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Based on interview, record review and policy review, the facility failed to ensure a patient was monitored as planned for patient safety management resulting in a near miss event and a potential for significant harm; and failed to record the event in the facility reporting system. This affected one (Patient #1) of ten patient record reviewed.

See A144

Based on interview, record review and policy review, the facility failed to ensure a patient was monitored as planned for patient safety management resulting in a near miss event and a potential for significant harm; and failed to record the event in the facility reporting system. This affected one (Patient #1) of ten patient record reviewed. The hospital census was two.

Findings include:

Review of Patient #1's medical record revealed an admission date of 07/25/24 from an acute care hospital due to suicidal ideations. There was an emergency hold order mandating admission to the psychiatric facility, due to unsafe behaviors and patient report of intent to harm themselves as manifested by a self-inflicted injury of a laceration on Patient #1's left arm which had been sutured.

Review of a history and physical report revealed Patient #1 had diagnoses including bipolar, schizophrenia, anxiety, major depressive disorder, hypothyroid disorder, gastroesophageal reflux disease, borderline personality disorder, post-traumatic stress disorder, and history of suicide attempts by overdose, hanging and self-harm cutting.

Review of the admission assessment dated 07/25/24 revealed Patient #1 had been admitted for a status post suicide/ self-harm action of cutting her left arm to an extent that required sutures at the emergency department and safety management required one to one staff monitoring, with constant supervision of her activities and location for safety. Patient #1 was identified as a risk for self-harm, high risk for adverse behaviors.

Review of Patient #1's plan of care and physician orders revealed that she had a level of monitoring for safety that included two staff to one patient ratio during waking hours and one to one staff to patient ratio during sleeping activity since admission.

Review of the nursing notes dated 08/31/24 for day shift (7 AM to 7 PM) revealed the level of safety observation was two Behavioral Health Technicians (BHT) with the Patient #1. The Patient #1 was in her room seated on her bathroom floor which was a common preference. The two BHT were in the room and supposed to be within line of sight to monitor the Patient #1.

Review of a nursing note dated 08/31/24 at 11:01 AM revealed that the nurse was alerted by a BHT that Patient #1 required assistance and assessment in the patient's room. Review of the documentation revealed that the nurse, Staff C, entered Patient #1's bathroom to find that Patient #1 was seated on the floor of the shower area with the shower curtain pulled to hide her. She was positioned with her head bowed down to her chest. When the nurse raised Patient #1's head, there was bandage gauze wrapped around Patient #1's neck with a knotted tie that could not be manually removed. Patient #1 was not unconscious, but her skin was abnormal in color, with a pale or bluish tinge, and the nurse used a scissors to cut the gauze allowing Patient #1's facial skin color to return to natural hue. An immediate assessment of Patient #1 after the removal of the ligature found her alert and oriented, breathing without difficulty, denying pain, verbalizing angrily and telling staff to leave her alone.


Review of the written nursing assessment of Patient #1's vital signs on 08/31/24 immediately post-event revealed that measurements were within normal limits including oxygenation values. Patient #1 was ambulatory and at 1:40 PM was tipping over chairs, pacing in the hallway and striking her head on the walls. Despite staff interventions to redirect her, Patient #1 continued with self-destructive actions and the staffing ratio continued to be two to one for safety monitoring. Review of the nursing notes revealed Patient #1's self-harm behavior continued with her head strikes causing bruising, redness with swelling and Patient #1 was evaluated by the facility's hospitalist physician at 6:50 PM who recommended evaluation at an acute care hospital to rule out acute injury of her head and neck.

Review of a hospital report dated 08/31/24 revealed Patient #1's head and neck imaging revealed no acute injury and she returned to the facility that evening.

Review of facility incident reports provided on 09/09/24 revealed there was no written report of the event for Patient #1 on 08/31/24.

During an interview on 09/09/24 at 4:35 PM, Staff G stated Patient #1 was positioned on the floor of the shower within the bathroom of her room and staff allowed her to close the curtain for a moment of privacy thinking that they were allowing her peace due to her constant insistence that she did not want to be closely supervised. Patient #1 used the opportunity that she gained out of sight of the two staff members to wrap a length of gauze around her neck and knot it before staff intervened to free her. Patient #1 did not experience an injury, had not lost consciousness and was fighting staff when they intervened to remove the gauze. Patient #1 was being monitored by two to one ratio, staff to patient safety supervision, prior to, during and after the event and should not have been allowed a moment out of direct sign of staff assigned to monitor her.


During an interview on 09/12/24 at 8:06 AM, Staff A stated the event with Patient #1 on 08/31/24 had not been recorded as an adverse event, had not been documented in the incident reporting system despite two nurses being on duty and aware of the facility's system for event reporting and having been involved in the event. Staff A confirmed that there were two staff supervising Patient #1 at the time of the event and that they misjudged the situation by allowing Patient #1 to have a moment of privacy behind the curtain, leaving her out of the direct line of sight that was planned for patient safety management. Staff A confirmed that the incident met the definition of the facility's Event Reporting policy, but no report was filed at the time of the event or within 24 hours post-event. Staff A said there was no written educational direction for staff post-event despite the patient's potential for harm in being out of direct sight for supervision. Staff A said the level of two to one safety monitoring had continued for Patient #1 and Patient #1 was sent out for evaluation on the evening of 08/31/24 after she engaged in additional self-destructive behavior of head banging, which was a result of her decompensated, agitated state of being that day.

Staff A said there was no report of incident, no investigation regarding the near miss event nor any inquiry regarding the use of a length of gauze for a patient with high risk for self-harm behavior.

During an interview on 09/17/24 at 9:22 AM , Staff A stated Patient #1 remained on the unit awaiting placement at a state psychiatric hospital, which had a waiting list due to bed availability.

Review of the facility's policies titled "Responsibilities in Event Reporting", number H-PC 07-007, revealed the policy of the facility was to ensure that personnel were responsible for reporting in a timely and efficient manner, patient and visitor events through the Event Reporting System that were separate from the patient's medical records, in a confidential file. The definition of an Event was "any occurrence or situation not consistent with the routine operation of the facility and which may have caused or may have the potential for causing injury to patients, visitors, or loss or damage to property. Events include any threat to patient safety; can include physical injury, patient dissatisfaction, and near misses." A report was to be completed within 24 hours and nursing staff was responsible for the documentation and reporting process.