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Based on document review and interview, it was determined for 1 of 1 (Pt. #1) patient admitted with suicidal ideation (wanting to kill self), the Hospital failed to place the patient on suicidal precautions or obtain the order for precautions, thus putting all potential patients with suicidal ideation at a serious safety threat for self harm. Refer to deficiencies at A-144. As a result, it was determined that the Condition of Participation for Patient Rights 482.13 was not in compliance.

1. The Hospital failed to appropriately monitor the patient with suicidal ideation to prevent the patient's attempted hanging. See deficiency at A-144.

2. The Hospital failed to ensure an order was written for suicidal precautions (1:1 observation - staff with arms reach of the patient). See deficiency at A-144.

The immediate jeopardy (IJ) began on 3/10/17 when the patient presented to the emergency room with complaints of suicidal ideation with a plan to hang self, followed by not by placing Pt. #1 on suicidal precautions after repeating the suicidal ideation to the staff on 3/11/17 and proceeding with a suicidal gesture (tried to hang self with bed sheet) on 3/11/17.

An IJ was announced on 3/22/17 at 9:30 AM, during a meeting, to the Vice President of Patient Care and the Vice President of Quality and Compliance. The immediate jeopardy was not removed by the survey exit date of 3/22/17.

A. Based on document review and interview, it was determined for 1 of 1 (Pt. #1) patient admitted with suicidal ideation (wanting to kill self), the Hospital failed to appropriately monitor the patient to prevent the patient's attempted hanging.

Findings include:

1. The Hospital policy titled, "Precaution (revised April 2015)" was reviewed on 3/20/17. The policy included, "Patients who have been assessed and evaluated who are determined to be at a high risk to harm themselves, who score 8 or greater on the suicide risk assessment scale, will be placed on suicide precautions 1:1 observation".

2. The clinical record of Pt. #1 was reviewed on 3/20/17. Pt. #1 was a 35 year old male admitted on 3/10/17 with the diagnosis of schizoaffective disorder. The psychiatric evaluation by MD #1, dated 3/10/17 [untimed] included, "Chief Complaint: Depression, suicidal ideation. Danger to self and others. ...He has suicidal thoughts and tried to think about hanging himself ..."

The clinical record included a physician's order dated 3/10/17 at 3:41 AM for Close Observation (every 15 minutes safety checks). Upon admission, the SAD Person Scale (assessing the risk for suicide), for Pt. #1 was scored as a 5 (requiring close observation).

The Rounding and Precaution form included that Pt. #1 was observed on routine rounds (every 15 minutes) in his room and awake at 1:45 PM on 3/11/17.

The internal incident report included that Pt. #1 was found on 3/11/17 at 1:45 PM with a torn sheet around his neck and the other end attached to the window.

3. The treating psychiatrist (MD#1) was interviewed on 3/21/17 at 8:45 AM. MD#1 stated that Pt. #1 did tell him that if he was discharged, he would kill himself or if anyone made him unhappy, he would try to kill himself. MD#1 stated, "This was not a true suicide attempt. I believe the patient has a diagnosis of borderline personality with Para suicidal symptoms. This makes a suicide attempt unpredictable, but not unpreventable. We treat the symptoms as they arise".

4. The Vice President of Patient Care (E#4) was interviewed on 3/21/17 at 1:30 PM. E#4 stated, "The SAD form was not utilized correctly. The staff was answering the questions subjectively and not objectively. When I completed the form, the patient would have been on 1:1 observation based on the suicide score". E#4 stated, "I was unable to find an order in this record for 1:1 observation."


B. Based on document review and interview, it was determined for 1 of 1 (Pt. #1) patient who made a suicidal gesture, the Hospital failed to ensure an order was written for suicidal precautions (1:1 observation).

Findings include:

1. The Hospital policy titled, "Precaution (revised April 2015)" was reviewed on 3/20/17. The policy included, "Orders for Precautions are written by the physician based on clinical needs of each individual patient at a specific time in treatment."

2. The clinical record of Pt. #1 was reviewed on 3/20/17. Pt. #1 was a 35 year old male admitted on 3/10/17 with the diagnosis of schizoaffective disorder. The psychiatrist's (MD#1) progress note dated 3/11/17 at 9:57 PM included, "He asked me to explain his lab results to him, I suggested him to wait for medical physician to explain to him, he became angry. Then he reports suicidal ideation and tried to hang himself with bed sheet in the unit ...From my evaluation, the patient is very manipulative, but for his safety, we have placed him on 1:1 suicidal precaution ..."

Although, the Rounding and Precaution form dated 3/11/17 included that 1:1 observation (staff within arms reach of the patient) was initiated at 2:00 PM, after Pt. #1 attempted to hang himself, the clinical record lacked documentation of a physician's order for the 1:1 observation.

3. The Vice President of Patient Care (E#4) was interviewed on 3/21/17 at 1:30 PM. E#4 stated, "I was unable to find an order in this record for 1:1 observation."

Based on document review and interview, it was determined that in 2 of 2 (Pt. #2 and #3) clinical records reviewed with restraint usage, the Hospital failed to ensure patient's care plans were amended to include the usage of restraints.

Findings include:

1. The clinical record of Pt. #2 was reviewed on 3/21/17 at approximately 2:00 PM. Pt. #2 was a 47 year old male admitted on 3/4/17 with a diagnosis of schizoaffective disorder (mental disorder in which a person experiences symptoms such as hallucination or delusion). Pt. #2's clinical record indicated that Pt. #2 was in restraints on 3/4/17 from 9:30 AM to 11:30 AM. However, Pt. #2's care plan failed to include restraints were used.

2. The clinical record of Pt. #3 was reviewed on 3/21/17 at approximately 2:00 PM. Pt. #3 was a 18 year old male admitted on 12/29/16 with a diagnosis of schizoaffective disorder. Pt. #3's clinical record indicated that Pt. #3 was in restraints from 11:15 AM to 1:15 PM on 1/2/17. However, Pt. #3's care plan failed to include wrist restraints were used.

3. The Hospital policy titled "Clinical Care Station Multi-Disciplinary Care Plan" (revision date 11/11) was reviewed on 3/22/17 and required, "Procedures:... B. The... problems requiring obvious nursing intervention or patient/family education are to be included in the patient's care plan... E... The patient's care plan must be reviewed... or updated as indicated by patient's status..."

4. On 3/22/17 at approximately 9:15 AM, the findings were discussed with the Vice President of Patient Care (E #4). E #4 stated that use of restraints with Pt. #2 and Pt. #3 restraints was not included in the care plan.

Based on document review and interview, it was determined for 1 of 2 (Pt. #2) patient records reviewed regarding use of restraint, the Hospital failed to ensure the time frame for the restraint order was specified.

Findings include:

1. The clinical record of Pt. #2 was reviewed on 3/21/17 at approximately 2:00 PM. Pt. #2 was a 47 year old male admitted on 3/4/17 with a diagnosis of schizoaffective disorder. Pt. #2's clinical record included an order for wrist restraint on 3/4/17. However, the time frame for restraint was not included in the physician's order sheet.

2. The Hospital policy titled "Restraint/Seclusion Policy" (revision date 4/14) was reviewed on 3/21/17 and required, "... 8. The restraint order must specify... The length of time that restraints are authorized..."

3. On 3/22/17 at approximately 9:15 AM, finding was discussed with the Vice President of Patient Care (E #4). E #4 stated that Pt. #2's restraint order did not specify the time frame.