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.

FRYE REGIONAL MEDICAL CENTER 420 N CENTER ST HICKORY, NC 28601 Oct. 24, 2013
VIOLATION: GOVERNING BODY Tag No: A0043
Based on hospital policy and procedure reviews, medical record review, staff and physician interviews the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection and promotion of Patients' Rights and ensure an organized Nursing Service for the provision of patient care in a safe environment.

The findings include:

1. The hospital's staff failed to protect and promote Patients' Rights by failing to follow established policy and procedures for suicide risk, sitter usage, and restraints to ensure care was provided in a safe environment.

~Cross refer to 482.13 Patients' Rights - Condition Tag A0115.

2. The hospital staff failed to have an organized Nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care for a safe environment.

~Cross refer to 482.23 Nursing Services - Condition Tag A0385.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on hospital policy and procedure reviews, medical record review, staff and physician interviews the hospital staff failed to have an organized Nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care for a safe environment.

The findings include:

The hospital's nursing staff failed to reassess a patient for suicide risk and implement measures to provide a safe environment per established hospital policy and procedures for 1 of 1 patients (#6) with a known known psychiatric history; who shattered and jumped out a glass window from the fourth floor of the hospital sustaining injuries.

~Cross refer to 482.23(b)(3) RN Supervision of Nursing Care - Standard Tag A0395.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure reviews, medical record review, staff and physician interviews, the hospital's nursing staff failed to reassess a patient for suicide risk and implement measures to provide a safe environment per established hospital policy and procedures for 1 of 1 patients (#6) with a known known psychiatric history; who shattered and jumped out a glass window from the fourth floor of the hospital sustaining injuries.

The findings include:

Review on 10/22//2013 of hospital policy "Suicide Risk Assessment/Suicide Precautions" revised date 04/2013 revealed "II. PURPOSE: The purpose of this policy is to describe the process for assessing for risk and developing a plan of care for patients thirteen years of age or older with suicidal ideation. Risk factors for suicide include but are not limited to A. Psychosocial Factors: history of suicide attempt, history of deliberate self harm, co-morbid alcohol and other substance disorders, current or past psychiatric disorders particularly mood disorders, schizophrenia, anxiety, and personality disorders, history of trauma or physical or sexual abuse, major physical illness, chronic pain, family history of suicide, history of violent or aggressive behavior and a triggering event leading to humiliation or despair, loss (job, financial, relational, social). B. Environmental Factors: easy access to firearms or other lethal means. III. DEFINITIONS: A. 'Suicidal patient' is one who has recently made an attempt in the last 12 months or has expressed the desire/compulsion to attempt to end his or her own life or is intending to end his or her own life in the near future. B. 'Risk Factors' ...psychological or environmental factors as described in Section II above. IV POLICY: At a minimum, all patients aged thirteen years or older entering the Emergency Department for care or admitted to the Hospital who present with a behavioral health related complaint or shows sign/symptoms of [DIAGNOSES REDACTED]? 2. Are you feeling hopeless to the extent that you would want to end your life? 3. Have you attempted suicide or had a plan to attempt within the last 12 months? A 'yes' Answer to any of the three questions puts the patient at risk of suicide and will require further assessment by a physician or qualified Registered Nurse who has demonstrated competency in determining the patient's level of risk ...Until the patient receives his or her in-depth assessment the nursing staff will use the Environment Patient Safety Checklist to ensure that the patient has been provided a safe environment. A. Emergency Department: 1. At a minimum, a Registered Nurse will complete a suicide risk screen on all patients 13 years of age or older who present with a behavioral health related primary complaint or who exhibit sign/symptoms of [DIAGNOSES REDACTED]. The result of the assessment will determine the level of risk and corresponding monitoring and interventions required to maintain patient safety. 3. If the patient can not be assessed upon arrival due to the patient's medical status, i.e. (example) the patient is unconscious, intubated, intoxicated, or mentally unable to respond, the assessment will be postponed until the patient can be assessed. This assessment should be performed as soon as the patient's condition permits. Any concerning or contributing history or circumstances that might indicate an increased risk of suicide shall be included in hand-off communication and communicate to all Hospital personnel involved in the care of the patient ...B. Inpatient Procedure 1. At a minimum, all patients admitted to the hospital 13 years of age or older with a behavioral health related chief complaint or shows sign/symptoms of [DIAGNOSES REDACTED]'s safety is maintained by the following: a. the patients environment is secured using the Environment Patient Safety Checklist at a minimum of every shift ...5. A patient who is suspected of self-harm but is unconscious, comatose or unresponsive due to his or her medical condition requires frequent assessments by the Registered Nurse ...as soon as the patient regains consciousness, the patient will be screened for suicidal risk and if appropriate assessed for level of risk and appropriate level of suicide precaution. 6. Implement close observation process using the Close Observation Record. Notify the Physician and receive consult for appropriate assessment by psychiatrist ...10. Inpatient Documentation: a. admitted patients will have the suicide screen documented as part of the initial assessment/screening form. b. the nursing staff will use the Environment Patient Safety Checklist to document securing the patient's environment and complete each shift. c. the nursing staff will document the patient's behavior and activity on the Close Observation Record. d. admitted patients at risk for suicide will have an assessment performed and documented on the Parasuicidal Risk Assessment Form. e. Clinical status of the patient will be documented along with changes in physical or emotional condition on the Close Observation Record. f. a daily suicidal risk assessment will be completed by a Registered Nurse using Para suicidal Risk Re-assessment. These results will be shared with the physician who will determine whether to continue, revise or discontinue suicide precautions ..."

Review on 10/22/2013 of hospital policy "Sitter Usage, Assessment, Implementation and Discontinuation" revised date of 09/04/2012 revealed "This policy applies to all clinical patient care areas of (Name) Regional Medical Center that utilized sitters for patient care and safety ...II. PURPOSES: ...to outline the process for the assessment, implementation, discontinuation, staffing, and monitoring/tracking of sitters. III. DEFINITIONS: A....'Psych' means related to the care of a psychiatric condition, suicidal ideations, or state-required observations. B. 'Non-psych' means related to the care of non-psychiatric conditions, interference with medical care confusion, or the inability to follow instructions ...V. PROCEDURE: A. Assessment of Sitter Usage 1. the nurse assesses the patient's physical condition, behaviors, and emotional status to determine if constant observation of the patient is needed to ensure the patient's safety ...2. The nurse assesses for the following criteria/risk factors for sitter usage: a. suicide precautions and/or state-required observations. b. danger to self ...c. severe behavioral or cognitive issues (impaired judgment, disorientation, confusion, agitation, impulsivity, etc.) ...f. wandering or at risk for elopement ...B. Clarification of Terms: sitters (unlicensed personnel) are utilized as a supplemental staffing solution when continuous observation of a patient is indicated to ensure the patient safety within the immediate care environment ...is appropriate in any clinical setting when a Registered Nurse's assessment determines that a patient's physical safety is at risk ...C. Ordering of sitters: 1. A physician may write an order for use of a sitter for the above stated reasons, however, it is not required ...E. Implementation of Sitters: 1. the RN assigned to the patient remains responsible for the nursing care throughout the shift regardless of the presence of a sitter ..."

Review on 10/22/2013 of hospital policy "Patient Assessment/Reassessment" revised date 12/2010 revealed "...POLICY: The assessment process is structured with two components: assessment and reassessment. 1. Assessment: a. all patients at this facility receiving inpatient, outpatient, or emergency services will have a timely, initial assessment of pertinent medical and psychosocial variables... b. the assessment process will determine the need for care and/or treatment and the type of care to be provided. All relevant patient physiological, psychological, and social-cultural variables will be analyzed in the decision-making process in order to determine patient needs and priorities ...2. Reassessment: a. reassessment is a component of the patient plan of care and is conducted at key determinate events as well as throughout the care continuum ...the goal of the assessment and reassessment process is to provide the patient with the best and most appropriate individualized care and treatment ...C. Structures Supporting the Assessment of Patients: ...2. All assessments/reassessments are documented in the patient's medical record ...I. Nursing: 1. Assessment: ...b. upon arrival to nursing areas, the patient is assessed ... The RN must review the data, identify patient problems that require planning and interventions ...The Care Plan are documented within 24 hours of admission ...2. Reassessment: a. Reassessment of inpatients is completed by a RN or LPN every shift ...c. Reassessment includes but is not limited to review of the following parameters: ...(2) Psychosocial ..."

Review on 10/22/2013 of hospital policy "Hand off Communication" last revised 02/2012 revealed "PURPOSE: to ensure accurate information about the patient's care, treatment and current condition including any recent changes are communicated to the next responsible care provider ...POLICY: ...2. Communication should address pertinent up-to-date information regarding the patient's treatment, care and services, as well as current condition and any recent or anticipated changes ...PROCEDURE: 1. Handoff communication is organized and based on SBAR (Situation/Background/Assessment/Recommendation) and may include: ...b. Background: brief and significant medical/surgical history ...c. Assessment: Systems review, activity ...social ...change in condition ...d. Recommendation: plan of care of the next shift..."

Review on 10/22//2013 of hospital policy "Suicide Risk Assessment/Suicide Precautions" revised date 04/2013 revealed "II. PURPOSE: The purpose of this policy is to describe the process for assessing for risk and developing a plan of care for patients thirteen years of age or older with suicidal ideation. Risk factors for suicide include but are not limited to A. Psychosocial Factors: history of suicide attempt, history of deliberate self harm, co-morbid alcohol and other substance disorders, current or past psychiatric disorders particularly mood disorders, schizophrenia, anxiety, and personality disorders, history of trauma or physical or sexual abuse, major physical illness, chronic pain, family history of suicide, history of violent or aggressive behavior and a triggering event leading to humiliation or despair, loss (job, financial, relational, social). B. Environmental Factors: easy access to firearms or other lethal means. III. DEFINITIONS: A. 'Suicidal patient' is one who has recently made an attempt in the last 12 months or has expressed the desire/compulsion to attempt to end his or her own life or is intending to end his or her own life in the near future. B. 'Risk Factors' ...psychological or environmental factors as described in Section II above. IV POLICY: At a minimum, all patients aged thirteen years or older entering the Emergency Department for care or admitted to the Hospital who present with a behavioral health related complaint or shows sign/symptoms of [DIAGNOSES REDACTED]? 2. Are you feeling hopeless to the extent that you would want to end your life? 3. Have you attempted suicide or had a plan to attempt within the last 12 months? A 'yes' Answer to any of the three questions puts the patient at risk of suicide and will require further assessment by a physician or qualified Registered Nurse who has demonstrated competency in determining the patient's level of risk ...Until the patient receives his or her in-depth assessment the nursing staff will use the Environment Patient Safety Checklist to ensure that the patient has been provided a safe environment. A. Emergency Department: 1. At a minimum, a Registered Nurse will complete a suicide risk screen on all patients 13 years of age or older who present with a behavioral health related primary complaint or who exhibit sign/symptoms of [DIAGNOSES REDACTED]. The result of the assessment will determine the level of risk and corresponding monitoring and interventions required to maintain patient safety. 3. If the patient can not be assessed upon arrival due to the patient's medical status, i.e. (example) the patient is unconscious, intubated, intoxicated, or mentally unable to respond, the assessment will be postponed until the patient can be assessed. This assessment should be performed as soon as the patient's condition permits. Any concerning or contributing history or circumstances that might indicate an increased risk of suicide shall be included in hand-off communication and communicate to all Hospital personnel involved in the care of the patient ...B. Inpatient Procedure 1. At a minimum, all patients admitted to the hospital 13 years of age or older with a behavioral health related chief complaint or shows sign/symptoms of [DIAGNOSES REDACTED]'s safety is maintained by the following: a. the patients environment is secured using the Environment Patient Safety Checklist at a minimum of every shift ...5. A patient who is suspected of self-harm but is unconscious, comatose or unresponsive due to his or her medical condition requires frequent assessments by the Registered Nurse ...as soon as the patient regains consciousness, the patient will be screened for suicidal risk and if appropriate assessed for level of risk and appropriate level of suicide precaution. 6. Implement close observation process using the Close Observation Record. Notify the Physician and receive consult for appropriate assessment by psychiatrist ...10. Inpatient Documentation: a. admitted patients will have the suicide screen documented as part of the initial assessment/screening form. b. the nursing staff will use the Environment Patient Safety Checklist to document securing the patient's environment and complete each shift. c. the nursing staff will document the patient's behavior and activity on the Close Observation Record. d. admitted patients at risk for suicide will have an assessment performed and documented on the Parasuicidal Risk Assessment Form. e. Clinical status of the patient will be documented along with changes in physical or emotional condition on the Close Observation Record. f. a daily suicidal risk assessment will be completed by a Registered Nurse using Para suicidal Risk Re-assessment. These results will be shared with the physician who will determine whether to continue, revise or discontinue suicide precautions ... C. Auditing and Monitoring: The Clinical Quality Department shall audit adherence to this policy in its Comprehensive Clinical Audits."

Review on 10/22/2013 of hospital policy "Sitter Usage, Assessment, Implementation and Discontinuation" revised date of 09/04/2012 revealed "This policy applies to all clinical patient care areas of (Name) Regional Medical Center that utilized sitters for patient care and safety ...II. PURPOSES: ...to outline the process for the assessment, implementation, discontinuation, staffing, and monitoring/tracking of sitters. III. DEFINITIONS: A....'Psych' means related to the care of a psychiatric condition, suicidal ideations, or state-required observations. B. 'Non-psych' means related to the care of non-psychiatric conditions, interference with medical care confusion, or the inability to follow instructions ...V. PROCEDURE: A. Assessment of Sitter Usage 1. the nurse assesses the patient's physical condition, behaviors, and emotional status to determine if constant observation of the patient is needed to ensure the patient's safety ...2. The nurse assesses for the following criteria/risk factors for sitter usage: a. suicide precautions and/or state-required observations. b. danger to self ...c. severe behavioral or cognitive issues (impaired judgment, disorientation, confusion, agitation, impulsivity, etc.) ...f. wandering or at risk for elopement ...B. Clarification of Terms: sitters (unlicensed personnel) are utilized as a supplemental staffing solution when continuous observation of a patient is indicated to ensure the patient safety within the immediate care environment ...is appropriate in any clinical setting when a Registered Nurse's assessment determines that a patient's physical safety is at risk ...C. Ordering of sitters: 1. A physician may write an order for use of a sitter for the above stated reasons, however, it is not required ...E. Implementation of Sitters: 1. the RN assigned to the patient remains responsible for the nursing care throughout the shift regardless of the presence of a sitter ..."

Closed medical record review on 10/23/2013 for Patient #6 revealed a [AGE] year old male admitted to the hospital's South Campus Psychiatric Unit on 10/03/2013 with an Admitting Impression of Paranoid schizophrenia - acute exacerbation, alcohol abuse and personality disorder. Review of Physician #1's History and Physical (H&P) dictated 10/03/2013 at 1219 revealed "History of Present Illness: Patient has a long-standing history of psychiatric disease since he was about 21 years of age....patient was recently released from prison where he was institutionalized for unadmitted guilt. Patient today has erratic, unpredictable behaviors, racing thoughts, flight of ideas, poor sleep. He reports auditory hallucinations of voices that are accumulating and getting stronger. ...he has no insight and judgment. He is depressed. He denies suicidal or homicidal ideations, but reports positive death fantasies..." Review of Physician #1's discharge summary dated 10/11/2013 revealed "REASON for ADMISSION: ...reports auditory hallucinations, command type, to hang himself; visual hallucination, seeing eyes and owls and tactile hallucinations, feels like he has ESP (extrasensory perception) and paranoid ideation ...During his hospital course he was placed on Latuda (antipsychotic medication)..with a decrease of auditory hallucinations ....he was discharged to outpatient care ..." Continued review revealed the patient was discharged on [DATE] at 1440.

Open medical record review on 10/23/2013 revealed Patient #6 presented to the hospital's Emergency Department (ED) on 10/11/2013 at 2358 (9 hours 18 minutes after discharge from the psychiatric unit) via EMS (emergency medical services) after being found face down in the dirt, unconscious, and unresponsive. Review of the ED Physician's (Physician #2) documentation revealed the patient was intubated and placed on ventilator support (machine breathing for the patient). Continued review revealed "...HPI (history of present illness): ...the patient presents with decreased mental status....he has just been discharged from (hospital name) South Campus earlier today...Past Medical History: Schizophrenia ...EXAM: ...patient appears comatose...Disposition: Critical Care...Disposition Summary: Admit ...Preliminary diagnosis are Altered LOC (level of consciousness) Pneumonia, Respiratory Failure, Fever ..."

Review of the ED RN (registered nurse) Nursing assessment dated [DATE] at 2358 revealed "Presentation: Presenting complaint: EMS states: Unresponsive ...Triage Assessment: General: Appears distressed, behavior is listless. Neuro: level of Consciousness is unresponsive...Historical: PMHx (past medical history): Schizophrenia...Screening: Abuse screen...fall risk screen...nutritional screening..." Continued review revealed no available documentation of a Suicide Risk Screen while the patient was in the ED. Continued review revealed the patient was admitted and transferred to the Neurologic Intensive Care Unit (NICU) on 10/12/2013 at 0426.

Review of the acute care admitting Physician #3's H&P dictated 10/12/2013 at 0419 revealed "...History of present illness: this is a [AGE] year old male with a past medical history of [DIAGNOSES REDACTED]...ASSESSMENT: ...recently discharged from the South Campus, who is now admitted with 1. Acute respiratory failure 2. Sepsis 3. Acute metabolic [DIAGNOSES REDACTED] 4. Probably right lower lobe pneumonia, likely healthcare acquired with aspiration 5. Dehydration."

Review of a NICU RN Admission Assessment completed on 10/12/2013 at 0528 revealed "...Medical History & Problems: Schizophrenia...Psychosocial/Suicide Screening: Suicide 13 years or older: Yes; (Comment: unable to answer questions, patient intubated, unresponsive, sedated); Suicide Attempt last 12 months: Yes; Suicide Feeling Depressed: Yes; Suicide Feeling Hopeless: Yes ..."

Review of nursing documentation dated 10/14/2013 revealed the patient was extubated and removed from ventilator support at approximately 1100. Review revealed the patient was assessed by a RN at 1230 as: Behavior: age appropriate, calm, cooperative ...Mood: Content; at 1615: Behavior: age appropriate, calm, cooperative ...Mood: Content; and at 2000: Behavior: Anxious, Cooperative, Remorseful. Mood: Appropriate. Further review of nursing documentation dated 10/15/2013 revealed the patient was assessed by a RN at 0400 as Behavior: Anxious, denying, excessive talk, insomnia, paranoid, restless; Mood: Anxious, despondent, remorseful; at 0805: Behavior: Anxious, Excessive talk, fearful; Mood: Anxious, despondent, remorseful; at 1128: Behavior: Anxious, Argumentative, Belligerent, Distractible, Excessive talk, Impulsive; Mood: Anxious, Despondent, Remorseful; at 1400: Behavior: Active, Delusional, Excessive talking, anxious and easily distracted. Continued review of nursing documentation dated 10/15/2013 at 0028 revealed "discussing religion with staff, excessive talk at times." and at 0549: "continuously states, 'I just feel weird', states 'all this medicine is making me feel funny'."

Review of the Interdisciplinary Progress Record Pastoral Notes dated 10/15/2013 at 1020 by a Hospital Chaplain, revealed "I was asked to visit pt (patient) at his request ...explained some of his psychological issues including schizophrenia and bipolar disorder and told me that he is currently manic. Pt had a new testament of the Bible open on his lap when I entered the room and he referred to scriptures several times during my visit. When I asked pt why he was here he said he'd fallen on the ground and was holding onto some tree bark ...Pt told me he'd taken a lot of pills and sometimes didn't take them ...he asked to be excused because he had to take care of something and asked me to close the curtain on my way out...RN thanked me ..."

Continued review revealed no available documentation of reassessment of the patients Psychosocial/Suicide Screening or Assessment after extubation on 10/14/2013 at approximately 1100. Continued review revealed no available documentation of the completion of the Parasuicidal Risk Assessment; the Parasuicidal Risk Re-assessment; the Close Observation Record; nor the Environment Patient Safety Checklist after the patient was extubated.

Continued review revealed the patient was transferred from the NICU to the 4th floor Nephrology/Oncology Nursing Unit (4 North) on 10/15/2013 approximately 1430. Review of the Nursing Communication report revealed "Past Medical History: Schizophrenia ...Psychosocial Factors: (0)." Continued review revealed no available documentation of a transfer note or SBAR (communication tool used among healthcare teams to communicate patient information: Situation, Background, Assessment, Recommendation) communication by the NICU RN communicating to the 4 North receiving RN that a Psychosocial/Suicide Screening and Parasuicidal Risk Assessment/Re-assessment needed to be completed on Patient #6.

Review revealed no available documentation of an assessment performed by the 4 North receiving RN after the patient arrived on the unit. Continued review revealed no available documentation of reassessment of the patients Psychosocial/Suicide Screening, completion of the Parasuicidal Risk Assessment, the Parasuicidal Risk Re-assessment, the Close Observation Record, or the Environment Patient Safety Checklist by the 4 North nurse.

Review of nursing documentation dated 10/15/2013 at 1748 revealed "When receiving report, I asked about the patient's need of a sitter. (Name of transferring RN) said that she would ask the Dr. (doctor) and let me know. She had to call me back b/c (because) Dr. was on another phone. She called me back and said that the Dr. said that the pt did not need a sitter. I called my manager and asked her about a sitter and she said that if the Dr. did not order one, that we could not have one. Pt had been up in room walking, going to the bathroom he would lay down, he said that we were all in God's hands and I agreed with him ...At (around) 1700 ...I heard a commotion at the desk, I heard window blinds making a noise, I came out to the desk and the unit secretary said that he (Patient #6) talking about 404 (room), had jumped out the window. I went and looked out the window and saw the pt laying in the aluminum square box, that I assumed had something to do with the heat ducts. He was getting up. It appeared the blinds were thru his head from my vantage point, but he just moved them and got up. I could see blood from his arm/hand and from one of his feet. He was looking for his bedroom shoes. He placed on his foot and was looking for the other. He was standing in what looked to be dirty water. I asked him to please sit down, he sat on one of the round things and was about to fall off. I asked him if he wanted to pray, I could not hear his response. He went toward the front of the bldg (building) and jumped up on the wall to the next room that would lead to the front of the blding (building) and what I thought was nothing between him and the street. I continued to talk to him and beg him to sit down when some other nurses got him to come to a window opposite the wall where he jumped out. He layed down on the roof and placed his left foot inside the window and they placed pressure on his ankle with a blanket or towel. I then saw an RN walk out on the roof to help...the police officer may have been out there first, I am unsure."

Continued review revealed EMS responded and transported the patient to the hospital's ED at 1751. Review of the ED Physician's (Physician #4) H&P dated 10/15/2013 at 1953 revealed "...The injury occurred at the hospital. Mechanism of injury: jumped from a window 4th story, landing on 2nd story roof. Associated injuries: the patient sustained injury to the head, injury to the chest, left arm and left leg ...the patient has been recently seen by a physician: in the hospital. Hx (history) of psychiatric d/o (disorder) ...apparently broke out window and jumped landing on an air vent. Reportedly got up and walked to jump to the ground when he was stopped. PMHx: Schizophrenia ...ROS (review of systems) ...Psych: Positive for psychosis ...Exam: 1953 - Psych: Behavior/mood is cooperative, affect is flat, delusions/hallucinations are present and described as I jumped because I wanted to go for a walk ...Lacerations: wound repair of 3cm (centimeter) ...left calf ...wound repair of 10cm tendon involved ...left foot and left lateral ankle ...wound repair of 3cm ...laceration to palmar aspect of left forearm ...Disposition: Critical Care ...preliminary diagnosis are Suicide Attempt, Ankle Laceration, Tendon Injury, Arm Laceration, Leg Laceration ..."

Record review revealed at 2006 the patient was transferred from the ED to the NICU with 1:1 RN care and 24 hour police officer presence until 10/17/2013 when Patient #6 was discharged from acute care and transferred to the hospital's South Campus Psychiatric Unit where he is currently a patient.

Record review revealed no available documentation of a Suicide Risk Assessment/Suicide Precaution, a Parasuicidal Risk Assessment, Parasuicidal Risk Reassessment, nor an Environment Patient Safety Checklist being completed during the patient's hospital admission from 10/11/2013(admission) through 10/17/2013 (time of transfer to Psychiataric Unit).

Review of the acute care attending Physician's (Physician #6) discharge summary dictated 10/18/2013 at 1328 revealed "Discharge diagnosis: Acute psychosis, Aspiration pneumonitis, Acute respiratory failure (resolved) ...laceration left forearm secondary to fall; laceration to left foot secondary to fall ...schizophrenia ...Reason for admission: ...[AGE] year-old-male with long standing medical history of [DIAGNOSES REDACTED]. He was intubated in the ED for airway protection ...Hospital course: the patient was admitted to the intensive care unit and maintained on ventilator support. He did well on ventilatory support ...following about 48 hours on ventilatory support, the patient was subsequently extubated successfully....and was resumed on his home psychiatric medications consisting of Latuda. The following day on 10/15/2013 the patient was transferred to a medical floor. He was place in a room across from the nurses' station. At approximately 5:00pm the nurses heard a pounding noise in the room and upon entering the room found that the patient had broken the window and the patient jumped from the window. He evidently landed on an air conditioning fan vent, which cushioned fall in an accordion type manner. He was noted to be walking on the roof 2 stories below following the leap.. The patient was attend to by staff on the roof and was subsequently taken to the ED where he was evaluated extensively. There was no evidence of fractures in his legs and no evidence of cervical fracture. No evidence of any broken ribs noted ...the patient was readmitted to the intensive care unit with involuntary commitment. He has had a sitter from the (city name) Police department since that time ...the patient was discharged to the South Campus (psychiatric unit) ...Condition at time of discharge: symptoms prompting admission have resolved. The patient unfortunately still has an acute psychosis and is involuntarily committed to the psychiatric facility."

Record review revealed upon admission to the hospital's South Campus Psychiatric Unit on 10/18/2013, Patient #6 was assessed by a Psychiatrist and "judged to be a risk to himself and others" with an initial impression of Paranoid Schizophrenia - acute exacerbation, Personality Disorder, Schizoaffective Disorder, and Status Post Suicide Attempt. Review revealed a Parasuicidal Risk Ass
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on hospital policy and procedure reviews, medical record reviews, staff and physician interviews the hospital's staff failed to protect and promote Patients' Rights by failing to follow established policy and procedures for suicide risk, sitter usage, and restraints to ensure care was provided in a safe environment.

The findings include:

1. The nursing staff failed to reassess and implement measures to provide care in a safe environment per established hospital policy and procedures for suicide risk and sitter usage for 1 of 1 patients (#6) with a known psychiatric history; who shattered and jumped out a glass window from the fourth floor of the hospital sustaining injuries.

~Cross refer to 482.13(c)(2) Patient Rights: Care in Safe Setting - Standard: Tag A0144.

2. The hospital's nursing staff failed to monitor a patient during restraint per hospital policy for 1 of 3 patients (#3) restrained for management of violent or self-destructive behaviors.

~Cross refer to 482.13(e)(10) Patient Rights: Restraint Or Seclusion - Standard Tag A0175.

3. The hospital's nursing staff failed to document one or more of the following elements: patient's immediate situation; reaction to restraint; medical and behavioral condition; and need to continue or terminate the restraint or seclusion; for the one hour face-to-face evaluation for 1 of 3 patients (#3) restrained for management of violent or self-destructive behaviors.

~Cross refer to 482.13(e)(12) Patient Rights: Restraint Or Seclusion - Standard Tag A0179.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure reviews, medical record review, staff and physician interviews, the hospital's nursing staff failed to reassess and implement measures to provide care in a safe environment per established hospital policy and procedures for suicide risk and sitter usage for 1 of 1 patients (#6) with a known psychiatric history; who shattered and jumped out a glass window from the fourth floor of the hospital sustaining injuries.

The findings include:

Review on 10/22/2013 of hospital policy "Suicide Risk Assessment/Suicide Precautions" revised date 04/2013 revealed "II. PURPOSE: The purpose of this policy is to describe the process for assessing for risk and developing a plan of care for patients thirteen years of age or older with suicidal ideation. Risk factors for suicide include but are not limited to A. Psychosocial Factors: history of suicide attempt, history of deliberate self harm, co-morbid alcohol and other substance disorders, current or past psychiatric disorders particularly mood disorders, schizophrenia, anxiety, and personality disorders, history of trauma or physical or sexual abuse, major physical illness, chronic pain, family history of suicide, history of violent or aggressive behavior and a triggering event leading to humiliation or despair, loss (job, financial, relational, social). B. Environmental Factors: easy access to firearms or other lethal means. III. DEFINITIONS: A. 'Suicidal patient' is one who has recently made an attempt in the last 12 months or has expressed the desire/compulsion to attempt to end his or her own life or is intending to end his or her own life in the near future. B. 'Risk Factors' ...psychological or environmental factors as described in Section II above. IV POLICY: At a minimum, all patients aged thirteen years or older entering the Emergency Department for care or admitted to the Hospital who present with a behavioral health related complaint or shows sign/symptoms of [DIAGNOSES REDACTED]? 2. Are you feeling hopeless to the extent that you would want to end your life? 3. Have you attempted suicide or had a plan to attempt within the last 12 months? A 'yes' Answer to any of the three questions puts the patient at risk of suicide and will require further assessment by a physician or qualified Registered Nurse who has demonstrated competency in determining the patient's level of risk ...Until the patient receives his or her in-depth assessment the nursing staff will use the Environment Patient Safety Checklist to ensure that the patient has been provided a safe environment. A. Emergency Department: 1. At a minimum, a Registered Nurse will complete a suicide risk screen on all patients 13 years of age or older who present with a behavioral health related primary complaint or who exhibit sign/symptoms of [DIAGNOSES REDACTED]. The result of the assessment will determine the level of risk and corresponding monitoring and interventions required to maintain patient safety. 3. If the patient can not be assessed upon arrival due to the patient's medical status, i.e. (example) the patient is unconscious, intubated, intoxicated, or mentally unable to respond, the assessment will be postponed until the patient can be assessed. This assessment should be performed as soon as the patient's condition permits. Any concerning or contributing history or circumstances that might indicate an increased risk of suicide shall be included in hand-off communication and communicate to all Hospital personnel involved in the care of the patient ...B. Inpatient Procedure 1. At a minimum, all patients admitted to the hospital 13 years of age or older with a behavioral health related chief complaint or shows sign/symptoms of [DIAGNOSES REDACTED]'s safety is maintained by the following: a. the patients environment is secured using the Environment Patient Safety Checklist at a minimum of every shift ...5. A patient who is suspected of self-harm but is unconscious, comatose or unresponsive due to his or her medical condition requires frequent assessments by the Registered Nurse ...as soon as the patient regains consciousness, the patient will be screened for suicidal risk and if appropriate assessed for level of risk and appropriate level of suicide precaution. 6. Implement close observation process using the Close Observation Record. Notify the Physician and receive consult for appropriate assessment by psychiatrist ...10. Inpatient Documentation: a. admitted patients will have the suicide screen documented as part of the initial assessment/screening form. b. the nursing staff will use the Environment Patient Safety Checklist to document securing the patient's environment and complete each shift. c. the nursing staff will document the patient's behavior and activity on the Close Observation Record. d. admitted patients at risk for suicide will have an assessment performed and documented on the Parasuicidal Risk Assessment Form. e. Clinical status of the patient will be documented along with changes in physical or emotional condition on the Close Observation Record. f. a daily suicidal risk assessment will be completed by a Registered Nurse using Para suicidal Risk Re-assessment. These results will be shared with the physician who will determine whether to continue, revise or discontinue suicide precautions ..."

Review on 10/22/2013 of hospital policy "Sitter Usage, Assessment, Implementation and Discontinuation" revised date of 09/04/2012 revealed "This policy applies to all clinical patient care areas of (Name) Regional Medical Center that utilized sitters for patient care and safety ...II. PURPOSES: ...to outline the process for the assessment, implementation, discontinuation, staffing, and monitoring/tracking of sitters. III. DEFINITIONS: A....'Psych' means related to the care of a psychiatric condition, suicidal ideations, or state-required observations. B. 'Non-psych' means related to the care of non-psychiatric conditions, interference with medical care confusion, or the inability to follow instructions ...V. PROCEDURE: A. Assessment of Sitter Usage 1. the nurse assesses the patient's physical condition, behaviors, and emotional status to determine if constant observation of the patient is needed to ensure the patient's safety ...2. The nurse assesses for the following criteria/risk factors for sitter usage: a. suicide precautions and/or state-required observations. b. danger to self ...c. severe behavioral or cognitive issues (impaired judgment, disorientation, confusion, agitation, impulsivity, etc.) ...f. wandering or at risk for elopement ...B. Clarification of Terms: sitters (unlicensed personnel) are utilized as a supplemental staffing solution when continuous observation of a patient is indicated to ensure the patient safety within the immediate care environment ...is appropriate in any clinical setting when a Registered Nurse's assessment determines that a patient's physical safety is at risk ...C. Ordering of sitters: 1. A physician may write an order for use of a sitter for the above stated reasons, however, it is not required ...E. Implementation of Sitters: 1. the RN assigned to the patient remains responsible for the nursing care throughout the shift regardless of the presence of a sitter ..."

Closed medical record review on 10/23/2013 for Patient #6 revealed a [AGE] year old male admitted to the hospital's South Campus Psychiatric Unit on 10/03/2013 with an Admitting Impression of Paranoid schizophrenia - acute exacerbation, alcohol abuse and personality disorder. Review of Physician #1's History and Physical (H&P) dictated 10/03/2013 at 1219 revealed "History of Present Illness: Patient has a long-standing history of psychiatric disease since he was about 21 years of age....patient was recently released from prison where he was institutionalized for unadmitted guilt. Patient today has erratic, unpredictable behaviors, racing thoughts, flight of ideas, poor sleep. He reports auditory hallucinations of voices that are accumulating and getting stronger. ...he has no insight and judgment. He is depressed. He denies suicidal or homicidal ideations, but reports positive death fantasies..." Review of Physician #1's discharge summary dated 10/11/2013 revealed "REASON for ADMISSION: ...reports auditory hallucinations, command type, to hang himself; visual hallucination, seeing eyes and owls and tactile hallucinations, feels like he has ESP (extrasensory perception) and paranoid ideation ...During his hospital course he was placed on Latuda (antipsychotic medication)..with a decrease of auditory hallucinations ....he was discharged to outpatient care ..." Continued review revealed the patient was discharged on [DATE] at 1440.

Open medical record review on 10/23/2013 revealed Patient #6 presented to the hospital's Emergency Department (ED) on 10/11/2013 at 2358 (9 hours 18 minutes after discharge from the psychiatric unit) via EMS (emergency medical services) after being found face down in the dirt, unconscious, and unresponsive. Review of the ED Physician's (Physician #2) documentation revealed the patient was intubated and placed on ventilator support (machine breathing for the patient). Continued review revealed "...HPI (history of present illness): ...the patient presents with decreased mental status....he has just been discharged from (hospital name) South Campus earlier today...Past Medical History: Schizophrenia ...EXAM: ...patient appears comatose...Disposition: Critical Care...Disposition Summary: Admit ...Preliminary diagnosis are Altered LOC (level of consciousness) Pneumonia, Respiratory Failure, Fever ..."

Review of the ED RN (registered nurse) Nursing assessment dated [DATE] at 2358 revealed "Presentation: Presenting complaint: EMS states: Unresponsive ...Triage Assessment: General: Appears distressed, behavior is listless. Neuro: level of Consciousness is unresponsive...Historical: PMHx (past medical history): Schizophrenia...Screening: Abuse screen...fall risk screen...nutritional screening..." Continued review revealed no available documentation of a Suicide Risk Screen while the patient was in the ED. Continued review revealed the patient was admitted and transferred to the Neurologic Intensive Care Unit (NICU) on 10/12/2013 at 0426.

Review of the acute care admitting Physician #3's H&P dictated 10/12/2013 at 0419 revealed "...History of present illness: this is a [AGE] year old male with a past medical history of [DIAGNOSES REDACTED]...ASSESSMENT: ...recently discharged from the South Campus, who is now admitted with 1. Acute respiratory failure 2. Sepsis 3. Acute metabolic [DIAGNOSES REDACTED] 4. Probably right lower lobe pneumonia, likely healthcare acquired with aspiration 5. Dehydration."

Review of a NICU RN Admission Assessment completed on 10/12/2013 at 0528 revealed "...Medical History & Problems: Schizophrenia...Psychosocial/Suicide Screening: Suicide 13 years or older: Yes; (Comment: unable to answer questions, patient intubated, unresponsive, sedated); Suicide Attempt last 12 months: Yes; Suicide Feeling Depressed: Yes; Suicide Feeling Hopeless: Yes ..."

Review of nursing documentation dated 10/14/2013 revealed the patient was extubated and removed from ventilator support at approximately 1100. Review revealed the patient was assessed by a RN at 1230 as: Behavior: age appropriate, calm, cooperative ...Mood: Content; at 1615: Behavior: age appropriate, calm, cooperative ...Mood: Content; and at 2000: Behavior: Anxious, Cooperative, Remorseful. Mood: Appropriate. Further review of nursing documentation dated 10/15/2013 revealed the patient was assessed by a RN at 0400 as Behavior: Anxious, denying, excessive talk, insomnia, paranoid, restless; Mood: Anxious, despondent, remorseful; at 0805: Behavior: Anxious, Excessive talk, fearful; Mood: Anxious, despondent, remorseful; at 1128: Behavior: Anxious, Argumentative, Belligerent, Distractible, Excessive talk, Impulsive; Mood: Anxious, Despondent, Remorseful; at 1400: Behavior: Active, Delusional, Excessive talking, anxious and easily distracted. Continued review of nursing documentation dated 10/15/2013 at 0028 revealed "discussing religion with staff, excessive talk at times." and at 0549: "continuously states, 'I just feel weird', states 'all this medicine is making me feel funny'."

Review of the Interdisciplinary Progress Record Pastoral Notes dated 10/15/2013 at 1020 by a Hospital Chaplain, revealed "I was asked to visit pt (patient) at his request ...explained some of his psychological issues including schizophrenia and bipolar disorder and told me that he is currently manic. Pt had a new testament of the Bible open on his lap when I entered the room and he referred to scriptures several times during my visit. When I asked pt why he was here he said he'd fallen on the ground and was holding onto some tree bark ...Pt told me he'd taken a lot of pills and sometimes didn't take them ...he asked to be excused because he had to take care of something and asked me to close the curtain on my way out...RN thanked me ..."

Continued review revealed no available documentation of reassessment of the patients Psychosocial/Suicide Screening or Assessment after extubation on 10/14/2013 at approximately 1100. Continued review revealed no available documentation of the completion of the Parasuicidal Risk Assessment; the Parasuicidal Risk Re-assessment; the Close Observation Record; nor the Environment Patient Safety Checklist after the patient was extubated.

Continued review revealed the patient was transferred from the NICU to the 4th floor Nephrology/Oncology Nursing Unit (4 North) on 10/15/2013 approximately 1430. Review of the Nursing Communication report revealed "Past Medical History: Schizophrenia ...Psychosocial Factors: (0)." Continued review revealed no available documentation of a transfer note or SBAR (communication tool used among healthcare teams to communicate patient information: Situation, Background, Assessment, Recommendation) communication by the NICU RN communicating to the 4 North receiving RN that a Psychosocial/Suicide Screening and Parasuicidal Risk Assessment/Re-assessment needed to be completed on Patient #6.

Review revealed no available documentation of an assessment performed by the 4 North receiving RN after the patient arrived on the unit. Continued review revealed no available documentation of reassessment of the patients Psychosocial/Suicide Screening, completion of the Parasuicidal Risk Assessment, the Parasuicidal Risk Re-assessment, the Close Observation Record, or the Environment Patient Safety Checklist by the 4 North nurse.

Review of nursing documentation dated 10/15/2013 at 1748 revealed "When receiving report, I asked about the patient's need of a sitter. (Name of transferring RN) said that she would ask the Dr. (doctor) and let me know. She had to call me back b/c (because) Dr. was on another phone. She called me back and said that the Dr. said that the pt did not need a sitter. I called my manager and asked her about a sitter and she said that if the Dr. did not order one, that we could not have one. Pt had been up in room walking, going to the bathroom he would lay down, he said that we were all in God's hands and I agreed with him ...At (around) 1700 ...I heard a commotion at the desk, I heard window blinds making a noise, I came out to the desk and the unit secretary said that he (Patient #6) talking about 404 (room), had jumped out the window. I went and looked out the window and saw the pt laying in the aluminum square box, that I assumed had something to do with the heat ducts. He was getting up. It appeared the blinds were thru his head from my vantage point, but he just moved them and got up. I could see blood from his arm/hand and from one of his feet. He was looking for his bedroom shoes. He placed on his foot and was looking for the other. He was standing in what looked to be dirty water. I asked him to please sit down, he sat on one of the round things and was about to fall off. I asked him if he wanted to pray, I could not hear his response. He went toward the front of the bldg (building) and jumped up on the wall to the next room that would lead to the front of the blding (building) and what I thought was nothing between him and the street. I continued to talk to him and beg him to sit down when some other nurses got him to come to a window opposite the wall where he jumped out. He layed down on the roof and placed his left foot inside the window and they placed pressure on his ankle with a blanket or towel. I then saw an RN walk out on the roof to help...the police officer may have been out there first, I am unsure."

Continued review revealed EMS responded and transported the patient to the hospital's ED at 1751. Review of the ED Physician's (Physician #4) H&P dated 10/15/2013 at 1953 revealed "...The injury occurred at the hospital. Mechanism of injury: jumped from a window 4th story, landing on 2nd story roof. Associated injuries: the patient sustained injury to the head, injury to the chest, left arm and left leg ...the patient has been recently seen by a physician: in the hospital. Hx (history) of psychiatric d/o (disorder) ...apparently broke out window and jumped landing on an air vent. Reportedly got up and walked to jump to the ground when he was stopped. PMHx: Schizophrenia ...ROS (review of systems) ...Psych: Positive for psychosis ...Exam: 1953 - Psych: Behavior/mood is cooperative, affect is flat, delusions/hallucinations are present and described as I jumped because I wanted to go for a walk ...Lacerations: wound repair of 3cm (centimeter) ...left calf ...wound repair of 10cm tendon involved ...left foot and left lateral ankle ...wound repair of 3cm ...laceration to palmar aspect of left forearm ...Disposition: Critical Care ...preliminary diagnosis are Suicide Attempt, Ankle Laceration, Tendon Injury, Arm Laceration, Leg Laceration ..."

Record review revealed at 2006 the patient was transferred from the ED to the NICU with 1:1 RN care and 24 hour police officer presence until 10/17/2013 when Patient #6 was discharged from acute care and transferred to the hospital's South Campus Psychiatric Unit where he is currently a patient.

Record review revealed no available documentation of a Suicide Risk Assessment/Suicide Precaution, a Parasuicidal Risk Assessment, Parasuicidal Risk Reassessment, nor an Environment Patient Safety Checklist being completed during the patient's hospital admission from 10/11/2013 (admission) through 10/17/2013 (time of transfer to Psychiataric Unit).

Review of the acute care attending Physician's (Physician #6) discharge summary dictated 10/18/2013 at 1328 revealed "Discharge diagnosis: Acute psychosis, Aspiration pneumonitis, Acute respiratory failure (resolved) ...laceration left forearm secondary to fall; laceration to left foot secondary to fall ...schizophrenia ...Reason for admission: ...[AGE] year-old-male with long standing medical history of [DIAGNOSES REDACTED]. He was intubated in the ED for airway protection ...Hospital course: the patient was admitted to the intensive care unit and maintained on ventilator support. He did well on ventilatory support ...following about 48 hours on ventilatory support, the patient was subsequently extubated successfully....and was resumed on his home psychiatric medications consisting of Latuda. The following day on 10/15/2013 the patient was transferred to a medical floor. He was place in a room across from the nurses' station. At approximately 5:00pm the nurses heard a pounding noise in the room and upon entering the room found that the patient had broken the window and the patient jumped from the window. He evidently landed on an air conditioning fan vent, which cushioned fall in an accordion type manner. He was noted to be walking on the roof 2 stories below following the leap.. The patient was attend to by staff on the roof and was subsequently taken to the ED where he was evaluated extensively. There was no evidence of fractures in his legs and no evidence of cervical fracture. No evidence of any broken ribs noted ...the patient was readmitted to the intensive care unit with involuntary commitment. He has had a sitter from the (city name) Police department since that time ...the patient was discharged to the South Campus (psychiatric unit) ...Condition at time of discharge: symptoms prompting admission have resolved. The patient unfortunately still has an acute psychosis and is involuntarily committed to the psychiatric facility."

Record review revealed upon admission to the hospital's South Campus Psychiatric Unit on 10/18/2013, Patient #6 was assessed by a Psychiatrist and "judged to be a risk to himself and others" with an initial impression of Paranoid Schizophrenia - acute exacerbation, Personality Disorder, Schizoaffective Disorder, and Status Post Suicide Attempt. Review revealed a Parasuicidal Risk Assessment was completed by an RN upon admission and the patient was assessed as a Moderate Suicide Risk.

Telephone Interview on 10/23/2013 at 1025 with RN #1 revealed "I cared for the patient after being seen in the ED post jumping from the window on 10/15/2013. After being seen in the ED he was transferred back to the NICU on 10/15/2013 around 7:00 - 7:30 pm. The ED nurse reported he had jumped from the 4th floor window and that he is psychotic. I knew the patient had a psychiatric history of schizophrenia because I had worked in the unit (NICU) prior to his transfer to the medical floor. Before being transferred to the medical floor he (Patient #6) kept talking off the wall about the bible...he would be singing a lot of religious songs ...I was not aware of any history of suicidal attempts. He said he jumped out the window because he wanted to go outside and he said God would take care of him. He was delusional, not sure if he was suicidal but he was delusional. No, I did not do a Suicide Risk Assessment or Re-assessment. He was my only patient, he was a 1:1 during his second stay in the NICU and a police officer set with him 1:1 also...I cared for the patient after he jumped from the 4th floor window and at no time did I complete a suicide risk screen or assessment..."

Interview on 10/23/2013 at 1100 with the ED nurse manager revealed "there was no Suicide Risk Screen or Suicide Risk Assessment completed in the ED since the patient was unconscious ...it should have been noted in the chart that the assessment was not able to be performed ...I was not aware of the policy that the patient's were to be screened once extubated and off the ventilator ...the staff knew he had been admitted to the South Campus (Psychiatric Unit) for schizophrenia but they were not aware of any suicidal risks ...ED nurse normally initiates the Suicide Risk Screen but in this case it was not done because the patient was not able to answer. If it is not done in the ED then it is to be completed by the nurse on the unit..." Interview confirmed the Suicide Risk Assessment was not completed in the ED per policy.

Interview on 10/23/2013 at 1100 with the nurse manager of the 4th floor (4 North) revealed "I was aware of the policy for assessment and reassessment of the patient ...the policy states if a patient can not answer the suicide risk assessment questions upon admission due to being intubated or other reason then the assessment is to be completed as soon as the patient is able to communicate. I was not aware of any of the forms we were to use that are mentioned in the policy. The staff knew he was admitted with history of schizophrenia but did not do a suicidal risk assessment ...it is documented in the chart that he was paranoid and after extubation there is no re-assessment of his suicide risk....There is no documented assessment by the receiving RN after his transfer to 4th floor. The nurse has 4 hours to make an assessment. The RN greeted and saw the patient but she did not have time to do her assessment before the patient jumped from the window...he was on the unit (4th North) approximately 2 hours. The nurse reported he was anxious, nervous and picking at his covers...We have hand off communication, the RN in the ICU called the nurse on 4 th floor and she gave her a verbal report that she writes down but it is not part of the permanent record...According to the admission risk assessment by the NICU RN the patient was assessed to be at risk for suicide but we don't know how she got the information since the patient was intubated but since he was identified upon admission there should have been a follow up reassessment and his suicide risk identified and a Parasuicide risk assessment done...we have identified the policy was not followed. The receiving nurse asked for 1:1 sitter for the patient because he had a history of Pedophilia and our unit is next to the Pediatric unit...she was concerned with safety of the Pediatric patients. She did not report to me his agitation nor his delusional behavior...we prefer to have a physician order for a sitter but the nurse can make that decision per policy...I would have expected the care plan to address his coping and anxiety and any risk of suicide but it was not addressed..." Interview confirmed the policy for Suicide Risk Assessment and Sitter Usage was not followed.

Telephone interview on 10/23/2013 at 1150 with the admission RN (#2) revealed "yes, I was the nurse that completed his admission assessment when he came to the NICU on 10/12/2013. I completed his Suicide Risk Screen based upon the history from the ED who reported, either from the ED doctor reports or the nurse that from his previous psychiatric admission he had attempted suicide or was suicidal. The ED record indicated they had reviewed his history from the Psychiatric unit since he was just discharged from there early that same day. I reviewed the documentation from the ED that was available and that's what I went by. I was aware he had history of suicide attempts. I did not know about the risk assessment policy regarding once the patient is extubated the Suicide Risk Form and Level of observation was to be completed. I wasn't aware of any other documents that needed to be completed once a patient was screened as a suicide risk...I don't recall if I reported to anyone he had a history of suicide attempts but did report he had extensive psychiatric history. I did not do the Care Plan due to time constraints..." Interview confirmed the patient had been screened for Suicide Risk and the nursing staff failed to follow policy for reassessment.

Interview on 10/23/2013 at 1159 with RN #3 revealed "I was the nurse caring for the patient when he was moved from NICU to 4-North. I cared for him on the 14th and the 15th. On the 15th when I came in that morning he had expressed wanting all the wires off him (medical equipment wires) which I did after getting an order. He was anxious, paranoid about why he had to have all of the equipment so I got an order to remove them...he wanted to put on his clothes and said he was looking forward to being discharged ...he was delusional and reading the bible and talking excessively about God....I was aware he had a history of Schizophrenia and had been a patient at the South Campus..I was not aware of his Psychosocial Suicide Risk Screen that was done upon admission. Unfortunately, it is not part of our daily reassessment, the risk screen is only done on admission. I am aware of the Suicide Policy and that if a patient is suicidal should be reassessed each day. I am not aware of the Parasuicidal Form or the other documents that are in the policy...I did not at anytime after the patient was removed from the ventilator complete a suicidal risk reassessment or complete the Parasuicidal Risk Assessment Form...When I transferred the patient to the 4 th floor I told (name) he seemed more anxious and I worried he might just walk out...we both felt he needed a sitter cause we felt he would walk out of the facility, I never felt like he would hurt himself. He was delusional but it was more obsession with God. I called the doctor for 1:1 sitter order but he (the doctor) felt it wasn't necessary since the patient was not IVC'd if he wanted to leave the facility he could. I thought you had to have a physician order...I did feel he was progressively more agitated, anxious, and delusional..." Interview confirmed the policy Suicide Risk Assessment and Sitter Usage Policy were not followed.

Telephone interview on 10/23/2013 at 1325 with RN #4 revealed "I was the nurse who received the patient upon transfer to the 4 North. I received a telephone report of his medical condition and informed he had history of Pedophilia and had extensive psychiatric history that had been reported when he came to the ED. Upon transfer I went with the patient and the NICU nurse to his room. He was pleasant. He asked me if he could exercise in the room...he was in street clothes, I did not do an assessment at that time I had every intention of doing my assessment but I didn't get it done before he 'exited' the window. I'm not sure what the policy says about reassessment of patients at time of transfer...he was restless...it wasn't reported to me that he was delusional just restless. I wasn't aware of any suicide risk screening or history of suicide risks...I did not do a Suicide Risk Screening. I did not complete the forms that are in the policy. I thought he might try to leave the hospital. I requested a sitter because I was afraid he would try to leave the hospital and because our unit is in close proximity to the Pediatric unit and with his history of pedophilia I was concerned for the safety of the Pediatric patients if he would wander off. We, the transferring nurse and I discussed the need of a sitter since we felt he was a flight risk. But Doctor (name) said it wasn't necessary. I called my nurse manager to make her aware of his psychiatric history and asked if we could have a sitter that I really felt he needed a sitter since I thought he was a flight risk but she denied the request. She said if the doctor didn't order it then it couldn't be granted. He (Patient #6) shut the door one time and I asked him to leave it open. He told me he wanted to go outside and play in the rain and I told him it wasn't raining and that the doctor wanted him to stay in his room. He had his Bible reading it. He was very religious...reading out loud. I was in another patient's room when I heard a loud noise and they told me he had jumped out the window. I looked out the window in his room and he was sitting on the roof with shards of glass still in the window. I was concerned because he was getting up...put his shoe on, walking around on the roof...I was scared he was going to run and jump off the roof on to the street but then other nurses were there helping him..." Interview confirmed the policy Suicide Risk Assessment and Sitter Usage Policy were not followed.

Telephone interview on 10/23/2013 at 1345 with Physician #6 revealed "I was aware of his discharge from the hospital's Psychiatric Unit the same day he was brought back to the ED unconscious
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, medical record reviews, and staff interviews the hospital's nursing staff failed to monitor a patient during restraint per hospital policy for 1 of 3 patients (#3) restrained for management of violent or self-destructive behaviors.

The findings include:

Review of hospital policy "Restraint and Seclusion" revised 07/2012 revealed "...V. PROCEDURE: ...D. Patient needs will be met during restraint use ...3. Monitoring and Reassessment a. The restrained patient is assessed, monitored, and reassessed by the LIP (licensed independent practioner), RN and LPN. ...c. Monitoring is accomplished by observation, direct face-to-face interaction with the patient or related direct examination of the patient by trained and competent staff. d. Appropriate interval for re-assessment is based on the patient needs, condition, and type of restraint use. ...Violent Restraint Track Continuous monitoring with real time documentation of assessment of restrained patient at least every 15 minutes (table). ...f. A patient in restraint or seclusion for violent or self-destructive behaviors is monitored through continuous, uninterrupted in-person observation by an assigned staff member who is competent and trained to do so. ..."

Closed medical record review on 10/23/2013 for Patient #3 revealed an [AGE] year old female admitted on [DATE] and discharged on [DATE] with a diagnosis of Anxiety, Attention Deficit Hyperactivity Disorder, et al. Review of a "Management of Violent Or Self-Destructive Restraint" form dated 10/18/2013 revealed an order for restraint signed by a physician at 0620 for the management of violent and self-destructive behaviors. Review revealed "refusing needed medical care (oxygen, etc) striking at nursing" and "Pt (patient) is very agitated, striking out at personnel, foul language, refusal to cooperate." Review revealed the patient was placed in restraint at 0615 and released at 0715 (60 minutes later). Review of nursing restraint monitoring documentation dated 10/18/2013 revealed documentation the patient was monitored at 0615 (at initiation), 0715 (at release), and 0815 (1 hour post release). Record review failed to reveal any available documentation the patient was monitored every 15 minutes per hospital policy at 0630, 0645, and 0700 while restrained.

Interview on 10/23/2013 at 1200 with Administrative Management Staff revealed patients placed into restraints for the management of violent and self-destructive behaviors are to be monitored every 15 minutes per hospital policy. Interview revealed the nursing staff are to assess and document the patients behavior/condition, care performed, and circulation checks each 15 minutes while restrained. Interview confirmed Patient #3 was restrained for violent and self-destructive behaviors. Interview confirmed the patient was placed in restraint at 0615 and released at 0715. Interview confirmed no available documentation of monitoring every 15 minutes at 0630, 0645, and 0700 while the patient was restrained. Interview confirmed the nursing staff failed to follow the hospital's restraint and seclusion policy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, medical record reviews, and staff interviews the hospital's nursing staff failed to document one or more of the following elements: patient's immediate situation; reaction to restraint; medical and behavioral condition; and need to continue or terminate the restraint or seclusion; for the one hour face-to-face evaluation for 1 of 3 patients (#3) restrained for management of violent or self-destructive behaviors.

The findings include:

Review of hospital policy "Restraint and Seclusion" revised 07/2012 revealed "...V. PROCEDURE: ...B. Authorization and Ordering of Restraints ...Additional assessment by physician or trained RN or PA required within 1 hour of order regardless of removal of restraint/seclusion. (table)..." Further policy review failed to reveal requirements for the trained staff to document the patient's immediate situation; reaction to restraint; medical and behavioral condition; and need to continue or terminate the restraint or seclusion; for the one hour face-to-face evaluation.
Closed medical record review on 10/23/2013 for Patient #3 revealed an [AGE] year old female admitted on [DATE] and discharged on [DATE] with a diagnosis of Anxiety, Attention Deficit Hyperactivity Disorder, et al. Review of a "Management of Violent Or Self-Destructive Restraint" form dated 10/18/2013 revealed an order for restraint signed by a physician at 0620 for the management of violent and self-destructive behaviors. Review revealed "refusing needed medical care (oxygen, etc) striking at nursing" and "Pt (patient) is very agitated, striking out at personnel, foul language, refusal to cooperate." Review revealed the patient was placed in restraint at 0615 and released at 0715 (60 minutes later). Review of nursing restraint documentation dated 10/18/2013 revealed documentation of a one hour face-to-face evaluation (#1) being conducted at 0620 (5 minutes after restraint application) by Registered Nurse A. Review of the face-to-face evaluation documentation failed to reveal documentation of the patient's reaction to restraint; medical condition; and need to continue or terminate the restraint. Further review revealed documentation by RN #B at 0730 (1 hour and 15 minutes after restraint application) of a face-to-face evaluation (#2) being conducted. Review failed to reveal documentation of the patient's immediate situation and medical condition.

Interview on 10/23/2013 at 1200 with Administrative Management Staff revealed the hospital's nursing supervisors conduct the one hour face-to-face evaluations for restrained patients on acute care units. Interview revealed the one hour face-to-face evaluation for Patient #3 was conducted at 0620 by a nursing supervisor (RN #A). Interview revealed the one hour face-to-face documentation by RN #A did not contain all of the elements required to be documented by CMS (Centers for Medicare and Medicaid) regulation. Interview revealed Patient #3 was reassessed at 0730 by a nursing supervisor (RN #B) and the restraints were removed. Interview confirmed the documentation by RN #B did not contain all of the elements required to be documented by CMS.