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Based on record review, observation and interview, the hospital failed to provide care in a safe setting for 1 patient (Patient #10) of 3 records reviewed (Patients #10, 11, and 12) for patients reportedly placed on suicide precautions on admission to the geriatric psych unit in the previous 6 months.

This failed practice compromised patient safety by allowing 1 patient with active suicidal ideations to have access to multiple ligature and safety hazards, potentially causing self-inflicted injury.

Findings:

A policy titled "Environmental Management" stated the admitting nurse would assess the benefits and risks of leaving potentially hazardous equipment in patient rooms, including call lights and oxygen tubing (representing strangulation hazards).

A policy titled "Patient Safety" stated the RN or Charge Nurse would determine risk of injury posed by hospital equipment, and the equipment would be removed from the room if determined to be hazardous; the alternative would be to reassign the patient to a different room without the hazardous equipment.

A policy titled "Suicidal Patients" stated all patients received a suicide risk assessment upon admission. Patients found to be at "Stable" or "Low Risk" for suicide required no increase in monitoring (standard level of monitoring required observations every 15 minutes).

A form titled "Suicide Lethality Scale" included the following items to be considered to make a determination of the level of risk:

1. Current suicidal ideation;
2. Suicide attempt greater than 72 hours prior to admission;
3. Behavior that is "only occasionally" impulsive;
4. Helplessness;
5. Feelings periodically distressing; and
6. Inconsistent reality perception.

Patient #11

A review of clinical records showed no documentation the patient had active suicidal ideations or that suicide precautions were followed, despite being included in the list given to the surveyor. Documentation showed Patient #11 was deemed to be low risk for suicide.

Patient #12

A review of clinical records showed staff maintained an arm's length distance from the patient to promote safety.

Patient #10

A review of the clinical record showed the following documentation:

1. A form titled "Patient Care Report" dated 08/07/17 at 4:50 pm listed the patient's precautions as suicide, elopement/AWOL, and falls.
2. A form titled "Mental Health Initial Psychiatric Evaluation" dated 08/08/17 stated the patient verbalized suicidal ideations with a plan, and had attempted suicide in the past. The section labeled "Justification for Admission" stated "Worsening agitation and psychosis with suicidal ideation."
3. Daily forms titled "24-Hour Observation Sheet" indicated the patient was monitored every 15 minutes. The types of monitoring documented were "behavioral" and "falls"; suicide precautions were not documented.

The patient was admitted to the Senior Focus unit from 08/07/17 to 08/11/17 in room 107-B. During a tour of the "Senior Focus" Unit (the unit provides geriatric psych services) on 09/19/17 at 2:00 pm, environmental hazards were observed, including:

1. Patient rooms 105 and 106 contained 2 standard hospital beds with open rails, wheels, and long electrical cords; and
2. Sinks and toilets in patient bathrooms were not of ligature-resistant design.

On 09/19/17 at 2:10 pm, Staff A stated the 7 patient rooms in the unit contained the same equipment observed in rooms 105 and 106 (the option to reassign the patient to a different room for safety was not available as all rooms contained the same hazards).

On 09/19/17 at 4:00 pm, Staff D stated the unit utilized different levels of suicide precautions and the "Suicide Lethality Scale" would be used as a guideline; the Charge Nurse would usually make the decision of the appropriate level. There were no current patients with suicide precautions at the time of the survey.

On 09/19/17 at 4:10 pm, Staff D stated belts, shoelaces, neckties and necklaces (representing strangulation hazards) were considered contraband and were not permitted in the unit; and also gave the example of electrical cords used to plug computers in were considered hazardous. Electrical cords on hospital beds were not considered hazardous.

On 09/19/17 at 4:15 pm, Staff D stated 1:1 patient monitoring for suicide precautions was used infrequently, 1 time a month on average; typically, patients with suicide precautions were monitored (observed) every 15 minutes and had no additional monitoring compared to the rest of the patient population.

Based on record review and interview, the hospital failed to ensure nursing staff developed and updated individualized care plans to address active patient problems for 2 (Patients #9 and 12) of 15 patient records reviewed.

This failed practice had the potential to result in worsening of documented problems (Patient #9's refusal to take medications due to confusion and Patient #12's controlled substance dependence) due to the lack of interventions to treat conditions effectively.

Findings:

A policy titled "Care Plan" stated an RN must develop and keep current a nursing care plan based on the individual patient's current problems, and the plan should be updated and/or revised according to the patient's current status.

A policy titled "Treatment Planning" stated each patient would have an interdisciplinary care plan (MTP), and the plan would be updated/revised according to changes in the patient's condition, and reviewed at least every 7 days. Changes would be reflected in resolution or addition of treatment goals and objectives.

Patient #9

The patient was admitted to the geriatric psych unit from 09/30/17 to 10/23/17.

A review of the clinical record showed the patient's MTP included interventions and goals initiated 09/30/17 for 2 diagnoses:
1. Alzheimer's disease and major neurocognitive disease with behavioral disturbances; and
2. Delirium secondary to urinary tract infection, possible.

The treatment plan for delirium included the short-term goal "...will be compliant with medication regimen by taking medications prescribed daily." There was no documentation of nursing interventions to be utilized to promote medication compliance.

A review of the clinical record including physician orders, treatment plans, nursing notes, and care plan reports showed the following documentation:

1. The patient refused to take routine oral medications on the following dates: 10/04/17, 10/05/17, 10/06/17, 10/11/17, 10/12/17, 10/13/17, 10/16/17, 10/20/17, and 10/21/17.
2. On 10/11/17 (11 days after admission), the physician ordered Haldol (an antipsychotic) 5mg PO BID, with the instruction to give the medication in an IM injection if the patient refused to take it by mouth.
3. On 10/11/17 at 10:45 am, the patient refused to take the medication by mouth and nursing staff gave the medication in an injection.
4. On 10/11/17 at 7:28 pm, the patient refused to take the medication by mouth and nursing staff gave the medication in an injection.


Documentation showed no updates or revisions to interventions and goals to the nursing care plan or the MTP regarding the worsening noncompliance with PO medications and the addition of IM injections.

Patient #12

The patient was admitted to the geriatric psych unit from 08/05/17 to 08/21/17.

A review of the clinical record including physician orders, history and physical, nursing notes, and psychological assessment showed documentation of narcotic pain medication and benzodiazepine use of greater than 20 years' duration; the amount of the benzodiazepine used was documented to be more than a typical dose for the patient's condition. The patient verbalized suicidal ideations reportedly after he/she was unable to obtain pain medications from a new physician.

The patient's MTP included interventions and goals initiated 08/07/17 for 1 diagnosis, Major depressive disorder. No treatments, interventions, objectives, or goals related to dependence on narcotic pain medication or benzodiazepines was included.

On 11/07/17 at 12:00 pm, Staff D stated he/she usually included anxiety, coping, and falls as active problems in patients' care plans, and specific problems such as substance abuse were not addressed because the interventions included for anxiety and coping were sufficient.

On 11/07/17 at 12:30 pm, Staff G stated care plans contained "3 or 4 core problems" related to admission, and an option existed to create a custom care plan in the EMR for a specific problem such as substance abuse, and this was not done.

Based on record review and interview, the hospital failed to ensure staff documented all pertinent patient information for 1 (Patient #10) of 3 clinical records (Patients #10, 11, and 12) reviewed for patients reportedly on suicide precautions within the last 6 months.

This failed practice had the potential to result in delayed recognition and treatment of potential self-harm behaviors of Patient #10 due to observations of the patient's behavior being unavailable to the treatment team for care decisions.

Findings:

The surveyor requested a list of all patients placed on suicide precautions within the last 6 months. Staff A gave the surveyor a handwritten list with the names of Patients #10, 11, and 12, and stated the electronic system did not have the functionality to compile a report; the list was compiled from a review of individual records.

Patient #10

The patient was admitted to the Senior Focus unit from 08/07/17 to 08/11/17. A form titled "Patient Care Report" dated 08/07/17 at 4:50 pm listed the patient's precautions as suicide, elopement/AWOL, and falls.

A review of the clinical record showed documentation the patient had active suicidal ideations. Refer to A0144.

A review of the clinical record including physician orders, nurses' notes, 15-minute rounding sheets, and treatment plans showed no documentation the patient was placed on suicide precautions. There was no documentation staff maintained an arm's length distance from the patient, or maintained a constant line of sight of the patient; 15-minute rounding sheets showed the patient was observed every 15 minutes, which is standard practice for all patients in the geriatric psych unit.

On 11/07/17 at 12:30 pm, Staff G stated a patient on suicide precautions should have 1:1 monitoring, and this would be documented on the 15-minute rounding sheets. He/she stated there should also be a suicide assessment form completed every shift.