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Based on review of the facility policy, medical record review, observation, and interview, the facility failed to perform safety checks and a room search for 1 psychiatric patient (Patient #1) of 3 psychiatric patients reviewed, resulting in Patient #1 self-administering medication, becoming unresponsive, requiring cardiopulmonary resuscitation, and transfer to an acute care facility.

Refer to A-144

Based on review of the facility policy, medical record review, observation, and interview, the facility failed to perform safety checks and a room search for 1 psychiatric patient (Patient #1) of 3 patients reviewed, resulting in Patient #1 self-administering medication, becoming unresponsive, requiring cardiopulmonary resuscitation, and transfer to an acute care facility.

The findings include:

Review of the facility's policy titled "Patient Monitoring and Safety Measures" dated 11/2019 showed "...to provide a sufficient degree of patient monitoring to maintain a safe and therapeutic patient care environment at all times...Routine observation checks...completed...at least every 15 minutes...will be through personal observation and interactions with staff members..."

Patient #1 was admitted to the facility on 2/20/2020 with diagnoses including Major Depression, Opiate Use, Recurrent Major Depression, and Suicidal Ideation.

Review of a 15 Minute Check Sheet (form used to document observation of a psychiatric patient) dated 2/20/2020 for Patient #1 showed no documentation the patient was observed by staff at 10:00 AM, 10:15 AM, 10:30 AM, and 1:30 PM.

Review of a facility video recording dated 2/21/2020 with the Security Manager, the Administrator, and the Nurse Manager showed on the morning of 2/21/2020 at approximately 8:30 AM Patient #1 was standing in line for breakfast then sat down on the floor and slumped over. Nursing staff quickly obtained the emergency crash cart and chest compressions were started on Patient #1. Patient #1 was transferred to an acute care facility via emergency medical services (EMS).

Review of an acute care facility Physician's Admission History and Physical dated 2/21/2020 at 1:01 PM revealed "...EMS stated when they got to [the facility] staff was doing CPR [cardiopulmonary resuscitation]...[Patient #1] was in respiratory distress...EMS gave Narcan [medication used to treat opioid overdose] and pt [patient] started breathing unassisted...she has been started on a Narcan drip with some improvement...[Patient #1] is positive on her UDS [urine drug screen] for benzodiazepines, opiates, amphetamines...although she is scheduled some of these medicines, it is unclear how she could have overdosed since she was in inpatient rehab...from a previous suicide attempt..."

Review of an acute care facility Physician's Discharge Summary dated 2/26/2020 at 9:59 AM revealed "...intentional overdose of a combination of Ambien [non-benzodiazepine hypnotic medication] Xanax [benzodiazepine], multiple other medications...it is unsure how the facility patient obtained these medications..."

During an interview on 3/9/2020 at 1:50 PM the Nurse Manager and Program Counselor (PC) #1 stated the PC's complete a room search of each patient's room every shift (every 12 hours) and "...look under the patient mattresses, on the shelves, drawers...for patient safety and infection control..." Further interview confirmed the facility was unable to show documentation Patient #1's room was searched each shift during her length of stay (2/20/2020 - 2/21/2020).

During an interview on 3/10/2020 at 10:15 AM, the Risk Manager and Nurse Manager stated the facility "...cannot say for sure if room sweeps are done every shift..." The Risk Manager, when asked about the missed documentation of the 15 Minute checks, stated "...sometimes we get busy and things happen..."

During a telephone interview on 3/10/2020 at 12:00 PM Patient #1 stated she was allowed to remain in her personal clothing while in the facility but her clothing was searched by facility staff during the intake process. The patient stated she attempted to hurt herself in the facility and she got the medication from a male employee. The patient stated she took "...a hand full...around 30 pills of Levorphanol [a synthetic narcotic]...were in a baggie...in purse..."

During an interview on 3/11/2020 at 1:20 PM, the Administrator and the Risk Manager stated they believed Patient #1 had placed the medications it in a body cavity up until the time she took them.