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.

ROYAL OAKS HOSPITAL 307 N MAIN WINDSOR, MO 65360 Sept. 13, 2017
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review, and policy review the facility failed to:
- Ensure patients admitted with suicidal ideation's (SI - thoughts of harming/killing self) were appropriately assessed for risk of suicide and that proper interventions were in place to prevent the potential for suicide for one current patient (#1) of 16 current patients that were admitted with suicidal ideation's. (Refer to A-0395)
- Develop interventions to correlate with the Columbia Suicide Severity Rating Scale (C-SSRS a suicide ideation rating scale created by researchers at Columbia University to evaluate suicidality in children ages 12 and up) to ensure consistent assessment and precautionary levels were placed on patients admitted with suicide ideation's for one current patient (#1) of 16 current patients reviewed. (Refer to A-0395)
- Ensure their facility policies showed direction for Registered Nurses (RN) (not a Licensed Practical Nurse, LPN) to perform the initial assessment/reassessments and the suicide risk assessment for all patients admitted to the facility. (Refer to A-395).

1. Patient #1 was an [AGE] year old male who was admitted on [DATE] after he had attempted to asphyxiate (suffocate) himself with plastic wrap. Patient #1's C-SSRS showed active suicidal thoughts, suicidal ideation with a plan to asphyxiate himself. Patient #1 was on 15 minute safety checks but had no other suicide precautions in place based on his suicide risk scale assessment or his attempt that led to his admission. The facility had no process to implement interventions in relation to how patients scored on this risk scale.

These failures had the potential to place all patients admitted to the facility at risk for their safety. The facility census was 30.

The severity and cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

2. On 09/12/17, after the survey team informed the facility of the IJ, facility staff created educational tools and began educating staff and put into place interventions to protect patient within the entire facility.

3. As of 09/13/17, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Revised the Suicide Risk Assessment Policy to include an intervention guide to correspond with the C-SSRS Assessment (completed 09/12/17);
- Medical Staff reviewed the updated policy revisions, amended and approved enhanced policy;
- Board meeting was scheduled for policy review and revision (In progress 09/12/17);
- Reviewed the revised Suicide Risk Assessment Policy with each nurse (began 09/12/17);
- Reviewed the Client Protective Levels Policy with the Mental Health Technicians (MHT) (began 09/12/17);
- Reassessed 100% of all patients who met the criteria for increased interventions, based on their C-SSRS, and placed on interventions to meet the newly revised policy;
- An additional Relias Suicide Training will be added to the nurses training environment. Course Title: Suicide Screening and Risk Factors. Course Description: The above course was developed by the National Institute of Mental Health and The American Foundation for Suicide Prevention. The course teaches specific risk factors that puts an individual at increased risk for suicide. Additionally, the course teaches about screening, the initial intake process and what to do if someone was suicidal. (Began 09/12/17);
- Completion of a computer based test;
- Scenario review by all nursing staff for all shifts (began 09/12/17 evening shift);
- Physician training for the C-SSRS intervention policy that was developed with the recommendations of the Assistant Medical Staff Director;
- All physicians received the guidelines on 09/12/17 during their Medical Staff meeting;
- Physicians participated in a face to face training, prior to seeing patients and will be 100% trained prior to their next patient encounter. The training included policy review, C-SSRS tool, the physician's role in the assessment and providing orders for safety. (Began 09/13/17);
- All part time staff and any staff on leave will be trained prior to providing patient care;
- Nursing staff were given a scenario and asked to complete the C-SSRS and apply the recommended interventions based on the screening criteria;
- MHT and admission staff completed a written test that included elements of medical stability, patient safety precautions, elopement precautions, body/belonging search, physical environment assessment and suicide rating scale. A score of 100% was to be obtained prior to assuming position, if the staff missed a question; immediate teaching was to be done until the staff verbalized the correct protocol;
- Daily monitoring and training on 100% of patients with suicide risks was to be done on all shifts for two weeks (began on 09/12/17 evening shift);
- When monitoring was 100% compliant the audit will decrease to 50-75% of suicidal patients twice per week then 25%-50% once per week then 10% per week as an ongoing monitoring to ensure continued compliance; and
- At any time if one staff missed the intent of the above process it would start over again with 100% compliance and resume daily on all shifts.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, observation, record review, and policy review, the facility failed to:
-Ensure patients admitted with suicidal ideations (SI - thoughts of harming/killing self) and/or suicide attempt was appropriately assessed for risk and that proper interventions were put into place to prevent either SI and/or attempt for nine current patients (#1, #2, #3, #4, #5, #6, #7, #8 and #9) out of 16 current patients reviewed admitted with either SI and/or attempt.
-Develop interventions to correlate with the Columbia-Suicide Severity Rating Scale (C-SSRS - a suicide ideation rating scale created by researchers at Columbia University to evaluate suicidality in adults and children) for nine current patients (#1, #2, #3, #4, #5, #6, #7, #8, and #9) out of 16 current patients reviewed.
-Ensure the facility's policy showed direction for Registered Nurses (RN) and not Licensed Practical Nurses (LPN) performed the initial assessment, reassessment and suicide risk assessment for three current (#3, #6 and #9) out of 16 current patients reviewed admitted with SI and/or attempt to the facility.

This placed all patients admitted with either SI and/or attempt at increased risk. The facility census was 30. The Pre-Adolescent Unit had four patients admitted with either SI and/or attempt, the Adolescent Unit had six patients admitted with either SI and/or attempt and the Adult Unit had six patients admitted with either SI and/or attempt.

Findings included:

1. Record review of the facility's policy titled, "Suicide Risk Assessment," reviewed 6/26/14, showed the following directives for staff:
A. Patients shall receive a suicide risk assessment screen to be completed at the following times:
- At admission.
- When a change from the patient's baseline is noted in mood, affect or cognition with suicide risk factors.
- When a change in the level of supervision (precautions) is considered.
- Prior to discharge by the nurse or by a member of the patient's treatment team.
- Other times as determined by the treating clinicians.
B. An RN/LPN will:
- Complete suicide risk assessment upon admission. Identify factors and features that may increase or decrease the risk of suicide.
- Review the results of the risk assessment screen and the need to notify the physician for moderate and high risk indicators.
- Place patient on precautionary levels such as every 15 minute checks, line of sight or 1:1 as ordered by the physician.

Record review of the facility's, form "Columbia - Suicide Severity Rating Scale (C-SSRS) and Pediatric/Cognitively Impaired - Lifetime Recent - Clinical," dated 6/23/10 showed the following directives:
- Disclaimer: This scale is intended to be used by individuals who have received training in its administration. The questions contained in the Columbia - Suicide Severity Rating Scale are suggested probes. Ultimately, the determination of the presence of suicidal ideation or behavior depends on the judgement of the individual administering the scale.
The assessment tool contained the following sections:
- Suicidal Ideation: Ask questions 1 and 2. If both are negative, proceed to "Suicidal Behavior" section. If the answer to question 2 is "yes", ask questions 3, 4 and 5. If the answer to question 1 and/or 2 is "yes", complete "intensity of Ideation".
1. Wish to be Dead;
2. Non-Specific Active Suicidal Thoughts;
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act;
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan; and
5. Active Suicidal Ideation with Specific Plan and Intent.
- Intensity of Ideation: The following feature should be rated with respect to the most severe type of ideation (i.e., 1-5 from above, with 1 being the least severe and 5 being the most severe).
- Lifetime - Most Severe Ideation: Type # (1-5) and Description of Ideation
- Recent - Most Severe Ideation: Type # (1-5) and Description of Ideation
- Frequency - How many times have you had these thoughts? (1) Only one time, (2) At
Times, (3) A lot, (4) All the time and (5) Don't know/Not applicable
- Suicidal Behavior:
- Actual Attempt;
- Interrupted Attempt;
- Aborted or Self-Interrupted Attempt;
- Preparatory Acts or Behavior; and
- Actual Lethality/Medical Damage:
0. No physical damage or very minor physical damage (e.g., surface scratches).
1. Minor physical damage (e.g., lethargic speech; first-degree burns; mild
bleeding; sprains).
2. Moderate physical damage; medical attention needed (e.g., conscious but
sleepy; somewhat responsive; second-degree burns; bleeding of major
vessel).
3. Moderately severe physical damage; medical hospitalization and likely
intensive care required (e.g., comatose with reflexes intact; third-degree
burns less than 20% of body; extensive blood loss but can recover; major
fractures).
4. Severe physical damage; medical hospitalization with intensive care
required (e.g., comatose without reflexes; third-degree burns over 20%
of body; extensive blood loss with unstable vital signs; major damage to a
vital area).
5. Death
- Potential Lethality: Only Answer if Actual Lethality=0: Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medial damage, had potential for very serious lethality: put gun in mouth and pulled the trigger but gun fails to fire so no medical damage, laying on train tracks wit oncoming train but pulled away before run over).
0 = Behavior not likely to result in injury.
1 = Behavior likely to result in injury but not to cause death.
2 = Behavior likely to result in death despite available medical care.

Record review of the facility's policy titled, "Client Protective Levels," reviewed 06/26/14, showed the following information:
Protective Levels:
- Q (every) 15-Minute Checks: Based on the patient's assessed needs, observation may be done more often than 15-minutes, but no longer than 15-minutes.
- Line of Sight While Awake (LOS w/a): Client is within staff line of sight while awake. While sleeping, the client is placed on Q 15.
- Line of Sight (LOS): Client is within staff line of sight. Location and activity is documented every 15-minutes. While sleeping, client remains on line of sight.
- One-on-One (1:1): One-on-One staff is assigned to one patient. Based upon the client's activity, staff may remain at the patient's door while the client is in the room alone. If a patient is bathing or toileting, the staff member is to remain at the door, with the door ajar to maintain privacy. Location and activity is documented every 15-minutes. While sleeping, client is placed on line of sight.
Precautions:
- Assault (AP): Patients who have demonstrated at risk of harming others.
- Elopement (EP): Patients with a history of wanting to leave or wander away from the facility or environment unsupervised, unnoticed and/or prior to their schedule discharge.
- Suicide (SP): Patients at risk for self-inflicted, life-threatening injury.
- Medical (MP): Patients at risk for medical complications.

2. Record review of Patient #1's medical record showed he was admitted to the facility's Preadolescent Unit on 09/08/17 at 9:50 PM with complaints of suicide attempt by trying to asphyxiate (suffocate) himself with plastic wrap.

Record review of the patient's Preadolescent Unit: Admitting Orders dated 09/08/17 showed the psychiatrist ordered the following precautions:
- Q 15-minute checks;
- Suicide precautions; and
- Assaultive precautions.

Record review of the patient's Psychiatric Evaluation dated 09/09/17 showed the patient had three episodes of suicide attempts that included holding a lighter to his finger until it blistered, ingesting soap and putting plastic wrap around his face.

Record review of the patient's C-SSRS Pediatric/Cognitively Impaired - Lifetime Recent - Clinical assessment dated [DATE] showed an RN documented the patient's Intensity of Ideation as follows:
- Lifetime - Most Severe Ideation: 3;
- Description of Ideation: Asphyxiation;
- Recent - Most Severe Ideation: 5; and
- Description of Ideation: Medusas (Greek mythology monster with snakes for hair) venom (poison).
Scale: 1-5 with 1 being the least severe and 5 being the most severe.

The assessment tool only rated the patient's level of suicide severity but did not provide any guidelines or precautions that staff might consider initiating based on the assessment score, for example, 1:1, line of sight at all times, line of sight while awake or line of sight during the night.

Staff did not initiate additional precautions to address the patient's suicide severity score results related to suicidal ideations with a plan to asphyxiate self or ingest soap in an attempt to commit suicide while an inpatient at the facility.

Record review of the patient's Treatment Interventions dated 09/08/17 showed:
Problem: Danger to self as evidenced by putting plastic film over face.
Interventions:
- Monitor patient's mood, safety and AP/SP. Frequency=Q 15-minutes.
- Assess patient for thoughts to harm self using 0-10 scale. Frequency=Q shift.
- Monitor patient's interactions with peers and staff. Frequency=Q shift.

3. Record review of Patient #2's medical record showed she was admitted to the facility's Preadolescent Unit on 09/05/17 at 2:45 AM, with complaints of SI with plan to hang self and homicide ideation (HI-thoughts of harming or killing others) with plan to stab her mom in the throat.

Record review of the patient's Preadolescent Unit: Admitting Orders dated 09/4/17 showed the psychiatrist ordered precautions of Q 15-minute checks and SP.

Record review of the patient's Psychiatric Evaluation dated 09/05/17 showed the patient was admitted for making suicidal and homicidal statements. The patient's mom reported that the patient:
- Had made homicide statements towards the mom going on 2 months.
- Made statements about wanting to kill herself.
- Kicked her [AGE]-year-old sister in the head.
- Having anger outburst at school.
- Gets angry at mom, brother and sister at home.
- Stealing money and jewelry from mom.
- Destroying the walls in her room and siblings' toys.
- Ran away from home yesterday and mom had to call the deputies.
- Made suicide and homicide statements in front of the deputies.

Record review of the patient's C-SSRS Pediatric/Cognitively Impaired - Lifetime Recent - Clinical assessment dated [DATE] showed an RN documented the patient's Intensity of Ideation as follows:
-Lifetime - Most Severe Ideation: 5;
-Description of Ideation: Hang self;
-Recent - Most Severe Ideation: 5; and
-Description of Ideation: Hang Self.

The assessment tool only rated the patient's level of suicide severity but did not provide any guidelines or precautions that staff might consider initiating based on the assessment score results related to the patient's SI with a plan to hang self while an inpatient at the facility.

Record review of the patient's Treatment Interventions dated 09/05/17 showed:
Problem: Danger to self/others as evidenced by suicidal with plan to hang self and homicidal with plan to stab mom in the throat.
Interventions:
- Monitor patient for safety and SP. Frequency=Q 15-minute checks.
- Assess patient for thoughts to harm self/others on 0-10 scale. Frequency=Q shift.
- Monitor patient for aggressive behaviors. Frequency=On-going.
- Assess patient's interactions with staff and peers. Frequency=Q shift.
- Monitor patient's mood and affect. Frequency=Q shift.

4. Record review of Patient #3's medical record showed she was admitted to the facility's Preadolescent Unit on 09/05/17 at 1:00 PM with complaints of SI.

Record review of the patient's Preadolescent Unit: Admitting Orders dated 09/05/17 showed the psychiatrist ordered the following precautions:
- Q 15-minute checks;
- Suicide precautions;
- Assault precautions; and
- Elopement precautions.

Record review of the patient's Psychiatric Evaluation dated 09/07/17 showed that the patient had been having thoughts of "killing her mom." She was there because she had been having auditory and visual hallucinations. She had been hearing voices telling her to harm herself and others. She had threatened to kill her mom. She had been having command hallucinations about killing herself and others and that usually happens whenever she got up mad. She had been hurting herself with a plastic knife but does not leave any marks. She has a history of burning down the house in August 2016. She had a history of threatening her mom in the past as well. She got angry over simple things and it was usually when things were not going her way. The patient stated that she had been getting mad because she had been hearing voices and had been seeing things. She mentioned that the voices were coming from inside her head. This was the patient's third time at the facility and she had previous admissions to other psychiatric facilities. The reason for hospitalization at those places was for hallucinations and aggressive behaviors.

Record review of the patient's C-SSRS Pediatric/Cognitively Impaired - Lifetime Recent - Clinical assessment dated [DATE] showed an LPN documented the patient's Intensity of Ideation for Lifetime and Recent was not scored because questions 1 and 2 were negative and the form directed staff to proceed to the "Suicidal Behavior" Section.

Record review of the patient's Treatment Interventions dated 09/05/17 showed:
Problem: Danger to self and others as evidenced by told mom she is going to kill her with a knife and hears voices telling her to kill herself.
Interventions:
- Monitor mood, behavior, safety and SP/AP/EP. Frequency=Q 15-minute checks.
- Assess on scale of 0-10 for thoughts of harm to self and others. Frequency=Q shift.
- Assess for self-harm or aggressive behaviors. Frequency=Q shift.
- Educate patient to identify two coping skills to use to calm self. Frequency=On-going.

5. Record review of Patient #4's medical record showed she admitted to the facility's Adolescent Unit on 09/08/17 at 8:30 PM with complaints of SI.

Record review of the patient's Adolescent Unit: Admitting Orders dated 09/08/17 showed the psychiatrist ordered the following precautions:
- Q 15-minute checks;
- Suicide precautions;
- Assault precautions; and
- Elopement precautions.

Record review of the patient's Psychiatric Evaluation dated 09/10/17 showed that she reported to the school counselor that she was thinking of harming herself. Her grandfather passed away over a week ago and she was having a hard time dealing with his death and she had not really talked about her feelings to her mom. She stated that when she was in fifth grade she lost friends, bullying increased a lot and she was considered an outcast because she came out as being transgender, so she feels like she needs to be a different sex and she has changed her name to James as a result of it. She was not taking any hormones because her mom and step-dad were "transphobic and homophobic." She reported that she is pan-romantic meaning that she dates boy, girls, people of neither sex and both sex. She was not sexually active, but she was romantic hence the term pan-romantic.

Record review of the patient's C-SSRS Lifetime Recent - Clinical assessment dated [DATE] showed an RN documented the patient's Intensity of Ideation as follows:
- Lifetime - Most Severe Ideation: 5;
- Description of Ideation: Patient has had thoughts about cutting wrists and hanging self;
- Recent - Most Severe Ideation: 5; and
- Description of Ideation: Patient has had thoughts about cutting wrists and hanging self.

The assessment tool only rated the patient's level of suicide severity but did not provide any guidelines or precautions that staff might consider initiating based on the assessment score results related to the patient's suicidal ideations with a plan to cut wrists and hang self while an inpatient at the facility.

Record review of the patient's Treatment Interventions dated 09/08/17 showed:
Problem: Danger to self as evidenced by thoughts of self-harm for two weeks.
Interventions:
- Monitor for patient safety and SP/AP/EP. Frequency=Q 15-minute checks.
- Assess for SI/self-harm thoughts on a 0-10 scale. Frequency=On-going.
- Educate patient on positive coping skills. Frequency=On-going.
- Monitor patients mood and affect. Frequency=On-going.

6. Record review of Patient #5's medical record showed she was admitted to the facility's Adolescent Unit on 09/10/17 at 8:00 AM with complaint of "I kept having suicidal thoughts."

Record review of the patient's Adolescent Unit: Admitting Orders dated 09/10/17 showed the psychiatrist ordered the following precautions: Q 15-minute checks and suicide precautions.

Record review of the patient's Psychiatric Evaluation dated 09/12/17 showed that the patient thinks about hanging or cutting herself. The thoughts do not stop and have been increasing in the past month.

Record review of the patient's C-SSRS Lifetime Recent - Clinical assessment dated [DATE] showed an RN documented the patient's Intensity of Ideation as follows:
- Lifetime - Most Severe Ideation: 5;
- Description of Ideation: Thought only cutting or overdose;
- Recent - Most Severe Ideation: 3;
- Description of Ideation: Thought only to either hang or cut self.

The assessment tool only rated the patient's level of suicide severity but did not provide any guidelines or precautions that staff might consider initiating based on the assessment score results related to the patient's reported thoughts of either hanging or cutting self while an inpatient at the facility.

Record review of the patient's Treatment Interventions dated 09/10/17 showed:
Problem: Danger to self as evidenced by SI statements.
Interventions:
- Monitor SP. Frequency=Q 15-minute checks.
- Evaluate SI/HI on 0 to 10 scale. Frequency=On-going.
- Monitor patient's safety. Frequency=On-going.
- Monitor patient's behavior and affect with staff and peers. Frequency=On-going.

7. Record review of Patient #6's medical record showed she was admitted to the facility's Adolescent Unit on 09/07/17 at 10:55 AM with complaints of thoughts of self-harm and SI.

Record review of the patient's Adolescent Unit: Admitting Orders dated 09/06/17 at 11:19 PM showed the psychiatrist ordered the following precautions:
- Q 15-minute checks;
- Suicide precautions; and
- Assault precautions.

Record review of the patient's Psychiatric Evaluation dated 09/07/17 showed she was admitted to the hospital due to suicidal thoughts and threats to kill herself with depressive symptoms.

Record review of the patient's C-SSRS Lifetime Recent - Clinical assessment dated [DATE] showed an LPN documented the patient's Intensity of Ideation as follows:
- Lifetime - Most Severe Ideation: 1;
- Description of Ideation: 8th Grade;
- Recent - Most Severe Ideation: 5; and
- Description of Ideation: This section was left blank.

Record review of the patient's Treatment Interventions dated 09/07/17 showed:
Problem: Danger to self as evidenced by thoughts of harming self by cutting and SI.
Interventions:
- Monitor patient safety and AP/SP. Frequency=Q 15-minute checks.
- Monitor thoughts of SI/Self-harm by cutting by rating on 0-10 scale, Frequency=On-
going.
- Educate patient on positive coping skills to help with SI, self-harm and cutting.
Frequency=On-going.
- Assist patient to set daily goals to help with SI, self-harm and cutting. Frequency=On-going.

8. Record review of Patient #7's medical record showed he was admitted to the facility's Adult Unit on 09/04/17 at 12:30 PM with complaints of SI with attempt.

Record review of the patient's Adult Unit: Admitting Orders dated 09/04/17 showed the psychiatrist ordered the following precautions:
- Suicide precautions;
- Assault precautions;
- Elopement precautions;
- Medical precautions; and
- Line of Sight while awake.

Record review of the patient's Psychiatric Evaluation dated 09/04/17 showed that the patient attempted suicide by cutting his wrist that required 19 stiches. The patient had left a note to his mother explaining why he had to kill himself. He stated that he wanted to hurt himself because his life was causing too many problems. The patient has felt depressed for the past two years and attempted suicide via carbon monoxide poisoning.

Record review of the patient's C-SSRS Lifetime Recent - Clinical assessment dated [DATE] showed an RN documented the patient's Intensity of Ideation as follows:
- Lifetime - Most Severe Ideation: 5;
- Description of Ideation: Carbon dioxide inhalation;
- Recent - Most Severe Ideation: 5;
- Description of Ideation: Wanted to kill myself.

The assessment tool only rated the patient's level of suicide severity but did not provide any guidelines or precautions that staff might consider initiating based on the assessment score results related to the patient's SI and attempt with plan of cutting wrist while an inpatient at the facility.

Record review of the patient's Treatment Interventions dated 09/04/17 showed:
Problem: Self-Injurious Behavior as evidenced by patient has three lacerations on his left arm requiring 19 sutures in the ER (emergency room ).
Interventions:
- Monitor and assess patient for safety, AP, SP and EP. Frequency=LOS w/a.
- Patient on medical schedule for left arm lacerations. Frequency=Times one.
- Monitor and assess patient for SI using 0-10 scale and document. Frequency=Q shift.
- Assist patient in developing two coping skills for feelings of self-harm by discharge.
Frequency=Daily until completed.

9. Record review of Patient #8's medical record showed he was admitted to the facility's Adult Unit on 08/25/17 at 11:10 PM with complaints of explosive outburst toward foster dad.

Record review of the patient's Adult Unit: Admitting orders dated 08/25/17 showed the psychiatrist ordered the following precautions:
- Q 15-minute checks;
- Suicide precautions;
- Assault precautions; and
- Elopement precautions.

Record review of the patient's Psychiatric Evaluation dated 08/26/17 showed that the patient had a history of intermittent explosive disorder. He is currently a direct admit on a 96-Hour Hold from a local facility after he was brought in via EMS (Emergency Medical Services - ambulance) activated by the police following an aggressive outburst towards his foster dad. The patient reports he has been more physically aggressive in the last week. Triggers include aggravated with foster dad and feeling out of control when grabbed or touched. Reports foster dad tried to grab him a week ago which was why he hit him and smashed his face to the wall. The patient went to jail after the incident last week with his foster dad.

Record review of the patient's C-SSRS Lifetime Recent - Clinical assessment tool dated 08/26/17 showed staff did not fill in the Intensity of Ideation section of the assessment and left it blank.

Record review of the patient's Treatment Interventions dated 08/26/17 showed:
Problem: Danger to self/others SI/HI as evidenced by assaultive behavior and statements.
Interventions:
- Monitor for SP/AP/EP. Frequency=Q 15-minute checks.
- Monitor mood and affect. Frequency=Q shift.
- Educate patient on coping skills to use when experiencing anger. Frequency=Daily.
- Encourage group attendance and participation. Frequency=Daily and PRN (as needed).

10. Record review of Patient #9's medical record showed she was admitted to the facility's Adult Unit on 09/08/17 at 5:30 PM with complaints of SI with attempt with overdose.

Record review of the patient's Adult Unit: Admitting Orders dated 09/08/17 showed the psychiatrist ordered the following precautions:
- Q 15-minute checks;
- Suicide precautions;
- Assault precautions; and
- Elopement precautions.

Record review of the patient's Psychiatric Evaluation dated 09/10/17 showed the patient was brought to a local ER by ambulance on 09/07/17 after she overdosed on an over-the-counter sleeping pills. The patient had bought the pills with the intent of overdosing. The patient's roommate found the patient and called 911. The patient has struggled with depression most of her life and had suicidal thoughts since middle school. She feels like she had limited family support and has been diagnosed with major depressive disorder, recurrent and severe.

Record review of the patient's C-SSRS Lifetime Recent - Clinical assessment dated [DATE] showed an LPN documented the patient's Intensity of Ideation as follows:
- Lifetime - Most Severe Ideation: 2;
- Description of Ideation: Vary intensity (situational);
- Recent - Most Severe Ideation: 5;
- Description of Ideation: Whole bottle of meds.

Record review of the patient's Treatment Interventions dated 09/08/17 showed:
Problem: Danger to self as evidenced by overdosed on over-the-counter sleeping meds and in ICU (Intensive Care Unit) on 09/07/17.
Interventions:
- Monitor mood, behavior and safety for SP/AP/EP. Frequency=Q 15-minute checks.
- Assess on scale of 0-10 for thoughts of harm to self and others. Frequency=Q shift.
- Assess for and assist identification of three internal coping strategies to handle feelings related to depression. frequency=Q shift.

11. During an interview on 09/12/17 at 9:26 AM, Staff A, RN, Preadolescent Unit Manager, stated that the C-SSRS assessment tool did not have guidelines or precautions related to the results of the assessment.

During an interview on 09/12/17 at 10:35 AM, Staff B, RN, Chief Nursing Officer (CNO), CQI (Continuous Quality Improvement) Director, stated that:
- The facility had recognized and identified that the C-SSRS assessment tool did not have a guide for staff to follow after they had assessed a patient and received a score from the assessment.
- After the nursing assessment, staff gave the assessment to the physician and identifies danger to self or others.
- Precautions would be ordered based on findings and per policy.

During an interview on 09/12/17, Staff C, RN, CQI Analyst, stated that a memo about the C-SSRS was sent out to staff on 06/29/17 and the official start date for staff to utilize the form began on 07/01/17.

12. Record review of the undated facility document titled, "Job Description - Licensed Practical Nurse," showed an essential function was to perform assessment and reassessment of patients coming on shift, throughout shift and before going off duty.

13. During an interview on 09/12/17 at 1:15 PM, Staff D, LPN, stated that:
- Patients are usually admitted with orders for SP/AP/EP.
- She can do suicide assessments for patients.
- She would either report to the charge nurse or the patient's psychiatrist any statements made by the patient about SI during the C-SSRS assessment.
- The suicide assessment gave high, medium and low risks.
- After staff gets the risk level from the assessment they contact the patient's psychiatrist.
- All patients are admitted with Q 15-minute checks but that can change depending on the assessment results and order from the psychiatrist.
- She received training and education on how to use the C-SSRS and the assessment tool was put into place for use approximately two or three months ago.
- The C-SSRS assessment tool has a number of questions and some of the questions have values and the tool asks how many suicide attempts the patient has had.
- The questions guide staff during the questions based on how the patient responds, for example, if a patient answers this way then ask this question.
- The C-SSRS assessment tool does not guide staff on what preventive measures to put into place based on the patient's answer or score.
- The level of acuity was based on the orders from the patient's psychiatrist and on results from the assessment for SI and patient behaviors.
- Staff used their own judgement when deciding what precautions were needed for the patient and not based on just the assessment.

14. Through record review three current patient's (#3, #6 and #9) of 16 current patient records reviewed showed an initial suicide risk assessment documentation by an LPN. RN's have the necessary education and would be the responsible staff for patient assessments including suicide risk assessments.

15. During an interview on 09/12/17 at 1:40 PM, Staff E, RN, stated that:
- He did assessments when patients were admitted .
- The facility recently went to the C-SSRS assessment tool and he received education and training on how to use the new tool.
- The tool was scored from a scale of 0-5.
- If a patient scores high, the patient would be placed on 1:1 precautions, which means the patient is on continuous observations and the environment is safe.
- The new suicide assessment tool did not have a guideline for the results of the assessment.
- The new assessment tool shows the scale of severity but did not include precautions to be taken as a result of the severity.
- He would refer to the facility's precaution policy for guidance.
- The patient's psychiatrist orders what level the patient needed based on the admission and intake information.
- After the assessment staff can request the level be increased or decreased per the psychiatrist orders the level can be changed.
- Elopement precautions were based on the patient's history and behaviors.

During an interview on 09/13/17 at 9:05 AM, Staff B, RN, CNO, CQI Director stated that:
- Staff received a memo about the C-SSRS on 06/29/17 and the assessment tool was implemented on 07/01/17.
- Approximately four weeks ago, she and the DON identified that the C-SSRS did not guide staff what to do after they had completed the tool and what the assessment reflected.
- She and the DON felt like staff still provided patients with appropriate screening.
- The facility contacted the developer of the C-SSRS and they informed the facility that they could not recommend what tool to use because there are several versions of the tool and the facility would need to decide what tool to use.
- The developer informed the facility it would have to come up with their own interpretation and precautions for the suicide severity score.
- The developer was contacted by the facility on 09/01/17.

During an interview on 09/13/17 at 11:35 AM, Staff A, RN, Preadolescent Unit Manager, stated that:
- Patient #1 was no longer in imminent danger related to using plastic wrap to asphyxiate himself since he would not have access to plastic wrap while on the unit.
- Staff would be expected to do on-going assessments for the patient's SI for other items/means to self-harm.
- Suicide assessments were on-going and if a patient had increased indications of SI the psychiatrist was notified so an increased level of precautions was initiated.
- Staff was to document the change in level of precautions in the patient's medical record, Kardex (medical information system used by nursing staff as a way to communicate important information about patients) and treatment plan would be updated to reflect the change.
- The C-SSRS gives a patient's suicide severity risk but does not have a guide as to what precautions were recommended for the results of the assessment.
- Staff would need to follow-up with the patient's psychiatrist with the results of the assessment if an increased level of acuity was needed.

16. During an interview on 09/13/17 at 1:45 PM, Staff F, RN, DON stated that:
- She would prefer the RN to do the C-SSRS assessment tool but LPNs have been trained to do the assessment.
- After an LPN does the assessment an RN is expected to review the LPNs assessment.
- LPNs were not able to do the physical part of the assessment.

17. During a telephone interview on 09/21/17 at 8:15 AM, Staff F, RN, DON stated that:
- Patient #7 was placed on LOS w/a because of the laceration to his wrist that required 19 stitches.
- Patient #7 was still at risk for self-harm and the potential he might try to remove the stitches from the wrist due to his SI.
- Patient #9 was placed on Q 15-minute checks because the imminent danger of overdosing on pills was removed when she was admitted .

The facility had 16 current patients that had been admitted with either SI and/or a recent attempt of suicide and the only precautions that were in place were the every 15 minute checks. These 16 patients were still at risk for the potential for a suicide attempt.