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.

ASPIRE BEHAVIORAL HEALTH OF CONROE, LLC 2006 SOUTH LOOP 336 WEST, SUITE 500 CONROE, TX 77304 April 16, 2019
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on record review and interviews, the facility failed to ensure that a thorough one-hour face-to-face evaluation was conducted on 4 of 5 patients (patient #1, #2, #15, and #17).

Findings:

Record review of policy, "Restraint and Seclusion" reviewed/revised December 31, 2018, showed: " ... 4.1.4 The original order is based on a face to face assessment of the patient by a physician or authorized RN, to occur within one hour after the initiation of restraint or seclusion. The results of the assessment will be documented in the patient's medical record and will include the following:

4.1.4.1 Patient's immediate situation

4.1.4.2 Patient's reaction to the intervention

4.4.1.3 Patient's medical and behavioral condition

4.1.4.4 Need to continue or discontinue restraint or seclusion ..."


Record review of the seclusion/restraint "packet" revealed the following components:

1. Physician Orders for Seclusion/Restraint;

2. Part I - RN Progress Note;

3. Part II - RN Post Special Treatment Procedure Assessment;

4. Part III - RN or MD Face-to-Face Evaluation;

5. Performance Improvement: Special Treatment Procedure;

6. Special Treatment Procedure Flowsheet; and

7. Staff Debriefing: Post Seclusion/Restraint.


Record review of the "Part III - RN or MD Face-to-Face Evaluation" showed that the form did not prompt the evaluation of the patient's reaction to the intervention and the patient's medical and behavioral condition. The form did prompt the RN to evaluate the following:

1. Indication for seclusion/restraint, and;

2. Present mental status findings, and physical status. Physical status prompted documentation of vital signs, complaints of discomfort, and physical assessment.


Record review of the restraint packet for patient #1 showed that Staff E, an RN, initiated a restraint on Patient #1 on 02/19/19 at 1:56 AM. The mental status, physical status, and need to terminate or continue the restraint/seclusion in "Part III - RN or MD Face-to-Face Evaluation" were marked "N/A."


Record review of the restraint packet for patient #2 showed that Staff E, an RN, initiated a restraint on Patient #2 on 03/20/19 at 1:39 AM. The indication for restraint, mental status, physical status, and need to terminate or continue the restraint/seclusion in "Part III - RN or MD Face-to-Face Evaluation" were marked "N/A."


Record review of the restraint packet for patient #15 showed that Staff K, an RN, initiated a restraint on Patient #15 on 03/06/19 at 5:17 PM. The indication for restraint, mental status, physical status, and need to terminate or continue the restraint/seclusion in "Part III - RN or MD Face-to-Face Evaluation" were left blank.


Record review of the restraint packet for patient #17 showed that Staff L, an RN, initiated a restraint on Patient #17 on 03/23/19 at 10:21 PM, followed by seclusion at 10:25 PM. The vital signs and physical assessment in "Part III - RN or MD Face-to-Face Evaluation" were blank.


In an interview on 4/16/19 at 12:10 PM, Staff C, the interim DON, stated that there should be no blanks on the "Part III - RN or MD Face-to-Face Evaluation" and that "N/A" is not an acceptable entry on the form.
VIOLATION: QAPI Tag No: A0263
Based on record review and interview, the facility failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program in the analysis of restraints and seclusions. Failure to measure, analyze, and track this high-risk, problem-prone area resulted in 37 of 37 incidents of restraint and seclusion not being analyzed for appropriateness, safety, and proper implementation.

Cross reference: A0273
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record review and interviews, the facility failed to analyze restraint and seclusion data for 5 of 5 quarters (4 quarters in 2018 and the first quarter of 2019). Failure to measure, analyze, and track this high-risk, problem-prone area resulted in 37 of 37 incidents of restraint and seclusion not being analyzed for appropriateness, safety, and proper implementation.

Findings:

Record review at time of survey of the facility's QAPI minutes and supporting documentation showed that only raw data, solely comprised of the number of restraints and seclusions each month, was captured. There was no analysis of the data and/or any proposed improvement activities with regards to attempting to address and decrease the incidence of the facility's restraints and seclusions. Further review of the supporting documentation showed raw data for five quarters. The number next to the month represents the total number of restraints and seclusions for that month.

2018 first quarter:
January-5,
February-2
March-0

2018 second quarter:
April-7
May-2
June-0

2018 third quarter:
July-5
August-0
September-0

2018 fourth quarter:
October-1
November-2
December-3

2019 first quarter:
January-5
February-4
March-6


Record review of the Restraint and Seclusion log titled "2019 Q2 RESTRAINT/SECLUSION" and the QAPI data for 2019 first quarter showed a discrepancy in the two reports.

1.The Restraint and Seclusion log titled "2019 Q2 RESTRAINT/SECLUSION" showed three incidents of Restraint/Seclusion.

2. The QAPI data for the first quarter of 2019 showed six incidents of Restraint/Seclusion.


Record review of the Restraint and Seclusion log titled "2019 Q2 RESTRAINT/SECLUSION" showed that Patient #1 was physically restrained for 17 minutes on 2/22/19 and given a "medication IM stat" (intramuscular injection of a medication given immediately). There was neither documentation of the rationale to hold the patient past 15 minutes nor identification of the medication administered.


In an interview on 4/16/19 at 11:00 AM, Staff A, Quality Manager, he stated that restraints and seclusions had been reported to QAPI committee on a monthly basis. He also stated that the data was "just basic info - the number of restraints and seclusions," adding that the data was not analyzed for the quarterly QAPI meetings. He concluded by saying that there was no performance improvement plan to address restraints and seclusions and that this was true for the entire year of 2018 and 2019 year to date.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on record review and interview:

A. The facility failed to ensure that the seclusion/restraint documentation on 5 of 5 patients (patient #1, #2, #15, #16, and patient #17) was properly filed and retained in the patient's chart.

B. The facility failed to ensure that changes to the medical record were documented according to their policy in 1 of 1 patient records (patient #15).

Findings:

A. Records properly filed.

Record review of policy, "Restraint and Seclusion" reviewed/revised December 31, 2018, showed that restraint and seclusion is to be documented in the "patient's medical record."

Record review of the seclusion/restraint packet for patients #1, #2, #15, #16, and #17 showed: "Original copy stays on chart."

In an interview with Staff A, Quality Director, on 04/11/19 at 11:00 AM, he stated that the documentation of a patient's restraint or seclusion is not kept in the patient's chart; they are kept in his office in a file.


B. Changes to the medical record.

Record review of policy, "Progress Record Documentation" reviewed/revised December 31, 2018, showed: " ... The documentation is to be ... accurate ... 8.0 The medical record is a legal document: thus, it includes facts ... 15.0 If there is a need to do a 'late entry' ... Put current date, time ... Label entry as 'late entry' ... Specify for what date/time it is a late entry ... Document and sign name."

In an interview with Staff A, Director of Quality, on 04/16/2019 at 11:00 AM, he stated he could provide five of the latest seclusion/restraint packets. [Staff A provided the seclusion/restraint packets for five patients, one of them was for Patient #15.]

Record review on 04/16/2019 at 12:00 PM of the seclusion/restraint packet for Patient #15, dated 03/06/2019 at 5:17 PM showed: Part III - RN or MD Face-to-Face Evaluation; Performance Improvement: Special Treatment Procedure; and Special Treatment Procedure Flowsheet were all blank.

Record review of the seclusion/restraint packet for Patient #15, dated 03/06/2019 at 5:17 PM that was faxed to the surveyors on 04/26/2019 showed changes made to the original seclusion/restraint packet. These changes included:

1. Part III - RN or MD Face-to-Face Evaluation: "Alert. Responsive to questions. Refused vital signs. Unable to conduct physical assessment, appears in no harm, verbalizes no harm. Patient currently out of seclusion/restraint (circle which) at this time." It was signed by Staff G and dated 03/06/2019 at 1800.

2. Performance Improvement: Special Treatment Procedure: Date: 3/6/19. RN notified 1740. Face to face within 1hour time: 1800. Name of staff solely monitoring patient's stability during physical hold: Staff K.

3. Special Treatment Procedure Flowsheet: The following items were circled: Behavior: Yelling, Hitting, Cursing. Interventions: Physical restraint, explained criteria for released [sic], Physical assessment, Seclusion;/Restraint Discontinued. Response: Talking with staff.


In a telephone interview with Staff C on 4/26/19 at 8:40 AM, she was asked to compare the original seclusion/restraint packet for Patient #15 with the faxed over copy. She stated the faxed copy was different from the original copy obtained during the survey. She stated she was unsure who had added documentation to Part III - RN or MD Face-to-Face Evaluation, Performance Improvement: Special Treatment Procedure, and Special Treatment Procedure Flowsheet. As she reviewed the discrepancies, she stated, "It concerns me very much," adding the changes should have been documented as a "late entry."


In a telephone interview with Staff A, Director of Quality, and Staff G, former DON on 4/26/19 at 11:30 AM, they were asked about the discrepancies with the two restraint and seclusion packets for Patient #15. Staff A stated that adding omitted information to medical records was standard practice when closing out the medical records.


During the same telephone interview, Staff G stated that he was the person who altered Patient #15's seclusion/restraint packed on 04/25/2019, adding that he back-dated his entry to 03/06/2019 at 1800 and did not designate it as a "late entry." He also stated he was the nurse who performed the Face-To-Face evaluation. He concluded by saying that he should have written "Late entry" on the form, as well as timed and dated it, and that it was "a mistake on my part."
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, review of medical records, and staff interviews, the facility failed to safeguard and uphold the rights of each patient in the facility.

A. In 10 of 10 patients (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and #25) on suicide precautions, patients were being placed in bedrooms and on a psychiatric unit that had multiple observable ligature risks.

B. In 10 of 10 patients (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and#25), patients were being assessed for suicide risk with two different suicide risk assessment tools during the admission process in the Intake Department. This resulted in contradictory suicide risk assessment findings.

C. In 1 (patient #24) of 10 patients being assessed as a "high" risk for suicide on the SADPERSONS assessment tool, patient #24 was not placed on a 1:1 as is delineated in the facility's policies.

D. In 1 (patient #26) of 20 patients, patient was in bed with the bedroom door closed during a scheduled group time contrary to the hospital policy on observation.

E. In 20 of 20 patients (patients #2, 14, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, and #35), patients were placed in bedrooms and on a psychiatric unit with numerous screws that were not tamper resistant. Ten of these patients (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and #25) were on suicide precautions.

Cross reference: A0144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, review of medical records, and staff interviews, the facility failed to ensure that patients received psychiatric care in a safe setting.

A. In 10 of 10 patients (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and #25) on suicide precautions, patoients were being placed in bedrooms and on a psychiatric unit that had multiple ligature risks. These ligature points could be used to attach material for the purpose of hanging or strangulation.


B. In 10 of 10 patients (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and #25), patients were being assessed for suicide risk with two different suicide risk assessment tools during the admission process in the Intake Department. This resulted in contradictory suicide risk assessment findings. Such contradictory findings created confusion as to the actual suicidal risk of the patient.

C. In 1 of 10 patients (patient #24), patients were being assessed as a "high" risk for suicide on the SADPERSONS assessment tool and not being placed on a 1:1 observation as is delineated in the facility's policies.

D. In 1 of 20 patients (patient #26), patient was in bed with the bedroom door closed during a scheduled group time. This is contrary to the facility's observation policies by allowing patients in unobserved areas.

E. In 20 of 20 patients (patients #2, 14, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, and #35), patients were placed in bedrooms and on a psychiatric unit with numerous screws that were not tamper resistant. Ten (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and#25) of these patients were on suicide precautions. Such hardware has the likelihood to be used by patients for self-harm.


Findings:

A. Patients on suicide precaution being placed in bedrooms on a psychiatric unit that had multiple ligature risks.

During a tour of the adult psychiatric unit on 04/11/2019 at 08:30 - 12:30 PM, 16 of 16 bedrooms and adjoining bathrooms (room 100, 101, 102, 103, 105, 106, 107, 108, 202, 203, 204, 205, 206, 207, 208, and room 209) were observed to have the following ligature risks:

1. Toilets were not mounted flush to the wall and floor, creating a loopable hole gap between the toilet bowl and the wall that could be used as a tie off point;

2. The plastic cover over the toilet pipes was not enclosed at the bottom, giving patients access to the pipes;

3. The plastic cover over the toilet pipes had been altered to allow access to the button flush system and the electric eye that triggers the automatic flushing system. The two holes, each about two inches in diameter, created a new tie off point; and

4. Bedroom door handles were standard door handles and posed a ligature risk. New handles had not been installed.


There were other ligature risks observed:

1. 2 of 16 bedrooms (rooms 107 and 209) had a door that lead from within the bedroom into a community shower room. The door handles on these two doors were had standard door handles and posed a ligature risk;

2. 3 of 16 lavatory sinks found in patient bathrooms (rooms 103, 206, and 209) were missing the side board to the right of the sink. The 13 other lavatory had the side board installed. Without the side board, it was possible to tie off onto the sink; and

3. 6 of 24 beds (room 100, 202, 203, 204, 205, and room 206) were not bolted to the floor.


In addition to the ligature risks outlined above, numerous other ligature risks were observed on the psychiatric unit during the tour. These ligature risks included:
The metal door handle attached to the metal plate or trim piece on the inside of the seclusion room was loose. This created a gap between the door handle and the metal plate, thus creating a ligature risk.

In an interview with Staff A and Staff C on 04/11/2019 at 2:00 PM, they stated that the toilet pipes, three lavatory sinks, unbolted beds, and door handles were ligature risks.

Observation of the bathroom in the lobby on 04/11/2019 at 8:45 AM showed the following ligature risks:
1. Standard door handle and hinges created tie off points;
2. The mirror had a ledge across the top that created a tie off point; and
3. The toilet was not mounted flush to the wall and floor, creating a loopable hole between the toilet bowl and the wall that could be used as a tie off point.

In an interview with Staff A, Staff R, and Staff C on 04/11/2019 at 8:45 AM, they stated that the patients in the Intake Department awaiting admission or in the admission process utilize the bathroom in the lobby. They also stated that the bathroom had ligature risks.

Record review of the Nursing Shift Report dated 04/11/2019 [not timed] showed patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and patient #25 to be on suicide precautions. Each patient was assigned to a bedroom:

Patient #2 - room 203
Patient #14 - room 205
Patient #18 - room 204
Patient #19 - room 102
Patient #20 - room 105
Patient #21 - room 106
Patient #22 - room 108
Patient #23 - room 206
Patient #24 - room 207
Patient #25 - room 208


Record review of the medical records of the 10 patients on suicide precautions showed the following:

Patient #2.

Record review of the Physician's Admission Orders dated 03/18/2019 at 11:47 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions."

Record review of the Psychiatric Evaluation dated 03/19/2019 at 10:06 AM by MD N showed, " ... [AGE]-year-old female ... hit by a car on March 13th ... disorganized and illogical ... The day before her accident, ... stated she was going to heaven ... Previous suicide attempt ... impaired insight, loss of judgement ... Admission [diagnoses]: Schizophrenia ... Hit by car, SAH [subarachnoid hemorrhage] partially resorbed, odontoid fracture ... Discharge Criteria: No longer is a danger to self ..."


Patient #14.

Record review of the Physician's Admission Orders dated 04/08/2019 at 3:59 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions."

Record review of the Psychiatric Evaluation dated 04/09/2019 at 1:30 PM by MD N showed, " ... [AGE]-year-old male ... suicide attempt by overdose on multiple medications [including] ... 60 0.5mg Xanax ... impaired insight [and] ... judgement ... Admission [diagnoses] Major Depressive Disorder, recurrent, severe ... Suicidal thoughts ... Overwhelming anxiety ... Discharge Criteria: No longer a danger to self ... "


Patient #18.

Record review of the Physician's Admission Orders dated 04/08/2019 at 11:23 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions."

Record review of the Psychiatric Evaluation dated 04/09/2019 at 2:23 PM by MD N showed, " ... [AGE]-year-old female ... suicidal ideation with voices telling her to kill herself ... previous known suicide attempt ... impaired insight [and] ... judgement ...Admission [diagnoses]: Major Depressive Disorder, recurrent, severe, ... blind both eyes ... overwhelming anxiety ... Discharge Criteria: No longer a danger to self ..."


Patient #19.

Record review of the Physician's Admission Orders dated 04/06/2019 at 3:46 AM showed "Suicide Precautions" ordered by MD J for this [AGE]-year-old male. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions."

Record review of the Psychiatric Evaluation dated 04/06/2019 at 10:17 AM by MD P showed, " ... he wanted to leave the nursing home ... the patient wrapped his call light around his neck ... He denies any suicidal ideation, intent, or plan ... Unkempt appearance ... Impaired insight [and] ... judgement ... Admission [diagnoses]: Major Depressive Disorder, recurrent, severe. There is some concern that the patient is minimizing ... Alzheimer's ... Suicidal thoughts ... Discharge Criteria: No longer is a danger to self ..."


Patient #20.

Record review of the Physician's Admission Orders dated 04/08/2019 at 2:32 AM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions."

Record review of the Psychiatric Evaluation dated 04/08/2019 at 8:29 AM by MD N showed, " ... [AGE]-year-old male ... [admitted on an] Emergency Detention Warrant ... out of the hospital for one week ... Delusions ... One previous suicide attempt in May 2017 by overdose on 50 Benadryl ... Suicidal behavior. Threatening suicide (holding knife to his throat) ... Impaired insight. Lack of judgement ... Admission [diagnoses]: Moderate manic bipolar I disorder (with psychotic features), substance use, misuse, abuse (marijuana use disorder) ... Discharge Criteria: No longer is a danger to self ..."


Patient #21.

Record review of the Physician's Admission Orders dated 04/08/2019 at 4:36 AM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions."

Record review of the Psychiatric Evaluation dated 04/08/2019 at 10:30 AM by MD N showed, " ... [AGE]-year-old male ... reports worsening depression ... Suicidal behavior. Threatening suicide (holding gun in his lap) ... impaired insight [and] ... judgement ... Admission [diagnosis]: Major Depressive Disorder, recurrent, severe ... Discharge Criteria: No longer is a danger to self ..."


Patient #22.

Record review of the Physician's Admission Orders dated 04/09/2019 at 12:21 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions."

Record review of the Psychiatric Evaluation dated 04/09/2019 at 2:41 PM by MD N showed, " ... [AGE]-year-old female ... [reported] bad anxiety and panic attacks, couldn't sleep ... Previous known suicide attempt. Suicidal behavior ... Has insight, impaired judgement ... Admission [diagnoses]: Major Depressive Disorder, first episode, severe ... GAD [Generalized Anxiety Disorder] ... Discharge Criteria: No longer is a danger to self ..."


Patient #23.

Record review of the Physician's Admission Orders dated 04/09/2019 at 4:30 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions."

Record review of the Psychiatric Evaluation dated 04/09/2019 at 3:21 PM by MD N showed, " ... [AGE]-year-old female ... Has insight. Impaired judgement ... Denies suicidal ideation ... Admission [diagnoses]: Major Depressive Disorder, recurrent, severe, ... Opiate Use Disorder, severe ... Discharge Criteria: No longer is a danger to self ..."


Patient #24.

Record review of the Physician's Admission Orders dated 04/09/2019 at 3:34 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions."

Record review of the Psychiatric Evaluation dated 04/09/2019 at 3:36 PM by MD N showed, " ... [AGE]-year-old female ... 'I have a paranoid problem' ... Delusions ... Has insight. Impaired judgement ... Admission [diagnosis]: Moderate Manic Bipolar I Disorder ... Discharge Criteria: No longer is a danger to self ..."


Patient #25.

Record review of the Physician's Admission Orders dated 04/10/2019 at 2:48 AM showed "Suicide Precautions" ordered by MD J. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions."

Record review of the Psychiatric Evaluation dated 04/10/2019 at 7:47 PM by MD J showed, " ... [AGE]-year-old female ... admitted with psychosis and suicidal ideation. She is guarded and will not share the reasons of her depressive psychosis ... a strong history of mental illness ... with multiple psychiatric hospitalization s ... hearing voices and ... insomnia ... Previous known suicide attempt. Suicidal behavior. Threatening suicide ... Impaired insight. Impaired judgement ... Admission [diagnoses]: Schizoaffective Disorder, mixed; Substance Use, Misuse, Abuse (Marijuana Dependence) ... Discharge Criteria: No longer is a danger to self ..."


B. Contradictory suicide risk assessments, all conducted during the admission process in the Intake Department.

In an interview with Staff R (Intake RN) and Staff C on 04/11/2019 at 1:25 PM, both staff members stated two suicide risk assessment tools are completed by the intake RN during the admission process: a suicide risk rating tool and the SADPERSONS. Staff R stated that these two assessments are part of the "Patient Assessment Report". Staff C stated that the suicide risk rating tool was a tool provided by Staff G. Staff C stated she did not know where Staff G obtained the tool. Staff C also stated that the standard of care in suicide risk assessment requires that clinicians conduct thorough suicide risk assessments.

Record review of the "Patient Assessment Report" showed two suicide risk assessments:

(1) A suicide risk rating tool and;
(2) SADPERSONS Suicide Assessment Scale.

(1) A suicide risk rating tool.

The name of the suicide risk rating tool was not indicated in the "Patient Assessment Report". The suicide risk rating tool showed 22 suicide risk indicators, each with a numerical value or weight. [The number in the parenthesis is the numerical value given to the indicator.] The first seven suicide risk indicators are LOW INTENSITY INDICATORS:

Use of alcohol or drugs to excess, infrequently (1)
Vague, fleeting thoughts of suicide with no plan or method (2)
No means to complete suicide (1)
No previous suicide attempts (0)
No recent or significant loss in the past (0)
In good physical health, few or no medical problems (0)
Rampant hostility - aggressiveness (1)

The next 15 (fifteen) suicide risk indicators are classified as HIGH INTENSITY INDICATORS:

High anxiety or panic (7)
Withdrawn or isolated (6)
Few resources (6)
Destructive coping strategies (7)
Verbal statements of intent (10)
Negative view of professional help in the past (7)
Non-verbal behavior indicating self-destructive thoughts (8)
Unstable lifestyle (8)
Excessive use of alcohol or drugs (7)
Specific suicide plan (10)
Recent or significant loss(es) (8)
Self-deprecating (7)
Impulsive behavior (9)
Hearing command hallucinations for self-harm (10)
In poor health, numerous medical problems (6)

Score total
Score on combined low and high intensity indicators.
Score 0-20 - Suicide risk is none - low (not verbalizing or suggesting suicidal ideation)
Score 21-59 - Suicide risk low (occasional or fleeting suicidal ideation, no plan, will contract for safety)
Score 60-79 - Suicide risk moderate (ongoing suicidal ideations [sic], vague plan, minimal insight, ambivalent about contracting
Score 80-125 - Suicide risk high (ongoing suicidal ideations [sic], command hallucinations or clear intent with concrete plan)

In an interview with Staff R (Intake RN) on 04/11/2019 at 01:25 PM, she stated that the suicide risk rating tool was "subjective" and the risk factors outlined on the tool were "open to interpretation." She also stated that some of the "Patient Assessment Report's do not have sufficient information, adding that she had found herself documenting more comprehensive assessments when she was handwriting the assessment as opposed to inputting the assessment into the computer.

(2) SADPERSONS Suicide Assessment Scale.

The SADPERSONS Suicide Assessment Scale has ten suicide risk indicators: male sex, older age, depression, previous attempt, ethanol abuse, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The score and risk scale:

SCORE RISK
0-4 Low
5-6 Medium
7-10 High

Record review of the Policy & Procedure, "Suicide Risk Assessment and Precautions," reviewed/revised February 1, 2019, showed: "Patients will be assessed for suicide risk using SADPERSONS as part of pre-admission screening and admission assessments ... Patients assessed to be at a heightened risk of suicide or self-injurious behaviors will be placed on suicide precautions commensurate with the assessed level of risk ... 1.0 SADPERSONS, a comprehensive assessment for suicide potential, suicide risk factors, suicidal ideation, planning, and protective factors are performed and documented on all patients during pre-admission screening and at the time of admission ..."

Record review of "The Sad Truth About the SADPERSONS Scale: An Evaluation of its Clinical Utility in Self-Harm Patients" in the Emergency Medicine Journal, October 31, 2014, (E-published July 29, 2019) by K. Saunders, F. Brand, K. Lascelles, and K. Hawton showed: "SADPERSONS failed to identify the majority of those either requiring psychiatric admission or community psychiatric aftercare, or to predict repetition of self-harm. The scale should not be used to screen self-harm patients presenting to general hospitals. Greater emphasis should be placed on clinical assessment which takes account of the individual and dynamic nature of risk assessment."

In an interview with Staff R on 04/11/2019 at 1:25 PM, she stated that each one of the suicide risk indicators on the SADPERSONS Suicide Assessment Scale have a numerical value of one point. She concluded by saying that the total score is calculated by totaling the number of suicide risk indicators that apply to the subject being evaluated.

In an interview with Staff A and Staff C on 04/16/2019 at 4:50 PM, they stated suicide risk is assessed in the intake Department using two tools: a suicide risk assessment tool and the SADPERSONS. They also stated that these tools are not evidence-based. They concluded by saying that there had been discussion about discontinuing these two tools and using an evidence-based tool, such as the Columbia-Suicide Severity Rating Scale.


Patient #2.

Record review of Progress Note by Staff Y dated 03/15/2019 at 11:05 AM showed: "Patient was talking prior about going to the light and there is now possibility that she was trying to commit suicide prior to coming into the emergency room when she was found."

Record review of the "Patient Assessment Report" by Staff Q dated 03/18/2019 at 11:52 PM showed:

Patient #2 was escorted to the facility by police with "suicidal ideation, psychosis, schizophrenia ... Patient had packed her bags stating she was going to heaven. The following day patient was hit by hit-and-run driver." "Not cooperating." Historian: "Medical Record." She admitted to suicidal thoughts within the last 72 hours but would not discuss her plan. Staff Q asked Patient #2 to explain how and when a suicide attempt had been attempted in the past and then documented, "NA" [Not Applicable]. Mood: depressed, bland. Affect: flat, blunted, guarded, constricted, congruent with mood. Thought processes: psychosis, delusions, non-logical. Recent or current behaviors: depression, social withdrawal, isolative, impaired judgement, poor insight, paranoid thinking - "unable to fully assess as patient will not answer questions." "Recently hit by car sustaining SDH [subdural hematoma] and SAH [subarachnoid hemorrhage]."

Suicide risk: "High"

Record review of the suicide risk rating tool by Staff Q dated 03/18/2019 at 11:52 PM showed the suicide risk indicators: mild depression; no previous suicide attempts; in good physical health; few or no medical problems; withdrawn or isolated; destructive coping strategies; verbal statements of intent; and non-verbal behavior indicating self-destructive thoughts.

Total score: 33. Suicide risk: Low

Record review of SADPERSONS Suicide Assessment Scale by Staff Q dated 03/19/2019 at 12:20 AM showed the suicide risk indicators were depression and rational thinking loss. "Unsure if patient attempted suicide by walking into traffic."

Total score: 2. Suicide risk: Low


Patient #14.

Record review of Comprehensive Assess[ment] - Psych Response Team by Staff U dated 04/05/2019 at 1:31 AM showed: " ... Patient made a lethal suicide attempt to overdose on multiple medications. His attempt was planned and a suicide note was left for his family. He has possible induced serious brain damage related to attempt ... denies attempt and lacks insight ... patient has a 1:1 sitter at bedside. 1:1 sitter should remain at bedside and have view of the patient at all times, including times when patient may need to use the restroom ... The patient's room should be made as psychiatrically safe as possible ... Medical staff was encouraged to be cognizant that every new individual who interacts with the patient has the ability to change the patient's mood, presentation, willingness to seek treatment. Even if family becomes present, a 1:1 sitter should still be present in the room."

Record review of the Psychiatry Consult Note by Staff T dated 04/06/2019 at 1:21 PM showed: " ... Hx [history] of MDD [Major Depressive Disorder] and ADHD [Attention Deficit Hyperactivity Disorder ... S/P [Status post] overdose on multiple psych meds including benzos [benzodiazepines]. He was intubated for 3-4 days ..."

Record review of the "Patient Assessment Report" by Staff V dated 04/08/2019 at 6:08 PM showed: " ... SA [suicide attempt] by OD [overdose] on meds." Patient #14 stated that he was separated from his wife which contributed to his depression. Staff V documented "NA" [not applicable] to the question, "Is patient experiencing psychotic features," Psychosis, "Harm to others risk, Detox and or withdrawal, Elopement risk, and Disposition issues and or plan.

Suicide risk: "High"

Record review of the suicide risk rating tool by Staff V dated 04/08/2019 at 6:08 PM showed the suicide risk indicators: mild to moderate anxiety; use of alcohol or drugs to excess, infrequently; destructive coping strategies; non-verbal behavior indicating self-destructive thoughts; specific suicide plan; recent or significant loss(es); and impulsive behavior.

Total score: 45. Suicide risk: Low

Record review of SADPERSONS Suicide Assessment Scale by Staff V dated 04/08/2019 at 6:08 PM showed the suicide risk indicators were male sex, older age, depression, previous attempt, organized plan, no spouse, and sickness.

Total score: 6. Suicide risk: Medium


Patient #18.

Record review of the "Patient Assessment Report" by Staff W dated 04/08/2019 at 10:18 PM showed: " ... Visual hallucinations, suicidal, anxious ... suicidal thoughts in the last 72 hours ... delusions ... auditory hallucinations ..."

Suicide risk: "High"

Record review of the suicide risk rating tool by Staff W dated 04/08/2019 at 10:18 PM showed the suicide risk indicators: No previous suicide attempts; high anxiety or panic; withdrawn or isolated; few resources; destructive coping strategies; verbal statements of intent; unstable lifestyle; impulsive behavior; and in poor health, numerous medical problems.

Total score: 59. Suicide risk: Low

Record review of SADPERSONS Suicide Assessment Scale by Staff W dated 04/08/2019 at 10:18 PM showed the suicide risk indicators were depression, rational thinking loss, social supports lacking, and sickness.

Total score: 4. Suicide risk: Low


Patient #19.

Record review of the "Patient Assessment Report" by Staff L dated 04/06/2019 at 7:06 AM showed: " ... wanted to leave nursing home so I made them think that I was crazy by putting the call light cord around my neck ... depression, hopelessness, helplessness, minimizes problems, anxiety, confusion"

Suicide risk: "Moderate"

Record review of the suicide risk rating tool by Staff L dated 04/06/2019 at 7:06 AM showed the suicide risk indicators: mild to moderate anxiety; few resources; destructive coping strategies; impulsive behaviors; and poor health, numerous medical problems.

Total score: 30. Suicide risk: Low

Record review of SADPERSONS Suicide Assessment Scale by Staff L dated 04/06/2019 at 7:06 AM showed the suicide risk indicators: male sex, older age, rational thinking loss, social supports lacking, no spouse, and sickness.

Total score: 6. Suicide risk: Medium


Patient #20.

Record review of the "Patient Assessment Report" by Staff L dated 04/07/2019 at 9:17 PM showed: " ... depression, suicidal ideation, anxiety ... suicidal thoughts in the last 72 hours. Put knife to throat. Always has a plan ... 2017 overdose ... loss of energy, hopelessness, helplessness, feelings of worthlessness and guilt, mood swings, manic, impaired judgment, poor insight, paranoid thinking, insomnia ... brought in by EMS [Emergency Medical Services] ...found with a knife to his throat, had to be restrained by family ... a danger to himself and others ..."
Suicide risk: Moderate

Record review of the suicide risk rating tool by Staff L dated 04/07/2019 at 9:17 PM showed the suicide risk indicators: mild to moderate anxiety; mild depression; destructive coping strategies; unstable lifestyle; specific suicide plan; impulsive behavior.

Total score: 38. Suicide risk: Low

Record review of SADPERSONS Suicide Assessment Scale by Staff L dated 04/07/2019 at 9:17 PM showed the suicide risk factors: male sex, depression, rational thinking loss, and no spouse.

Total score: 6. Suicide risk: Medium


Patient #21.

Record review of the "Patient Assessment Report" by Staff L dated 04/08/2019 at 4:45 AM showed: " ... depression, suicidal ideation, anxiety ... 'Times are getting harder. I just can't take it anymore' ... racing thoughts, had a gun in hand, but couldn't do it ... depression, loss of energy, low self-esteem, hopelessness, helplessness, feelings of worthlessness and guilt, impulsive, impaired judgment, anxiety, insomnia ... hearing voices ... visual hallucinations.

Suicide risk: Moderate

Record review of the suicide risk rating tool by Staff L dated 04/08/2019 at 4:45 AM showed the suicide risk indicators: high anxiety or panic; destructive coping strategies; specific suicide plan; impulsive behavior; and hearing command hallucinations for self-harm.

Total score: 43. Suicide risk: Low

Record review of SADPERSONS Suicide Assessment Scale by Staff L dated 04/08/2019 at 4:45 AM showed the suicide risk indicators: male sex, older age, depression, rational thinking loss, no spouse, and sickness.

Total score; 6. Suicide risk: Medium


Patient #22.

Record review of the "Patient Assessment Report" by Staff V dated 04/09/2019 at 1:13 PM showed: " ... depression, suicidal ideation, anxiety ... brought in by family for taking 10 pills of Xanax two days ago in suicide attempt ... husband left for another woman ... depression, loss of energy, low self-esteem, hopelessness, helplessness, feelings of worthlessness and guilt, decreased concentration, impulsive, impaired judgement, minimizes problems, anxiety, panic attacks, insomnia ... Elopement risk - NA ... Disposition issues and or plan - NA ..."

Suicide risk: "High"

Record review of the suicide risk rating tool by Staff V dated 04/09/2019 at 1:13 PM showed the suicide risk indicators: no professional help in the past, or no positive experiences associated with this help; use of alcohol or drugs to excess, infrequently; high anxiety or panic; destructive coping strategies; non-verbal behavior indicating self-destructive thoughts; specific suicide plan; recent or significant loss(es) self-deprecating; and impulsive behavior.

Total score: 57. Suicide risk: Low

Record review of SADPERSONS Suicide Assessment Scale by Staff V dated 04/09/2019 at 1:13 PM showed the suicide risk indicators: depression, previous attempt, organized plan, and no spouse.

Total score: 4. Suicide risk: low


Patient #23.

Record review of the "Patient Assessment Report" by Staff V dated 04/08/2019 at 6:23 PM showed: " ... opioid abuse, dependence ... chronic pain ... social withdrawal, isolative, impulsive, impaired judgement, poor insight, anxiety, insomnia ..."

Suicide risk: NA

Record review of the suicide risk rating tool by Staff V dated 04/08/2019 at 6:23 PM showed the suicide risk indicators: mild to moderate anxiety; no declarative statement; no non-verbal behavior indicating self-destructiveness; withdrawn or isolated; few resources; excessive use of alcohol or drugs, and impulsive behavior.

Total score: 30. Suicide risk: Low

Record review of SADPERSONS Suicide Assessment Scale by Staff V dated 04/08/2019 at 6:23 PM showed the suicide risk indicators: previous attempt, social support lacking, and no spouse.

Total score: 3. Suicide risk: Low


Patient #24.

Record review of the "Patient Assessment Report" by Staff R dated 04/09/2019 at 12:15 PM showed: " ... bipolar disorder with suicidal ideation ... running from an abusive relationship ... manic and suicidal ... patient was minimizing ... has a history of alcohol intoxication as a suicide attempt ... hopelessness, helplessness, feelings of worthlessness and guilt ... impaired judgement, poor insight, anxiety, panic attacks, deterioration of ability to care for self, insomnia, decreased appetite ... "

Suicide risk: "High"

Record review of the suicide risk rating tool by Staff R dated 04/09/2019 at 12:15 PM showed the suicide risk indicators: mild to moderate anxiety; mild depression; no non-verbal behavior indicating self-destructiveness; use of alcohol or drugs to excess, infrequently; high anxiety or panic; few resources; unstable lifestyle; specific suicide plan; recent or significant loss(es); impulsive behavior; and in poor health, and numerous medical problems.

Total score: 59. Suicide risk: Low

Record review of SADPERSONS Suicide Assessment Scale by Staff R dated 04/09/2019 at 12:15 PM showed the suicide risk indicators: older age, depression, previous attempt, ethanol abuse, social supports lacking, organized plan, no spouse, and sickness.

Total score: 8. Suicide risk: High


Patient #25

Record review of the "Patient Assessment Report" by Staff X dated 04/10/2019 at 1:26 AM showed: " ... depression, suicidal ideation, psychosis ... racing thoughts, wants to hurt self ... prior suicidal attempts times two ... suicidal thoughts in the last 72 hours ... 'jump off a bridge' ... Attempted suicide in the past ... drank a bottle of fingernail polish on one [occasion]. Second [occasion] took bottle of Tylenol ... depression, loss of energy, hopelessness, social withdrawal, isolative, loss of interest in activities, decreased concentration, mood swings, manic, irritability, impaired judgement, minimized problems, assaultive, and hypersomnia ... Shadows and voices telling her to harm herself ... "

Suicide risk: "High"

Record review of the suicide risk rating tool by Staff X dated 04/10/2019 at 1:26 AM showed the suicide risk indicators: vague, fleeting thoughts of suicide with no plan or method; in good physical health, few or no medical problems; withdrawn or isolated; verbal statements of intent; unstable lifestyle; excessive use of alcohol or drugs; impulsive behavior; and hearing command hallucinations for self-harm.

Total score: 52. Suicide risk: Low

Record review of SADPERSONS Suicide Assessment Scale by Staff X dated 04/10/2019 at 1:26 AM showed the suicide risk indicators: depression, previous attempt, ethanol abuse, rational thinking loss, social supports lacking, and no spouse.

Total score: 5. Suicide risk: Medium


C. Patients with documented "high" risk for suicide were not placed on a 1:1 at the time of admission.

Record review of the Policy & Procedure: "Comprehensive Interdisciplinary Patient Assessment" reviewed/revised February 1, 2019 showed: "The information obtained on initial preadmission screening includes: ... 1.1.3 Suicide/Homicide Risk via SADPERSON [sic] (score of 7 or above automatically generates a 1:1 status ...) "

Record review of the Policy & Procedure: "Admission Procedure (Nursing)" reviewed/revised February 1, 2019 showed " ... 5.0 The admission interview includes: 1.1 An immediate review of the SADPERSONS assessment (a score of seven (7) or greater necessitates high risk precautions for the duration of the patient's hospitalization ..."

Record review of SADPERSONS Suicide Assessment Scale for Patient #24 by Staff R dated 04/09/2019 at 12:15 PM showed the suicide risk indicators: older age, depression, previous attempt, ethanol abuse, social supports lacking, organized plan, no spouse, and sickness.

Total score: 8. Suicide risk: High

Record review of the Physician's Orders for Patient #24 dated 04/09/2019 at 03:34 PM showed "Suicide Preca
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on record review and interview:

A. The facility failed to ensure that staff had received required education, training, and demonstrated knowledge for the monitoring of any special requirements associated with the one-hour face-to-face evaluation. Failure to provide this training resulted in 6 of 6 RNs (Staff C, Staff E, Staff G, Staff K, Staff L, and Staff M) conducting the one-hour face-to-face evaluation without the required training.

B. The facility failed to ensure that a face-to-face evaluation was conducted within one hour after the initiation of the restraint/seclusion intervention on 5 of 5 patients (patient #1, #2, #15, #16, and patient #17).

Findings included:

A. Required education.

Record review of facility policy titled "Provision of Care, Restraint and Seclusion" dated 12/31/18, section 4.1.4 stated that a face to face assessment of the patient was to occur within one hour of initiation of restraint or seclusion by an "authorized RN."

Record review of the personnel files for 6 of 6 RNs (Staff C, Staff E, Staff G, Staff K, Staff L, and Staff M) showed that there had been no documented education, training, or demonstrated knowledge to conduct the one-hour face-to-face evaluation.

In an interview with Staff O, Human Services Director, on 04/16/2019 at 12:05 PM, she stated that Staff C, Staff E, Staff G, Staff K, Staff L, and Staff M had not received any competency training to be qualified to conduct the one-hour face-to-face evaluation. She went on to say that none of the RNs working at the hospital had received this training.

In an interview with Staff C, Interim DON, on 04/16/2019 at 2:00 PM, she stated that none of the RNs working at the hospital had received any competency training to be qualified to conduct the one-hour face-to-face evaluation.

B. Face-to-face evaluation within one hour of initiation of restraint/seclusion intervention.

Record review of the "Part III - RN or MD Face-to-Face Evaluation" for patient #1, #2, #15, #16, and patient #17 showed no documentation of a signature, date, or time by an RN or an MD for completion of this Face-to-Face Evaluation.

In an interview with Staff C, Interim DON, on 04/16/2019 at 2:00 PM, she stated that the "Part III - RN or MD Face-to-Face Evaluation" should document the signature of the individual that completed the evaluation, along with the date and time.