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.

Based on review of records and interview, it was determined that the governing body did not ensure that nursing staff always comply with facility policies and procedures.

Findings were:

Facility policy entitled "Patient Rights and Responsibilities" stated in part "Each Seton patient receives a copy of the Seton Patient Rights and Responsibilities and Healthcare Choices sheet which defines their rights as defined below:

* Participate in the development and implementation of your plan of care and make decisions regarding your care including pain management.
* Make informed decisions regarding your care, including being informed of your health status, being involved in your care planning and treatment, and being able to request or refuse treatment ...
* Personal privacy.
* Receive care in a safe setting.
* Be free from all forms of abuse or harassment
* Care that is considerate and respectful of personal values and beliefs ...
* Have Seton use its best efforts to meet your special communications needs."

Facility Policy entitled "Precaution Levels-Assessment" stated under "Levels of Observation:
1. Routine Observation-this is the routine minimum patient observation of at least every 15 minutes.
2. Fifteen-minute checks-for suicide/self-injurious behavior, assaultive/aggressive behavior, elopement risk, and/or sexual acting out.
3. Other precautions may include falls and seizure.
4. 1:1 Line of Sight-this is where the patient is visible to a staff person at all times. This may be done from a distance but the line of vision between the patient and staff person is kept clear. This level of observation can be ordered for a specific precaution.
5. 1:1 Observation-is where staff are to remain within arm's length except at night when patient is sleeping, staff may move to doorway in exceptional instances, as with a paranoid patient, the physician may expand the boundary to a specified number of feet ....
6. The Charge Nurse is responsible for ensuring that all patient observations are completed and documented by a member of the nursing staff. The Charge Nurse will cosign the precautions sheet.
a) A patient check is the visual identification of the patient with his/her location and observable behavior. This means that a patient's face must remain visible (not covered by linen or clothing) and the appropriate time spent to observe the rise and fall of the chest is required."

On 7/10/19, Patient # 1 was found in his room dead. He had committed suicide by strangulation. Per documentation, the patient was checked on every 15 minutes throughout the night. At 7am, he was found cold and lifeless with rigor mortis (according to Forensic Ecogenomics, 2018, rigor mortis occurs 3-4 hours after death).

In an interview with the Chief Administrative Officer on 12/4/19, it was confirmed that neither the Charge Nurse nor the Behavioral Health Technician followed facility policy in monitoring the patient throughout the night. While the patient was observed, the rise and fall of his chest was not.
Based on review of records and interview, it was determined that Patient # 1 was not provided with a safe environment.

Findings were:

Patient # 1 committed suicide while at Seton Shoal Creek Hospital during the morning of July 10, 2019. The patient was left in his room with personal medical equipment (wheelchair) whose Velcro straps enabled him to fashion a ligature device.

The above incident was admitted to by the Director of Nursing and the Chief Administrative Officer during an interview on December 4, 2019.