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Based on interviews, record reviews and policy review, it was determined the facility failed to ensure one (1) of ten (10) sampled patients received care in a safe setting (Patient #1). Patient #1 came to the hospital on 09/05/12 after overdosing on Effexor, Inderal, three bottles of Tequila and Melatonin in a suicidal attempt. The admitting physician admitted the patient on suicidal precautions and ordered Level IV (one to one) monitoring. Patient #1 was monitored one to one and changed to Level III (line of sight) monitoring on 09/07/12. The evening of 09/09/12, Patient #1's behavior changed, he/she was agitated and he/she did not want the staff following him/her. Registered Nurse (RN) #1 informed RN #2 the patient was acting not his/her usual self. RN #1 told RN #2 the patient was up to something and his/her level of monitoring should be increased to Level IV (one to one) monitoring. RN #2 agreed with RN #1 about increasing his/her level of supervision. RN #1 had also informed the Mental Health Technician (MHT) #1 to watch the patient as if he/she was on one to one monitoring. The patient went to his/her room and prepared for a shower. MHT #1 was inside the bathroom with the patient, but outside the shower. The MHT permitted the patient to have the shower curtain pulled with area opened so he could observe the patient. MHT #1 checked the patient 30 seconds after entering the shower. MHT #1 went to check the patient on the second 30 second interval and pulled the shower curtain back to find Patient #1 with a string and a pair of shorts wrapped around his/her neck. Patient #1 was starting to kneel and he/she was pulling upward with his/her arms above his/her head in an attempt to hang him/herself. This failure placed patients at risk for injury, harm, impairment or death. On 09/14/12, Immediate Jeopardy was determined to exist. The facility initiated corrective actions and the Immediate Jeopardy was determined to be abated on 09/14/12, prior to the exit.


Refer to A-144

Based on interviews, record reviews, and review of the facility's policies and procedures, it was determined the facility failed to ensure one of ten sampled patients (Patient #1) was provided care in a safe environment. Although there were written policies and procedures governing all aspects of the operation of the hospital and services, the staff failed to follow the hospital's policies and procedures for observation/special precautions, as a Mental Health Technician (MHT #1) was assigned to monitor Patient #1 and when his/her behavior changed, Registered Nurse (RN) #1 informed MHT #1 to monitor the patient as if he/she was on a one to one observations. Patient #1 went to his/her room and prepared for a shower with MHT #1 monitoring. MHT #1 entered the bathroom with the patient, but stayed outside the shower. The patient entered the shower and pulled the curtain with area opened so he/she could observed by MHT #1. MHT #1 checked the patient 30 seconds after entering the shower. MHT #1 went to check the patient on the second 30 second interval and pulled the shower curtain back to find Patient #1 with a string and a pair of shorts wrapped around his/her neck with his/her arms above his/her head pulling upward as he/she knelt in an attempt to hang him/herself. MHT #1 monitored the patient as though he/she was on line of sight monitoring, even though RN #1 had informed him to monitor him/her like one to one observation. Immediate Jeopardy was identified on 09/14/12 and it was determined the facility had implemented corrective action as of 09/14/12 to abate the jeopardy.

Findings include:

A review of the policy entitled "Levels of Observation/Special Precautions" effective 03/02 and revised 11/11 revealed all patients will be routinely observed in compliance with written physician orders. Staff members assigned to each patient will provide continuous monitoring of precautions, as well as oversight and intervention to provide for his/her safety and security. The intensity of patient observation, and the frequency of documentation of those observations, will be commensurate with the assessed level and type of risk. Staff members are educated about their responsibility for patient care and oversight throughout their shift, regardless of the frequency of documented observations. Patient's observation level and precautions are reviewed in treatment team meetings. Level III -Line of Sight Observation meant the patient would remain in direct view of the assigned staff member at all times. Staff will document on the Patient Observation Sheet every 15 minutes. When patients shower, change clothes or use the bathroom, staff will remain outside the bedroom or bathroom door with the door slightly opened and visually check the patient at least every 30 seconds. Staff will attempt to maintain the patient's privacy as much as possible; however, the safety of the patient must be the consideration. Level IV -One to One Observation meant a specified and dedicated staff member was within approximately one arm's length of the patient on 1:1 observation. This continuous direct visual observation will continue even when the patients shower, change clothes or use the bathroom. Staff will attempt to maintain the patient's privacy as much as possible; however, the safety of the patient must be the main consideration.

An interview with MHT #1, on 09/12/12 at 4:15 PM, revealed he was monitoring the patient at the time he/she tried to hang him/herself. RN #1 monitored the patient while he/she was on smoke break. When they returned inside, another MHT was assigned to monitor. The other MHT was monitoring the patient, when he was alerted by Patient #1's roommate of his/her attempt to run from the facility when they went to get a soda. MHT #1 stopped the other MHT from taking the patient for a soda and RN #1 changed Patient #1's monitoring. MHT #1 indicated RN #1 told him to watch the patient as though he/she was on one to one supervision. Patient #1 went to his/her room and decided he/she was going to shower. MHT #1 entered the bathroom with the patient and stayed outside the shower. The patient disrobed, turned on the water and stepped in the shower. He completed the initial check on the patient and was told by the patient he/she was all right. The patient had the shower curtain pulled with an area opened for view and MHT #1 went to complete his second check of the patient and decided to pull the curtain back revealing Patient #1 attempting to hang him/herself with a string in a pair of shorts. MHT #1 intervened immediately and hollered for help.

An interview with RN #1, on 09/13/12 at 3:26 PM, revealed she monitored the patient while the MHT was on break. While she monitored the patient, he/she was anxious and Patient #1 asked to go to his/her bedroom alone. She told Patient #1 she could not lower his/her supervision. RN #1 directed MHT #1 to resume monitoring the patient and treat him/her as though he/she was on 1 to 1 supervision. She returned to the nursing desk and informed RN #2 of what was going on. Patient #1's roommate came up and requested to see the therapist. She went down the hall looking for the therapist but could not locate her. After returning to the nursing desk, Patient #1's roommate told her he/she had been given a note to give to the therapist. At the time of the suicide attempt, she was completing room checks but she did not understand how the patient was able to hang him/herself while on the 1 to 1. While on a 1 to 1, staff have to be within an arms length and you have to keep your eyes on the patient at all times.


An interview with RN #2, on 09/13/12 at 11:24 AM, revealed she was working the night Patient #1 attempted suicide. The patient was on line of sight supervision and had spoke with the therapist requesting to come off the line of sight monitoring. Following the conversation with the therapist, she told us to keep a close eye on the patient. RN #1 monitored the patient while the MHT's were taking their break. While monitoring the patient, RN #1 observed the patient was anxious. Patient #1 was telling her to leave him/her alone. RN #1 assigned MHT #1 to treat the patient as if he/she was on one to one supervision. When RN #1 returned to the desk, she stated she was going to raise his/her level to 1:1. Before RN #2 could notify the physician of the changes in the patient, she heard MHT #1 yelling. She took off running to the room. When she arrived in the bathroom, MHT #1 had removed the shorts from his/her neck and the patient was leaning against him sobbing. The patient was placed on one to one supervision and the physician was contacted related to his/her behavior as well as obtaining an order for some medication to help him/her calm down.

An interview with therapist, on 09/17/12 at 10:47 AM, revealed during a discussion on 09/09/12, the patient asked for his/her level of supervision to be changed and to be left alone. Another patient on the unit informed her Patient #1 asked his/her roommate to give a suicide note to her the following day. He/she was told he/she could not be left alone and the Patient #1 was mad because the staff was watching him/her so closely. She told the nurses on duty to raise his/her level of supervision. The therapist left the facility and she called the Director of Clinical Services to make her aware of what was going on. Upon the direction of the Director of Clinical Services, she called back to the facility and informed the nurses to increase the patients level of supervision for the second time.

Based on interview, record review and review of the facilities policy and procedure, it was determined the facility failed to ensure supervision and evaluation of the nursing care for one (1) of ten (10) sampled patients (Patient #1). On 09/09/12, Patient #1 requested to be left alone for a minute although he/she was on line of sight monitoring and Registered Nurse (RN) #1 observed a change in his/her behavior. RN #1 changed the patient from line of sight supervision to one to one observation related to his/her behavior. Mental Health Technician (MHT) #1 was asked by RN #1 to monitor the patient as if he/she was on one to one observation. Patient #1 and MHT #1 went to his/her room for a shower. The patient went to the bathroom to shower and a small area was left opened for staff to monitor the patient. MHT #1 completed the first 30 second check on the patient as if he/she was on line of sight monitoring and went to complete the next check. MHT #1 found Patient #1 with a string attached to a garment wrapped around his/her neck trying to hang him/herself. MHT #1 intervened immediately and hollered with staff responding. This failure placed patients at risk for injury, harm, impairment or death. On 09/14/12, Immediate Jeopardy was determined to exist. The facility initiated corrective actions and the Immediate Jeopardy was determined to be abated on 09/14/12, prior to the exit.


Refer to A-395.

Based on interview, record review and review of the facilities policy and procedure, it was determined the facility failed to ensure supervision and evaluation of the nursing care for one (1) of ten (10) sampled patients (Patient #1). On 09/09/12, Patient #1 requested to be left alone for a minute although he/she was on line of sight monitoring and Registered Nurse (RN) #1 observed a change in his/her behavior. RN #1 changed the patient from line of sight supervision to one to one observation related to his/her behavior which entailed staff having direct sight of the patient at all times. Mental Health Technician (MHT) #1 was asked by RN #1 to monitor the patient as if he/she was on one to one observation. MHT #1 went with Patient #1 to the bathroom but remained outside the shower. The patient went into shower and the shower curtain was not completely pulled closed. MHT #1 completed the first 30 second check on the patient as if he/she was on line of sight monitoring and went to complete the next check. MHT #1 found Patient #1 with a string attached to a garment wrapped around his/her neck trying to hang him/herself. MHT #1 intervened immediately and hollered with staff responding. She returned to the nursing desk to inform RN #2 of what was going on. Patient #1's roommate came up and requested to see the therapist because he/she had been given a note to give to the therapist. This failure placed patients at risk for injury, harm, impairment or death. On 09/14/12, Immediate Jeopardy was determined to exist. The facility initiated corrective actions and the Immediate Jeopardy was determined to be abated on 09/14/12, prior to the exit.

Findings include:

A review of the policy entitled "Levels of Observation/Special Precautions" effective 03/02 and revised 11/11 revealed all patients will be routinely observed in compliance with written physician orders. Staff members assigned to each patient will provide continuous monitoring of precautions, as well as oversight and intervention to provide for his/her safety and security. The intensity of patient observation, and the frequency of documentation of those observations, will be commensurate with the assessed level and type of risk. Staff members are educated about their responsibility for patient care and oversight throughout their shift, regardless of the frequency of documented observations. Patient's observation level and precautions are reviewed in treatment team meetings. Level III -Line of Sight Observation meant the patient would remain in direct view of the assigned staff member at all times. Staff will document on the Patient Observation Sheet every 15 minutes. When patients shower, change clothes or use the bathroom, staff will remain outside the bedroom or bathroom door with the door slightly opened and visually check the patient at least every 30 seconds. Staff will attempt to maintain the patient's privacy as much as possible; however, the safety of the patient must be the consideration. Level IV -One to One Observation meant a specified and dedicated staff member was within approximately one arm's length of the patient on 1:1 observation. This continuous direct visual observation will continue even when the patients shower, change clothes or use the bathroom. Staff will attempt to maintain the patient's privacy as much as possible; however, the safety of the patient must be the main consideration.


An interview with RN #1, on 09/13/12 at 3:26 PM, revealed she had monitored the patient while a MHT was on a break. Patient #1 was anxious and she had a thought the patient was up to something. She requested MHT #1 to monitor the patient after his/her failed attempt to elope from the facility. She told MHT #1 to treat him/her like he/she was on a 1 to 1 observation and the nurse would contact the physician to get him/her changed to a 1 to 1. She returned to the nursing desk to inform RN #2 of what was going on. Patient #1's roommate came up and requested to see the therapist as soon as possible. She took off down the hall to look for the therapist but she did not find her. When she returned to the nursing desk, Patient #1's roommate informed her of a note he/she was given by the patient for the therapist. At the time of the suicide attempt, she was completing room checks but she did not understand how the patient was able to hang him/herself while on the 1 to 1. While on a 1 to 1, staff have to be within an arms length and you have to keep your eyes on the patient at all times.

An interview with RN #2, on 09/13/12 at 11:24 AM and 09/17/12 at 3:10 PM, revealed Patient #1 was on line of sight supervision when she came on duty on 09/09/12. The therapist came to us (nurses) and told us to raise the patient's level of monitoring about 15 to 20 minutes before the incident. The therapist indicated something was not right with the patient. RN #2 revealed she received a phone call and she had not contacted the on-call physician before the patient made a suicide attempt. RN #2 had monitored the patient previously and determined his/her level of supervision needed to be increased. MHT #1 was in the bathroom, but outside of the shower area when Patient #1 made the suicide attempt. With line of sight monitoring in the bathroom, staff checked the patient every 30 seconds. With 1:1 supervision, the staff had to be in arms length of the patient and keep their eyes on the patient. As a nurse, we can raise a level of observation but we can not discontinue it.

An interview with MHT #1, on 09/12/12 at 4:15 PM, revealed he was monitoring the patient at the time he/she tried to hang him/herself. He revealed the patient was on line of sight observations when he started the shift. Patient #1 had returned from a smoke break and was with another MHT attempted to elope from the facility when Registered Nurse (RN) #1 had him/her but gave it back. RN #1 informed him she was going to change his/her level from line of sight to a higher level. MHT #1 went with the patient to the shower and placed a chair outside of the shower. The patient disrobed, turned on the water and stepped in the shower. He completed the initial check on the patient and was told by the patient he/she was all right. The shower curtain was pulled but not completely closed and MHT #1 pulled the curtain back revealing Patient #1 attempting to hang him/herself with a string in a pair of shorts on his second check of the patient. He revealed the line of sight supervision meant staff had to keep the patient in their line of sight at all times, but in the bathroom or shower they checked them every 30 seconds. A 1 to 1 meant, staff were only an arms length away and they had to keep their eyes on the patient at all times.

An interview with the Director of Nursing (DON), on 09/12/12 at 1:05 PM, revealed she was in the building on 09/09/12 when the incident happened with Patient #1. She stated the patient was seen by the therapist earlier and the patient gave his/her roommate a suicide note. The patient was changed from line of sight supervision to 1 to 1 supervision and the staff was on heighten alert.

An interview with the therapist, 09/17/12 at 10:47 AM, revealed the patient was acting strangely all during the day. She monitored the patient that evening from the doorway of his/her bedroom while changing into a pair of pants and a shirt. She would not let him/her be alone inspite of Patient #1 asking to change his/her clothes alone and to decrease his/her level of supervision. He/she was told he/she could not be left alone and the Patient #1 was mad because the staff was watching him/her so closely. Between 8:00 and 9:00 PM, she told RN #1 & RN #2 at the nursing station to increase his/her level of supervision because he/she was acting weird all during the day. The therapist left the facility and notified the Director of Clinical Services. Upon the direction of the Director of Clinical Services, she called back to the facility to let RN #2 know to increase Patient #1's level of monitoring.

An interview with the Director of Clinical Services, on 09/17/12 at 9:27 AM, revealed she was contacted by the therapist related to her concern about Patient #1. She told the therapist to call the facility back and tell the nurses what her concerns were. The therapist informed her, she had already advised the nurses to put the patient back on 1 to 1 monitoring. The Director of Clinical Services called back to the facility and was told the nurse was on the phone with the physician.