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Based on observation, interview and record review, it was determined the facility failed to ensure care was provided in a safe environment. The facility failed to ensure one (1) of eleven (11) sampled patients (Patient #1) received care in a safe setting. Patient #1 was admitted to the facility for suicidal ideations and with a known history of self inflicted injuries and suicidal attempts. Facility staff gave Patient #1 a razor and failed to supervise the patient. Patient #1 took the razor to his/her room and cut himself/herself, causing self inflicted wounds to the upper extremities. These failures placed patients at risk for serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist related to Patient Rights.

Refer to A-144

Based on observation, interview and record review, it was determined the facility failed to ensure care was given in a safe environment. The facility failed to ensure one (1) of eleven (11) sampled patients received care in a safe setting (Patient #1). Patient #1, who was admitted for suicidal ideations, received a razor from a staff member, took the razor to his/her room and cut himself/herself.

The findings include:

Interview with the Director of Patient Care Services/Director of Nursing, on 07/13/12 at 2:45 PM, revealed there was no razor policy at the time, but they were currently working on a policy and the first draft deadline was due that day.

Review of the clinical record revealed the facility admitted Patient #1 on 06/25/12 for expressing suicidal ideations. Continued record review revealed Patient #1's diagnoses included Depressive Disorder NOS, Severe Borderline Personality Disorder, Polysubstance Abuse, Posttraumatic Stress Disorder. Review of the Suicide Risk Assessment, dated 06/25/12, revealed the facility assessed Patient #1 as a high risk for suicide. Further review of the Suicide Risk Assessment revealed Patient #1 had two (2) recent psychiatric hospitalizations and upon discharge from both facilities, Patient #1 had attempted self harm.

Review of the Admission History, dated 06/26/12, revealed Patient #1 stated "If I go back out, I'll just hurt myself". Continued review of the medical record revealed this was the 2nd of two recent psychiatric hospitalizations, both due to his/her suicidal ideations along with polysubstance abuse.

Review of the record revealed the initial level of supervision was "safety", which meant the patient must stay on the unit with checks by staff every fifteen (15) minutes. On 06/26/12 at 11:15 AM, Patient #1 was placed on "support" level supervision, which meant the patient could attend Recovery Mall for classes and was to be monitored the rest of the time every thirty (30) minutes.

Interview with the Licensed Clinical Social Worker (LCSW), on 07/10/12 at 1:30 PM, revealed that she had worked with Patient #1 on this admission and during the first admission. The LCSW stated she was providing
Dialectical Behavior Therapy (DBT) with Patient #1 three (3) times a week as ordered. The LCSW stated DBT therapy targeted suicidal ideations and self harm. She stated she thought Patient #1 was making progress. The LCSW stated Patient #1 had been harming self since he was thirteen (13) years old and that Patient #1 would always be at risk for self harm. The LCSW stated if Patient #1 wanted to hurt himself/herself, he/she would always find a way.

Interview with Mental Health Associate (MHA) #1, on 07/10/12 at 9:30 AM, revealed on 07/03/12 he had given Patient #1 the razor blade. MHA #1 stated he was at the nurses' station monitoring a patient on close observation, when Patient #1 came to the nurses' station requesting a razor so that he/she could shave. MHA #1 stated MHA #2 was standing in the doorway of the bathroom waiting for Patient #1 to return to the bathroom with the razor. MHA #1 stated, "We were short staffed", he continued by saying when he gave Patient #1 the razor, he made eye contact with MHA #2 who was standing in the doorway of the bathroom.

Interview with MHA #2, on 07/10/12 at 9:55 AM, revealed on 07/03/12 he was in the bathroom monitoring Patient #3 shave, when Patient #1 came into the bathroom requesting to shave. MHA #2 stated he had no more razors with him, so he stood in the door frame and told MHA #1 to give Patient #1 a razor. MHA #2 stated he did not see Patient #1 receive the razor because one of the patients in the bathroom asked him a question and he turned around to answer the question. MHA #2 stated, Patient #1 came into the bathroom and told MHA #2, that he/she had changed his/her mind and did not feel like shaving. MHA #2 stated he did not see the razor, so Patient #1 left the bathroom with the concealed razor. MHA #2 stated he should have had Patient #1 wait until the evening or watched Patient #1 receive the razor.

Interview with Risk Manager #1, on 07/10/12 at 12:50 PM, revealed the investigation of the incident of Patient #1 and the suicide attempt had not been completed. Review of the video of the incident revealed, at 9:20:43 AM, MHA #1 was standing at the nurses' station, reached out his hand to Patient #1. Patient #1 walked across the hall to the bathroom, then walked to the end of the hall to his/her room. At 9:22:15 AM MHA #3 walked to Patient #1's room and assisted him/her down the hall to the nurses station.

Interview with MHA #3, on 07/12/12 at 9:00 AM, revealed she was sent to Patient #1's room to get Patient #1 for staffing with the team. MHA #3 stated when she opened the door to the patient's room, he/she was standing with the razor blade to his/her arm and blood was on both arms and hands. MHA #3 stated, Patient #1 was then escorted to the nurses station, Patient #1 then dropped the razor and the Nurse Practitioner proceeded to give Patient #1 first aid which required steri-stips. MHA #3 stated staff was not doing anything different since the incident, patients that were high risk could not shave, all other patients must shave with supervision.

Interview with the Wendell Four (4) Nurse Manager, on 07/11/12 at 9:50 AM, revealed she was not on the unit when the incident occurred. She stated the staff thought Patient #1 was stable. The Nurse Manager stated on the second admission to hospital, Patient #1 returned with the same issues, he/she had cut himself/herself and started on the DBT program. The Nurse Manager stated there had been a breakdown in communication between the staff members. She continued by saying a razor was never supposed to leave staff's sight. The Nurse Manager stated she met with her staff on both the 7-3 and 3-11 shifts and sent an e-mail to her staff and that by 2:00 PM the hospital had written a new policy.

Interview with Patient #2, on 07/12/12 at 9:00 AM, revealed he/she was Patient #1's roommate and the he/she had been in the bathroom shaving when Patient #1 came into the bathroom wanting to shave. Patient #2 stated Patient #1 talked to him/her frequently about committing suicide.

Based on observation, interview and record review, it was determined the facility failed to ensure the delivery of nursing services to one (1) of eleven (11) sampled patients (Patient #1). Patient #1 was admitted to the hospital for suicidal ideations and with a known history of self inflicting harm and attempts at suicide. The facility assessed Patient #1 as being a high risk for suicided; however, the facility failed to ensure adaquate supervision for Patient #1. The facility failed to ensure nursing services and supervision were provided when Patient #1 was given a razor by a staff member. Patient #1 took the razor to his/her room unsupervised and cut himself/herself. It was documented in the medical record that it was an attempt to commit suicide. The facility's failure place patients at risk for serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist related to Nursing Services.

Refer to A-395

Based on observation, interview and record review, it was determined the facility failed to ensure supervision and evaluation of the nursing care for one (1) of eleven (11) sampled patients (Patient #1). Patient #1, who was admitted for suicidal ideations and a known history of self inflicted injury and attempts at suicide, received a razor from a staff member, took the razor to his/her room and cut himself/herself.

The findings include:

Interview with the Director of Patient Care Services/Director of Nursing, on 07/13/12 at 2:45 PM, revealed there was no policy for supervision of patients during shaving.

Review of the clinical record revealed the facility admitted Patient #1 on 06/25/12 for expressing suicidal ideations. Continued record review revealed Patient #1's diagnoses included Depressive Disorder NOS, Severe Borderline Personality Disorder, Polysubstance Abuse and Posttraumatic Stress Disorder. Review of the Suicide Risk Assessment, dated 06/25/12, revealed the facility assessed Patient #1 as a high risk for suicide. Further review of the Suicide Risk Assessment revealed Patient #1 had two (2) recent psychiatric hospitalizations and upon discharge from both facilities, Patient #1 had attempted self harm.

Review of the Admission History, dated 06/26/12, revealed Patient #1 stated "If I go back out, I'll just hurt myself". Continued review of the medical record revealed this was the 2nd of two (2) recent psychiatric hospitalizations, both due to his/her suicidal ideations along with polysubstance abuse.

Review of the record revealed the initial level of supervision was "safety", which meant the patient must stay on the unit with checks by staff every fifteen (15) minutes. On 06/26/12 at 11:15 AM, Patient #1 was placed on "support" level supervision, which meant the patient could attend Recovery Mall for classes and was to be monitored the rest of the time every thirty (30) minutes.

Interview with the License Clinical Social Worker (LCSW), on 07/10/12 at 1:30 PM, revealed that she had worked with Patient #1 on this admission and during the first admission. The LCSW stated she was providing
Dialectical Behavior Therapy (DBT) with Patient #1 three (3) times a week as ordered. The LCSW stated DBT therapy targeted suicidal ideations and self harm. She stated she thought Patient #1 was making progress. The LCSW stated Patient #1 had been harming self since he/she was thirteen (13) years old and that Patient #1 would always be at risk for self harm. The LCSW stated if Patient #1 wanted to hurt himself/herself, he/she would always find a way.

Interview with Mental Health Associate (MHA) #1, on 07/10/12 at 9:30 AM, revealed on 07/03/12 he had given Patient #1 the razor blade. MHA #1 stated he was at the nurses' station monitoring a patient on close observation, when Patient #1 came to the nurses' station requesting a razor so that he/she could shave. MHA #1 stated MHA #2 was standing in the doorway of the bathroom waiting for Patient #1 to return to the bathroom with the razor. MHA #1 stated, "We were short staffed", he continued by saying when he gave Patient #1 the razor, he made eye contact with MHA #2 who was standing in the doorway of the bathroom.

Interview with MHA #2, on 07/10/12 at 9:55 AM, revealed on 07/03/12 he was in the bathroom monitoring Patient #3 shave, when Patient #1 came into the bathroom requesting to shave. MHA #2 stated he had no more razors with him, so he stood in the door frame and told MHA #1 to give Patient #1 a razor. MHA #2 stated he did not see Patient #1 receive the razor because one of the patients in the bathroom asked him a question and he turned around to answer the question. MHA #2 stated, Patient #1 came into the bathroom and told MHA #2, that he/she had changed his mind and did not feel like shaving. MHA #2 stated he did not see the razor, so Patient #1 left the bathroom with the concealed razor. MHA #2 stated he should have had Patient #1 wait until the evening or watched Patient #1 receive the razor.

Interview with Risk Manager #1, on 07/10/12 at 12:50 PM, revealed the investigation of the incident of Patient #1 and the suicide attempt had not been completed. Review of the video of the incident revealed, at 9:20:43 AM, MHA #1 was standing at the nurses' station, reached out his hand to Patient #1. Patient #1 walked across the hall to the bathroom, then walked to the end of the hall to his/her room. At 9:22:15 AM MHA #3 walked to Patient #1's room and assisted him/her down the hall to the nurses station.

Interview with MHA #3 on 07/12/12 at 9:00 AM, revealed she was sent to Patient #1's room to get Patient #1 for staffing with the team. MHA #3 stated when she opened the door to the patient's room, he/she was standing with the razor blade to his/her arm with blood on both arms and hands. MHA #3 stated, Patient #1 was then escorted to the nurses station, Patient #1 then dropped the razor and the Nurse Practitioner proceeded to give Patient #1 first aid which required steri-strips. MHA #3 continued by stating she went to Patient #1's room to do a room search and found a plastic knife and additional "contraband". MHA #3 stated staff was not doing anything different since the incident, patients that were high risk could not shave, all other patients must shave with supervision.

Interview on License Practical Nurse (LPN) #1, on 07/13/12 at 10:10 AM, revealed she assisted in supervising the MHA's. She stated she expected everyone to do their job role. LPN #1 also stated that everyone did the every fifteen and thirty minute checks, not just the MHAs.

Interview with the Charge Nurse, on 07/13/12 at 10:10 AM, revealed he was Charge Nurse on 07/13/12, but not the day of the incident related to Patient #1. The Charge Nurse stated after the incident, he went to Patient #1's room to do a room search. He stated he found a plastic knife, a can of tobacco, sugar packets and pieces of broken plastic. He stated as Charge Nurse, he made the assignment, made the MHA's aware of their assignment, checked the surveillance sheets to ensure the surveillance was being done. The Charge Nurse stated the all staff were adults and he let them do their thing, but ensured vital signs and labs were done and patients were safe and secure.

Interview with the Wendell Three (3) Nurse Manager, on 07/13/12 at 11:20 AM, revealed the Charge Nurses had a two (2) weeks of orientation where they learned their responsibility for monitoring the patients. When they got to the unit, they had preceptors. After time with the preceptor, they were given a test that went over all the information the preceptor had went over with them.

Interview, on 07/11/12 at 9:50 AM, with the Wendell Four (4) Nurse Manager revealed she met with the 7-3 and 3-11 shift staff and sent an e-mail to her staff about supervision during shaving. However, continued interview revealed she had no way of knowing if the staff she had e-mailed had received and read the e-mail related to supervision of patients while shaving.

Review of an e-mail sent by the Hospital Educator, to all hospital staff on 07/03/12, revealed staff were informed of the supervision required during shaving and proper handling of razors. However, there was no documented evidence that staff had received or read the e-mail. In addition the instructions in the e-mail were to be placed in the communication binders on each unit; however, review of the binders on Wendell One, Three, and Four, on 07/13/12, revealed no evidence of the e-mailed safety instructions being place in the binders.

Interview with the Director of Nursing, on 07/13/12 at 2:45 PM, revealed the Risk Managers had not yet completed the investigation of the icident. She stated when the investigation was completed they would then determine if education or what education should be provided to staff, then a facility wide education session would be conducted. She continued to say the facility would monitor that education at that time to ensure all staff had received it.