HospitalInspections.org

Based on interview, record review and policy review the facility failed to:
- Adequately assess/monitor patients for risk of suicide for one patient (#1) of 11 patients reviewed.
- Adequately review and/or utilize patients' histories of being a risk for suicide for one patient (#1) of two patients who attempted suicide.
-Provide direction to staff to communicate essential information related to risk for suicide.
- Thoroughly investigate and recognize opportunities for improvement for nursing staff to prevent suicide attempts.
-Re-assess current patient risk and put education and/or interventions in place to prevent suicide for those at risk.
- Provide nursing education and monitoring of staff assigned to 15 minute patient rounding.
The facility census was 88.

These failure to assess and monitor at risk patients for suicide placed any patient with suicidal ideations in an unsafe environment. The facility failed to appropriately respond with preventive measures and education to prevent further suicide attempts for those at risk; it placed the patients at immediate risk for their health and safety, also known as Immediate jeopardy (IJ).

On 08/20/14, prior to the surveyor team exit, the facility provided a plan of correction sufficient to abate the IJ by immediately implementing the following:
-To immediately educate all nursing staff on 15 minute observations, communication and documentation including new employee orientation and annual competencies (yearly education).
-To monitor and track compliance with observation rounds.
-To monitor and track compliance with Hand-off Communication.
-To monitor and track compliance with Documentation.

Based on interview, record review, policy review and observation the facility failed to:
-Thoroughly assess patients to determine the appropriate level of suicide precautions to prevent a suicide attempt for Patient #1.
-Effectively communicate pertinent information concerning the risk of suicide for Patient #1.
-Follow the facility policy to document "real time" on 15 minute checks and vary rounding patterns for 11 patients (#12, #13, #14, #15, #16, #17, #18, #19, #20, #21 and #22) of 28 records reviewed.
-Thoroughly investigate suicide attempts and recognize opportunities for improvement.
-Provide education to nursing staff concerning assessing risk of suicide, communication and documentation after the suicide attempt of Patient #1.
These failure to assess and monitor at risk patients for suicide placed any patient with suicidal ideations in an unsafe environment.
The facility census was 88.

Findings included:

1. Record review of the facility policy titled, "Assessing Level of Care" revised 02/10, showed the following direction for the Clinical Intake Assessor:
- To efficiently and effectively collect the information necessary to determine the most appropriate level of care and disposition based on clinical information obtained.
-Information obtained by this assessment and the resultant disposition is to be shared with the patient and significant others. Appropriate [facility] personnel are also notified where applicable to ensure continuity of care.

No documentation was found in the medical record as to the assigned level of care or that this information was shared.

Record review of the facility policy titled, "Precaution and Observation Levels" revised 10/11, showed the following:
-Patients are assessed for and assigned a precaution/observation level to assure safety for all patients and staff.
-All patients are monitored at a minimum of every 15 minutes during their entire hospitalization.
-Patients that present an imminent danger of harm to themselves or others are placed on an increased level of observation/precautions.
The following observation levels are used in Behavioral Health Services:
-15 minute observation rounds documentation: Patients on this level are assessed to be in minimal danger of implementing suicide, or harmful behavior toward self/others.
- Documentation required each shift and is to include patient's behavior, level of functioning, unit participation, current assessment of suicidal ideation/homicidal ideation and plan, ordered precautions, response to interventions, and notation that the patient is on 15 minute observation checks.
-Within-Line-of Sight at all times: Patients who are on Within Line of Sight observation are at high risk for self injury or high risk of danger to others, but do not have the means to complete actions (i.e. run in front of a bus, jump off bridge, etc). Patients are in staff view at all times.
-Within-arm-length-reach at all times: Patients who are on Within Arms's Length Reach are at imminent risk for self injury, or high risk of danger to others. These patients may have made overt gestures, statements, or actions that are potentially harmful to themselves or others.
-Each level of observation has specific documentation requirements.
-Only a physician can decrease the level of observation. Registered Nurses (RN) may initiate or intensify levels of observations, but the physician evaluation and subsequent order is required to decrease or remove precautions.
-15 minute Observation Checks: All patients are monitored and documented on the Daily Observation Flowsheet a minimum of every 15 minutes. Patients on this level of observation are assessed to be in minimal danger of implementing suicide, or harmful behavior toward self/others. Patient behavior may include: thoughts of hurting self or others with or without plan, absence of means (or person) to complete actions, able to make commitment to safety, exhibits some insight into existing problems.
- Nursing interventions: Check patient every 15 minutes.

2. Record review of Patient # 1's ED visit showed Patient #1 arrived by ambulance on 08/03/14 with suicidal ideation (there was an altercation between he and his neighbor and the police had been called). An affidavit was submitted by a friend of the patient stating he heard the patient thought about hurting himself instead of the neighbor hurting him (patient). He stated he did not have a plan because, "I haven't gotten that far."

Record review of the ED physician's assessment showed the patient had previously been admitted to this facility on 01/20/14 through 01/24/14 following a three day admission to the Intensive Care Unit (ICU) after an intentional overdose of Lithium (a medication used to treat the manic stage [mood is persistently elevated, expansive and irritable] of bipolar disease).
Further documentation in the physical exam by the ED physician showed the patient was anxious, speech was rapid and/or pressured, agitated, thought content was paranoid and [the patient] expressed suicidal ideation. The laboratory report showed the patient was positive for marijuana and anti anxiety drugs.

3. During an interview on 08/18/14 at 4:15 PM, Staff N, ED Physician, stated that the patient expressed suicidal ideation without a plan. He stated that he would have expected him to be on suicide precautions and would have thought that anyone presenting with suicidal ideation's would be on suicide precautions. He stated that he usually had a conversation with the Central Intake Assessor to let him know that the patient is medically stable and he wrote the order for admission.

4. Record review of the Progress Notes dated 08/03/14 at 3:18 PM, Staff T, RN, documented Patient #1 was loud and refused medications. The patient denied Suicidal Ideation's and/or Homicidal Ideation's (SI/HI) and stated "no but it could easily get to that" .

Record review of Patient #1's assessment dated 08/03/14, completed by the Clinical Intake Assessor showed:
-Informants were the patient, ED staff, affidavit and the medical record.
-Patient stated to assessor that he "never got around to thinking of a plan" today but is afraid of what would happen to him if he were at home.
-Patient reported two prior suicide attempts, one which was a serious medication overdose and the other attempt was by drinking bleach.
-Patient had disorganized thinking (unable to think straight), had push of speech (rapid, nonstop, hard to interrupt), was hypertalkative, paranoid (distrustful and obsessively anxious about something, or unreasonably suspicious of other people and their thoughts or motives) of the ED staff's intentions, had racing thoughts and stated he "hasn't been hallucinating much" today.
-Multiple admissions to facility; the last being January of 2014;
-Mood was labile, provocative and verbally very aggressive and demeaning toward ED staff;
-Poor insight, judgment and poor decision-making skills.
No level of care was documented in the assessment. Level of care examples were: minimal danger of implementing suicide, imminent danger of harm to themselves or imminent risk for self injury.

5. During an interview on 08/18/14 at 5:15 PM, Staff O, Clinical Intake Assessor, stated that he:
-Was to expedite the admission.
-Acted as a liaison between nursing, the in-patient unit and the psychiatrist.
-Documented the screening of the patient in the electronic record.
-Does not verbally share the results of the assessment with any staff such as prior suicide attempts.
-Calls the psychiatrist and reports the assessment.
He also stated that the unit nurse would call the psychiatrist for orders and the psychiatrist would order medications, laboratory and suicide precautions.
Staff O stated that the information he gathered was documented in the medical record but that he did not share the patient's suicidal level of care with the nursing staff.

6. Record review of the Nurse Practitioners (NP) Psychiatric Initial Evaluation showed the patient was agitated, aggressive, had an altercation with a neighbor and suicide ideation. Further assessment documentation showed the patient was volatile, manipulative to get his own way, no impulse control, labile mood (tearful one minute and agitated and aggressive the next), flight of ideas and loose associations, denied SI/HI at time of interview with poor insight and judgment. The patient had a previous history of suicidal symptoms and a history of overdose.

During an interview on 08/19/14 at 9:25 AM, Staff H, NP, stated that she was aware the patient was admitted for SI and that he had previous suicide attempts; the most recent in January of this year. She stated that he denied suicidal ideation when she spoke to him.

7. During an interview on 08/19/14 at 9:45 AM, Staff J, RN, stated that she had been told by Staff I, Psych Tech, that Patient #1 showed her a torn tee shirt and how he could put it around his neck and hang it from the door. She stated that she did not document this and did not communicate this to the on-coming shift. She stated that she talked with the patient and he "contracted for safety" (a procedure used in the management of suicide risk where the patient promises not to hurt themselves and will tell the staff if they are thinking of hurting themselves) four times during that shift. She stated that if she had known the patient had a recent suicide attempt, it would have made a difference in how she responded to his statements and she would have increased the precautions to line of sight [the patient was on 15 minute observations]. She also stated that when she acts as the admitting nurse her responsibility is to call the psychiatrist for orders. She stated that she did not give him the specifics of the ED report (such as SI/HI).

During an interview on 08/19/14 at 2:20 PM, Staff I, stated that she was doing rounds on 08/04/14 and observed Patient #1 in his room staring out a blurred (not clear) window. She stated that Patient #1 ripped his shirt and hung it over the door saying, "this is how I can hang myself. I want to give it to you [his shirt]." Staff I stated that she took the patient to his nurse, Staff J, RN. Staff J stated to the patient that she might need to put him on line of sight. Patient #1 responded by saying that he did not want to be on line of sight. She stated that she was assigned to another unit and left the adult unit with the impression that Patient #1 would be put on line of sight (increased direct supervision).

8. During an interview on 08/19/14 at 8:15 AM, Staff G, RN, stated that she was assigned to Patient #1 and had taken report from the day nurse. She stated that she was told that the patient was med seeking and had a fit earlier in the day about his medications. She stated that she was not aware that he had previous suicide attempts. She stated she was not told that the patient had demonstrated to another staff how he would try to hang himself with a tee shirt. She stated that if she had been told she would have increased his level of suicide risk.

9. Record review of a late entry (from 08/04/14 at 1:30 PM) of a progress note documented by Staff J, RN, on 08/07/14 at 5:00 PM showed the following: "Went into patient's room to check on him. Tech was in room and reported that patient had asked to speak with her and had told her he had a plan to rip his tee shirt and put it over the door to hurt himself. This RN discussed positive coping skills. [Patient] stated I do not want to be on line of sight, I just had thoughts of hurting myself and wanted to talk to someone."

10. During an interview on 08/19/14 at 3:45, PM Staff L, Psychiatrist, stated that most of their patients knew what to say to get into the facility. They exhibit SI or HI without a plan when they come into the ED. But once they are accepted as an inpatient, they no longer exhibit those behaviors because they are in a safe environment.

11. During an interview on 08/20/14 at 8:50 AM, Staff U, RN on the Adult Unit, stated that he often gets report from the ED on patients to be admitted to the unit. He stated that the information is very brief and problematic because they do not give you any history on the patient. He stated that the admitting nurse is not always the nurse that takes report from the ED and the information does not get documented or passed on - it happens all the time.

12. Record review of the facility's document titled, "Regulatory Compliance and Risk Management Investigation" dated 08/11/14 showed the following:
- At approximately 2230 [10:30 PM]on August 4, Psychiatric Care Tech, [this was inaccurate as Staff D's title is Clinical Partner], presented to the patient's room to complete the required 15 minute interval observation rounding of the patient. It was noted that the door was closed and the Tech was unable to open the door. The Tech knocked and called out for the patient with no response. Upon opening the safety wicket door (a smaller door within a door with a separate lock), the patient was found slumped in the corner between the door and wall, facing the wall, with a sheet wrapped very tightly around his neck. Patient #1 was purple, non-responsive and pulseless. The sheet was not knotted or tied off to anything.
- Our investigation revealed no apparent gaps in assessment and care, or any deviation in processes that are designed to ensure patient safety. The document was signed by Staff B, Regulatory Compliance and Risk Manager.

13. Observation on 08/18/14 at 3:45 PM showed a white sheet with a slip knot (a knot that slips easily along the rope or cord around which it is tied). This sheet was identified by facility administration as being the sheet Patient #1 used to attempt suicide. Staff B confirmed the slip knot and that it tightened when pulled.

14. Record review of the facility's policy titled, "Observation Rounds for Inpatient Behavioral Health Services" revised 02/12, showed the following direction to staff on all Behavioral Health Inpatient Units:
- Safety will be maintained by intermittent observational rounds of patient condition and whereabouts.
- All patients admitted to inpatient units are observed a minimum of every 15 minutes not to exceed 20 minutes, during their entire hospitalization.
- Upon admission to the unit, an observation sheet is implemented for each patient. Staff document on the observation sheet the patient precautions as indicated by the physician order and or nursing judgment as well as the patient's location every 15 minutes. Each form is for a 24 hour period and starts at midnight.
- Staff are to write the exact time on the rounds sheet that they observe each patient.
- Vary the pattern of rounds.
- Ask for help before getting behind on rounds.
- The RN/LPN [Licensed Practical Nurse] will ensure that rounds are being done correctly and that documentation is current and up-to-date.
- All employees completing the rounds sheet will sign their name, initials and licensure legibly on the rounds board. The rounds board should never be left unattended.
- Physician admission orders include frequency of observation rounds and all precautions to be taken.
- Staff receives information during Psych Specific orientation, unit specific (preceptor), and periodically thereafter regarding observation rounds.

15. Record review of Patient #1's Daily Observation Flowsheet dated 08/04/14 showed no rounding entries documented for 10:00 PM, 10:15 PM or 10:30 PM. The time of the attempted suicide by Patient #1 was approximately 10:30 PM on 08/04/14. Of the 42 timed entries made on Patient #1's flow sheet only nine varied from the exact minute of 00, 15, 30 and 45.

16. Observation on 08/18/14 at 4:40 PM of the video tape for the night of 08/04/14 at 10:00 PM, prior to the patient's attempted suicide, showed that Staff D completed rounding on 14 patients including Patient #1. She did not have the rounding board in hand and conducted the rounds using the same pattern of observation at 10:00 PM, 10:15 PM and 10:30 PM.

During a concurrent interview on 08/18/14 at 4:40 PM, Staff A, Director, and Staff B, Risk Coordinator, stated that they had watched the video twice before but did not notice that Staff D did not vary her pattern when conducting her rounds and did not carry the rounding board.

During an interview on 08/18/14 at 5:10 PM, Staff A stated that she had previously watched the video of the event but she had not had a discussion with Staff D about rounding procedures. She stated that she had not checked the Daily Observation Flowsheets (also referred to as rounding sheets) of any staff since the attempted suicide of Patient #1 on 08/04/14. She stated that she observed that Staff D conducted the rounds exactly the same each time. Staff failed to recognize variations in policy and procedures during rounding with opportunities to re-educate staff and improve patient care.

17. Record review of 28 Daily Observation Flowsheets on the Adult Psychiatric Unit for 11 patients (#12, #13, #14, #15, #16, #17, #18, #19, #20, #21 and #22) dated 08/14/14, 08/15/14 and 08/16/14 completed by Staff D, showed that she had not documented the exact times of observation.

18. During an interview on 08/19/14 at 7:30 AM, Staff D stated that she was never given any direction on how to complete patient rounds. Staff D stated that on the evening of 08/04/14 when Patient #1 attempted suicide she was also involved with a patient admission and had not carried the rounding board or written down the times of observation for any of the patients for the last two rounds. Staff D stated that she was never directed to vary her patterns of observation.

During an interview on 08/19/14 at 7:46 AM, Staff E, RN, stated that she was the House Supervisor the night of 08/04/14. She stated that there had been no staff education to her knowledge since the attempted suicide of Patient #1. She stated that the exact time of patient observations should be written on the Daily Observation Flowsheets and that staff usually go in the same pattern when rounding.

During an interview on 08/19/14 at 8:07 AM, Staff F, Psychiatric Therapist on the Adolescent Unit, stated that the exact times of observation should be documented on the Daily Observation Flowsheets but the observation patterns weren't always changed.

During an interview on 08/19/14 at 1:10 PM, Staff Q, Clinical Partner on the Adolescent Unit, stated that she makes the observation rounds in the same way each time and doesn't vary her pattern.

19. Observation on 08/19/14 at 2:00 PM showed Staff F, Psych Tech, making 15 minute checks without the rounding board on the Adult Unit.





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