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Based on interview, record review, policy review, and picture review, the facility failed to provide a safe environment and protect one Patient (#2) from successful suicide when he hung himself from a bathroom light fixture. The facility also failed to ensure a safe environment in the psychiatric unit with the following findings:
- All patient room lights and patient bathroom lights could be pulled down from the ceiling, which exposed the metal bracket (looping hazard) that anchored the lights to the ceiling, as well as electrical wiring (shock hazard).
- Metal plumbing covers (boxes to prevent access to a looping hazard) around the back of toilets had rusted, sharp edges (cutting hazard).
- Mirrors in the patients' rooms could be easily pulled from the walls, which exposed large, sharp, threaded anchors (cutting hazard).
- Beds frames were metal, moved on casters (roller style wheels), and had metal cranks that raised and lowered the head and foot of the bed (looping, barricade and entrapment hazards).
- Shower rooms locked from the inside (patient side) where patients were left alone, and not all staff had keys to unlock the doors (potential delay in access to patients).
- Metal plumbing and electrical covers, located in the hallways, contained large sharp screws, that could be removed by hand (cutting or swallowing hazard).
- Ceiling mounted, metal air vent covers had sharp edges (cutting hazard).
- The nurses station hallway had uncovered oxygen and gas valves (potential for tampering).

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The hospital census was 26. The psychiatric unit census was 17.

The severity of these practices had the potential to place all patients on the psychiatric unit at risk for their safety, also known as Immediate Jeopardy (IJ).

On 07/17/18, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 07/18/18, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
-Education on the new Suicide Reporting Policy (SRP), including Suicide Warning Signs began immediately to all Department Heads and they began educating all their staff to the policy.
-100% of all employees on site and all reporting for the next shift were educated.
-All employees, including as needed (PRN) employees, will be educated before their next shift.
-Employees throughout the building will randomly, on each shift, be asked about the appropriate response to patient's suicidal comments and reporting of such. If less than 100% compliance to these questions then re-education will be given.
-The SRP training will be added to the new employee orientation and annual training.
-Employees will be given a questionnaire to demonstrate compliance at new hire orientation and annual training to demonstrate understanding. This information will be kept in the employees personnel file.
-All current patients with suicidal ideations (SI, thoughts of suicide) were put on one-to-one observation (one staff member is assigned to observe one patient at all times, to ensure the patient is safe).
-Any future patients expressing SI will be placed with one-to-one observation, and an immediate assessment by a qualified staff member will be completed.
-Qualified staff members completing the assessments can place patients on one-to-one observation immediately and then consult with the provider for written orders.
-All nurses and therapists will be trained by the providers on completing the Columbia-Suicide Rating Scale (C-SSRS, this scale supports the suicide risk assessment through a series of simple questions to help identify if someone is at risk for suicide and assess the severity and immediacy of that risk). 100% education will be documented by the providers. The Director of Nursing (DON) and/or designee will review and verify 100% compliance.
-The nurses currently on duty were educated by the provider.
-On call providers will be available 24/7 for staff to consult with the results of the C-SSRS to determine the risk status mode. The risk will always be considered higher, rather than lower until a face to face consultation with the provider.
-Suicide risk assessments by nurses will be increased in frequency from every shift to every medication pass. This includes 9:00 AM, 3:00 PM. 9:00 PM, and any additional medication times for individual patients. This will be observed by the Director of Nursing (DON) and/or designee and if not 100% compliance, re-education will be given.
-While awaiting the necessary safety updates and repairs all SI patients will remain on one-to-one observation status.

Based on interview, record review, policy review, and review of pictures, the facility failed to protect one Patient (#2) from successful suicide, of one suicide reviewed, when the patient hung himself from a bathroom light fixture in the psychiatric unit. The facility also failed to ensure a safe environment, when multiple areas on the psychiatric unit presented looping, cutting, swallowing, shock and tampering hazards. These deficient practices had the potential to result in self-inflicted injury, or injury caused by another patient, and could affect the health and safety of all patients on the psychiatric unit. The hospital census was 26. The psychiatric unit census was 17.

Findings included:

1. Review of Patient #2's medical record showed that Patient #2 presented to the ED on 07/11/18 at 3:00 PM, and complained of increased anxiety and was unable to tell what was real and what was not. The History and Physical (H&P) documentation showed bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) and severe depression (a long period of feeling worried or empty with a loss of interest in activities once enjoyed), with psychotic features (characterized by false ideas about what is taking place or who one is).

During an interview on 07/17/18 at 11:55 AM, Staff C, Respiratory Therapist (RT), and Staff D, RT, stated that on 07/11/18, Patient #2 said to them, "This world is mean, people are mean, and I don't want to live like this anymore." Staff C told the patient to take his medicine, get a good nights sleep, and talk to his counselor.

Staff C and Staff D failed to report these statements to anyone.

During an interview on 07/17/18 at 1:33 PM, Staff E, Psychiatrist, stated that Patient #2 had suicidal thoughts and was bothered by hallucinations (seeing or hearing things which are not there), but she "didn't get the vibe from him that he was suicidal."

During an interview on 07/17/18 at 11:19 AM, Staff B, Certified Nurses' Aide (CNA), stated that on 07/12/18 at 4:15 PM, she visualized Patient #2 walking back and forth in his room, and at 4:20 PM, the patient was found hanging from the light fixture in his bathroom by another patient.

Review of two pictures showed the light fixture in the bathroom was pulled down from the ceiling by the base, which exposed electrical wires and a metal bracket, which was where Patient #2 tied his bed sheet and hung himself.

Patient #2 was pronounced dead on 07/12/18 at 4:55 PM.

2. Observations on the psychiatric unit on 07/17/18 at 10:55 AM showed:
- All patient room lights and patient bathroom lights could be pulled down from the ceiling, which exposed the metal bracket (looping hazard) that anchored the lights to the ceiling, as well as electrical wiring (shock hazard).
- Metal plumbing covers (boxes to prevent access to a looping hazard) around the back of toilets had rusted, sharp edges (cutting hazard).
- Mirrors in the patients' rooms could be easily pulled from the walls, which exposed large, sharp, threaded anchors (cutting hazard).
- Beds frames were metal, moved on casters (roller style wheels), and had metal cranks that raised and lowered the head and foot of the bed (looping, barricade and entrapment hazards).
- Shower rooms locked from the inside (patient side) where patients were left alone, and not all staff had keys to unlock the doors (potential delay in access to patients).
- Metal plumbing and electrical covers, located in the hallways, contained large sharp screws, that could be removed by hand (cutting or swallowing hazard).
- Ceiling mounted, metal air vent covers had sharp edges (cutting hazard).
- The nurses station hallway had uncovered oxygen and gas valves (potential for tampering).


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