psychiatrist reviewed Patient R8's assault and violence risk assessment.

In a face-to-face interview on 07/30/13 at 9:03 a.m., S11RN indicated that S19LPN, who is the Intake Nurse, performs the suicide, assault, and violence risk assessments for patients who arrive during "business hours" Monday through Friday. He further indicated that patients who were admitted after hours and on weekends had the risk assessment performed by either S37RN House Supervisor (3:00 p.m. to 11:00 p.m. shift) or S25RN House Supervisor (weekends).

In a face-to-face interview on 07/31/13 at 3:05 p.m., S2DON indicated that more than 50% (per cent) of the admissions and suicide, assault, and violence risk assessments were done by S19LPN. She further indicated that the assessment was "pretty complex". When asked if complex nursing tasks could be delegated by the RN to a LPN, S1DON answered "No." When asked if she was aware that a RN delegating assessments or complex nursing tasks to a LPN was against the LSBN Nurse Practice Act, S2DON answered "Yes." When asked why the hospital had a LPN in the position to perform suicide, assault, and violence risk assessments, which are complex nursing tasks, S2DON indicated S19LPN was in that position when she (S2DON) began her employment at the hospital. She further indicated that the RN on the nursing unit had to review the assessment performed by S19LPN.

2) The RN failed to assess a patient with a change in condition (burn to forearm and abrasions to scalp and forehead):

Review of the hospital policy titled "Admission & (and) Assessment Process For Inpatient Psychiatric Treatment", policy number AS 00-017, revised 01/20/06, and presented by S2DON (director of nurses) as a current policy, revealed no documented evidence that the hospital policy addressed patient assessments by the RN other than at admit, such as at the time of a change in condition.

Review of Patient #1's medical record revealed he was a 25 year old male admitted on 07/15/13 with a diagnosis of Depression. Further review revealed he had a Physician's Emergency Certificate (PEC) signed on 07/15/13 at 9:00 a.m. due to starting an alcohol binge on 07/11/13, stating he attempted suicide twice, maintaining suicide ideation impulses, and being a danger to himself. A Coroner's Emergency Certificate (CEC) was signed on 07/16/13 at 1:16 p.m. that revealed Patient #1 was suicidal and a danger to himself.

Review of Patient #1's "Physician's Orders" revealed an order on 07/16/13 at 5:20 a.m. for Silverdene Cream to burns to left forearm twice a day for 7 days and TAO (triple antibiotic ointment) twice a day to scalp/forehead abrasions for 5 days.

Review of Patient #1's admission assessment performed by S11 on 07/15/13 at 6:00 p.m. revealed no documented evidence that physical findings was addressed as evidenced by "NSF" (no significant findings) not being checked and no markings noted on the picture of the body to note bruises, incisions, lacerations, rashes, decubiti, scars, lesions, tattoo, piercing, and such.

Review of the nursing documentation for 07/16/13 at 6:00 a.m. and 07/16/13 at 8:20 a.m. revealed no documented evidence of an assessment of burns to the left forearm or abrasions to the scalp/forehead for which medication was ordered.

Review of the physician's progress notes documented on 07/18/13 at 8:25 a.m. revealed that Patient was "amnesic for how he burned his arm." Review of the "Physician Progress Notes" dictated on 07/21/13 by S18Psychiatrist revealed a diagnosis of second degree burns.

In a face-to-face interview on 07/30/13 at 8:23 a.m., S11RN indicated that he had performed Patient #1's admission assessment and provided his care on the day shift of 07/16/13. He offered no explanation for not completing the physical findings section of the admit. After review of Patient #1's nursing documentation, S11RN confirmed there was no documentation regarding how Patient #1 received burns to the left forearm and forearm and abrasions to scalp/forehead. He further confirmed there was no nursing documentation related to the burns until 07/18/13 at 9:00 a.m. and the abrasions until 07/20/13 at 6:30 p.m.

3) The RN failed to implement the hospital's policy and procedure for a patient who was assessed as an elopement risk by the RN:

Review of the hospital policy titled "Code Green - Elopement Unauthorized Leave of Absence", policy number TX-01-007, revised 04/20/11, and presented as a current policy by S31RN Human Resource Director, revealed that upon indication that a patient is an elopement risk, the RN will notify the DON and/or Quality Assurance Coordinator. The patient will be placed on elopement precautions. The attending physician will be notified, and an order for continuation of elopement precautions will be obtained. Further review revealed that the nursing staff should document an assessment of continued elopement risk and interventions in the progress notes each shift. Review of the entire policy revealed no documented evidence of what interventions were to be implemented when a patient was placed on elopement precautions.

Review of Patient #1's medical record revealed he was a 25 year old male admitted on 07/15/13 with a diagnosis of Depression. Further review revealed he had a Physician's Emergency Certificate (PEC) signed on 07/15/13 at 9:00 a.m. due to starting an alcohol binge on 07/11/13, stating he attempted suicide twice, maintaining suicide ideation impulses, and being a danger to himself. A Coroner's Emergency Certificate (CEC) was signed on 07/16/13 at 1:16 p.m. that revealed Patient #1 was suicidal and a danger to himself.

Review of Patient #1's "Suicide/Self-Harm Assessment Tool" completed on 07/25/13 (incorrectly dated, should be 07/15/13) at 4:30 p.m. by S19LPN and reviewed by S11RN (no date or time documented when S11RN reviewed the LPN's assessment) revealed that Patient #1 was not an elopement risk.

Review of Patient #1's "Psychiatric Evaluation" performed by S4Medical Director on 07/16/13 revealed no documented evidence that he was an elopement risk.

Review of Patient #1's "Assessment For Potential Risk" revealed that he was assessed as an elopement risk by S11RN on 07/21/13 at 8:15 a.m., on 07/23/13 at 10:30 a.m. and 3:30 p.m., and on 07/28/13 at 8:15 a.m. and 3:00 p.m. Further review revealed no documented evidence that S11RN informed the DON or Quality Assurance Coordinator and notified S18Psychiatrist to obtain an order for elopement precautions. Further review revealed no documented evidence of an assessment in the nursing notes regarding Patient #1's risk for elopement.

In a face-to-face interview on 07/30/13 at 8:23 a.m., S11RN indicated he didn't need a physician's order to place a patient on elopement precautions. After reviewing his documentation, S11RN confirmed that he did not document his assessment of Patient #1 being an elopement risk on 07/21/13, 07/23/13, and 07/28/13.

Based on record reviews and interviews, the hospital failed to ensure a registered nurse (RN):
1) Made the staffing assignments for mental health techs (MHT) as evidenced by not having each patient assigned to a MHT for 2 of 7 shifts reviewed between 6/14/13 at 7:00 a.m. to 6/16/13 at 7:00 a.m. and
2) Assigned the nursing care of each patient to personnel who met the qualifications listed in their job description and had been evaluated for competency to perform their job duties for 5 of 8 MHTs' personnel files reviewed from a total of 46 employed MHTs (S14, S20, S26, S29, S30), for 3 of 3 RNs' personnel files reviewed from a total of 14 employed RNs (S5, S11, S22), and 1 of 1 LPN's (licensed practical nurse) personnel file reviewed from a total of 13 employed LPNs (S27).
Findings:

1) Review of the Crossroads Regional Hospital Patient Classification/Observation Status Assignment Form for 6/14/13 7a-3p, 3p-11p, 11p-7a; 6/15/13 7a-3p, 3p-7a, 11p-7a; and the 6/16/13 7a-3p shifts (from admission of patient #3 to incident involving patient #3) revealed 2 of 7 shifts did not have patient assignments done by the RN for the shift.

The 6/15/13 7a-3p shift Observation Status Assignment Form did not have patient assignments. The RN Charge Nurse was S5RN.

The 6/15/13 3p-11p shift Observation Status Assignment Form did not have patient assignments. The RN Charge Nurse was S33RN.

In an interview on 7/31/13 at 3:02 p.m. with S2DON she confirmed the assignment sheets were not complete per hospital policy.

Review of a hospital policy titled "Nurse Staffing & Patient Classification Acuity System", policy number TX-00-022, date developed 6/27/00, last revised 12/14/12, presented as current hospital policy read in part: "Policy: It is the policy of Crossroads Regional Hospital (CRH) to ensure that patients receive quality nursing care, through the specialized skills of RN's, LPN's, and Mental Health Technicians to provide a safe therapeutic environment. CRH utilizes a standard format for measuring individual patient acuity levels. Patient admissions may be based on capability of availability of required staff to patient ratio...Procedure:..B. The Charge RN will complete the Patient Classification Observation Status Assignment Form and determine the staff requirements for the oncoming shift..."

2) Assigned the nursing care of each patient to personnel who met the qualifications listed in their job description and had been evaluated for competency to perform their job duties:
Review of the hospital policy titled "Employment of Personnel", policy number HR-00-004, revised 05/09/06, and presented by S31RN Director of Human Resources as a current policy, revealed that personnel records would be maintained on each employee and should include job applications and professional licensing information. Further review revealed that Health and Staff Development information would be maintained in a separate file. Further review revealed no documented evidence that the policy addressed the specific job requirements for each disciplined employed at the hospital, such as CPR (cardiopulmonary resuscitation) certification and nonviolent crisis prevention intervention.

Review of the hospital policy titled "Recruitment and Selection", policy number HR-00-019, revised 06/22/06, and presented as a current policy by S2DON (director of nursing), revealed it was the hospital's policy to select the best candidate for employment by ensuring that the hospital appropriately structure and document the job to be filled in a written job description, that the essential functions of the job have been identified, and that the prospective employee at least met the minimum standards for the position.

Review of the MHT job description revealed aggressive behavior training and CPR certification were qualifications required for the MHT position.

S14MHT
Review of S14MHT's personnel file revealed he was hired on 12/01/08. Further review revealed his CPR certification expired 1231/12, and his "Handle With Care" certification (specific program used by the hospital to certify staff in nonviolent crisis prevention intervention techniques) expired on 12/19/11. Further review revealed his CPR certification expired on 12/31/12.

S20MHT
Review of S20MHT 's personnel file revealed he was hired on 10/08/12. Further review revealed no documented evidence of prior health care or psychiatric hospital experience prior to this employment. There was no documented evidence that S20MHT was evaluated for competency to perform his job duties as a MHT.

S26MHT
Review of S26MHT's personnel file revealed her "Handle With Care" certification expired on 07/15/12.

S29MHT
Review of S29MHT's personnel file revealed he was hired on 08/20/12. Further review revealed no documented evidence that he had training and was certified in "Handle With Care".

In a face-to-face interview on 08/01/13 at 11:50 a.m., S31RN Human Resource Director confirmed there was no evidence in S29MHT's personnel file that he had completed a "Handle With Care" course/

S30MHT
Review of S30MHT's personnel file revealed he was hired on 05/10/12. Further review revealed his "Handle With Care" certification expired on 05/11/13.

S5RN
Review of S5RN ' s personnel file revealed she was hired on 11/15/10. Further review revealed no documented evidence of a competency evaluation of duties performed in the psychiatric setting other than taking vital signs and use of the glucometer. Review of S5RN' s "Handle With Care" certificate revealed her certification expired on 12/19/11.

S11RN
Review of S11RN's personnel file revealed he was hired on 04/18/11 as a MHT and began duties as a RN on 09/13/12. Further review revealed no documented evidence that S11RN had signed a job description for RN and that he had been oriented to the duties of the RN in a psychiatric setting and was evaluated for competency to perform his job duties as an RN. Further review revealed no documented evidence of current certification in "Handle With Care Behavior Management".

In a face-to-face interview on 07/31/13 at 11:03 a.m., S11RN indicated that he graduated in nursing in 2003 with a Bachelor of Science degree. He further indicated that he had a suspended RN license in 2010 and was in the Recovery Nurse Program, and his RN license was reactivated in 09/12. S11RN indicated his prior nursing experience was in intensive care, cardiology, and the cardiac catheterization lab. He further indicated that his present employment was his first experience in a psychiatric hospital setting.

S22RN
Review of S22RN's personnel file revealed she was hired on 03/07/11. Further review revealed her "Handle With Care" certification expired on 07/15/12.

S27LPN
Review of S27LPN's personnel file revealed she was hired on 06/10/13. Review of her "Employment Application" revealed no documented evidence of prior health care or psychiatric inpatient experience. Review of her job description revealed one year experience in providing care to hospitalized patients was required of LPN's employed at the hospital.

On 08/01/13 at 11:15 a.m. a third request was made to S31RN Director of Human Resources for personnel policies regarding which employees were required to have CPR and Handle With Care Certification. Review of the 2 policies presented by S31RN Director of Human Resources, "Employment of Personnel" and "Verification and Annual Review of Licenses, Certifications", revealed no documented evidence that CPR and Handle With Care certification was addressed in either policy. No policy was presented by the hospital regarding these job requirements by the end of the survey on 08/01/13.

In a face-to-face interview on 08/01/13 at 3:25 p.m., when asked why the above mentioned employees did not have current training/certification in nonviolent crisis prevention intervention, S2DON indicated the person who was hired for staff development had lied to her and S1CEO (Chief Executive Officer). She further indicated they were told by that employee that the training had been done. S2DON indicated after the staff development staff member was terminated, the human resource staff member was going to do the training, but that employee left the hospital's employment before the training was done. She confirmed that the above listed employees did not have current certification or training in nonviolent crisis intervention, and their competency evaluations were not documented. S2DON indicated that she had hired S27LPN and confirmed that her application revealed no prior experience in providing care to hospitalized patients as required by her job description.

Based on observation, record review, video review, and interview, the Hospital failed to meet the Condition of Participation: Special Staff Requirements for Psychiatric Hospitals as evidenced by:

1) failing to ensure patients on the Adult Male Psychiatric Unit were observed by the MHT's according to hospital policy and physician orders for 4 of 5 current sampled patients (#1, #2, #4, #5) and 4 of 8 current random patients (R3, R4, R5 and R7). (see findings at B0146)

On 7/31/13 at 5:25 p.m. Crossroads Regional Hospital's S1CEO (Chief Executive Officer) and S2DON (Director of Nursing) were notified of an Immediate Jeopardy. The Immediate Jeopardy Situation was that the hospital failed to ensure patients were monitored in accordance with hospital policy and procedure and the orders of the physician responsible for the care of the patient.
a) An observation on 7/29/13 at 2:50 p.m. revealed Patient #2, Patient #R3, and Patient #R4, for whom record review revealed physician orders for Status B (Line Of Sight), were seated on the sofa in the male Adult Unit Dayroom with no hospital staff within Line Of Sight.
b) An observation on 7/30/13 at 11:20 a.m. revealed Patient # R5, for whom record review revealed physician orders for Status B, entered the bathroom in room " a " with S28MHT standing in the hallway outside room " a " . In an interview on 7/30/13 at 11:40 a.m. S28MHT confirmed he did not have Patient #R5 in Line Of Sight while the patient was in the bathroom.
c) Review of video surveillance provided by the hospital of the male Adult Unit for 7/30/13 from 1:00 a.m. to 5:00 p.m. revealed Patient #R3, Patient #R6, Patient #R7, and Patient #R8 were not being observed according to hospital policy and physician orders from 12:52 a.m. to 1:03 a.m. (11 minutes). Further observation revealed patient #1, whose medical record revealed physician orders for 1:1 Observation (within arms reach), was left unattended by S30MHT from 1:10 a.m. to 1:12 a.m. In an interview on 7/31/13 at 2:55 p.m. with S2DON she confirmed the above patients were not observed according to hospital policy and physician orders.

d) Review of video surveillance provided by the hospital revealed Patient #3, who was ordered to be on Line Of Sight (constant visual observation) by the physician, was left unattended in the restroom by hospital staff for 27 minutes on the morning shift of 06/16/13 beginning at approximately 8:44 a.m. Patient #3 was found on the floor of the bathroom at 9:11 a.m. with a drawstring wrapped around his neck. Patient #3 was cyanotic per staff. This drawstring (contraband) was introduced into the hospital undetected in a pair of shorts. Patient #3 left the hospital via EMS at 9:37 a.m.

Observations and review of the implementation of the Plan of Removal for the Immediate Jeopardy submitted by the facility and accepted as adequate to lift the Immediate Jeopardy on 08/01/13 at 3:39 p.m. revealed the following: "Action/Changes:
1. The 11 p.m. to 7 a.m. tech observation sheet dated 08/01/13 had been revised to reflect q (every) 5 minutes documentation by the mental health techs;with hourly checks by the RN/LPN to ensure appropritate patient monitoring per MD orders and patient safety until staff inservice and orientation of Status Observation Policy. Tech observation sheets were changed and introduced to reflect hourly monitoring by the RN/LPN of appropriate observation status by the Mental Health Techs. (form presented to surveyors) The RN/LPN is to sign off on the observation sheet every hour to ensure appropriate monitoring and patient safety.
2. Observation by surveyors on 08/01/13@ 11:50 a.m. of the employee sign in sheet reflected all RN's, LPN's (licensed practical nurse), Mental Health Techs, and Social Workers received educational material on observation status and patient safety. This included handouts and visual demonstrations of appropriate observation techniques. (copy provided to surveyors). Training will be completed prior to employee's return to work station, until 100% of employees have been trained. Trainer/Designee on duty prior to beginning of each shift to ensure compliance with mandatory training.

Responsible Person: (S2DON) (S16ADON) (S31RN, HR) or Designee.
Completion Date: 08/01/13. Any employee who has not completed training will not be allowed to render patient care.
Monitoring:
1. The Employee Roster and Educational Sign In Sheet will be monitored daily at 100% of the medical records for 30 days.
2. If no significant findings monitoring will decrease to 100% of the medical records one day of each week for 30 days.
3. If no significant findings monitoring will decrease to 100% of the medical records one day of the month, monthly for 3 months.
4. If no significant findings monitoring will be incorporated into the nightly chart audit process.
Video monitoring:
1. Is being conducted daily in no less than 30 minute increments on each shift daily for 30 days.
2. If no significant findings video monitoring will decrease to no less than 30 minute increments on each shift for 1 day of the week for 30 days.
3. If no significant findings video monitoring will decrease to no less than 30 minute increments on each shift for 1 day of the month for 3 months.
4. Then randomly."
The document was signed by (S1CEO) at 3:39 p.m. on 08/01/13.

The Immediate Jeopardy was lifted on 08/01/13 at 3:39 p.m. The deficient practice remains at the Condition Level.

2) failure of the the Director of Nursing to ensure that Nursing Services performance improvement activities were developed and implemented in response to adverse patient events. This was evidenced by the Director of Nursing having no documented evidence of implementation of a plan to measure, analyze, and/or track MHT monitoring of patients; after an incident on 6/16/13 whereas a patient (#3) with MD orders of line of sight monitoring was left unattended in the bathroom for 27 minutes and found on the floor with a string tied around his neck and turning blue. The lack of patient monitoring level according to MD orders and hospital policy continues to present for 8 of 8 current patents (#1, #2, #4, #5, #R3, #R4, #R5 and #R7). (see findings at B0148)

Based on observation, record review, video review, and interview, the RN failed to ensure the MHT's observed patients on the Adult Male Psychiatric Unit according to hospital policy and physician orders for 4 of 5 current sampled patients (#1, #2, #4, #5) and 4 of 8 current random patients (R3, R4, R5 and R7). Findings:

Review of the hospital policy titled "Observation Status Categories", policy number AS-00-006, revised 11/27/12, and presented as a current policy by S2DON, revealed that:
A) Patient's status is assigned at the time of admission, re-evaluated, and changed as clinically indicated.
B) Any time the patient's observation status changes, there must be an accompanying physician's order.
C) A RN may initiate a change in an observation status to 1:1 from Line of Sight or to Line of Sight from close observation if the patient's behavior indicates the need for closer monitoring, and the physician must be notified within 2 hours of the change to obtain a physician's order.
D) Nurse's documentation must reflect the patient behaviors that warranted the increased observation status.

Status guidelines were as follows:

a) One to One or Status A - staff must be within arms' length at all times; staff must constantly monitor the patient at all times such as bathroom, shower, walking out of group and must be within arms' length at all times; patient will not be allowed to leave the unit unless ordered so by the physician; the patient's face and hands must be seen by the staff member at all times. 1:1 is used for extremely disturbed patients who are in imminent risk of harming themselves or others, such as suicidal patients, high elopement risk patients, or those patients with extremely unpredictable behavior who present imminent risk to others. The need for 1:1 observation status should be reviewed and updated by the clinician daily or at least every 48 hours with documentation of continued need for observation at this level.

b) Line of Sight Observation During Waking Hours or Status B - staff must visually observe patients by "scanning the patient care area"; a staff member may observe more than one patient at a time, but the patient must remain in the assigned staff member's eyesight at all times; the patient must continue to be visualized by a staff member during shower and bathroom time. Line of Sight is used for patients who are "quite volatile, who give specific evidence that a suicide attempt is suspected, showing minimal impulse control, or those who are experiencing a high level of mood swings". During hours of sleep staff members will be strategically placed down hallways to ensure that patients are monitored at least every 5 minutes and a 1 to 6 staff to patient ratio is maintained at all times. Each patient care unit will have an additional staff member assigned to accomplish observation of each patient in their bed area every 5 minutes by making continuous walking rounds of the unit during sleeping hours.

c) Line of Sight Observation During Waking Hours with off unit privileges is ordered, the reason for off unit privileges should be documented in the physician's order. Documentation for 1:1, Line of Sight Observation During Waking Hours, and Special Observation During Waking Hours status will have an entry made every 15 minutes on the "Tech Notes/Observation Sheet."

Patient #1
Review of Patient #1's medical record revealed he was a 25 year old male admitted on 07/15/13 with a diagnosis of Depression. Review of his "Physician's Orders" revealed an order on 07/17/13 at 10:00 a.m. for observation Status A 1:1 with Off Unit Privileges.

Observation of the area across from the nursing station near the exit door of the Adult Male Psychiatric Unit on 07/30/13 at 9:26 a.m. revealed Patient #1 (who was ordered to be on 1:1 observation) was ambulating in the area. Further observation revealed S32MHT, who was assigned to observe Patient #1 one-to-one, did not keep Patient #1 within his arms' length while Patient #1 was ambulating in the area. Observation revealed S11RN made signs with his hands to S32MHT indicating to move closer to Patient #1.

In a face-to-face interview on 07/30/13 at 9:26 a.m., S11RN confirmed that S32MHT was not in arms' length of Patient #1 at all times as ordered by the physician and according to hospital policy.

Patient # 2
Review of Patients #2's medical record revealed that he was a 26 year old male admitted on 7/29/13 with a diagnosis of Bipolar Disorder. Review of his "Physician's Admit Orders" dated 7/29/13 with no documented evidence of the time the telephone order was received, revealed Patient #2's observation status ordered was Status B, line of sight during waking hours and every 5 minute checks during the house of sleep.

Patient #4
Review of Patient #4's medical record revealed he was a 21 year old male admitted on 07/28/13 with a diagnosis of Depression. Review of his "Physician's Orders" revealed he was ordered on 07/29/13 to be on Status B with off unit privileges.

Patient #5
Review of Patient R5's medical record revealed he was a 19 year old male admitted on 07/23/13 with a diagnosis of Psychosis. Review of His "Physician's Orders" revealed an order on 07/23/13 at 10:27 a.m. for Status B with off unit privileges.

Patient R3
Review of Patient R3's "Tech Observation Sheet" dated 07/29/13 from 11:00 p.m. to 07/30/13 at 11:00 p.m. revealed he was admitted on 07/24/13 and was on Status B observation.

Patient #R4
Review of Patient R4's medical record revealed he was a 30 year old male admitted on 07/22/13 with a diagnosis of Schizophrenia. Review of his "Physician's Admit Orders" dated 07/22/13, with no documented evidence of the time the telephone order was received, revealed Patient R4's observation status was Status B, line of sight during waking hours and every 5 minute checks during the hours of sleep.

Observation in the Day Room of the Adult Male Psychiatric Unit on 07/29/13 at 2:50 p.m. revealed Patients #2, R3, and R4, seated on the sofa with no observation of a MHT observing the 3 patients who had orders to be in a staff member's line of sight at all times during waking hours. Further observation revealed S38Lead MHT standing at the nursing station with his back to the Day Room (the sofa was not visible from the area where he was standing if he had turned around to face the Day Room).

In a face-to-face interview on 07/29/13 at 2:50 p.m., S38Lead MHT indicated that S32MHT was assigned to observe Patients R3, and R4, but left the area to go to the bathroom. S38Lead MHT confirmed that the three patients were not within any staff member's line of sight during the time that S32MHT was in the bathroom.

Patient #R5
Review of Patient R5's medical record revealed he was a 19 year old male admitted on 07/23/13 with a diagnosis of Psychosis. Review of his "Physician's Admit Orders" dated 07/23/13 at 3:00 p.m. revealed his observation status was Status B, line of sight during waking hours and every 5 minute checks during the hours of sleep.

Observation on 07/30/13 at 11:20 a.m. on the Adult Male Psychiatric Unit revealed Patient R5 ambulating to the bathroom with S28MHT in attendance. While observing from the nursing station which provided a full view of the hall where patient rooms were located, S28MHT was observed standing in the hall outside Room "e" while Patient R5 was in the bathroom.

In a face-to-face interview on 07/30/13 at 11:34 a.m., S11RN, while standing in the area where S28MHT stood to observe Patient R5 in the bathroom, confirmed that even with the bathroom door open, a patient could not be seen when standing at the toilet.

Patient R7
Review of Patient R7's medical record revealed he was a 25 year old male admitted on 07/26/13 with a diagnosis of Opiate Dependence. Review of his "Physician's Orders" revealed he was to ordered to be on Status B.

Observation of the Adult Male Psychiatric Unit on 07/29/13 at 11:20 a.m. revealed a hall extended from the nursing station that included the patients' rooms. Further observation revealed when standing with one's back to the nursing station the left side of the hall consisted of Rooms "b", "d", "f", and "h", and the right side of the hall consisted of Rooms "a", "c", "e", and "g".

Review of the "Patient Charting Assignment" for the 11:00 p.m. to 7:00 a.m. shift on 07/29/13 revealed S29MHT was assigned to observe Patients #4, #5, R3, R4, and R7 who were all to be monitored at least every 5 minutes with a 1 to 6 staff to patient ratio maintained at all times during the hours of sleep. Further review revealed S30MHT was assigned to observed Patient #1 one-to-one (staff must be within arms' length at all times).

Review of the "Alpha Census For 07/28/13 Sunday" presented on 07/29/13 at 12:50 p.m. by S23Human Resource staff member revealed that Patient 4 was in Room "e" in the bed by the door, Patient #5 was in Room "b" in the bed by the door, Patient R3 was in Room "a" in the bed by the window, Patient R4 was in Room "h" in the bed by the window, Patient R7 was in Room "d" in the bed by the door, and Patient #1 was in Room "c" in the bed by the window".

Observation of a video surveillance disc made by the hospital of the night shift from 1:00 a.m. to 5:00 a.m. on 07/30/13 on the Adult Male Psychiatric Unit revealed the following observations:
00:52 - S29MHT rose from a chair placed in the hall between Rooms "a", "b", "c", and "d" (position allowed S29MHT to see patients in Rooms "a", "b", "c", "d") and began to walk towards the nursing station;
00:54 - S29MHT began to walk from the nursing station toward the chair in the hall between Rooms "a", "b", "c", and "d" and then steps out of the view of the camera;
01:03 - S29MHT returns to sit in chair in hall outside Rooms "a", "b", "c", and "d".
Continued observation of the video surveillance revealed Patients #4, #5, R3, R4, and R7 were not observed by S29MHT every 5 minutes according to hospital policy and physician orders when he was away from the patients' rooms for 11 minutes. Further observation revealed that S29MHT could not visualize Patient #4 who was in Room "e" and Patient R4 who was in Room "h" from his seated position in the hall across from Rooms "a", "b", "c", and "d".
01:10 - S30MHT was seated in Room "c" in a chair at the door used to enter Room "c" (he was not within arms' length of the patient who was in the bed by the window); S30MHT got up from the chair and walked into the hall with his back to the room for 3 seconds;
01:14:58 - S30MHT walks into the hall from Room "c" with his back to the room;
01:15:21 - S30MHT returns to Room "c";
01:15:24 - S30MHT stands outside Room "c" in the hall looking at his cell phone with another MHT;
01:17:35 - S30MHT returns to Room "c".
Observation revealed Patient #1 was never within arms' length of S30MHT for the 25 minutes of video surveillance observations. Further observation revealed Patient #1 was not in S30MHT's sight for 2 minutes and 37 seconds.

Review of the "Tech Observation Sheet: for Patients #4, #5, R3, R4, and R7 revealed that S29MHT documented that these patients were asleep in their room laying on the bed/mattress and in his line of sight on )7/30/13 from 12:45 a.m. to 1:30 a.m. Review of the "Tech Observation Sheet: for Patient #1 revealed that S30MHT documented that Patient #1 was on 1:1 observation and asleep in his room laying on his bed/mattress.

In a face-to-face interview on 07/31/13 at 2:55 p.m., S2DON confirmed that S29MHT could not visibly see patients in Rooms "e" and "h" without walking from where he was seated in the hall between Rooms "a", "b", "c", and "d". She also confirmed that S29MHT did not visibly observe Patients #4, #5, R3, R4, and R7 every 5 minutes as required by the hospital's policy and physician orders. S2DON confirmed that S30MHT should have been seated within arms' length of Patient #1 and that he was not supposed to step out of the room at any time without being replaced.

Based on observation, record review, and interview the Director of Nursing failed to ensure that Nursing Services performance improvement activities were developed and implemented in response to adverse patient events. This was evidenced by the Director of Nursing having no documented evidence of implementation of a plan to measure, analyze, and/or track MHT monitoring of patients; after an incident on 6/16/13 whereas a patient (#3) with MD orders of line of sight monitoring was left unattended in the bathroom for 27 minutes and found on the floor with a string tied around his neck and turning blue. The lack of patient monitoring level according to MD orders and hospital policy continues to be present for 8 of 8 current patents (#1, #2, #4, #5, #R3, #R4, #R5 and #R7). Findings

Patient #1
Review of Patient #1's medical record revealed he was a 25 year old male admitted on 07/15/13 with a diagnosis of Depression. Review of his "Physician's Orders" revealed an order on 07/17/13 at 10:00 a.m. for observation Status A 1:1 with Off Unit Privileges.

Observation of the area across from the nursing station near the exit door of the Adult Male Psychiatric Unit on 07/30/13 at 9:26 a.m. revealed Patient #1 (who was ordered to be on 1:1 observation) was ambulating in the area. Further observation revealed S32MHT, who was assigned to observe Patient #1 one-to-one, did not keep Patient #1 within his arms' length while Patient #1 was ambulating in the area. Observation revealed S11RN made signs with his hands to S32MHT indicating to move closer to Patient #1.

In a face-to-face interview on 07/30/13 at 9:26 a.m., S11RN confirmed that S32MHT was not in arms' length of Patient #1 at all times as ordered by the physician and according to hospital policy.

Patient # 2
Review of Patients #2's medical record revealed that he was a 26 year old male admitted on 7/29/13 with a diagnosis of Bipolar Disorder. Review of his "Physician's Admit Orders" dated 7/29/13 with no documented evidence of the time the telephone order was received, revealed Patient #2's observation status ordered was Status B, line of sight during waking hours and every 5 minute checks during the house of sleep.

Patient #4
Review of Patient #4's medical record revealed he was a 21 year old male admitted on 07/28/13 with a diagnosis of Depression. Review of his "Physician's Orders" revealed he was ordered on 07/29/13 to be on Status B with off unit privileges.

Patient #5
Review of Patient R5's medical record revealed he was a 19 year old male admitted on 07/23/13 with a diagnosis of Psychosis. Review of His "Physician's Orders" revealed an order on 07/23/13 at 10:27 a.m. for Status B with off unit privileges.

Patient R3
Review of Patient R3's "Tech Observation Sheet" dated 07/29/13 from 11:00 p.m. to 07/30/13 at 11:00 p.m. revealed he was admitted on 07/24/13 and was on Status B observation.

Patient #R4
Review of Patient R4's medical record revealed he was a 30 year old male admitted on 07/22/13 with a diagnosis of Schizophrenia. Review of his "Physician's Admit Orders" dated 07/22/13, with no documented evidence of the time the telephone order was received, revealed Patient R4's observation status was Status B, line of sight during waking hours and every 5 minute checks during the hours of sleep.

Observation in the Day Room of the Adult Male Psychiatric Unit on 07/29/13 at 2:50 p.m. revealed Patients #2, R3, and R4, seated on the sofa with no observation of a MHT observing the 3 patients who had orders to be in a staff member's line of sight at all times during waking hours. Further observation revealed S38Lead MHT standing at the nursing station with his back to the Day Room (the sofa was not visible from the area where he was standing if he had turned around to face the Day Room).

In a face-to-face interview on 07/29/13 at 2:50 p.m., S38Lead MHT indicated that S32MHT was assigned to observe Patients R3, and R4, but left the area to go to the bathroom. S38Lead MHT confirmed that the three patients were not within any staff member's line of sight during the time that S32MHT was in the bathroom.

Patient #R5
Review of Patient R5's medical record revealed he was a 19 year old male admitted on 07/23/13 with a diagnosis of Psychosis. Review of his "Physician's Admit Orders" dated 07/23/13 at 3:00 p.m. revealed his observation status was Status B, line of sight during waking hours and every 5 minute checks during the hours of sleep.

Observation on 07/30/13 at 11:20 a.m. on the Adult Male Psychiatric Unit revealed Patient R5 ambulating to the bathroom with S28MHT in attendance. While observing from the nursing station which provided a full view of the hall where patient rooms were located, S28MHT was observed standing in the hall outside Room "e" while Patient R5 was in the bathroom.

In a face-to-face interview on 07/30/13 at 11:34 a.m., S11RN, while standing in the area where S28MHT stood to observe Patient R5 in the bathroom, confirmed that even with the bathroom door open, a patient could not be seen when standing at the toilet.

Patient R7
Review of Patient R7's medical record revealed he was a 25 year old male admitted on 07/26/13 with a diagnosis of Opiate Dependence. Review of his "Physician's Orders" revealed he was to ordered to be on Status B.

Observation of the Adult Male Psychiatric Unit on 07/29/13 at 11:20 a.m. revealed a hall extended from the nursing station that included the patients' rooms. Further observation revealed when standing with one's back to the nursing station the left side of the hall consisted of Rooms "b", "d", "f", and "h", and the right side of the hall consisted of Rooms "a", "c", "e", and "g".

Review of the "Patient Charting Assignment" for the 11:00 p.m. to 7:00 a.m. shift on 07/29/13 revealed S29MHT was assigned to observe Patients #4, #5, R3, R4, and R7 who were all to be monitored at least every 5 minutes with a 1 to 6 staff to patient ratio maintained at all times during the hours of sleep. Further review revealed S30MHT was assigned to observed Patient #1 one-to-one (staff must be within arms' length at all times).

Review of the "Alpha Census For 07/28/13 Sunday" presented on 07/29/13 at 12:50 p.m. by S23Human Resource staff member revealed that Patient 4 was in Room "e" in the bed by the door, Patient #5 was in Room "b" in the bed by the door, Patient R3 was in Room "a" in the bed by the window, Patient R4 was in Room "h" in the bed by the window, Patient R7 was in Room "d" in the bed by the door, and Patient #1 was in Room "c" in the bed by the window".

Observation of a video surveillance disc made by the hospital of the night shift from 1:00 a.m. to 5:00 a.m. on 07/30/13 on the Adult Male Psychiatric Unit revealed the following observations:
00:52 - S29MHT rose from a chair placed in the hall between Rooms "a", "b", "c", and "d" (position allowed S29MHT to see patients in Rooms "a", "b", "c", "d") and began to walk towards the nursing station;
00:54 - S29MHT began to walk from the nursing station toward the chair in the hall between Rooms "a", "b", "c", and "d" and then steps out of the view of the camera;
01:03 - S29MHT returns to sit in chair in hall outside Rooms "a", "b", "c", and "d".
Continued observation of the video surveillance revealed Patients #4, #5, R3, R4, and R7 were not observed by S29MHT every 5 minutes according to hospital policy and physician orders when he was away from the patients' rooms for 11 minutes. Further observation revealed that S29MHT could not visualize Patient #4 who was in Room "e" and Patient R4 who was in Room "h" from his seated position in the hall across from Rooms "a", "b", "c", and "d".
01:10 - S30MHT was seated in Room "c" in a chair at the door used to enter Room "c" (he was not within arms' length of the patient who was in the bed by the window); S30MHT got up from the chair and walked into the hall with his back to the room for 3 seconds;
01:14:58 - S30MHT walks into the hall from Room "c" with his back to the room;
01:15:21 - S30MHT returns to Room "c";
01:15:24 - S30MHT stands outside Room "c" in the hall looking at his cell phone with another MHT;
01:17:35 - S30MHT returns to Room "c".
Observation revealed Patient #1 was never within arms' length of S30MHT for the 25 minutes of video surveillance observations. Further observation revealed Patient #1 was not in S30MHT's sight for 2 minutes and 37 seconds.

Review of the "Tech Observation Sheet: for Patients #4, #5, R3, R4, and R7 revealed that S29MHT documented that these patients were asleep in their room laying on the bed/mattress and in his line of sight on )7/30/13 from 12:45 a.m. to 1:30 a.m. Review of the "Tech Observation Sheet: for Patient #1 revealed that S30MHT documented that Patient #1 was on 1:1 observation and asleep in his room laying on his bed/mattress.

In a face-to-face interview on 07/31/13 at 2:55 p.m., S2DON confirmed that S29MHT could not visibly see patients in Rooms "e" and "h" without walking from where he was seated in the hall between Rooms "a", "b", "c", and "d". She also confirmed that S29MHT did not visibly observe Patients #4, #5, R3, R4, and R7 every 5 minutes as required by the hospital's policy and physician orders. S2DON confirmed that S30MHT should have been seated within arms' length of Patient #1 and that he was not supposed to step out of the room at any time without being replaced.

Patient #3
Review of the Physician Admit Order for patient #3 revealed the following: "Order to Admit: Admit to: Adult Psych. Accepting Physician: (S17MD) to services of Attending Physician: (S18MD). 1:50P (p.m.). TO (telephone order) (S17MD)/S19LPN. 6/14/13 1830 pm ...Admission Orders: Date and Time: 6-14-13 1:50P. 1. Provisional Diagnosis: Depression. Level: Evaluation. 3. May have roommate. 4. Status B (Line of Sight during waking hours and every 5 minute checks during hours of Sleep) ..." Further review of the Physician's Orders revealed an order dated 6/14/13 at 1830 by S17MD that read as follows: "BOUP (status B with Off Unit Privileges)." There is no further documentation regarding the OUP status.

Review of the Nursing Mental Status Exam dated/timed 6/16/13 at 0940 by S11RN revealed the following: "...Physical Appearance: Appropriate clothes. Mood: Sad, Anxious, Depressed. Affect: Sad ...Assessment for Potential Risk: Suicidal...Narrative Note: Pt was in restroom (review of the video tape revealed patient #3 was in the restroom for 27 minutes), and MHT (S9MHT) walked to door and found pt lying on R (right) side with a drawstring wrapped twice and tied around his neck. Immediately, MHT (S9MHT) called for help. I found pt lying on the ground and turning cyanotic. I called for emergency services. (S10RN) got scissors and cut the string off. Pt was still breathing and color returned and pt began responding to pain stimuli and then verbal. (S4MD) was on site at nurse's station and walked to pt's room and stayed on site until EMS arrived. 0945: Contacted (S2DON) and notified of the incident. Pt at that time is awake and alert responding to verbal stimuli. No blood vessels ruptured in eyes OU (both eyes) visible at present. Noted small abrasions across the midline of his neck from nurse trying to put fingers underneath the strings to cut. 0950: (S17MD) was contacted and notified of the incident. 1005: (S18MD) contacted and notified of incident. Ordered to (Hosp "a") for eval and tx for possible neck injuries from self-strangulation attempt. 1015: (EMS) on site with (Police Department) and (Fire Department) 1st responders. Pt sitting upright on stretcher verbally responding. Photo taken of marks on neck. Report called to (name) at (hosp "a") ER (emergency room). (name) is the attending MD for pt."

Review of the Tech Observation Sheet for 6/16/13 at 8:30 a.m. and 8:45 a.m. revealed patient #3 was documented as BN (Line of Sight and Dayroom).

Review of the video tape revealed patient #3 was in room "c" at 8:16:52 a.m. and got in his bed at 8:17:03 a.m. Further review of the video tape revealed patient #3 exited room "c" at 8:36:52 a.m. and re-enters room "c" at 8:38:40 a.m. Patient #3 got into his bed 10 seconds later at 8:38:50 a.m.

Further review of the video tape revealed patient #3 entered the bathroom inside of room "c" at 8:44:18. The video displays that there is no MHT inside of patient #3's room performing Line of Sight Observation. Review of the video tape revealed that at 9:11:41 S9MHT entered room "c" and opened the bathroom door. (27 minutes and 23 seconds since patient #3 entered the bathroom) At 9:12:02 a.m. (20 seconds after entering the bathroom) S9MHT exits and appears to call for help.

Review of a document titled "Crossroads Regional Hospital Quality/Risk Management Report of Event" revealed the following: "WHO?...Inpatient ...WHEN? 6/16/13 0940. WHERE? Adult Males ...DESCRIPTION OF OCCURRENCE/COMPLAINT. (Self-strangulation attempt) Pt was in restroom and MHT (S9MHT) walk to door and found pt lying on his R (right) side with a drawstring wrapped twice and tied around his neck. Immediately MHT called for help. I found pt lying on the ground turning cyanotic. I called for Emergency Services. (S10RN) got scissors and cut the string off. Pt was still breathing and color returned and pt began responding to verbal and tactile stimuli...Completed By: (S11RN). Reviewed by: (S3RN/Risk Management)

Review of a Louisiana Department of Health and Hospitals - Hospital Abuse/Neglect Initial Report revealed: "Type of Incident: Alleged Neglect...Incident Information. Date of Incident: 6-16-13. Time of Incident: 9:40 a.m...Specific Location of Incident: Adult Unit Room ("c"). Patient Information: Name: (patient #3)...Admit Date: 6-14-13...Admitting Diagnoses: Depression...On initial investigation it was noted that on 6-15-13 Mom brought in a pair of shorts that had a draw string in the waist band. The tech (S8MHT) failed to remove the draw string when logging in the shorts. It is also noted that on the morning of 6-15-13 (patient #3) voiced to (S5RN) that he was feeling suicidal and would cut his wrist or shoot himself. (S5RN) did not document that the physician was notified at that time and she did not initiate any special safety precautions. Completed investigation to follow." Typed names of S2DON and S3RN, Risk Management are on the line for Name and Title of person preparing report. The document is dated June 17, 2013.

In an interview on 7/31/13 at 3:02 p.m. with S2DON she confirmed that she has not yet developed and/or implemented a plan to prevent similar occurrences related to the incident of 6/16/13. S2DON reviewed the Status A and Status B policy and stated the "Status B policy needs revision, can't differentiate between the two." S2DON confirmed the policy has not been revised and stated the incident involving patient #3 on 6/16/13 was "directly caused by staff not following hospital policy and procedure."