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Based on record review and interviews, the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by failing to ensure a patient received care in a safe setting by completing twice daily suicide risk assessments for a patient on suicide precautions (See Finding Tag A0144).



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Based on record review and interview, the hospital failed to ensure each patient's right to receive care in a safe setting. The deficient practice was evidenced by failure of nursing staff to accurately complete twice daily suicide risk assessments for 7 (Patients # 3, 5, R1, R2, R3, R4, R5) of 10 patients (#1-5 & R1-R5) reviewed for suicide precautions.
Findings:

Review of the policy titled, Suicide Assessment AMSR (Assessing and Managing Suicide Risk), with an effective date of 05/2024, revealed in part "Reassessment of Risk:
1. Reassessment of suicidality will occur every waking shift for any patient on suicide precautions or who exhibits a sudden or significant change in mental status. This is documented using the Daily/Shift Suicide Risk Assessment forms or other applicable format. All other patients will be screened using a screening tool at least daily in acute settings.
2. All other patient will be screened using a screening tool at least daily in acute settings by Brentwood Hospital.
3. Patients who continue, or begin to present at higher-risk for suicidality are to continue on, or be evaluated for, heightened observations or precaustions, as outline below.
4. Patients, who no longer meet criteria (lower risk status) for heightened protective measrues or precautions upon reassessment will be evaluated for a decrease in precautions by a physician who will provide appropriate orders...
7. All reassessments shal be considered by the treatment team and incorporated into the patient's individualized treatment plan as indicated and as outlined in the Treatment planning."

Patient #R1
Review of the medical record for Patient #R1 revealed the patient was admitted on 01/28/2025 with suicidal and homicidal ideations.

Review of the orders for Patient #R1 revealed the patient was placed on suicide precautions at the time of admission and the order remained active throughout the admission.

Review of the medical record for "Daily Suicide Risk Assessment" revealed the assessments were not performed on 02/02/2025 during the day shift, 02/03/2025 during the evening shift, and
02/04/2025 during the day shift. Further review of the "Daily Suicide Risk Assessments" present in the record revealed incomplete documentation by the nursing staff. Review of the assessments revealed in part:

01/29/2025 at 5:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NEW ADMIT NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/29/2025 at 9:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/29/2025 at 4:00 PM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/30/2025 at 5:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/30/2025 at 9:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/30/2025 at 4:00 PM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/31/2025 at 5:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/31/2025 at 9:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/31/2025 at 4:00 PM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/01/2025 at 6:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/01/2025 at 8:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- No change insight limited
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/01/2025 at 7:30 PM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/02/2025 at 5:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/03/2025 at 5:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/03/2025 at 8:30 AM
Risk State as compared to previous shift: [NO ANSWER]
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/05/2025 at 5:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/05/2025 at 9:00 AM
Risk State as compared to previous shift: LOWER
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/05/2025 at 3:48 PM
Risk State as compared to previous shift: LOWER
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/06/2025 at 5:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/06/2025 at 9:45 AM
Risk State as compared to previous shift: LOWER
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/06/2025 at 4:00 PM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/06/2025 at 5:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/07/2025 at 5:00 AM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/06/2025 at 5:00 AM
Risk State as compared to previous shift: SIMILAR;
Why? (indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

02/07/2025 at 11:00 AM
Risk State as compared to previous shift: SIMILAR;
Why? (indicate most important factors for assessment)- NO CHANGE
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

In an interview on 02/26/2025 at 9:26 AM, S1Risk Manager verified the hospital policy. If the patient is on suicide precautions, the nursing staff are supposed to completely fill out the "Daily Suicide Risk Assessment" form on each shift, day and evening. S1Risk Manager also verified the orders for suicide precautions were active the entire time Patient #R1 was admitted.

In an interview on 02/26/2025 at 9:53 AM, S1Risk Manager verified the suicide risk assessments were not performed as required per policy.

Patient #R2
Review of the medical record for Patient #R2 revealed admission on 02/21/2025 with a diagnosis of major depressive disorder. Patient #R2 was admitted to Room b.

Review of the orders revealed Patient #R2 was placed on suicide precautions at the time of admission and the order was still active.

Review of the "Daily Suicide Risk Assessment" revealed assessments were not performed on
02/22/2025 for the evening shift, 02/24/2025 for the evening shift, and 02/23/2024 for the day and evening shift. Further review of the "Daily Suicide Risk Assessments" present in the record revealed incomplete documentation by the nursing staff. Review of the assessments revealed in part:

02/22/2025 at 8:50 AM
Risk State compared to previous shift: [BLANK]
Why?(indicate most important factors for assessment): NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

02/23/2025 at 3:00 PM
Risk State compared to previous shift: [BLANK]
Why?(indicate most important factors for assessment): [BLANK]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

02/24/2025 at 10:00 AM
Risk State compared to previous shift: LOWER
Why?(indicate most important factors for assessment): [BLANK]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

02/25/2025 at 8:15 AM
Risk State compared to previous shift: LOWER
Why?(indicate most important factors for assessment): NO THOUGHTS POSITIVE COPING SKILLS
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

During a tour of the patient's unit on 02/26/2025 at 11:17 AM, S4RN verified Patient #R2 was on suicide precautions.

On 02/26/2024 at 11:25 AM, S1Risk Manager verified the suicide risk assessments were not performed as required per policy.

Patient #R3
Review of the medical record for Patient #R3 revealed admission on 02/19/2025 with a diagnosis of alcohol and drug use disorder.

Review of the physician orders revealed Patient #R3 was admitted with suicide precautions.

Review of the "Daily Suicide Risk Assessment" sheets revealed assessments were not performed for the day and evening shift of 02/21/2025 and 02/23/2025, the evening shift of 02/24/2025 and the evening shift of 02/25/2025. Further review of the "Daily Suicide Risk Assessments" present in the record revealed incomplete documentation by the nursing staff. Review of the assessments revealed in part:

02/19/2025 at 2:00 PM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

02/20/2025 at 8:20 AM
Risk State as compared to previous shift: [NO ANSWER]
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

02/20/2025 at 8:00 PM
Risk State as compared to previous shift: SIMILAR
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

02/24/2025 at 11:00 AM
Risk State as compared to previous shift: [NO ANSWER]
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

02/25/2025 at 2:00 PM
Risk State as compared to previous shift: [NO ANSWER]
Why? (indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

On 02/26/2025 at 10:58 AM, S1Risk Manager verified the suicide risk assessments were not performed as required per policy.

On 02/26/2025 at 11:03 AM, during a tour of Patient #R3's unit, S2MHT verified that Patient #R3 was on suicide precautions.

Patient #R4
Review of the medical record for Patient #R4 revealed an admission of 02/18/2025 with diagnosis of alcohol use disorder.

Review of current physician orders revealed the patient had an order for suicide precautions.

Review of the "Daily Suicide Risk Assessment" sheets revealed assessments were not performed on 02/19/2025 for the evening shift, 02/21/2025 for the day and evening shift, 02/22/2025 for the day and evening shift, 02/23/2025 for the day and evening shift, 02/24/2025 for the day shift, and 02/25/2025 for the night shift. Further review of the "Daily Suicide Risk Assessments" present in the record revealed incomplete documentation by the nursing staff. Review of the assessments revealed in part:

02/19/2025 at 7:40 AM
Risk State as compared to previous shift: [BLANK]
Why? (indicate most important factors for assessment)- [BLANK]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

02/20/2025 at 8:20 AM
Risk State as compared to previous shift: [BLANK]
Why? (indicate most important factors for assessment)- [BLANK]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

02/20/2025 at 8:00 PM
Risk State as compared to previous shift: [SIMILAR]
Why? (indicate most important factors for assessment)- [BLANK]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

02/24/2025 at 11:00 AM
Risk State as compared to previous shift: [BLANK]
Why? (indicate most important factors for assessment)- [BLANK]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

02/25/2025 at 2:00 PM
Risk State as compared to previous shift: [BLANK]
Why? (indicate most important factors for assessment)- [BLANK]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK]

On 02/26/2025 at 11:00 AM, observation revealed Patient #R4 was at group therapy in the unit. At that time, interview with S2MHT revealed that Patient #R4 was on suicide precautions.

On 02/26/2025 at 11:05 AM, S3RN confirmed the Patient #R4 had been on suicide precautions since admit.

On 02/26/2025 at 2:30 PM, S1Risk Manager revealed that Patient #R4's record was reviewed and confirmed the patient had been on suicide precautions since admit. S1Risk Manger verified that the suicide risk assessments were not performed twice daily as required by policy.

Patient #R5
Review of the medical record for Patient #R5 revealed an admission of 02/24/2025 with diagnosis of major depressive disorder and suicidal ideations.

Review of physician orders revealed no order for suicidal precautions.

Review of the record revealed no "Daily Suicide Risk Assessment" sheets were completed.

On 02/26/25 at 11:25 AM, S1Risk Manager verified the above missing suicide risk assessments.

Review of Patient #R5's "Daily Nurse Progress Note" dated 02/25/2025 at 9:30 AM revealed the patient "endorses thoughts of suicide". Further review of this form/progress note revealed a section titled "AMSR Daily Screen". Under this section it asked "Since you were last asked, have you actually had thoughts about killing yourself". The nurse checked "Yes".

On 02/26/2025 at 11:30AM, S4RN verified that Patient #R5 had been on suicide precautions since admit.

On 02/26/2025 at 1:50 PM, interview with S1Risk Manager stated that there was no order put in for suicide precautions upon admit. She stated that it was on the patient's intake paperwork, but never got put in the electronic medical record system. S1Risk Manager further stated that the order for suicide precautions was just entered into the patient's medical record at this time, after being questioned by the surveyor. S1Risk Manager further verified she was unable to provide any "Daily Suicide Risk Assessment" forms for Patient #R5.

Patient #3
Review of the medical record for Patient #3 revealed the patient was admitted on 01/08/2025 with suicidal ideations.

Review of the orders for Patient #3 revealed the patient was placed on suicide precautions at the time of admission and the order remained active throughout the admission.

Review of the Patient #3's medical record for completed the "Adolescent Daily Self Report" revealed the following in part:

01/08/2025
1) How are you feeling this morning? "Empty"
3) Do you feeling like hurting yourself? "Yes"
If YES, Last thought: "Would anyone miss me"
5) Do you feel depressed? "Yes"
If YES, rate (0-10): "8"

01/09/2025
1) How are you feeling this morning? "Depressed"
3) Do you feel like hurting yourself? "Yes"
If YES, Last thought: "I don't remember"
5) Do you feel depressed? "Yes"
If YES, rate (0-10): "9.5"

01/10/2025
1) How are you feeling this morning? "Depressed"
3) Do you feel like hurting yourself? "Yes"
If YES, Last thought: "I wanna cut my wrist open."
5) Do you feel depressed? "Yes"
If YES, rate (0-10): "10"
7) Are you having irritability/mood swings? "Yes"
9) Are you having confusion/difficulty concentrating? "Yes"
10) Are you having visual hallucinations? "Yes"
If YES, please explain what you are seeing: "People"
11) Are you having auditory hallucinations? "Yes"
If YES, please explain what you are hearing: "Creepiness and whispering"

01/12/2025
1) How are you feeling this morning? "Depressed"
3) Do you feel like hurting yourself? "Yes"
If YES, Last thought: [LEFT BLANK]
5) Do you feel depressed? "Yes"
If YES, rate (0-10): "9"
7) Are you having irritability/mood swings? "Yes"
9) Are you having confusion/difficulty concentrating? "Yes"
10) Are you having visual hallucinations? "Yes"
If YES, please explain what you are seeing: "A girl with wet black hair standing"
11) Are you having auditory hallucinations? "Yes"
If YES, please explain what you are hearing: "Crying and yelling"

01/13/2025
1) How are you feeling this morning? "Depressed/tired"
3) Do you feel like hurting yourself? "Yes"
If YES, Last thought: "I don't remember."
5) Do you feel depressed? "Yes"
If YES, rate (0-10): "10"
7) Are you having irritability/mood swings? "Yes"
8) Are you having crying spells? "Yes"
9) Are you having confusion/difficulty concentrating? "Yes"
10) Are you having visual hallucinations? "Yes"
If YES, please explain what you are seeing: "A man"
11) Are you having auditory hallucinations? "Yes"
If YES, please explain what you are hearing: "Crying"

01/14/2025
1) How are you feeling this morning? "Numb"
3) Do you feel like hurting yourself? "Yes"
If YES, Last thought: "I want to cut my wrist."
5) Do you feel depressed? "Yes"
If YES, rate (0-10): "9"
7) Are you having irritability/mood swings? "Yes"
8) Are you having crying spells? "Yes"
9) Are you having confusion/difficulty concentrating? "Yes"
10) Are you having visual hallucinations? "Yes"
If YES, please explain what you are seeing: "A tall woman in a white dress."
11) Are you having auditory hallucinations? "Yes"
If YES, please explain what you are hearing: "Help over and over in a weird voice."

01/16/2025
1) How are you feeling this morning? "Numb"
3) Do you feel like hurting yourself? "Yes"
If YES, Last thought: "I don't remember."
5) Do you feel depressed? "Yes"
If YES, rate (0-10): "9"
7) Are you having irritability/mood swings? "Yes"
9) Are you having confusion/difficulty concentrating? "Yes"
10) Are you having visual hallucinations? "Yes"
If YES, please explain what you are seeing: "A woman"
11) Are you having auditory hallucinations? "Yes"
If YES, please explain what you are hearing: "Help"

01/18/2025
1) How are you feeling this morning? "Depressed"
3) Do you feel like hurting yourself? "Yes"
If YES, Last thought: "I wanna kill myself."
5) Do you feel depressed? "Yes"
If YES, rate (0-10): "8"
7) Are you having irritability/mood swings? "Yes"
9) Are you having confusion/difficulty concentrating? "Yes"

01/19/2025
1) How are you feeling this morning? [LEFT BLANK]
3) Do you feel like hurting yourself? "Yes"
If YES, Last thought: "I don't remember."
5) Do you feel depressed? "Yes"
If YES, rate (0-10): "7"
9) Are you having confusion/difficulty concentrating? "Yes"

Review of the Patient #3's Physician Daily Progress Notes revealed the following in part:

On 01/09/2025 at 9:30 AM - Patient #3 is positive for suicidal ideations and depression. Treatment was just beginning. Currently on suicidal precautions. Signed by S6MD.

On 01/13/2025 at 10:01 AM - Patient #3 was positive for suicidal ideations and depression. Affect was depressed and anxious. Though content was suicidal content with no plan, didn't want to be alive. Perception with auditory hallucinations of moaning or crying mostly at night time. Patient #3 was in DCFS custody. She was on and should remain on suicidal precautions. Signed by S6MD.

On 01/14/2025 at 8:32 AM - Patient #3 was positive for depression, flat affect, didn't want to be alive but had no plan to kill herself. She had increased anxiety and worrying about siblings because she did not know where/who they were with. She described her mood as "numb" with suicidal thought content with no plan. Her perception had no hallucinations but she did at times hear things at night time. She had no change in her suicide risk, and was still positive for suicidal ideations. She was on and was to remain on suicidal precautions. Signed by S6MD.

On 01/15/2025 at 9:10 AM - Patient #3 reported her depression was still the same. Still felt suicidal and wanted to cut herself. She was apathetic with decreased sleep and appetite disturbances. She had a flat and depressed affect with suicidal thought content with thoughts to cut. She was on and was to remain on suicidal precautions. Signed by S6MD.

On 01/16/2025 at 11:58 AM - Patient #3 was anxious, isolative, and guarded. She was rambling and thought blocking. She told the nurse her arm was scratched and bleeding. Patient #3 denied the scratch was self-harm and stated the scratch was an accident. Patient #3 stated to S7NP "I don't really feel anything right now" when asked about her mood. Patient #3 continued to have suicidal thought content and stated to S7NP she "wished she weren't alive but wasn't sure why just didn't like living anymore." She shared she had been having visual and auditory hallucinations at night time and on during the prior night she saw a little girl crying in the corner of her room. She stated the crying didn't bother her and sometimes her mom saw stuff too. She was on and should remain on suicidal precautions. Signed by S7NP.

On 01/17/2025 at 10:15 AM - Patient #3 was withdrawn, guarded with anxiety, depression and had mood swings with crying spells. She had refused to attend group the prior day. She presented during the assessment with a blunted affect with suicidal thought content she reported had occurred before getting out of bed that morning. She was positive for suicidal ideations and could not identify any reason to live. She was on and should remain on suicidal precautions due to her elevated suicidal risk due to her very depressed state and danger to self. Signed by S7NP.

Review of Patient #3's Daily Nurse Progress Notes revealed the following in part:
On 01/14/2025 at 8:40 AM - Patient #3 admitted to feeling suicidal but did not have a plan or specific reason. Patient #3 was questioned about stress and depression. Patient #3 denied having a plan. Patient #3 was encouraged to talk to staff when feeling suicidal and encouraged to use positive coping skills. Staff continued to monitor for mood, behavior, and safety every 15 minutes.

On 01/17/2025 at 10:00 AM - Patient #3 reported thoughts of suicidal ideation but stated she had no plan or intent to act on the thoughts. Patient #3 was withdrawn most of day and rarely interacted in group or with peers.

On 01/19/2025 at 9:00 AM - Patient #3 was participating in group activities. Patient had thoughts of suicidal ideation. Nurse and RN spoke to patient and patient stated "I don't know why I feel depressed and like I want to kill myself." Patient did state "I don't know how I would hurt myself." Patient had not hurt herself at that time. Patient remained on every 15 minute observations and was closely monitored.

Review of Patient #3's Interdisciplinary Notes within her medical record revealed the following in part:
On 01/15/2025 at 10:00 PM - During observation rounds, Patient #3 reported injury. Nurse observed a scratch on patient's left forearm that was actively bleeding. Patient #3 was assisted to the nurse's station, nurse staff on unit cleaned and bandaged wound. Nursing staff will continue to monitor during every 15 minute observation rounds. Signed by S8RN.

Review of the medical record for "Daily Suicide Risk Assessment" revealed the assessments were not performed during the following day shifts: 01/13/2025, 01/23/2025, 01/25/2025; and were not performed during the following evening shifts: 01/11/2025, 01/13/2025, 01/15/2025, 01/20/2025, 01/21/2025, 01/23/2025, and 02/03/2025. Further review of the "Daily Suicide Risk Assessments" in Patient #3's medical record revealed incomplete documentation by the nursing staff. Review of the assessments revealed in part:

01/08/2025 at 12:37 AM
1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO]
5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO]
Risk State as compared to previous shift: [NO ANSWER]
Why? (Indicate most important factors for assessment)- NEW ADMIT
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/08/2025 at 10:26 AM
1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO]
5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO]
Risk State as compared to previous shift: SIMILAR
Why? (Indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/08/2025 at 8:00 PM
1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO]
5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO]
Risk State as compared to previous shift: SIMILAR
Why? (Indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/09/2025 at 9:30 AM
1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO]
5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO]
Risk State as compared to previous shift: SIMILAR
Why? (Indicate most important factors for assessment)- [NO ANSWER]
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/09/2025 at 8:00 PM
1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO]
5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO]
Risk State as compared to previous shift: SIMILAR
Why? (Indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/10/2025 at 8:00 AM
1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO]
5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO]
Risk State as compared to previous shift: SIMILAR
Why? (Indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER]

01/10/2025 at 8:00 PM
1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO]
5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO]
Risk State as compared to previous shift: SIMILAR
Why? (Indicate most important factors for assessment)- NO CHANGES
Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO