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A. Based on policy review, clinical record review and staff interview, it was determined that for 1 of 11 clinical records reviewed (Pt. #1), the hospital failed to identify suicidal trigger points verbalized by Pt. #1, failed to ensure a debriefing occurred with Pt #1 and family members after visitation. As a result, it was determined that the Condition of Patient Rights was not in compliance.

An Immediate Jeopardy (IJ) and serious threat to patients' safety and wellbeing was created from the cumulative effects of this systematic practice.

Findings include:

1. An Immediate Jeopardy (IJ) was identified on 12/22/11 at 2:45 PM and the Hospital's Director of Patient Safety was notified at 3:00 PM during a teleconference call. The IJ identified was the Hospital's failure to identify suicidal ideation trigger points verbalized by Pt. #1 during the triage process and failure to ensure debriefing occurred after the two family visits.

2. On 11/29/11 at 6:54 AM, Pt. #1 was admitted to the inpatient psychiatric unit with a diagnosis of Acute Psychosis. Pt. #1 expressed suicidal ideation as documented by the triage nurse. The triage nurse documented, " Pt. states he doesn't think he could kill himself but lately he is not sure. Pt. went to CVS and got a bottle of bleach, states he dropped it on his clothes which they do smell of bleach. Pt. states he bought it to " chug " but couldn't and then it spilled. Pt. also states he has a feeling that people are trying to poison him, by spraying pot and he thinks they do something to the beer when he buys them ... " . Staff failed to identify the need to place Pt. #1 on suicide precautions. Pt. #1 committed suicide on the Behavioral Health Unit and could not be resuscitated. Refer to tag A 144(A).

3 .Pt.#1 clinical record contained documentation that two family visits occurred, however, there was no documentation that a follow up assessment and analysis was conducted with the patient or family to see if the patient was at risk for behavioral changes in order to adequately monitor the patient's condition. Refer to tag A 144(B).

4. The Hospital's "Root Cause Analysis (RCA)/Action Plan" dated 12/01/11 included" Pt.#1 gave no indication of self harm and denied when asked by staff...." The Hospital's Corrective Action Plan did not include activities put in place to address suicidal triggers as verbalized by patients and meeting with patient and family members after visitation for debriefing to assess, analyze and take appropriate actions for monitoring patients.

A. Based on clinical record review, policy review and staff interview, it was determined that for 1 of 11 clinical records reviewed (Pt. #1), the hospital failed to identify suicidal ideation trigger points as stated by Pt. #1 and increased monitoring activities which could potentially place 173 patients on census at risk.

Findings include:

1. On 12/13/11 at approximately 10:00 AM, the clinical record for Pt. #1 was reviewed. Pt. #1, a 23 year old male, presented to the emergency department on 11/29/11 at 1:40AM requesting an evaluation for paranoid feelings and panic attacks. The triage nurse documented vital signs as: BP 154/87, pulse 105, resp 18 and temp 97.8 and documented, "Pt. states he doesn't think he could kill himself but lately he is not sure. Pt. went to CVS and got a bottle of bleach, states he dropped it on his clothes which they do smell of bleach. Pt. states he bought it to "chug " but couldn't and then it spilled. Pt. also states he has a feeling that people are trying to poison him, by spraying pot and he thinks they do something to the beer when he buys them ... ".

2. On 11/29/11 at 6:54 AM, Pt. #1 was admitted to the inpatient psychiatric unit with a diagnosis of Acute Psychosis. Pt. #1 admission orders included close observation, elopement precautions and combative precautions with every fifteen minute safety checks. RN(E#1) documented safety checks for pt. #1 on 12/1/11 at 9:00 PM. At 9:15 PM and 9:30 PM RN (E#2) documented the 15 minute safety checks for Pt. #1. The next safety check which was to be done at 9:45 PM by E#1 was not completed. A nurse's progress note by (E#1) dated, 12/1/11 at 9:45 PM included,"Called pt. on intercom to come to desk for meds. No response from patient. Called patient a second time. No response. Thought patient may be sleeping in his room. Came out from nurse's station and saw RN (E#2) at the end of the hall asked RN (E#2) if patient was in TV room. After looking in TV room, RN (E#2) responded " No". Writer then proceeded down hallway to Pt's room. Patient's door was ajar ...slowly opened bathroom door writer saw Pt. hanging from door. Immediately writer grabbed pt. lowering to floor yelling out his name. Once on the floor writer attempted to remove patient gown that had been placed around patient's neck. Writer was calling for help. All staff arrived a code was called at 9:55 PM ... " CPR was initiated at 9:56 PM on 12/1/11 according to documentation the Code Blue record. The code lasted until 10:24 PM. At 10:24 PM, Pt.#1 was pronounced dead.

3. On 12/19/11 at approximately 9:10 AM, the Psychiatrist (E#13) was interviewed. The psychiatrist stated that he reviewed the entire medical record including the triage and ED physician documentation. E#13 stated that he asked Pt. #1 about the bleach suicide attempt and the Pt. denied purchasing bleach or attempting to drink the bleach. E#13 stated that he did not order suicide precautions because the monitoring is the same as close observation. The distinction between Close Observation and Suicide Precautions according to hospital policy is: "Behaviors observed during Close Observation Rounds include escalation of anxiety, unpredictability, medication toxicity and harm to self or others through aggression. Behaviors evaluated during Suicide Precautions 11 include any behavior suggesting impending harm to self and statements suggesting impending harm to self, hopelessness and helplessness".

4. On 12/19/11 at approximately 10:00 AM, facility policy titled, "Suicidal Precautions Type 1 and Type 11 and Self Mutilating precautions (revision date 5/2011)" were reviewed. The policy included," It is the policy of the behavioral Health Inpatient Unit that special patient monitoring will be instituted to deter patients from harming themselves or others. Indications of suicidal intent or increasing agitation will be evaluated by staff to determine need for special monitoring...Special Precautions 11(SP2) means visual monitoring for safety is conducted on the patient every 15 minutes...Specific documentation of the special monitoring will be done on the "Precautions Monitoring Checklist. Documentation will be done every 15 minutes on the checklist by any BHS staff. Additional detailed documentation by the RN or Therapist may be found in the Shift Assessment Group notes, Patient Care Notes or Continuum Care Notes. A physician, registered nurse or therapist may place a patient on special monitoring..."

5. On 12/19/11 at approximately 11:00 AM, facility policy titled,"Close Observation Precautions" approved 4/06, was reviewed. The policy included, Purpose:To provide intensive supervision and support to patients in need of such, but whose problems are not at the level of severity to warrant suicidal precautions. To provide intensive supervision to patients with severe anxiety, unpredictable behavior, or other conditions requiring close monitoring i.e. fire setting precautions etc. Patients recognized as needing close observation are placed on close observation by attending physician or a staff nurse, on a written order or telephone order...monitor the patient's behavior, and note any changes. Take all necessary measures needed to ensure patient safety...make patient rounds every 15 minutes and document this on the Precaution Monitoring Checklist every 15 minutes unless in group therapy sessions."

6. The above findings were verified with the Director of Safety during an interview on 12/19/11 at 1:00 PM with Administrative staff in attendance.


B. Based on clinical record review, a review of facility's Root Cause Analysis/Action Plan and staff interview, it was determined that for 1 of 11 clinical records reviewed (Pt. #1), the hospital failed to ensure a debriefing of family visit occurred with Pt #1 and family members after visitation to assess and analyses outcome of visitation and put appropriate action in place. This could potentially place 173 patients on census at risk. .

Findings include:

1 On 12/13/11 at approximately 10:00 AM, the clinical record for Pt. #1 was reviewed. Pt. #1, a 23 year old male, presented to the Emergency Department (ED) on 11/29/11 at 1:40AM requesting an evaluation for paranoid feelings and panic attacks. The triage nurse documented a recent history of suicidal ideation. The ED physician also stated during an interview on 12/15/11 that Pt.#1 stated that he left his house due to an argument with his mother after telling her that he was a homosexual. On 11/29/11 at 6:54 AM, Pt. #1 was admitted to the inpatient psychiatric unit with a diagnosis of Acute Psychosis. There were two family visits as documented by the nurse. The first family visit was documented by an RN on 12/1/11 at 1:30 PM. The RN documented, " Dad, mom and sister in for a brief visit after finding out he was in the hospital after a missing person ' s report was made on him " The second family visit occurred on 12/1/11 at 9:39 PM. A nurse documented, " Mom here visiting and supportive. Shift assessment remains unchanged." There was no documentation that a follow up assessment and analysis was conducted with the patient or family to see if the patient was at risk for behavioral changes in order to monitor the patient's condition.

2. The Director of Patient Safety provided a document titled,"Root Cause Analysis (RCA)/Risk Reduction Strategies" dated 12/1/11. The Reduction Strategies failed to identify the need to be proactive by placing Pt. #1 on Suicide Precautions that would allow for increased monitoring based on the triage nurse's documentation of an earlier suicide attempt, and the need to conduct debriefing assessments and evaluations post patient/ family meetings.

3. The above findings were verified with the Director of Patient Safety on 12/22/11 at 3:00 PM during the teleconference.