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Based on interview and document review, the hospital failed to develop a system to ensure therapeutic observations were performed for 1 of 11 patients, (P1), reviewed when P1 who was on frequent observations, was not observed at the 15 minute frequent observation interval and P1 was found with a string wrapped around her neck. Staff who found the patient did not have a way to summon emergency help and left the patient alone to get help. This resulted in an Immediate Jeopardy situation for three patients who are currently on frequent observations as well as the additional 15 patients who require hourly observations.

Findings include:

The hospital did not meet the Condition of Participation of Patient Rights at 42 CFR 482.13. This deficient practice had to potential to impact all patients on unit who require observations.

The hospital was notified of the immediate jeopardy on October 5, 2017 at 12:50 p.m. The immediate Jeopardy began on September 27, 2017 when the hospital failed to ensure interventions were in place to prevent a re-occurrence of the staff failure to provide the required frequent observations and failed to ensure all staff had a way to summon help in an emergency.

The hospital failed to provide care in a safe setting when staff failed to develop a system to ensure frequent observations are performed and are delineated from other tasks on the unit, and ensure all staff are provided with a means to summon help in an emergency situation.

A patient who was on frequent observations was not observed at the 15 minute frequent observation interval because the staff assigned to frequent observations assumed the responsibility of serving a meal and forgot to perform the observations as required. The patient was found with string wrapped around her neck. Staff who found the patient did not have a way to summon emergency help and left the patient alone to get help. This failure has the potential to affect the three patients who are currently on frequent observations as well as the additional 15 patients who require hourly observations (refer to A144.)

The immediate jeopardy that began on September 27, 2017, was removed and the administrative staff were notified on October 6, 2017 at 6:45 p.m. after verification of the removal plan through observation, interview, and document review. The facility educated all direct care staff on their policy and procedure for therapeutic observations that included the responsibilities for frequent observations (15-minute safety checks), distant 1:1's, and close 1:1's. All staff interviewed identified the standards set forth by the policy. The staff assignment sheets were updated to reflect staff who were on frequent observations, distant or close 1:1, and hourly observation had no other assigned tasks during these shift assignments. Staff were able to identify the changes in the staff assignments. The assignment sheets were completed prior to the oncoming shift, reviewed during report by the oncoming team of staff for any necessary changes, and the registered nurse in charge reviews the assignments for final approval to ensure there is no overlap in assigned tasks, and all task are assigned. Observations before, during, and after the dinner meal on the unit showed the staff who were providing therapeutic observations and hourly observations performed no other tasks on the unit other than providing therapeutic observations. During observations and staff interviews, all staff were observed to have a personal building safety/emergency call button on them and verbalized the purpose of its use. The facility created a tracking document for staff to sign out and back in the alarm pendants at each change of shift, and the charge nurse ensured each staff before working on the unit had a personal alarm pendant. Staff were educated on the use of alarm tracking sheets along with abuse prevention plans that outlines the use of the personal alarms to ensure patients receive care in a safe setting. Charge nurse interviews demonstrated they were trained on the on their role and responsibilities on the unit, and identified the changes to completing staff assignments and managing the personal alarm to ensure patients receive care in a safe setting.

Based on interview and document review the hospital failed to ensure patients received care in a safe setting to reduce the risk of patient self-harm for 1 of 11 patients, (P1), reviewed who was found with string wrapped around her neck when frequent observations were not performed. Staff who found the patient did not have a way to summon emergency help and left the patient alone to get help.

Findings include:

P1's medical record review was reviewed.

P1's admission social work assessment, dated September 7, 2017 indicated P1 was had a court commitment for mental illness.

P1's psychiatric assessment, dated September 6, 2017 indicated P1's diagnoses included major depression and P1 had current suicidal thoughts, but no suicide plan.

P1's therapeutic observation record, dated September 27, 2017 indicated P1's plan of care included frequent observations (at least every 15 minutes or less), initiated on September 25, 2017.

During an interview on October 4, 2017 at 12:30 p.m., mental health program assistant (MHPA)-F stated that on September 27, 2017 he was responsible for doing the frequent observations for patients on the frequent observation level of supervision, including P1. He completed the observations timely including the 4:40 p.m. observations. After the 4:40 p.m. observations, patients started asking for their dinner. Several patients were waiting for dinner in the common area near the kitchen. MHPA-F stated no one in particular was responsible for getting the meal and no one else was available at the time and he felt pressure to get the meal, so he stared getting dinner ready. During the meal preparations, he forgot about doing the next set of rounds that should have been completed by 4:55 p.m. at the latest. Sometime after 5:00 p.m., he heard MHPA-G shout and run into the hall and press another staff person's personal building safety (PBS)/emergency call button. Several staff members were running to P1's room. When he arrived at P1's room he saw that P1's face was bulging, she had something tied around her neck and her face was purple/blue in color. He ran to get a pair of scissors to cut off what P1 had tied around her neck. When he got back the staff in the room was cutting off what was tied around P1's neck, and he left the room.

During an interview on October 4, 2017 at 3:10 p.m., MHPA-G stated she signed up to perform the rounds and frequent observations starting at 5:00 p.m. on September 27, 2017. When she started looking at the documentation from the previous shift at about 5:00 p.m., she saw that the frequent observations scheduled to be completed by 4:55 p.m. was not documented as completed. She decided to start her frequent observations early. At some time after 5:00 p.m., she opened the door to P1's room to perform her observation check. The room was dark, P1's face was discolored, and she had something tied around her neck. P1 stated, "It's not working." MHPA-G understood that to mean that whatever was tied around her neck was not completely cutting off her breathing. MHPA-G stated although staff are all supposed to have a PBS alarm to summon help in an emergency when on the unit with patients, she did not have one because there were none available when she started her shift. MHPA-G stated she had to leave P1 alone in her room with strings from a blanket tied around her neck in order to get help. MHPA-G stated she ran into the hall and grabbed Registered Nurse (RN)-H and pushed the button on his PBS alarm, then ran to get scissors at the nursing station. MHPA-G stated that frequently she is responsible for frequent observations as well as getting meals ready because the nurses rarely assist with either task. MHPA-G stated there are not always enough PBS alarms for all staff to have one when they are on the floor with patients. This occurs approximately two shifts per week.

During an interview on October 4, 2017 at 3:30 p.m., RN-H stated he was working on September 27, 2017. At some time after 5:00 p.m., MHPA-G ran up to him, pulled on his PBS alarm, and sounded the alarm. He ran into P1's room and found P1 in her bed sitting up. Her face was purple and she had strings from a blanket tied around her neck. P1 stated, "It's not working." RN-H stated he understood this to mean she was attempting to kill herself and it was not working. Several staff arrived into the room trying to remove the string from P1's neck. RN-H stated no staff is assigned to meal preparation responsibilities and he assumed the MHPA staff or Health Services Technician (HST) staff usually performs that task.

During an interview on October 4, 2017 at 3:00 p.m., Supervisory RN-E stated no staff member is assigned to the task of getting meals for patients. The expectation is that if you are available, you help get dinner ready. There is no policy related to who is responsible for getting the meal ready, and about half of the time the staff member responsible for frequent observations is the same staff member who readies the meals for the patients. RN-E stated staff sent P1 to the local emergency room later in the evening on September 27, 2017, due to complaints of shortness of breath, and she returned to the hospital after being assessed with no permanent injury related to the incident.

During an interview on October 5, 2017 at 12:00 p.m. Administrative RN-D stated the hospital had identified a problem with running out of PBS alarms around 8/16/2017. Hospital staff initiated a system to count alarms and sign them out as well as a system to notify staff if they signed one out that cannot be found in the hospital. On October 1, 2017, staff identified that there were 18 alarms potentially available for staff use. On September 21, 2017, charge staffs were notified that they were responsible to ensure each staff member on the unit had a PBS alarm. RN-D confirmed that although all staff members who are on the unit are required to have a PBS alarm, on September 27, 2017 not all staff on the unit had a PBS alarm.

The policy titled Program Abuse Prevention Plan dated April 6, 2017 indicated all direct care staff to wear a personal building safety device and identified assessment/factors that might contribute to abuse/neglect, physical/verbal aggression toward others and/or property.

The policy titled Therapeutic Observations, dated January 27, 2017 indicated under all staff will provide for the safety of clients whose clinical presentation requires additional supervision, observation, and/or restricted access to potential items. The level of observation, supervision or restriction identified will be the least restrictive or intrusive necessary. Frequent observations was defined as staff observing the client at least every 15 minutes.