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Based on review of video surveillance, record review, interviews, and policy review, the facility failed to ensure the safety of patients receiving care in behavioral health unit (south) when staff failed to complete 15-minute patient monitoring rounds on 18 of 22 patients, resulting in one patient death from suicide (Patient #1), and failed to enter an order for increased patient monitoring for 1 of 3 patients sampled (Patient #1).

Refer to A0144, Standard.

The findings included:

The facility provided and demonstrated a mitigation plan for the events which led to the death of Patient #1 on 4/26/2025 which was implemented prior to the survey.
1. All scheduled staff members will complete a safety rounding expectation
attestation and an in-person competency check by May 9th, 2025. This plan was implemented and documented prior to the survey and confirmed through onsite review of signatures. Interviews with mental health technician (MHT) F on 5/14/2025 at 2:00pm, registered nurse (RN) C on 5/14/2025 at 2:15pm, and RN D 5/14/2025 at 3:18pm.
2. Department director or their designee will complete 20 live (in person)
patient safety rounding audits per week. Completed audit tools were reviewed onsite. Sampled and reviewed 11 audits which were completed between 5/9/2025 and 5/12/2025.
3. Department director or their designee will complete 3 video audit reviews
per week. Audits will be completed on one day, one night, and one weekend
shift and cover a minimum of 2 consecutive hours of rounding activity to
validate the patient safety round was performed to standard. - Video was reviewed onsite and this measure was confirmed as implemented in an interview with the director of quality on 5/15/2025 at 2:00pm.
4. Patients with an increased level of observation will be included on the end of
shift report for department director/manager order review. This was confirmed through observation of house supervisor end of shift report and interviews with Clinical Nurse Coordinator, RN C on 5/14/2025 at 2:15pm and house supervisor, RN H on 5/15/2025 at 4:30pm.
5. Staff members will perform an environmental safety round each change of
shift, to include all spaces of the patient room and bathroom to ensure that
there are no concerns for self-harm in the care area i.e. excess linens, patient
items that have been altered to potentially cause harm, or other contraband.
Any items that are found will be removed immediately. - This was confirmed through onsite observation and video surveillance observation on 5/15/2025 at 3:05 - 3:20pm.
Additionally, the facility removed shower curtains from the behavioral health units and reported the failure of the breakaway function for ligature-resistant shower curtain hooks to the product distributor. The medical director of the behavioral health unit communicated the expectations for order entry for escalated patient monitoring to providers serving the behavioral health unit, per interview on 5/16/2025 at 12:14pm.
The director of quality confirmed in an email received on 5/21/2025 at 5:10pm that MHT A was removed from patient care at 12:30pm on 4/26/2025. At the time of the survey, MHT A was suspended pending investigation and per interview with the director of quality on 5/16/2025, the hospital terminated employment of MHT A.

Based on review of video surveillance, record review, interviews, and policy review, the facility failed to ensure the patients' right to a safe environment when staff failed to complete 15-minute patient monitoring rounds on 18 of 22 patients, resulting in one patient death from suicide (Patient #1), and failed to enter an order for increased patient monitoring for 1 of 3 patients sampled (Patient #1).

The findings include:

A medical record review found that Patient #1 was admitted to the behavioral health unit of the hospital on the evening of 4/24/2025 after presenting to the emergency department voluntarily seeking help for auditory hallucinations and being off psychiatric medications for about 2 weeks. The admission/shift assessment, documented 04/24/2025 at 6:17pm identified the patient in the BH setting: Mod: Close Observation & Re-evaluation. Place patient on close observation, minimally with every 15 min checks completed and documented. Consider need for continuous observation based on patient's ability to cooperate, follow verbal cues and maintain safety." The record included several assessments for suicide risk including documentation on 4/24/2025 at 10:55pm which indicated Patient #1 did not have suicidal thoughts and had not attempted, planned to attempt, or prepared to end life since last contact.

04/25/25 at 09:30am, note electronically signed by Dr. G. Includes mental status examination indicating affect is moderately anxious, tearful. Patient does not appear to be responding to internal stimuli. Patient denies any thoughts of self harm or harm to others, thought process is concrete, focused on his dog. Insight is poor, judgment is poor at this time. Attention and concentration were adequate for interview. Clinical impression: Schizophrenia and Amphetamine abuse. Plan - continue involuntary psychiatric admission for further stabilization. Medications were restarted. Overall level suicide risk: low risk.

RN Shift assessment documented on 4/25/2025 at 4:53PM by Employee D, a registered nurse (RN), documented Patient #1, Paranoid ideation/delusions hallucinations: "Present/Exists.: Delusions: "Persecution". Statement of delusion indicates - "Believe(s) the sheriff is out to get him and put him in jail for life. as having "non-specific active suicidal thoughts since last contact: yes. wish to be dead or not wake up since last contact: no; active ideation with plan and intent since last contact: no. - Calculated suicide risk level: Moderate risk"

A subsequent note entered by Employee D on 4/25/2025 at 5:27pm noted "Patient has been anxious, tearful, and upset because he can't find his dog. Believes the police took the dog. Patient would not make suggested calls to find the location or what happened to his dog but later did call a girlfriend and patient found the whereabouts of his dog. Also, patient informed staff that he was looking for a way to kill himself on the unit, like the shower curtain can be used to hang himself. Tech sat with patient and later patient on LOS (line of sight) in front of nurses' station. Doctor informed (used name of Employee G, the psychiatrist involved in Patient #1. When assessed concerning SI (suicidal ideation), patient states the reason he is having suicidal ideation is because the sheriff wants to arrest him and put him in jail for the rest of his life. No charges against patient that would be a life sentence. Patient states 'oh, the sheriff is trumping up charges on him; he has his ways.' Patients given Seroquel 50 milligrams and Ativan per order. Patient is sitting in front of the nurses' desk with blanket over body and crying until patient fell asleep. Patient reassessed and patient states he is feeling much better now that he found out his dog is safe and no longer SI (suicidal ideation). Note that while patient was on line of sight patient talking to people that were not there and reaching out and trying to grab at things that were not there. Patients eat well and taking medications. Patient appeared disheveled but took a shower and cleaned this afternoon and states it also helped him feel better, the shower."

A suicide risk assessment completed on 4/26/2025 at 1:14am indicated "non-specific active suicidal thoughts since last contact: "yes."; active ideation without method, plan or intent since last contact: "Yes"; Active ideation with some intent and wo plan since last contact: No; Active suicidal ideation with plan an intent since last contact: No; Attempted, planned to attempt, or prepared to end life since last contact; "No"; Calculated suicide risk level: "Moderate risk."

Nurse note, 04/26/2025 at 07:41am indicates 1900-0700: [Patient] is in milieu watching TV but isolates to self. He is disorganized and illogical. Endorses SI (suicidal ideation) due to OCSO (Okaloosa County Sheriffs Office) wanting to arrest him denies HI (Homicidal ideation)/AVH (Auditory Verbal Hallucinations). He is 'medication' adherent. He ate snack and appears to have slept 6.5+ hours as of 0630. Plan of care and safety monitoring ongoing."

A late entry noted "4/26/2025 at 10:18am **based on video review, staff interview, and observation of actual events** Patient was found in patient bathroom with shower curtain tied around his neck. CPR was initiated and Code Blue activated. Time of death pronounced at 10:41am."
In an interview with the nursing director for behavioral health, RN J, on 5/14/2025 at 2:44pm, she explained that all patients in the behavioral health unit are on patient monitoring rounds of no less than every 15 minutes unless there is an indication for more frequent monitoring such as line of sight or one-to-one monitoring.

A review of the Patient Monitoring form for Patient #1 for 4/26/2025, marked as "Standard (q15)" monitoring which begins at 12:00am indicated he was in bed sleeping between 12:00am and 6:30am, at the medication room (in line) at 6:45am, in the unit milieu interacting at 7:00am, in the unit milieu watching tv at 7:15 and 7:30am, and illegible markings are noted on the form for the 7:45, 8:00, 8:15, 8:30, 8:45, and 9:00am time slots. According to a review of recorded video surveillance, Patient #1 was observed in the common area at 7:00am, observed on the phone around 8:45am, and observed returning to his room at 9:02am. The form was signed off for each 15-minute increment from 12:00am through 10:0am and blank after the 10:00am time slot. The 9:15am, 9:30am, 9:45am, and 10:am time slots were initialed by mental health technician (MHT) A.

On 5/14/2025 at 4:10pm, MHT A stated in an interview that she did not perform these checks. This was also confirmed through video observation of the period between 8:00am - 10:18am. The notations by MHT A at 9:15, 9:30, 9:45, and 10:00am all noted the code "2H" indicating the patient was in his room and quiet during these observations.

MHT A described the events of the morning of 4/26/2025 as "the whole reason this is happening is because I was slacking and not keeping up with the q15 (minute) rounds. I was doing other stuff and got behind. I was helping other patients with their belongings, and I was on the computer. I was doing work stuff on the computer. We chart groups. I was charting the morning group. It was me being very tired and having a bad day and I just slacked off. There were 2 techs, including myself (me and one other person), there were 3 nurses and there were around 26-28 patients. That is typical." When asked if she has help, MHT A responded, "It depends on the nurse. I don't like asking the nurses for help, now I see that I should. If nurses don't offer to help, I just do it myself."

There were no observations made for patient #1 from 09:03am, until the time he was found deceased at 10:18am.

The census on the behavioral health unit where Patient # 1 was admitted on 4/26/2025 was 22. A review of the Patient Monitoring forms for all 22 patients on 4/26/2025 included documentation by MHT A. There were 2 patients (11 and #20) who were missing documentation in the time slots for 10:15am and 10:30am.

The following patients were documented as having been "in bed" by MHT A during the period between 8:00am when the last round was observed in the patient room halls by the nurse and 10:18am when the code blue for Patient #1 was initiated: Patient #1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #16, #18, #19, #20, #21, #22, and #23.

On 5/14/2025 at 3:18pm, an interview took place with registered nurse (RN) D, who was assigned on 4/25/2025 to the behavioral health unit of the hospital where Patient #1 was admitted. During the interview, RN D said she was the nurse who spoke with Doctor G, the psychiatrist overseeing the care of Patient #1 on 4/25/2025. RN D confirmed that she informed Doctor G in a face-to-face conversation of concerns for suicidal ideation by Patient #1. She stated, Doctor G thought this was due to the patient being off medications for two weeks and thought restarting the medications would help. She said Doctor G ordered the medications which were administered to Patient #1 that day. As she remembered the conversation, RN D said, "Doctor G didn't think after talking with the patient earlier that he was suicidal, so I just kept him online-of-site." RN D described the interactions with Patient #1 on 4/25/2025 as "Patient #1 voiced the suicidal thoughts after breakfast and before lunch. I worked till about 6 - 6:15pm. Patient #1 was sitting in front and talking to himself when no one was there. He was reaching into the nurses' station grabbing for things that weren't there. Later the techs went with him to take a shower, and he said he felt better. I saw him at dinner, quieter and not so anxious. He wasn't real paranoid about the cops or anything at that time. There was no indication for the rest of the day that he should have been on one to one. Through different conversations with the techs, he didn't seem like he was going to kill himself. He was very worried about his dog, but he had calmed down about that. When he found out the dog was safe and ok, he said he felt better and less anxious." Regarding the use of shower curtains on the unit, RN D said, "We could have taken the shower curtain down. He said he was looking for things. The decision not to remove it was based on the fact that the shower curtain was supposed to break and when they move the shower curtains, they (the shower curtains) fall. We don't want the patients to think we are going to take everything away from them. It seemed like he was calm. He did say that he was looking for things like the shower curtain to kill himself, but because we knew that the shower curtains break away and he was on line-of-site, we didn't think we needed to take it away. If we think the patient is going to smuggle utensils and use them to self-harm, we have put them on finger foods. We do take things and assess for that, but we didn't think that he was at risk at the time after calming down. During the day while he was still on line-of-site, the techs did go with him to check on him while he was showering. When he showered, he got dressed and came back out, he didn't make any attempt during the shower to mess with the curtain."

During a tour of the unit on 5/14/2025 at approximately 1:45pm - 2:15pm, an observation was made of a patient room and bathroom. There was no shower curtain present. In an interview during the tour, the nursing director of the behavioral health unit, RN J, said all shower curtains on the unit have been removed from all bathrooms. There were no other obvious ligature risks observed, and door handles, faucets, and furniture were observed to be the type commonly seen in a behavioral health setting and designed to reduce ligature risk.

In a follow up interview with the vice president of quality/risk management and the director of quality on 5/14/2025 at approximately 3:10pm, the director of quality said the shower rods and hooks have all been removed. The shower curtain hooks that were used on the unit when Patient #1 used the shower curtain as a strangulation device, were "ligature approved and supposed to break away with tension. Each hook was supposed to have been weight rated for 10 pounds of tension. These have now been removed from all the organization's facilities, and this has been reported to the product distributor."

On 5/16/2025 at 12:14pm, the medical director for behavioral health services was interviewed and said he has been working at the facility since 2017 and safety of shower curtains has been addressed to ensure safety several times and "in the time I've been here, this is the third version of shower curtains, and we had confidence of the breakaway curtains functioning as expected."

An interview took place on 5/14/2025 at approximately 2:15pm with RN C, the charge nurse working on the behavioral unit and who was also the charge nurse on the unit on 4/26/2025, the day Patient #1 was found deceased in his bathroom. Describing the events that took place on 4/26/2025 and what has occurred since the events of 4/26/2025, RN C described "there was a tech that had not done what she was supposed to do that day. There were several rounds that were missed. There is much more rounding now and I am doing much more rounding with staff and observing their rounds." RN C was not aware that Patient #1 had voiced feelings of self-harm and described Patient #1 as "bright and talking and progressing and doing better" and expressed that there was no indication that morning that Patient #1 required an increased level of monitoring.

An interview was conducted with Doctor G on 5/14/2025 at 3:46pm. Doctor G described meeting Patient #1 on 4/25/2025 in the morning and that Patient #1 was tearful about his dog and emotional, very focused on that and forward thinking. Patient #1 said he needed to get into a detox program, and he did have some plans for when he left. Doctor G said, in terms of his evaluation of Patient #1 for suicide risk, "the forward-thinking behaviors were promising." Doctor G went on to describe that RN D "said he made comments about wanting to hang himself, this was about 9am, and we put in meds (medication orders) at that time. RN D said they would keep him at the nurses' station and on line-of-site."

In a follow up interview with Doctor G on 5/16/2025 at 12:05pm, regarding placing an order in the electronic medical record for line of sight monitoring, Doctor G said "From my understanding right after I had seen Patient #1, RN D told me about the voicing suicidal ideation, but when he was with me just prior to this, he was not voicing suicidal ideation and was very concerned about the dog. Patient #1 wasn't SI (suicidal ideation) with me, he wanted to get back into a detox program. He was more forward thinking. In terms of RN D saying that, I don't know the timeframe when she first heard that, but I was going to put the medications in for him. We did not talk about who would enter the order (for line-of-sight monitoring). I would say, classically, it all falls on my shoulders. In terms of putting in orders that a nurse comes to me with. In terms of the follow up, the facility has reinforced that nursing can put in the order, if the doctor is not in front of the computer. It can only be de-escalated by a provider. In moving forward, we have discussed how to better ensure those orders about behavior monitoring have been addressed. In terms of that day, the intervention was there, the order wasn't. If they had come back to me that day, he would have been taken off the line of site that evening around 4-5pm. During every evening, I read notes at home one last time and I saw RN D's note, and I feel comfortable that every patient was reviewed. The note was clearly there. From a reflective perspective, I can't say I would have done anything different. RN D came to me, the interventions were implemented, and the reassessment was that he was no longer suicidal, and I would have discontinued the line of site then. The patient was also seen going to get his medication just before a phone call immediately before the (death) event took place, so I just keep going over in my head, that doesn't make sense that he came out to get his meds, then did this, it doesn't track with suicidal behavior and wouldn't have triggered an intervention."

In an interview with the medical director for behavioral health, Doctor I, on 5/16/2025 at 12:14pm, he said "It would have been an expectation to do a separate note to document the need for the line of sight or to amend the intake note to add the description of what happened that warranted line of sight and to put in the order, if he was on the unit and accessible. With Doctor G being in house, that was our failure to put the order in and the documentation justifying that. We have had some conversations since then to ensure that our providers understand that changing the level requires an order and it can be co-signed or put in if available. Going in reverse, we do not want to reduce the coverage until the order is in and documentation is in to justify the reduction in level of monitoring. We understand from a provider standpoint that we added to the level of confusion about what monitoring the patient should have been on, but clinically, the end result would have been the same. He (Patient #1) would have been back on q15 (every 15 minutes) observation the evening of the 25th. Objectively, his emotions and behavior resolved. He was no longer covering his head with a blanket and his affect was stable. By that evening he would have been on q15."

A review of a position description for a "Mental Health Technician II" signed by MHT A on 12/05/2023 includes a description of duties to include "provides and documents on patient care and observes patient behaviors based on the nursing process, established hospital policies and procedures, unit specific policies and procedures, and/or Standards of Care/Practice. Participates in the safety rounds rotation. Maintains accurate and detailed documentation of assigned safety rounds. Observes reports and documents the patient's physiological and psychological status, informing a registered nurse of any incongruencies in the above."


The director of quality confirmed in an email received on 5/21/2025 at 5:10pm that MHT A was removed from patient care at 12:30pm on 4/26/2025. At the time of the survey, MHT A was suspended pending investigation and per interview with the director of quality on 5/16/2025, the hospital terminated employment of MHT A.

A policy titled "Guidance for Standard and Special Observation"," PolicyStat number 17353486, with an effective/approved date of 1/17/2025 and most recent revision documented as October, 2024 was reviewed and included the following Guidance Procedure: "To maintain the safety of each patient and the stability of the therapeutic milieu. All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient's assessment and needs.
A. The Clinical Nurse Coordinator (CNC) or designee on each shift will assign the
15-minute Patient Monitoring and document these assignments on the Shift
Assignment Form.
B. The assigned staff member(s) personally locates each patient listed and documents the
patient's location and safety on the Patient Monitoring form under the appropriate time
column. The staff member places his/her initials at the top of the column above the time. At the time of joint rounds, both staff members initial the Patient Monitoring form.
C. While making the patient monitoring round, the staff member observes the environment for safety risks."
H. If the patient is in their room, the staff member must enter the room to observe the
condition of the patient. When a patient appears to be sleeping/ resting, staff should
observe the rise and fall of the chest.
The policy also included that "The attending physician/provider orders the implementation, discontinuation, or change in the standard level of q15 min (every 15 minutes) patient monitoring. An RN or therapist may increase a patients' level of monitoring prior to contacting the physician for orders. Clinical Assessment justifies implementation of the least restrictive and most appropriate level of monitoring.
A. Obtain a provider order for the specific level of monitoring required.
1. The attending physician, provider, RN, or therapist assesses the patient and implements the appropriate level of monitoring.
2. If a therapist or RN implements any level other than standard monitoring (q15 minute checks) the RN must also contact the attending/ covering provider to obtain the appropriate order.
3. The provider's order includes the designated level and the reason for the increase level of monitoring (suicidal risk, 1:1 or continuous observation elopement risk).
B. The reason and procedure for this level of monitoring is explained to the patient.
C. A provider's order is necessary to discontinue or change the level of monitoring.
The policy also contained instructions for ensuring a quality assurance process of the monitoring as follows:
Quality Monitoring
o Patient Monitoring Rounds and q2 (every 2) hour Nursing Rounds -
o Audits are performed monthly and reviewed for overall percentage compliance.
o BHS (behavioral health service) Leadership, House Supervisors, or any Hospital Executives rounding on the Behavioral Health Unit (BHU) will randomly review the patient monitoring form to identify accuracy and timeliness. When variations are found, these should be addressed immediately and reported to the BH executive, or appropriate nursing/ quality leader as soon as possible for follow-up. The number of patient monitoring forms reviewed each month is determined by the facility's leadership.
o Video Review Monthly Requirements - At a minimum of twice per month, each shift, each unit, should be monitored for staff's correct performance of safety checks while
rounding. The review shall capture a cross section of staff to assess accountability and
competence.
o Video review may be competed by BHS Leadership, Hospital Leadership, CNC or designee
o Reviews shall include weekends and holiday shifts.
o A minimum of one hour of video review should be conducted.