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.

ST JOSEPH'S HOSPITAL 45 WEST 10TH STREET SAINT PAUL, MN 55102 Jan. 24, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and document review, the facility failed to ensure staff appropriately assessed, monitored, and intervened timely for 1 of 1 patient (P1) who attempted suicide with a pair of office scissors after repeated requests for staff to intervene regarding her pain control. The IJ began on 12/26/18, at 11:45 p.m. when it was determined the facility failed to ensure P1 was adequately supervised by staff, failed to ensure staff intervened on continued complaints of pain, failed to follow facility policies and procedures, and failed to complete a timely and thorough investigation when P1 attempted suicide by a self-inflicting stab wound to her abdomen with a pair of office scissors. The facility's lack of appropriate suicide precautions, assessment, monitoring and physician notification resulted in an Immediate Jeopardy (IJ) resulting in actual harm and serious injury with the potential for death. In addition, the facility failed to implement appropriate suicide precautions, perform assessments, monitor, and perform physician notification for potential suicide attempts for 6 of 10 patients (P3, P5, P6, P7, P9, and P10).

Facility administration were notified of the IJ on 1/18/19, at 3:44 p.m. The IJ was removed on 1/23/19, at 1:15 p.m. when the facility took steps to remove the immediate situation by launching an investigation of the incident, updating policies and procedures, auditing medical records, ensuring appropriate monitoring of suicidal patients, and educating staff.

Findings include: Refer to A-144.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview and document review, the facility failed to ensure staff appropriately assessed, monitored, and intervened timely for 1 of 1 patient (P1) who attempted suicide with a pair of office scissors after repeated requests for staff to intervene regarding her pain control. The IJ began on 12/26/18, at 11:45 p.m. when it was determined the facility failed to ensure P1 was adequately supervised by staff, failed to ensure staff intervened on continued complaints of pain, failed to follow facility policies and procedures, and failed to complete a timely and thorough investigation when P1 attempted suicide by a self-inflicting stab wound to her abdomen with a pair of office scissors. The facility's lack of appropriate suicide precautions, assessment, monitoring and physician notification resulted in an Immediate Jeopardy (IJ) resulting in actual harm and serious injury with the potential for death. In addition, the facility failed to implement appropriate suicide precautions, perform assessments, monitor, and perform physician notification for potential suicide attempts for 6 of 10 patients (P3, P5, P6, P7, P9, and P10).

Facility administration were notified of the IJ on 1/18/19, at 3:44 p.m. The IJ was removed on 1/23/19, at 1:15 p.m. when the facility took steps to remove the immediate situation by launching an investigation of the incident, updating policies and procedures, auditing medical records, ensuring appropriate monitoring of suicidal patients, and educating staff.

Findings include:

P1 arrived in the emergency department on 12/20/18, at 11:40 a.m. via ambulance (EMS) with diagnoses of suicidal ideation after ingesting alcohol and Ambien (sleep medication). P1 was found to have a depressed mood, suicidal ideation, a suicide plan, and previous history of suicide attempts. P1's family member had committed suicide 1 year ago. P1 had attempted suicide approximately at that same time. P1's spouse committed suicide in 2008. Social worker (SW) assessed P1 on 12/20/18, and determined P1 wanted to end her life by, "Any means necessary," and reported she would, "Try again." The SW recommended inpatient (IP) treatment at that time. P1 was transferred to the behavioral emergency center (BEC) holding area at 4:39 p.m. while she awaited her room placement. At 7:00 p.m. P1 was admitted to the IP psychiatric (psych) unit.

P1's 12/21/18, physician progress notes by psychiatrist (MD)-A identified P1's safety goal upon admit to IP psych was to remain free from injury during her stay. P1 had a history of nonepileptic seizures and depression for more than 20 years. P1 had a history of multiple suicide attempts. P1 overdosed on opiates in 2015 as a result of a history of chronic pain related to her back fusion. P1 was homeless at the time of her admission, was staying with her daughter. P1's family has a history of mental illness. P1 reported she was depressed, anxious, suicidal, and had no interest and received no enjoyment in doing anything. P1 was to be on 1:1 continuous observation. P1 was also placed on seizure precautions at that time as P1 reported she would get pseudo-seizures (nonepileptic seizures that are psychological in nature) when she was stressed or in pain.

P1's nursing progress notes indicated the following:
(1) 12/22/18, at 6:40 a.m. P1 was up walking in the hall at 2:00 a.m. and had heat applied to her back for pain. P1 accepted pain medication at 4:36 a.m. for pain rated 8/10 (pain scale with 0 being no pain to 10 being excruciating pain) with some relief. P1's 1:1 sitter was close by for safety and suicide precautions. P1 reported poor sleep related to pain.
(2) 12/23/18, at 5:00 a.m. P1 wanted to walk at 2:00 a.m. related to her back pain. Staff offered Tylenol, but P1 declined as she stated Tylenol would not help. P1 was offered a massage, and grew emotional stating the staff person was so kind to her for helping. An ice pack was also applied, and P1 was able to rest.
(3)12/23/18, at 10:00 a.m. P1 was identified as being angry and irritable. Pt complained of 8/10 pain in her lower back. Scheduled medication was given, and staff reported it seemed to be helpful. P1 was noted as having behavior outbursts in group therapy. P1 complained about the psych unit, and stated staff had not answered her questions to her satisfaction. P1 was still on a 1:1, however staff documented P1 requested to be off 1:1 as she stated she "was ok." At that time P1 denied suicidal or homicidal ideation, and made a verbal contract with staff for safety. The charge nurse was made aware of the request, was to reassess, and follow up.

P1's physician order dated 12/23/18, at 1:05 p.m. made by MD-B, a Hospitalist, had discontinued the 1:1 ordered by MD-A, for P1's seizure activity only. There was no mention MD-B had approved or was aware of the discontinuation for suicide precautions, or if staff had asked MD-A (P1's psychiatrist) if it was ok for P1 to be off suicide precautions with her previous history of saying she would commit suicide by any means possible, and still had suicidal ideation, but no definitive plan reported at that current time.

P1's nursing progress note dated 12/23/18, at 2:20 p.m. identified P1 as having been out for her noon meal, used an ice pack for her lower back, and was off 1:1 at that time.

Further review of P1's nursing progress notes indicated the following:
12/24/18, at 7:27 a.m. P1 complained of "overwhelming depression, hopelessness, and suicidal thoughts if her chronic pain becomes overwhelming because it is not well controlled." There was no indication if staff had notified the physician regarding new onset of suicidal thoughts related to her pain after the 1:1 had been discontinued for suicide precautions.
12/24/18, at 9:56 a.m. P1 was noted to "endorse SI [suicidal ideation] with no plan. Contracted for safety. Will continue to monitor."
12/24/18, at 12:16 p.m. P1 was still at risk for self harm.
12/24/18, at 12:19 p.m. P1 wanted to speak with MD-A regarding a transfer to a neighboring hospital. P1 told the SW she felt like she was a "bother" to hospital staff. The SW made no mention she had asked or followed-up on why P1 felt she was a bother to staff. The SW did identify barriers to discharge were symptom stabilization, medication management, and coordination of care.
12/24/18, at 12:30 p.m. MD-A noted P1 had not slept well related to back pain. P1 had chronic pain and stated she was resisting surgery prior to her admission, but she was now ready to do it. P1 was taken off opiates (narcotic pain medication) because she had overdosed in the past. MD-A noted P1 was off 1:1 precautions, but continued to have suicidal thoughts. MD-A noted P1 was on baclofen (medication for muscle spasms) 10 milligrams (mg) three rimes per day (TID). MD-A increased P1's dosage to include an as needed (PRN) dose of baclofen 5 mg TID in addition to the 10 mg dose, for muscle spasms, and added a lidocaine (topical anesthetic/pain) patch twice daily.
12/24/18, at 10:48 p.m. P1 rated her pain a 6/10, and declined intervention. There was no indication of what interventions were offered; either medical or non-pharmacological.
12/25/18 at 2:26 p.m. Staff reported P1 had a flat affect and was depressed, and continued to have suicidal thoughts. P1 was noted to be on a 1:1 at that time for behavior, and fall precautions.
12/25/18, at 3:04 a.m. P1 was given 5 mg baclofen and an ice pack per her request for 8/10 lower back pain. P1 was incontinent at that same time.
12/25/18, at 5:55 a.m. A rapid response (RR) was called when P1 became unresponsive. When P1 became responsive again, she complained her legs would not work because of her back pain. P1 complained staff were not helping her [with her pain]. P1 stated, "Why can't you move me to [the] medical [floor]? I can't take it up here." P1 reported she had seizure like activity when her back pain got bad. P1 reported to have these episodes when her "back pain was out of control." Staff administered meloxicam (nonsteroidal anti-inflammatory med) for pain and Vistaril (antihistamine) for anxiety. There was no indication if the medications were effective, or if P1 was reassessed to identify her level of pain.
12/25/18, at 7:13 a.m. MD-C (a resident physician) noted he responded to the RR. P1 began to talk about her back pain, and wanted a second opinion from a spine surgeon. P1 advised MD-C she had tried to commit suicide because of her back pain, and that was the reason she overdosed prior to admission. There was no indication MD-C reviewed P1's current medication regime or care plan, to identify if additional intervention could be made.
12/25/18, at 7:55 a.m. P1 complained of intractable pain (constant and severe pain). P1 had a pseudo seizure lasting approximately 20 minutes, and had fallen and hit her head. At that time she had no loss of bowel or bladder, but her blood pressure was markedly high at 171 (80-120 is normal) systolic. P1 demanded a transfer to a medical floor to have her back pain treated. P1 was wailing loudly that no one [staff] cared. P1 rated her pain at 10 almost every time she was asked. P1 received baclofen, Tylenol, Vistaril, meloxicam and omeprazole (treats stomach upset/ heartburn) early. By 8:30 a.m. P1 had a total of 4 pseudo seizures, and continued to demand to go to the medical unit to be treated for pain. P1 was hysterical, loud, and was rushing at the locked door on the step down psychiatric unit. P1 was escorted to the higher level lock-down unit (C-side) located within the psych unit.
12/25/18, at 11:46 a.m. P1's pain and discomfort was noted as manageable, yet P1 still complained of back pain. P1 declined her pain medication, but it was unknown which medication had been offered, as P1 reported earlier Tylenol would not work at controlling her pain. There was no indication if staff did a pain assessment to identify what pain level was manageable/acceptable to P1, or how P1 managed her pain before she came to the facility.
12/25/18, at 5:13 p.m. P1 demonstrated the ability to cope with her hospitalization and illness. There was no indication how that determination was made.
12/25/18, at 9:10 p.m. P1 began having gait disturbance and was unsteady with her walking. P1 was focused on her pain, and was upset she had not received Toradol (non-narcotic pain medication). P1 was preoccupied with her pain, and stated her depression was related to her pain, "I just want to die because of it." P1's ability to walk declined as the shift progressed. P1 required a pivot transfer to her bed with staff assistance. P1 remained on a 1:1 for suicide and falls. P1 was unable to contract for safety. There was no indication if P1's requests for non-narcotic pain medication had been conveyed to the physician, or any interventions made.
12/26/18, at 6:15 a.m. P1 remained on a 1:1. At 4:20 a.m. P1 requested a hot pack for her back. P1 slept in the chair as her back pain would not allow her to lay on her bed. At 6:10 a.m. P1 took a hot shower.
12/26/18, at 2:50 p.m. P1 was calm and cooperative, and was visible in the lounge. She complained of chronic back pain. P1 had reportedly refused pain meds, although there was no indication of what pain medication was offered. P1 contracted for safety. There was no indication if P1 remained on a 1:1 at that time.
12/26/18, at 4:00 p.m. MD-A noted P1 asked for a Toradol injection for pain. MD-A remarked he would ask the Hospitalist for it. At 5:38 p.m. an order was placed for a consult with the Hospitalist. The indication for the consult was back pain. It was noted P1 had overdosed on opiates in 2015. MD-A asked if the Hospitalist would consider a Toradol injection. The consult was ordered to be done that day.
12/26/18, at 11:45 p.m. Registered nurse (RN)-C noted she was giving report to the night shift when a behavioral technician (BT) entered the nurses station saying, "We have an emergency, the patient [P1] stabbed herself with a scissor." RN-C immediately went out of the nurses station. P1 was sitting in the lounge area with a scissors in her upper abdomen. No blades were visible outside of P1's body. P1 was able to talk and stated, "I did it because none of you will pay attention to me when I say I have pain. Now you will have to pay attention to me." RN-C noted she asked a code blue (emergency call) be called for emergency assistance. RN-C immobilized the scissors that remained in P1's abdomen. P1 became unresponsive and her pulse was lost. Cardiopulmonary resuscitation (CPR) began. After approximately 1 minute, P1 gasped and opened her eyes. Arm restraints were placed on P1, and the scissors was left in P1's abdomen, stabilized by bandages to prevent further trauma.
12/27/18, at 12:40 a.m. RN-C reported P1 was transferred to [admitting hospital] with EMS personnel. A report was given to EMS on significant events including time of initial stab. P1's assigned nurse [unknown] gave report as personnel arrived. The administrator on call was notified by the nursing supervisor. The unit was cleaned and safety checked to ensure no tubing or sharps used in the code were left unattended. There was no indication if staff had began an immediate investigation as to how P1 came across a scissors, what type of scissors it was, or if all scissors located on the locked unit were accounted for.

P1's admitting hospital's medical record identified P1 required exploratory surgery to identify the trauma from the scissors. The following notes were made in P1's medical record:
The operating room note dated 12/27/18, written by surgeon MD-D, identified the preoperative diagnosis was a self-inflicted abdominal stab wound. MD-D noted P1 had reportedly stabbed herself with a pair of "office-type" scissors.

The emergency department (ED) admitting nurse reported on 1/26/19, at the time of transfer the RN from the facility had reported to her P1 had a history of depression and suicidal ideation. P1 had a fall earlier that evening and hit her head on a table [in the lounge area]. P1 was reportedly walking around asking for snacks when a "code" happened on the unit and "all staff" responded to the code. Some staff member had been using a scissors for a project and left the scissors on the table when the code happened. The facility RN reported when staff came back to the lounge after the code, they discovered P1 sitting on the floor with a scissors sticking out of her abdomen.

On 12/27/18, at 11:56 a.m. P1 received a psych consult from MD-D. MD-D reported P1 was well known to the admitting hospital due to multiple admissions and ED visits related to suicidal ideation, overdoses, and behaviors. P1 was admitted to the transferring facility 8 days previous after overdosing on alcohol and Ambien. P1 reported she felt frustrated that her back pain wasn't being treated, and felt staff were not listening to her. P1 stole some scissors and made what she described as an "impulsive suicide attempt" although she had described it as a "cry for help" or attention. P1 noted ongoing suicidal ideation off and on, and she continues to have those thought at the present time. She denied a plan or intent "as she did at [transferring hospital] before this occurrence."
On 12/27/18, at 1:22 p.m. the admitting facility social worker (SW) documented her multiple attempts to call the State Agency (SA) over concern of care from the transferring facility. The SW was unable to get through.

Tour of the inpatient psych unit on 1/18/19, at 8:45 a.m. and interview during the tour with the vice president (VP)-B and behavioral health nursing director BHND-A. BNHD-A identified a T shaped locked unit consisting of 36 beds. 8 of the 36 beds were in the interior higher acuity lockdown unit (C). The unit was staffed with 2 RNs and 2 behavioral therapists. If a patient was on 1:1, additional staff were assigned to the unit from the float pool, or another psych staff member would be called in. P1 was in the high acuity C wing at the time of the incident. There was a nurses station with closed doors on the regular and locked units for staff. VP-B indicated staff had reportedly began an investigation, but were unable to identify where the scissors came from or what type of scissors it was.

On 1/18/19, at 9:50 a.m. interview with the BHND-A indicated the decision to take a patient off 1:1 was a patient and team decision. BHND-A stated there was no documentation how or who made this determination for P1. BHND-A stated she would expect staff to have documented how they came to the determination to end a 1:1, and consulted the appropriate physician.

On 1/18/19, at 10:15 a.m. interview with professional practice nurse (PPN)-D was conducted. PPN-D stated her expectation was staff were to document how they came to the conclusion to take a patient off 1:1, with the guidance of the interdisciplinary team (IDT). PPN-D was unaware when P1 came off 1:1s.

Interview on 1/18/19 at 10:36 a.m. with PPN-D and BHND-A identified staff could not recall what type of scissors had been used, or where P1 obtained them from. The Quality Assurance team was still investigating. There was no physician's order to start or stop the 1:1 immediately proceeding the stabbing. P1 had come off 1:1 sometime between 10:52 a.m. on 12/26/18, and 4:00 p.m.

P1's medication administration record (MAR) indicated she was given:
Tylenol, 1- 2 times per day. Her last dose was administered on 12/26/18, at 9:25 p.m., 17 hours after the prior administration on 12/25/18, at 3:40 a.m.. There were no PRN doses noted as offered or given.
Baclofen 10 mg TID was given 3 x per day beginning on 12/24/18.
Baclofen 5-10 mg TID was ordered beginning 12/21/18, and ending on 12/23/18. There was no indication how staff were to determine the parameters for which dose was appropriate. Staff had administered a 5 mg dose with each administration.
Lidocaine patch, 1 patch every 12 hrs was administered daily at approximately 8 a.m. and off at 9:00 p.m. from 12/24/18, to 12/26/18.
Baclofen 5 mg TID PRN was given once daily beginning on 12/22/18.

P1's pain assessments scored 0-10, immediately preceding the incident identified on:
12/25/18, at 5:00 p.m. P1 rated her back pain at a 10.
12/26/18, at 6:10 a.m. P1 rated her pain at a 5.
12/26/18, at 10:52 a.m. P1 rated her pain at an 8.
12/26/18, at 10:26 p.m. P1 rated her pain a 4.

P1's 12/20/18, care plan intervention related to pain identified her goal was to have pain or discomfort manageable. Daily outcomes identified P1 was progressing towards her goal. On 12/26/18, at 10:56 a.m., RN-E made a goal note identifying P1 was not progressing in her goal as she complained of chronic severe back pain, and needed a medication adjustment. RN-E "left a note for providers." It was unclear if RN-E passed the information on to staff or followed up on provider calls that were placed.

Interview and document review on 1/19/18, at 8:41 a.m. with quality and patient safety director (QSD)-C and quality and patient safety staff (QS)-D identified timeline events surrounding P1's stabbing were recorded as follows:
On 12/26/18, a high harm debrief with immediate staff occurred.
An undated report of a vulnerable adult by risk management occurred. There was no indication of who that report was made to.
On 1/9/19, a determination meeting was held.
On 1/10/19, a root cause analysis (RCA2) process was initiated.
On 1/11/19, staff interviews were conducted.
On 1/16/19, a RCA2 team was developed to investigate the incident.
Staff were scheduled to review the timeline of the event on 1/21/19, 26 days after the event.
Additional interviews were to occur with no date determined to be completed by.
After interviews, additional information was to be added to the chart review and timeline.
A meeting was to be scheduled to propose a final action and determine action item and next steps. There was no evidence to support a timely or thorough investigation had occurred.

Interview on 1/18/19, at 11:10 a.m., with RN-B regarding the events surrounding P1's stabbing identified the decision for a patient to come off 1:1 would be directed by the charge nurse on duty. If a staff nurse felt a patient had improved emotionally and was not at risk, they would notify the charge nurse who made the determination. Staff were to document reasons and rationales in the medical record. RN-B stated she had not received reeducation from management after the incident related to the safety of a patient with suicidal risk.

Interview on 1/18/19, at 2:31 p.m. with RN-A regarding the events surrounding P1's stabbing identified she was working at the time of the incident. One of the BT's notified nursing staff P1 had stabbed herself with a scissors. RN-A recalled P1 was not on 1:1 precautions at 3:00 p.m. that day. RN-A identified the scissors to be a blue handled office scissors. P1 told staff, "Now you are going to pay attention to me." RN-A was told by security P1 had the scissors earlier, although she could not recall when. RN-A stated staff had a debriefing over the incident the morning of 12/27/18. RN-A was told security checked the cameras and identified P1 had the scissors earlier that day. RN-A was unaware of what time that was. BHND-A advised staff they would have another debriefing, but it had not occurred. RN-A stated in order for a patient to come off 1:1, staff do "a trial." If by the next shift the patient is deemed ok, staff would call the MD and advise them they are taking the patient off 1:1. Nurses can decide to take a patient off 1:1 if they feel they are ok. Staff do room-sweeps every shift to look for and identify objects that could be potentially harmful. There was no designated time this occurred, but it occurred once per shift. There have been other patients who have attempted suicide while off 1:1 observation. RN-A recalled seeing 1 patient [unknown name] with a blanket in her hand in an attempt to commit suicide. Staff had to give that patient finger foods as they would steal silverware. That patient ran into the nurses station approximately 2 months ago and attempted to grab a scissors at that time.

Review of the debriefing of staff on 12/27/18, identified 3 staff were called to see how they "were doing after the event." RN-C reported she had not known where the scissors came from. P1 would not tell her where she found it.
RN-A stated she thought the facility should investigate purchasing new armbands. RN-F was not at work at the time of the event. RN-A was providing 1:1 earlier that day on another patient.

Review of the email to management on 12/28/18, by the BHND-A indicated, "We put in a work order today to have the sharp scissors attached to the wall in the nurses station so they cannot be removed from the room by staff. We can look at these scissors next week." There was no further communication provided management intervened to ensure patient safety after the incident for P1.

Interview documented by the facility on 1/9/19, by MD-C indicated he was asked if he felt the environment was safe. MD-C replied, "Not sure. She [P1] got scissors, not sure how. There was no further questioning on this subject." MD-C was asked if he felt he had enough resources he needed to respond to the situation. "Not up there. Takes forever to get things up there. The crash cart is basic. Took a while to get an IV. Things like rapids [RR] take a lot longer than on other floors."

Interview documented by the facility on 1/10/18, of RN-A indicated when asked what could have been done to prevent the event, RN-A replied, "When I talked to her [P1's family member], she said [P1] was expressing she wanted to kill herself. They [staff] shouldn't have taken her off 1:1. I don't know if the [family member] said this, but she [P1] did express she was going to kill herself. She should have had a really close 1:1. You could never really trust [P1]. [P1] did contract for safety, how do you believe someone like that?" RN-A further stated "OT [occupational therapy] uses scissors. They [OT] count them at the end of OT after they leave from activities. About 3 months ago, we lost scissors and had to do a room sweep and we found them."

Interview on 1/19/18, at 9:05 a.m. with service line executive (SLE)-E identified she was unsure if a consult for R1's pain had ever been completed. SLE-E was unsure whose job it was to follow-up to ensure consults were completed in a timely manner as ordered.

Interview and policy review on 1/19/18, at 9:36 a.m. with VP-B indicated several of the facility's policies related to suicide had conflicting information. VP-B agreed the policies needed to be accurate and concise.

Interview on 1/23/19, at 11:30 with RN-G identified it was her expectation staff should always have a doctor's order to remove a patient off 1:1, although she has seen and known of nurses that "just do it without [a doctors order]." The facility used to have a pain management team, and RN-G was unaware if one still existed.

Interview on 1/23/19, at 12:03 p.m. with BT-A identified the facility had changed their policy after 1/19/19, to ensure nursing station doors remained closed at all times. It used to be if staff were in the nurses station, they could leave the door open, and only shut and lock it if they left, "This is an old building. It gets hot in there."

Interview and document review on 1/23/19, at 2:15 p.m., with psychiatric medical director (PMD)-F identified she was unaware a timely and thorough investigation had not been completed by the facility. PMD-F wanted to get the records from the admitting hospital, but was told it may be a potential Health Insurance Portability and Accountability Act of 1996 (HIPAA) violation, and not to worry about it. PMD-F assumed facility management were following up on the events surrounding P1's stabbing. When told an RR happened on the unit immediately prior to P1 stabbing herself, as reported to the admitting hospital, PMD-F agreed staff need a designate 1 person to watch over the remainder of the patients, if a code green was called. Nurses should have followed-up on P1's chronic severe pain. PMD-F found it odd staff hadn't. PMD-F agreed staff should have detailed instructions to follow after an incident to immediately begin an investigation. With regard to P3 who was on a 1:1 in the ER for suicide, but was not upon being admitted to the unit, PMD-F stated physician's need to document the rationale for 1:1 removal and determine needed level of care. PMD-F stated the nurses station door should never be opened, even if staff are directly in the room. PMD-F was unaware of RN-A's documented interview, stating another patient tried to get a scissors [from the nurses station] 2 to 3 months prior.

Review of additional medical records surrounding suicidal patients with BHND-A indicated the following:
P3 was admitted on [DATE], at 4:42 p.m. to the ED with diagnoses of schizophrenia, Cluster B personality, and suicide attempt with a plan. At 9:00 p.m. P3 was moved to the psych unit. There was no documentation to show the level of care related to 1:1 that P3 required upon being admitted to the floor.
P5 was admitted on [DATE], at 8:27 a.m. with suicidal ideation. P5 had a history of multiple past suicide attempts. P5 was admitted to IP psych until discharge on 1/21/19. There was no documentation to support Colombia Suicide Severity Rating Scales (suicide assessments) were performed each shift to identify if P5 had indeed a plan to act on her ideation. BHND-A's stated the expectation was the Columbia Scales were to be performed each shift.
P6 was admitted on [DATE], to the ED with suicidal ideation. P6 stated if he was released from the ED, he would get his brother's gun and kill himself. On 1/17/19, 1:1 precautions were discontinued even after P6 admitted a plan to die with use of a sheet. On 1/19/19, P6 reported hearing voices telling him to jump out of the building and commit suicide, and was asked to move to C-side as he made inappropriate sexual comments. At 1/19/19, at 3:25 p.m. P6 told the nurse he wanted to kill himself and leave. At 10:32 p.m. P6 reported having hallucinations telling him to throw himself out the window. Staff had not notified the MD of P6's plans to kill himself. BHND-A stated the MD should have been notified, and 1:1 put back into place.
P7 was admitted on [DATE], with suicidal ideation. P7's Columbia Scale assessments were not performed every shift. On 1/17/19, P7 had suicidal ideation with a plan. At 2:15 that same day, P7 denied suicidal ideation. There was no documentation to support P7's physician was notified at that time. On 1/18/19, and again on 1/22/19, staff failed to complete a Columbia assessment on the evening shift. BHND verified management needed to work with staff to ensure physicians were notified, and Columbia Scales were performed for patient safety.
P9 was admitted on [DATE], after overdosing on medication in a suicide attempt, and told staff he wanted to "hurt those people. They are already dead." On 1/4/19, at 10:52 a.m. P9 began screaming and hitting the wall in his room. Security was called, and P9 was moved to the C-wing. At 1:03 p.m. P9 was on a 1:1 related to severe psychosis. On 1/5/19, at 5:47 a.m. a nursing noted identified P9 was observed per routine. The next note wasn't until 1/6/19 at 6:15 a.m. "observed per routine." This note was duplicated again on 1/7/19, at 5:59 a.m. On 1/8/19, P9 stated the MD was on the top of the "list of reckoning." On 1/8/19, at 9:09 a.m. a nursing notes identified P9 was moved back to C-side. It was unknown when P9 had left the more secured unit. On 1/9/19, at 11:28 a.m. the physician made an assessment related to P9's security. Staff were to continue assault precautions. The MD made no mention of formal precautions staff were to take. P9 was on 15 minute checks, and not a continuous 1:1. On 1/10/19, additional video monitoring was deemed necessary by staff as P9 tried to step on the throat of another patient. Monitoring was to be used to detect if there was other behavioral symptoms. Per BHND-A, there was no policy on video monitoring. On 1/11/19, at 2:20 p.m. the physician noted she reviewed the nursing notes, but failed to mention she was advised of P9 stepping on another's throat. On 1/15/19, staff heard a loud bang. P9 punched the wall, and was given Haldol (antipsychotic) injection. There was no reassessment after the Haldol administration to determine it was effective. On 1/20/19, at 3:45 p.m. R9 began pounding on the windows and radiator and stated he heard voices. On 1/21/19, at 10:43 a.m. P9's physician performed the assessment in the presence of three security guards. The MD determined P9's computer time "will be suspended." At 1:32 p.m. staff noted P9 was using the computer during the day shift, even after the MD had denied privileges. At 7:22 p.m. staff continued to give P9 computer time. There was no documentation to show this was approved by the MD, even though he restricted it earlier the day before. On 1/22/19, at 12:55 p.m. the MD indicated P9 was out, but his computer time was again to be suspended. Per BHND-A, there was no documentation staff followed MD orders, or had called the MD to ask for privileges to be restored. P9's care plan made no mention he was restricted from computer time. BHND-A verified that was not mentioned or identified on the care plan. It was her expectation, nursing should have followed and clarified orders. The Columbia Scales were not performed on the evening of 1/14/19, or 1/17/19. BHND-A verified staff failed to perform critical suicidal assessments.
P10 was admitted for suicidal ideation on 1/20/19. From 11/22/18, to 1/17/19, staff repeatedly failed to perform a Columbia assessment on each shift. BHND-A verified staff failed to perform the assessments as ordered.

The January 2015, Notification of Physicians- Licensed Independent Practitioner Regarding Significant Change in Patients Condition and Critical test Results policy directed the RN will notify the MD in a timely manner of a significant change in a patient's condition to the MD responsible for medical care of the patient in a timely manner.

The August 2016, Nursing Assessment and Reassessment of the Patient, Mental Health directed an ongoing assessment for psychosocial and behavioral assessment- safety risks each shift, unless an Observation Care Patient, then staff were to evaluate and have a focused assessment at least every 4 hours.

The 9/20/18, Pain Management Policy- Adult policy directed the 0-10 pain scale was to be used. 1-3 mild pain, 4-6 moderate pain, and 7-10 indicates severe pai