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Based on interview, record review, and review of facility policies, staff failed to supervise patient #1 and failed to follow facility policy for prohibiting dangerous articles being left with the patient. As a result, patient #1 was left unsupervised on August 22, 2010, and sustained superficial lacerations as a result of self-injurious behavior when the patient was left alone with two (2) razors. Nurse aide #1 left the patient because there was a smell of smoke in the air and the nurse aide was allergic to the smoke. In addition there was no evidence that staff investigated the smell of smoke which the nurse aide reported.

The findings include:

Review of the facility's policy titled Checking patients for Dangerous Articles revealed the facility had guidelines that prohibited dangerous articles on the grounds of the Psychiatric Center. According to the policy, patients were searched upon arrival to the psychiatric unit and the patient's clothing was laundered to ensure no dangerous objects were in the patient's possession.

Review of the facility's policy titled Supervision of Patients revealed the facility had a policy in place for adequate patient monitoring consistent with patient safety. Patients placed on higher levels of supervision had increased behaviors that included but was not limited to the following: suicidal thoughts, threats, gestures, plan or attempt, assaultive or aggressive behavior, elopement risk or medical conditions such as unsteady gait. (It should be noted patient #1 had suicide gestures prior to admission. Patient #1 was on suicide precautions at the time the patient was left alone with two razors).

The Facility Investigator stated in interview on October 27, 2010, that it was clearly evident patient #1 had sustained superficial lacerations as a result of self-injurious behavior when patient #1 was left unattended while shaving. According to the Facility Investigator, nurse aide #1 was allergic to smoke and had to leave the area due to smoke in the area where patient #1 was shaving. The Facility Investigator stated nurse aide #1 received disciplinary action regarding the incident. However, there was no evidence that an investigation had been conducted regarding the smoke in the air which caused nurse aide #1 to leave patient #1 unattended.

An interview was conducted at the facility on October 26, 2010, at 2:00 p.m., with nurse aide #1, who left patient #1 unattended on August 22, 2010. Nurse aide #1 stated patient #1 requested a razor to shave on August 22, 2010, at approximately 2:00 p.m. The nurse aide accompanied patient #1 to the patient's room and stood outside the door to observe the patient shave. The nurse aide stated there was a smell of smoke in the air and due to the nurse aide's allergy to smoke the nurse aide had respiratory difficulty. The nurse aide walked to the nursing station "to catch a breath of fresh air" and did not notify other staff that patient #1 had been left unattended with the razors. Nurse aide #1 stated another patient came to the nursing station and told staff that patient #1 had cut his/her wrist with a razor. Nurse aide #1 went to patient #1's room and observed that patient #1 had self-inflicted razor blade wounds to the left wrist. Nurse aide #1 stated, "I shouldn't have left the patient." Nurse aide #1 did not recall if anyone investigated the smoke smell but added patients frequently sneak in cigarettes and lighters.

An interview was conducted at the facility on October 26, 2010, at 2:15 p.m., with nurse aide #2, who was working at the time of the incident and provided one-to-one supervision for patient #1 after the incident occurred. According to nurse aide #2 patients were never left alone with razor blades while shaving. Nurse aide #2 stated, "These patients are unpredictable."

Medical record review revealed patient #1 was admitted to the above facility on July 27, 2010. Patient #1 was admitted on an involuntary basis and the patient had become depressed with suicidal ideation. Patient #1 was in jail prior to the hospital admission and had self-injurious behaviors (cut wrist) at the jail prior to admission. Patient #1 had a medical history of seizures when coming off drugs, substance-induced mood disorder, chronic neck and back pain, legal issues, addiction, and grief/loss. Patient #1 was placed on suicide/assault precautions with 15-minute safety checks at the time of the admission to the facility. Review of the Multidisciplinary Progress Note dated August 22, 2010, at 2:00 p.m., revealed a peer came to the nursing desk and told staff that patient #1 had cut his/her wrist. Staff evaluated patient #1's injury and found several superficial lacerations to the left wrist.

An interview was conducted at the facility on October 26, 2010, at 5:00 p.m., with the House Supervisor, who was working at the time of the incident. The House Supervisor stated a call was received from the Mountain Unit on August 22, 2010, that patient #1 had cut his/her wrist with a razor. The House Supervisor did not recall who reported the incident but recalled being told that nurse aide #1 smelled smoke in the air and was allergic to smoke so the nurse aide left the patient unsupervised. The House Supervisor did not go to the Mountain Unit to assess patient #1 and there was no evidence that the smell of smoke was ever investigated.