The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TWIN RIVERS REGIONAL MEDICAL CENTER 1301 FIRST ST KENNETT, MO 63857 July 18, 2013
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, record review and policy review, the facility failed to:
- Identify, reassess and implement individualized interventions to prevent suicide attempt (actions taken to self-harm) for one patient (#14) of two patients reviewed that were suicidal on the Adult Psychiatric unit (APU-utilized to treat patients aged 18-55), and failed to implement interventions to prevent a potential injury to the roommate of one discharged patient (#26) of one reviewed on the APU. (Refer to A 0395).
- Follow physician's orders for suicide precautions for one patient (#14) of two patients reviewed that were suicidal on the APU. (Refer to A 0395).
- Provide required suicide precautions; every 15-minute patient observation with documentation, for one patient (#14) of two patients reviewed that were suicidal on the APU. (Refer to A 0395).
- Ensure the APU patients were searched and contraband (cosmetics, drugs, cigarettes, shoestrings, lighters, belts, sharp objects, etc.) confiscated for one patient (#14) of two patients reviewed that were suicidal on the APU. (Refer to A 0395).
- Provide one-on-one supervision (within an arms length) after a suicide attempt, even though recommended, for one patient (#14) of two patients reviewed that were suicidal on the APU. (Refer to A 0395).
- Ensure the APU environment was free of looping/ligature, stabbing and cutting hazards, and/or provide the required staff oversight for one patient (#14) of two current patients and one patient (#26) of one discharged patients reviewed that were suicidal and/or homicidal (thoughts of harm to others) on the APU. (Refer to A 0395).
- Provide the required nurse supervision to prevent one patient (#17) of one patient from threatening and combative behavior, and an elopement (leaving the facility without prior notification/permission) from the Geriatric Psychiatric Unit (older adult) (GPU). (Refer to A 0392).

These failures had the potential to affect all patients admitted to the psychiatric in-patient units.

The capacity of the three psychiatric units were as follows:
- The APU = 12;
- The GPU = 10; and
- The adolescent unit = seven.

The three psychiatric units' total census was 21. Ten patients on the APU, seven on the GPU, and four on the adolescent. The total facility census was 47.

The cumulative effect of these deficient practices had the potential to place all patients, in the three psychiatric units at risk for their health and safety (also know as Immediate Jeopardy-IJ).

The facility staff implemented actions to abate the IJ, and provided an acceptable plan of correction to minimize any further immediate risks by the end of the survey.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on interview and record review the facility failed to provide the required nurse supervision to prevent one patient (#17) of one patient from developing threatening and combative behavior and eloping from the Geriatric Psychiatric Unit (GPU). This failure had the potential to affect all patients on GPU. The unit census was seven.

Findings included:

1. Review of the facility's policy titled, "Staffing Plan for Nursing," dated 05/11, showed the policy:
- Served to direct the staffing plan for the facility.
- Considered the number, skill mix, and qualifications of direct care nursing staff needed for each unit;
- Monitored and evaluated staffing effectiveness on a continued basis and revised the plan annually and as necessary.

2. Review of the facility's staffing plan for the GPU showed a census of seven patients on the day shifts (7:00 AM to 7:00 PM) required two nurses (Registered Nurses[RNs] / Licensed Practical Nurses [LPN's]) and one certified nurse's aide (referred to as Mental Health Technicians [MHTs])

3. Record review of Patient #17's medical record showed:
- The patient was admitted to the GPU with a diagnoses of major depression (a long period of feeling worried or empty with a loss of interest in activities once enjoyed) and dementia (a loss of cognitive/thinking abilities and an impairment of memory).
- On 07/14/13 the patient demanded to leave the facility, threatened to assault the nurse on duty with a chair. He stated "you can't keep me here".
- The patient eloped from the locked unit.
- The patient went to the neighboring rehabilitation unit, attempted to get on the elevator, was met by several staff who responded to a page for Code Strong (an auditory page requesting assistance for a behavioral disturbance), and escorted him back to the unit.

4. During an interview on 07/17/13 at 9:20 AM, Staff S, RN, stated that on 07/14/13:
- Patient #17 became upset following a visit with his family.
- The patient came down the hallway; demanded to leave the facility; picked up a chair and threatened to harm her with it.
- While she was getting medication for patient, he eloped from the unit, and was escorted back to the unit by facility staff.
- The unit census was seven.
- Staffing for the shift was one RN and one MHT; short one RN/LPN.
- She, the only RN, was in the staff break room, a room adjacent to the main entrance of the GPU, and had the door propped open with a chair.
- The MHT was on the unit supervising the patients.
- Staff S was the only nurse on the unit and was not supervising patient care prior to the patient's elopement.

5. During an interview on 07/18/13 at 9:45 AM, Staff E, RN, Nurse Manager stated that:
- She was the Nurse Manager for all three psychiatric units.
- She was notified on 07/14/13 that the GPU, per the staffing plan, was short one nurse for the seven patients on the unit.
- She could not provide coverage, and that left the unit with only two staff.
- She pulled an additional staff member for the GPU after the elopement, but did not prior to the event.
- It was not acceptable that the nurse was in the staff break room with the door propped open.
- While in the break room, the nurse could not observe the patient care area and supervise patients.
- While the nurse was in the break room, only one staff (MHT) was left to supervise patients.

6. Record review of the facility's investigation, dated completed on 07/15/13 showed:
- On 07/14/13 at 12:55 PM, Patient #17 became angry after his family visited.
- Patient was noted to have belongings in hand and attempted to leave the unit by kicking and hitting the locked door.
- The patient left the unit and attempted to get onto the elevator.
- The patient was restrained by Code Strong staff and returned to unit.
- The investigation documentation did not show the GPU was short staffed; that the RN was not on the unit supervising patients and that the RN did not provide any remedial actions to prevent further elopements.
- The investigation documentaiton did not show the GPU was short staffed; that the RN was not on the unit supervising patients; and that the RN did not provide any remedial actions to prevent further elopements.

Supervision by an additional RN, may have provided earlier intervention and prevented escalation of behaviors that caused the patient's elopement.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review and policy review, the facility failed to:
- Identify, reassess and implement individualized interventions to prevent suicide attempt (actions taken to self-harm) for one current patient (#14) of two patients reviewed that were suicidal on the Adult Psychiatric unit (APU-utilized to treat patients aged 18-55), and failed to implement interventions to prevent a potential injury to the roommate of one discharged patient (#26) of one reviewed on the APU.
- Follow physician's orders for suicide precautions for one patient (#14) of two patients reviewed that were suicidal on the APU.
- Provide required suicide precautions, every 15-minute patient observation with documentation, for one patient (#14) of two patients reviewed that were suicidal on the APU.
-Ensure staff working on the APU were properly trained prior to actually working with psychiatric unit patients.
- Ensure the APU environment was free of looping/ligature, stabbing and cutting hazards, and/or provide the required staff oversight for one patient (#14) of two current patients and one patient (#26) of one discharged patient reviewed that were suicidal and/or homicidal (thoughts of harm to others) on the APU.
- Ensure the APU patients were searched and contraband (cosmetics, drugs, cigarettes, shoestrings, lighters, belts, sharp objects, etc.) confiscated for one patient (#14) of two patients reviewed that were suicidal on the APU.
- Provide one-on-one supervision (within an arms length) after a suicidal attempt, even though recommended, for one patient (#14) of two patients reviewed that were suicidal on the APU.
These failures had the potential to affect all patients residing on one (APU) of three psychiatric in-patient units.

The census on the APU was ten.
The census on the GPU was seven.
The census on the Adolescent unit was four.

Findings included:

1. Record review of the facility's policy titled, "Patient Monitoring," reviewed 06/09, showed the following:
- All patients are monitored as to their location and activity at regular intervals, depending on the patient's assessed psychiatric condition.
- The attending physician orders the implementation of, or change in level of patient monitoring.
- Acute monitoring required patient visualization at 15-minute intervals.
- The implementation of special monitoring is communicated to the treatment team.
- The need for special monitoring is added to the treatment plan.
- One-on-one monitoring requires the assignment of one staff to be within arms length of the patient at all times.
- A staff member will note on the Close Observation form the location and behavior of the patient at a minimum of 15-minute intervals.
- One-on-one monitoring will be documented in the nurses' notes stating that it was provided throughout the shift.

2. Record review of the facility's policy titled, "Care of the Suicidal Patient," dated 08/97, showed the following:
- A patient is placed on suicide precautions if he/she is determined to be either a risk for self-harm through verbalization of self-destructive thoughts or feelings, or if he/she is an immediate risk for self-harm through behaviors.
- Only the attending physician may discontinue an order for suicide precautions.
- If the Registered Nurse (RN) determines the patient is a suicide risk, all other team members are notified so that proper precautions are taken.

3. Record review of the facility's policy titled, "Nursing Rounds," dated 08/97, showed that the charge nurse was responsible for assigning nursing staff to make unit rounds in order to account for all patients' whereabouts and ensure a safe environment. While making rounds, the staff member observed the environment for unsafe conditions.

4. Record review of the facility policy's titled, "Contraband Material,"dated 06/07/10, showed that any contraband found on a patient or in their belongings will be confiscated.

5. Record review of the facility's policy titled, "Search, Seizure, and Disposition of Drugs, Weapons, and Potentially Harmful Substances," dated 08/97, showed that every effort was made to determine how the banned items were brought onto the unit. Potentially harmful objects were to be given to security when found.

6. Record review of Patient #14's admission orders showed the patient was admitted on [DATE] with a diagnosis of major depression (long periods of feeling worried or empty with a loss of interest in activities once enjoyed) with suicidal ideations. The physician ordered suicide precautions (requiring patient visualization every 15-minutes).

Record review of the patient's Admission Data Form dated 07/08/13, showed the patient said, "Want to kill myself."

Record review of the patient's Behavioral Health Services Suicide Lethality Scale (a assessment tool utilized to determine the patient's potential of suicide risk-scored as low [0-30], minimal [31-39], moderate [40-79], and high [80-125]) dated 07/08/13, showed that the patient was a moderate risk for suicide. The plan (developed by the RN) showed that the patient had a specific plan/method, had high anxiety, was impulsive, and had an unstable lifestyle. The patient had a recent significant loss (boyfriend and job).

Record review of the patient's Psychosocial assessment dated [DATE], showed the patient had been recently unemployed and had broken up with her boyfriend. The patient felt homicidal toward the boyfriend.

Record review of the patient's Interdisciplinary Plan of Care (IPC) dated 07/08/13, showed the patient was a high risk for violence to self related to suicidal and homicidal ideations. Interventions, developed by the RNs included the following:
- Remove all potentially hazardous objects from the environment.
- Assess the patient for overt and covert signs of suicidal behaviors.
- Encourage appropriate expressions of angry feelings.

Further review showed all the above interventions were documented as discontinued/completed on 07/10/13 at 3:58 PM.

Record review of the patient's nurses' notes showed the following:
- On 07/11/13 at 8:00 AM, the patient stated she did not know if she was suicidal or not, but wanted to hurt somebody.
- On 07/11/13 at 7:25 PM, the patient reported she was still suicidal and homicidal. The patient reported, "I've had a lot of anger and rage today. I want to cut his hand off so that he can't work......" (referring to the boyfriend). The RNs failed to evaluate and re-institute the patient's IPC to address the suicidal and homicidal thoughts.
- On 07/12/13 at 7:30 AM, the patient reported she was still suicidal and homicidal. The RNs again failed to evaluate and re-institute the patient's IPC to address the suicidal and homicidal thoughts.

Record review of the patient's physician's orders showed an order for suicide precautions on 07/13/13 at 7:20 PM.

Further record review of the patient's nurses' notes showed the following:
- On 07/14/13 at 7:25 AM, the patient reported she had suicidal thoughts sometimes.
- On 07/14/13 at 6:30 PM, the patient told the nurse, "You better call the Dr. [doctor], my boyfriend said he didn't want nothing to do with me. I'm having thoughts of killing myself." The RNs again failed to evaluate and re-institute the patient's IPC to address the suicidal and homicidal thoughts. The RNs failed to again re-assess the patient for suicidal tendencies, her stated plan and/or method. The RNs failed to evaluate that increased monitoring to prevent an attempt of suicide was needed (The patient expressed intent).
- On 07/14/13 at 6:40 PM, just ten minutes later, the patient was found trying to cut her left wrist with a bobby pin. The nurse recommended one-on-one supervision (staff within an arm's length away from the patient).
- Further review of the nurses' notes through 07/17/13, showed no documentation that the patient was placed on one-on-one.
- On 07/14/13 at 7:05 PM, the patient was placed on suicide precautions (requires visualization every 15-minutes), after the threat and attempt at suicide (rather than after the threat and before the attempt).
- On 07/15/13 at 8:25 AM, the patient reported she was still suicidal with a plan to cut herself. The RN staff failed to evaluate and re-institute the patient's IPC to address the suicidal and homicidal thoughts.

Record review of the patient's Close Observation Precaution Flow Sheets from admission through 07/15/13 showed that the staff failed to monitor the patient at a minimum of every 15-minutes, per the suicide precautions policy, from 07/13/13 at 7:20 PM, through 07/15/13 at 5:49 PM when the suicide precautions were discontinued.

During an interview on 07/16/13 at 3:20 PM, Staff E, RN, Nurse Manager, stated that the patients were searched for contraband when they were admitted . Contraband should be removed and kept locked up by the nursing staff. Cosmetics were considered to be contraband. Staff E stated that Patient #14 should have received one-on-one supervision, as recommended by the RN, and the 15-minute checks should have been instituted per physician's order, but verified they were not. Staff E stated that the mental health technician (MHT-Staff HH) doing the patient rounds on the APU was not a regular staff person on the behavioral health unit. Staff E stated that the RN on the unit should have communicated to the MHT the type of precautions Patient #14 required.

During an interview and concurrent observation on 07/17/13 at 8:57 AM, Patient #14 stated that she had repeatedly stabbed a sharp bobby pin into her veins of the left wrist because she was angry after talking to her boyfriend on the phone. Patient #14 stated that she tried to use a comb on her wrist first, but it did not work. Patient #14 stated that she got the bobby pin from her cosmetic bag, which was searched and returned to her on admission. Patient #14 stated her wrist was cut enough that it bled. Patient #14 stated that the RN put her in the APU hallway and made her sit there while the physician was notified. The RN administered medication and she was allowed to go back to her room, without one-on-one supervision. Patient #14 confirmed she was never placed on one-on-one supervision. Patient #14 had two circular-type scabbed areas on her left wrist, each about one-half inch in diameter. Patient #14 also stated that her room was searched and a razor was confiscated.

During an interview on 07/17/13 at 9:51 AM, Staff E stated that the tech on duty on 07/14/13 (Staff HH), when the patient attempted suicide, was not assigned to do dedicated hall monitoring, but had other tech duties as well (leaving the hallway unmonitored at times unless the nurses could monitor from the hallway or nurses' station).

7. Record review of the facility's internal investigation related to the patient's suicide attempt dated 07/14/13, showed the following:
- The patient was found in her room attempting to punch vein with a hair pin.
- The patient was searched and one-on-one monitoring was put into place.
- The patient received no harm.
- The Manager investigated the incident.
- The Outcome/Resolution was left blank.

During an interview on 07/17/13 at 1:00 PM, Staff U, Director of Risk Management, stated that Staff E investigated this particular issue. Staff U stated that this specific investigation did not have/include enough information to determine an outcome/resolution. Staff U stated that there was no further investigation information on this incident. Staff failed to determine the system failure that contributed to the attempt at suicide; therefore, failing to develop a resolution.

8. During an interview on 07/17/13 at 1:34 PM, Staff E, stated that she did not know where Patient #14 got the bobby pin from. Staff E admitted she failed to determine exactly what had occurred and how, so no corrective actions were put into place to prevent another similar incident.

9. During an interview on 07/17/13 at 2:15 PM, Staff HH, stated that she worked on the APU on 07/14/13 from 7:00 PM to 11:00 PM. Staff HH, MHT stated she had no knowledge of any incident regarding Patient #14 during that shift (incident occurred at 6:40 PM). Staff HH stated that the RN made no specific report of any change in Patient #14's precaution status.

10. During an interview on 07/17/13 at 5:00 PM, Staff FF, Psychiatric physician, stated that Patient #14 should have been on suicide precautions (requiring patient visualization every 15-minutes) as of the order on 07/13/13, and this precaution level would have been expected.

11. During an interview on 07/18/13 at 8:41 AM, Staff A, Chief Nursing Officer, stated that she would have expected suicide precautions to be followed, and 15-minute monitoring to be completed per policy. Staff A stated she would have also expected RNs to update the treatment plan with specific, useful interventions, and follow them, to prevent incident.

12. During an interview on 07/18/13 at 9:20 AM, Staff A, stated that Staff HH (MHT) failed to receive behavioral health competencies (was not checked for her knowledge of the care needed for behavioral health patients) prior to working on the APU on 07/14/13.

13. Record review of the facility's policy titled, "Work Orders-Prioritizing," dated 08/04, showed that any emergency work requests will be processed immediately for safety purposes. The highest priority areas (intensive care unit, obstetrics, operating room and central sterile) will be monitored on a weekly basis, all other areas will be reviewed on a monthly basis via a "walk-through."

14. Observation and concurrent interview on 07/16/03 at 1:30 PM, showed:
- The APU, a total patient capacity of 12, with a current census of 10. Two current patients were on suicide precautions.
- The APU consisted of one long hallway with one nurses' station and six semi-private patient rooms, a dining room area, offices, and treatment rooms. The nurses' station was completely enclosed either by walls or a safety glassed-in area. The door was employee-controlled via a key.
- A randomly viewed patient entered the restroom and closed the door, without supervision of staff.
- In the patient men's restroom, there was a stiff metal grate/screen covering the ceiling light bulb. This grate had been pulled loose (the screw was missing) from one corner and was hanging down about two inches from the ceiling. The edges of the corner was sharp and a cutting hazard. The sink, in the restroom, had a water faucet and two handles that were looping hazards.
- In the patient women's restroom, the sink had a water faucet and two handles that were looping hazards.
- Staff E, Behavioral Health Manager, stated that all six patient rooms had the same type water faucets and handles. Staff E also stated that the unit had four medical beds, with open rail siderails, which can be a looping hazard.
- In Room 306, a plastic wall plug outlet cover (face plate) was broken in half, leaving sharp edges that could be used for cutting.

15. During an interview on 07/16/13, at 1:50 PM, Staff E, stated that all patients on the unit were allowed to use the restrooms without supervision, with the door closed. Staff E stated that staff were to check on a patient in the restroom after a few minutes; however, there was no policy stating exactly how long a patient can be allowed without supervision in the restrooms.

16. During an interview on 07/17/13 at 10:00 AM, Staff P, Director of Plant Operations, stated that environment of care (EOC) rounds were completed quarterly. Staff P stated that nursing staff also submitted work orders for repairs and/or hazards. Staff P stated that work was prioritized according to patient safety needs. Staff P stated he was unaware of the hanging metal grate/screen in the men's restroom and the broken outlet cover in Room 306.

17. Record review of the most current EOC rounds, dated 05/13, showed that was the last time all three psychiatric units were examined for environmental safety rounds, via a tour. Some safety items (damaged tiles, stains on ceilings, gas cylinders secured, chemicals stored properly, etc.) were identified on the APU; however, these were not marked as corrected. The unit Program Director signed the rounds form on 05/21/13.

Record review of the facility's forms titled "Request Work Orders" showed Behavioral Health Unit (BHU) staff failed to identify, and report, the hanging metal grate in the men's restroom and the broken outlet cover in Room 306 as patient safety hazards.

18. Record review of the facility's policy titled, "Event Reporting and Tracking Policy," revised 07/22/10, showed that an event was described as any happening which is not consistent with the routine operation of the facility. The policy listed the process for investigation of the event to determine the potential causes, potential for reoccurrence, system failures, severity, and any corrective action or other action that may need to be implemented.

19. Record review of discharged Patient #26's psychiatric evaluation dated 05/19/13, showed the patient was admitted on [DATE] with psychosis (a major mental disorder causing a gross impairment in reality).

Record review of the patient's IPC dated 05/17/13, showed the staff assessed the patient as a high risk for violence. The IPC directed staff to remove all potentially harmful objects from the environment as an intervention. The patient had poor impulse control and coping skills and could be aggressive.

Record review of the patient's Safety/Security Event Report form dated 05/18/13, showed the following:
- The patient took the metal height measuring piece off of the facility body weight scales, took it to his room and threatened to use it to kill his roommate and staff.
- Security staff had to intervene;
- The "Resolution" section of the form showed this event was caught by chance (staff found patient in room with metal piece).

During an interview on 07/17/13 at 2:54 PM, Staff E stated that the scale had been kept in the clean linen room. All patients had free access to the scale and at the time of this incident. Staff E stated that the only corrective action performed after this incident was that the scale was moved to a locked location. The staff failed to proactively identify the overall system failure that contributed to the attempt at harm and/or homicide to another patient and therefore, failed to develop a systemic resolution.




Surveyor: Howard, Jacqueline
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to develop/maintain a comprehensive, individualized plan of care (IPC) for:
- One patient (#17) of one patient reviewed who demanded discharge, threatened assault, eloped (left the locked unit without permission) and had to be restrained on the Geriatric (older adult) Psychiatric Unit (GPU).
- One patient (#14) of two patients reviewed that had suicidal ideation's (thoughts of killing oneself) and/or attempted suicide on the Adult Psychiatric Unit (APU).
- One patient (#26) of one discharged patient reviewed that had suicidal/homicidal ideation's (thoughts of harm to self and others) and/or threatened to harm a roommate and staff on the APU.
These failures could potentially lead to improper provision of care for all psychiatric patients. The census on the GPU was seven; the census on the APU was 10 and the census on the adolescent unit was four.

Findings included:

1. Review of the facility's policy titled, "Interdisciplinary Plan of Care," (IPC) revised 06/12, showed that:
- Within 24 hours of admission, all patients have a plan for care, treatment, and services generated by the registered professional nurse (RN).
- The plan for care, treatment, and services is a dynamic process that addresses the execution of care, treatment, and services.
- The plan of care shall be updated, with revisions reflecting the reassessment of needs of the patient.

2. Record review of Patient #17's medical record showed:
- The patient was admitted to the Geriatric Psychiatric Unit (GPU) (older adult) with diagnoses of major depression (a long period of feeling worried or empty with a loss of interest in activities once enjoyed) and dementia (a loss of cognitive/thinking abilities and an impairment of memory).
- On 07/14/13 the patient demanded to leave the facility and threatened to assault the nurse on duty with a chair.
- The patient eloped from the locked unit.
- The patient tried to get on the elevator, and was met by several staff, who responded to an overhead page for behavioral assistance, and escorted him back to the unit.
- There was no revision to the IPC when the patient demanded discharge, threatened harm to the nurse and eloped from the unit.

During an interview on 07/17/13 at 9:20 AM, Staff S, RN, stated that on 07/14/13:
- Patient #17 became upset following a visit with his family.
- The patient left the locked unit without permission and was escorted back by facility staff.
- She should have revised the IPC for his demand for discharge, threats of physical aggression, and attempted elopement from unit.

During an interview on 07/17/13 at 12:15 PM, Staff A, Chief Nursing Officer, stated she would have expected a revision to the IPC following the aggressive episode and attempted elopement of the patient.

3. Record review of Patient #14's admission orders showed the patient was admitted to the Adult Psychiatric Unit (APU) on 07/08/13 with a diagnosis of major depression with suicidal ideation's. The physician ordered suicide precautions (requiring patient visualization every 15-minutes).

Record review of the patient's Behavioral Health Services Suicide Lethality Scale (a assessment tool utilized to determine the patient's potential of suicide risk-scored as low [0-30], minimal [31-39], moderate [40-79], and high [80-125]) dated 07/08/13, showed that the patient was a moderate risk for suicide. The plan showed that the patient had a specific plan/method, had high anxiety, was impulsive, and had an unstable lifestyle. The patient had a recent significant loss (boyfriend and job).

Record review of the patient's Psychosocial assessment dated [DATE], showed the patient had been recently unemployed and had broken up with her boyfriend. The patient felt homicidal toward the boyfriend.

Record review of the patient's IPC dated 07/08/13, showed the patient was a high risk for violence to self related to suicidal and homicidal ideation's. The interventions included the following:
- Remove all potentially hazardous objects from the environment.
- Assess the patient for overt and covert signs of suicidal behaviors.
- Encourage appropriate expressions of angry feelings.

Further review showed all the above interventions were documented as discontinued/completed on 07/10/13 at 3:58 PM.

Record review of the patient's nurses' notes showed the following:
- On 07/11/13 at 7:25 PM, the patient reported she was still suicidal.
- On 07/12/13 at 7:30 AM, the patient reported she was still suicidal.
- On 07/14/13 at 7:25 AM, the patient reported she had suicidal thoughts sometimes.
- On 07/14/13 at 6:30 PM, the patient told the nurse, "You better call the Dr. [doctor], my boyfriend said he didn't want nothing to do with me. I'm having thoughts of killing myself." Staff failed to re-institute the patient's treatment plan to address the suicidal thoughts, even though the patient expressed intent.
- On 07/14/13 at 6:40 PM, just ten minutes later, the patient was found trying to cut her left wrist with a bobby pin. The nurse recommended one-on-one supervision.
- On 07/15/13 at 8:25 AM, the patient reported she was still suicidal with a plan to cut herself.

Record review of the patient's IPC after 07/10/13 showed staff failed to re-institute and/or develop a more specific treatment plan to address the patient's suicidal thought and acts. Staff also failed to revise the IPC to include interventions addressing finding and removing contraband such as bobby pins.

4. Record review of Patient #26's psychiatric evaluation dated 05/19/13, showed the discharged patient was admitted on [DATE] with psychosis (a major mental disorder causing a gross impairment in reality).

Record review of the patient's IPC dated 05/17/13, showed the patient was assessed as a high risk for violence. The care plan directed staff to remove all potentially harmful objects from the environment as an intervention. Staff failed to assess for and actually remove the hazardous environmental items as directed by the treatment plan.

Record review of the patient's Safety/Security Event Report form dated 05/18/13, showed the following:
- The patient took the metal height measuring piece off of the weight scales; took it to his room and threatened to use it to kill his roommate and staff.
- The Security staff had to intervene.
- The Resolution section of the form showed this event was caught by chance.

5. During an interview on 07/18/13 at 8:41 AM, Staff A, stated that the IPCs should be updated as needed, but reviewed at least every shift. Staff A stated that the RNs and licensed nurses were responsible for updating the treatment plans. She would have expected Patients #14 and #26's treatment plans to have been updated and followed.