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Based on observation, interview and record review the facility failed to:
- Follow their staffing plan and have an adequate number of nursing staff to ensure patient safety rounds (visual inspection to the location and safety of each patient) were completed every 15 minutes on 10/02/12 and on 10/03/12 in the ITU (Intensive Treatment Unit) wing of the Adult Unit.
- Provide constant oversight for patients while in an off unit dining room.
- Complete accurate, comprehensive assessments and re-assessments with individualized interventions put into place to prevent patient elopements (a patient who is aware he is not permitted to leave, but does so with intent) on the adult unit;
- Complete accurate, comprehensive assessments and re-assessments with individualized interventions put into place to prevent suicide attempts on the adult unit and on the adolescent unit; and
- Provide line-of-sight observation as ordered on the Senior Adult Unit.

These failures had the potential to affect all patients residing on all (three of three units-geriatric, adolescent, and adult with intensive treatment) of this psychiatric in-patient hospital. The facility census was 76.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.23 Nursing Services.

See A0392 and A0395.

Based on observation, interview and record review the facility failed to:
- Follow their staffing plan and have an adequate number of nursing staff to ensure patient safety rounds (visual inspection to the location and safety of each patient) were completed every 15 minutes for eight (#24, #25, #26, #27, #29, #30, #31, and #32) of 11 patients on 10/02/12; and for seven (#24, #26, #45, #27, #29, #31, and #32) of ten patients on 10/03/12 in the ITU (Intensive Treatment Unit) wing of the Adult Unit.
-Provide constant oversight for nine ( #12, #16, #49, #52, #53, #54, #55, #56 and #57) of nine patients on the Senior Unit while the patients were eating in a central dining room located off of the Senior Unit.

These failures had the potential to affect all patients residing on two of three units (Senior and Adult/Intensive Treatment Unit) of this psychiatric in-patient hospital. The facility census was 76.

Findings included:

1. Review of a facility policy titled, "Staffing Plan," revised 07/12, showed the following:
-There shall be a sufficient number of professional nurses on duty at all times to meet the needs of the patients;
-Staff in orientation were not counted as actual staff within the guidelines;
-The unit specific staffing plans shall indicate the actual staffing and patient census for each shift;
-Additional staff is added when in the judgment of the Nursing Manager that additional staff is required;
-Staffing less than the plan dictates is discussed with the Chief Nursing Officer (CNO);
-Staffing, both in numbers and competency, will be sufficient at all times to ensure that assessment/reassessment and interventions address patient care needs on admission, during their stay, reassessment as patient condition changes, upon transfer, and discharge; And, patient safety requirements are met.

2. Observation on 10/01/12 showed three psychiatric treatment areas:
-An Adolescent Unit;
-A Senior Unit for older adults; and
-An Adult/Intensive Treatment Unit (ITU-utilized to treat the acutely ill psychiatric patient), which is a combined unit with a total bed capacity of 56; 36 beds on the Adult side and 20 beds on the ITU side. A doorway divides the two units. Each side of the combined unit has a nurses station.

3. Review of the 2012 facility staffing guidelines for the combined Adult/Intensive Treatment Unit required the following:
-For a census of 27-33 on day and evening shifts= 3 Registered Nurses (RNs) and 3 Mental Health Technicians (MHTs), and on night shift= 2 RNs and 2 MHTs;
-For a census of 34-40 on day and evening shifts= 4 RNs, and 4 MHTs, and on night shift= 2 RNs and 2 MHTs;
-For a census of 41-44 on day and evening shifts= 4 RNs and 4 MHTs, and on night shift= 3 RNs and 2 MHTs;
-For a census of 45-51 on day and evening shifts= 5 RNs and 4 MHTs, and on night shift= 3 RNs and 3 MHTs;
-For a census of 52-56 on day and evening shifts= 6 RNs and 4 MHTs, and on night shift= 4 RNs and 4 MHTs.

4. Review of the facility's staffing for the week of 09/23/12 through 09/29/12 showed for the ITU wing:
-On 9/23 one MHT short on the evening shift and night shift;
-On 9/24 one RN short on evening shift, and one RN and one MHT short on night shift;
-On 9/25 one MHT short on night shift;
-On 9/28 one MHT short on day shift, and one RN short for one-half of the evening shift;
-On 9/29 one MHT short for one-half of the evening shift and one MHT short on the night shift.

5. During an interview on 10/02/12 at 9:35 AM, Staff I, RN, Adult ITU Supervisor, stated that the facility had been having trouble with staffing on the weekends. Staff I stated that managers were supposed to come in and cover any shortages.

The review of the staffing for the combined Adult/Intensive Treatment Unit for the week of 09/23/12 through 09/29/12 showed nine shifts were understaffed according to the 2012 staffing guidelines.

6. During an interview on 10/02/12 at 4:20 PM, Staff A, the Chief Nursing Officer (CNO), stated that it was a challenge to constantly bring in good people (hiring of staff) that are kind and patient. Staff A stated that she expected the managers to fill in if short a staff person. Staff A confirmed the lack of staff listed on the reviewed staffing schedules. Staff A stated that when she reviewed the staffing schedules she confirmed additional management staff had failed to cover staffing shortages.

7. Review of facility data regarding nursing vacancies showed the facility RN vacancy had increased from 1.4% in October 2011 to 18.2% in June 2012.

8. During an interview on 10/01/12 at 3:37 PM, Staff F, RN, stated that:
-The current combined census on the Adult/ITU unit was 43.
-There were currently four RNs and three MHTs (this indicated one MHT short based on the facility provided staffing guideline);
-Suicide risk was assessed daily for those patients considered low (score of 0-2) to medium risk (score of 3-5) and twice daily for those considered high risk (score of 6-9);
-All patients were on 15-minute monitoring via an Observation Flowsheet unless they were on a physician-ordered close observation (one staff member for one patient with the patient in line of sight at all times) or one-on-one status (one staff member per one patient with the patient being within an arms length of a staff member.)

9. Review of staffing documentation, census and patient rounding for the combined Adult/ITU unit for 10/01/12 showed the following:
-Staff documented the census as 43 on a dry erase board in the staff work room;
-The nursing staff schedule, dated 10/01/12, showed only three RNs and three MHTs on duty ( indicating one RN and one MHT short based on the facility provided staffing guidelines);
-The patient's individual rounding sheets showed a pre-printed 15-minute interval whereby staff documented they observed the patient, showing where and what the patient was doing;
-The patient census, dated 10/01/12, which included the suicide risk score of each, showed 19 of the 43 patients on the combined Adult/ITU were a medium risk for suicide. One patient was considered a high risk for suicide (Patient #1).

10. Review of facility wide event logs, from 01/01/12 -10/01/12, showed four elopements (two in 02/12, one in 04/12, and one in 06/12) and six suicide attempts.

11. During an interview on 10/04/12 at 10:13 AM, Staff GG, MHT, stated that staffing in general was not good, but especially on the weekends. Staff GG stated that the RNs don't do MHT work when counted as such. Staff GG stated that he did not feel patients were safe with the current staffing patterns, and this had been the situation for about eight to nine months.

12. Record review of the facility policy, "Observation of the Patient Through 1:1, Close Observation and 15-Minute Checks", showed the following requirements:
-On admission, all inpatients will be placed on a minimum of 15-minute checks for safety;
-In order to reduce their predictability, 15-minute checks are to be done in a random order within each 15-minute period of time so that the patient cannot anticipate when the staff member will next return;
-The staff member will observe the patient within every 15-minute increment of time, and document their location and activity on the Observation Flow sheet throughout their hospitalization; and
-The Charge Nurse will be notified in the event of interruptions so that 15-minute checks can be reassigned and continued.

13. Record review of the facility's Nursing Staff Schedule for the ITU wing dated 10/02/12 showed a census of 11 with one RN and two MHTs scheduled for patient care on the day shift (7:00 AM to 3:30 PM.)

14. However observation on 10/02/12 from 2:00 PM to 3:00 PM, showed one RN (Staff U) and only one MHT (Staff T) present in the ITU. The ITU unit was short one MHT.

Staff F, RN Supervisor confirmed through payroll records that Staff GG, MHT, left at 1:57 PM, which left one RN and one MHT for patient care on the ITU.

15. Record review on 10/02/12 at 2:30 PM, of ITU's Observation Flowsheets (15 minute patient safety rounds form) dated 10/02/12, showed no 15 minute rounding documentation for patient safety from 2:15 PM through 2:30 PM (15 minutes) for eight (Patients #24, #25, #26, #27, #29, #30, #31, and #32) of eleven patients. The ITU suicide risk score report for 10/02/12 showed three of 11 patients on the unit were at medium to high risk for suicide.

16. During an interview on 10/02/12 at 3:00 PM, Staff U, (the RN on duty in ITU) stated that between 2:15 PM and 2:30 PM:
-One RN (Staff U) and one MHT (Staff T) provided care for patients in ITU;
-Staff T, MHT (Mental Health Technician) prepared three patients for discharge which caused the omission of patient safety rounds.
-Staff T, provided off unit escort for one patient who was discharged;
-She (Staff U) prepared patients for discharge and that caused her inability to provide back up to complete the patient safety rounds;
-She (Staff U) denied requesting assistance to complete patient care; and
-She (Staff U) assessed she had sufficient staff in ITU.

The two staff on duty between 2:00 PM and 3:00 PM for patient care in ITU were unable to document evidence of patient safety rounds on Observation Flowsheets for eight patients as required by facility policy. The number of staff assigned to provide care and lack of documented patient rounds placed eight of 11 patients in ITU at potential risk of harm.

17. Record review of the facility's Nurse Staff Schedule for ITU dated 10/03/12 showed patient care assignments of one RN and one MHT for the day shift with a census of ten.

18. Record review on 10/03/12 at 1:45 PM, of ITU's Observation Flowsheets dated 10/03/12, showed no 15 minute rounding documentation for patient safety from 1:30 PM to 1:45 PM (15 minutes) for six (Patients #24, #45, #27, #29, #31, and #32) patients on ITU and no documentation from 1:15 PM to 1:45 PM (30 minutes) for one (Patient #26) out of 10 patients. In addition, there were no Observation Flowsheets for two patients (Patient #7 and #46). The unit's suicide score report for 10/03/12 showed seven of ten patients at medium to high risk for suicide.

19. During an interview on 10/03/12 at 2:00 PM, Staff F, RN Supervisor, stated that Staff X, MHT, was responsible for conducting two patient safety rounds between 1:15-1:45 PM, and that he (Staff X) did not complete the safety rounds as expected.

The staff assigned patient care were unable to document evidence of patient safety rounds from 1:30 PM to 1:45 PM for six patients, and from 1:15 PM to 1:45 PM for one patient. This failure to conduct patient safety rounds placed nine of 10 patients in ITU at potential risk of harm.

20. Record review of the facility's policy, "Cafeteria, Use Of", updated 08/12, showed staff members will supervise behavior of patients in the cafeteria. Appropriate behavior is required to ensure patient safety and to re-emphasize acceptable behavior in society.

Record review of the facility's policy, "Safety, Nursing Responsibilities", updated 06/12 showed the following:
- Utilize appropriate patient precautions;
- Follow procedures for patient who may be on any specific precautions related to assaultive, elopement and suicide;
- Perform duties according to procedures;
- Monitor patients on an ongoing basis in accordance with appropriate level of observation (15-minute checks, close observation, one to one) at all patient locations during all patient activities;
- Escort patients to and from all activities;
- Follow procedures for monitoring patients for safety;
- Hand-off any patients being observed to other staff when taking meal breaks or other situations that require you to leave the area.

21. Record review of the facility's 2012 Staffing Guidelines for the Senior Unit showed, for a census of 19, the day shift staffing requirements were one Nurse Manager, one Team Charge Nurse, two RNs, three MHTs, and 0.5 Unit Coordinator (UC.)

22. During an interview on 10/04/12 at 8:45 AM Staff JJ, RN, Nurse Manager for the unit, stated that the Senior Unit census for the day was 19 patients. Staff JJ stated that the staffing for the unit included three RNs (one RN was the Team Charge Nurse), two MHTs and one Nurse Manager. Staff JJ stated the unit did not have a unit coordinator for the day.

According to the staffing guidelines, for a census of 19, the unit was short staffed one MHT and 0.5 UC.

23. Observation on 10/04/12 at 12:10 PM, showed Staff EE MHT escorted nine patients( #12, #16, #49, #52, #53, #54, #55, #56 and #57) from the Senior Unit to the central cafeteria/dining room. The central cafeteria was not a lock area. At one point, Staff EE got up from her chair, exited the cafeteria leaving the patients unattended and left the clip board with patient's rounding sheets on a table. Staff EE did not ask anyone to monitor the patients or hand off the clip board before she exited the cafeteria. No other staff was available in the cafeteria to monitor the patients. Staff EE left the patients in the cafeteria unattended for approximately five to eight minutes. During Staff EE's absence one patient left the area to get a drink and when Staff EE returned to the cafeteria she did not notice the patient had left the table. When all patients finished eating, Staff EE lined up the patients to exit the cafeteria. Staff EE allowed eight patients to exit the cafeteria and return to the Senior Unit without supervision and oversight. After the eight patients left the cafeteria, Staff EE stayed behind in the cafeteria with a patient in a wheelchair for approximately 10 minutes before she returned to the Senior Unit.

24. Record review of Patient #12's Nursing Assessment dated 10/03/12 showed he was on assault precautions.

25. Record review of Patient #16's Nursing Assessment dated 10/03/12 showed he was on elopement and wandering precautions.

26. Record review of Patient #49's Nursing Assessment dated 10/4/12 showed she was on self harm potential alert.

27. Record review of Patient #52's Nursing Assessment dated 10/04/12 showed potential for self harm and wandering and suicide precautions.

28. Record review of Patient #53's Nursing Assessment dated 10/04/12 showed the patient was assaultive to others and was on assault precautions.

29. Record review of Patient #54's Nursing Assessment dated 10/03/12 showed she was on fall and seizure precautions.

30. Record review of Patient #55's Psychiatric Evaluation dated 09/29/12 showed she was extremely agitated and had been residing at a local nursing home and was aggressive with others. She was not on any type of precautions.

31. Record review of Patient #56's Nursing Assessment dated 10/04/12 showed she was on wandering precautions.

32. Record review of Patient #57's Psychiatric Evaluation dated 09/29/12 showed she recently eloped from a nursing home, went into a street and tried to get hit by a car recently. Record review of the patient's Nursing Assessment dated 10/03/12 showed she was on elopement and fall precautions.

The facility failed to monitor the Senior Unit patients at all times while in the dining room. The facility allowed patients at risk for elopement, wandering, self harm, suicide, falls and assaultive behavior to wander the halls when the patients were allowed to leave the cafeteria without staff oversight/escort. This gave the patients ample time to wander, get lost or attempt elopement.


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31891

Based on observation, interview and record review the facility failed to:
- Complete accurate, comprehensive assessments and re-assessments with individualized interventions put into place to prevent patient elopements (a patient who is aware he is not permitted to leave, but does so with intent) for two patients (#42 and #33) on the adult unit;
- Complete accurate, comprehensive assessments and re-assessments with individualized interventions put into place to prevent suicide attempts for two patients (#41 and #43) on the adult unit and two patients
(#39 and #35) on the adolescent unit; and
-Provide line-of-sight observation for one discharged patient (#40,) while awake, as ordered on the Senior Adult Unit.

A total of two patients were reviewed for elopement and five patients reviewed for suicide attempt. The facility census was 76.

Findings included:

1. Review of a facility policy titled, "Elopement Precautions," revised 06/12, showed the following:
-Every psychiatric patient is to be considered a potential elopement risk;
-The unit charge nurse will observe the patient and notify the physician with an assessment of the patient's behavior;
-The unit charge nurse can initiate elopement precautions for the protection and safety of the patient without a physician's order;
-Patients with an elopement risk shall not be permitted outside in the patio areas until authorized by the physician.

2. During an interview on 10/04/12 at 9:17 AM, Staff C, Quality RN, stated that the facility did not have an official/documented assessment that identified elopement risk. Staff C stated that the staff based the elopement risk on observations and ongoing assessments of the patient.

3. Observation on 10/01/12 at 3:37 PM, showed:
-An Adult/Intensive Treatment Unit (ITU-utilized to treat the acutely ill psychiatric patient), which is a combined unit with a total bed capacity of 56; 36 beds on the Adult side and 20 beds on the ITU side. A doorway divided the two units. Each side of the combined unit had a nurses station.
-There was a locked doorway leading outside to a fenced-in area, approximately 20 feet by 20 feet, utilized for the smoking patients. (Any outdoor smoking area created an area and opportunity for elopement if patients are not carefully observed by staff.)

4. Review of a facility policy titled, "Smoking," revised 07/12, showed patients were allowed to smoke at designated times and in designated places (the patio outside the adult/ITU), if there were no elopement precautions in place.

5. Review of Patient #33's history and physical dated 02/14/12, showed the patient was admitted to the Adult unit on 02/12/12 with a recent past history of suicide attempt by hanging. He was admitted from a local jail on an involuntary basis.

The medical record did not document that Patient #33 was an elopement risk. Staff failed to assess that the patient was an elopement risk based on his involuntary admission and possible return to the jail.

6. Record review of Patient #33's Nurses' Notes dated 02/15/12, at 7:50 PM, showed the patient had a flat affect and depressed mood. (These could be considered flight/elopement risk factors) The patient reported he had just gotten some bad news. The patient rated his mood an "8" on a scale of 1-10 with "10" being the worst mood. The patient rated his anxiety as a "5-6" on the same type scale. (These could be considered elopement risk factors) The patient was on standard 15-minute checks.

7. Record review of an Event Report dated 02/16/12 at 12:30 AM, showed the Patient #33 "Went over the fence during smoke break on 02/15/12 at 9:00 PM (last smoke break scheduled from 9:00 PM to 9:20 PM each day) ....and isn't back yet." The report showed staff discovered the patient was missing three and 1/2 hours after the smoke break. Staff found the patient
had stuffed blankets under the bedspread [in his room] to make it look as if he was in bed.

8. Record review of the Observation Flowsheets dated 02/15/12 from 9:00 PM through 12:30 AM on 02/16/12 showed staff documented Patient #33 was on the patio smoking from 9:00 PM through 9:15 PM. Then, staff documented the patient was in the dayroom, or in bed, from 9:30 PM to 12:30 AM. (The patient eloped from the facility between 9:00 PM and 9:15 PM).

9. Record review of Sentinel Event (a risk or an event that may cause an unexpected or unanticipated outcome, death or serious injury) minutes dated 03/01/12, showed the patient had been distraught at 9:00 PM [on 02/15/12] after he was informed he would return to jail after discharge from the hospital [a strong elopement indicator or assessment piece]. Staff EE, Mental Health Technician (MHT) took the patient out to the patio for a smoke break. Staff EE was asthmatic and stayed inside the door of the patio. Just shortly after 9:00 PM, a peer (another patient) witnessed Patient #33 elope over the patio area fence. From 9:30 PM through 11:15 PM Staff FF, MHT, documented that the patient was in the dayroom. And, from 11:30 PM through 12:30 AM on 02/16/12, the patient was in bed. The resolution to this event directed staff to accompany patients outside at all times, and place themselves between the patients and the fence to deter elopements over the fence.

10. During an interview on 10/03/12 at 3:05 PM, Staff EE, MHT, stated that she did not know Patient #33 had eloped until the morning after the incident. Staff EE stated that she did not count patients as they went out onto the smoking patio or when they came back in, to verify all were accounted for. Staff EE stated that she did not go outside with the patients during the scheduled smoke break. Staff EE stated that she was the only MHT on duty that evening monitoring patients on smoke break.

11. During an interview on 10/03/12 at 3:20 PM, Staff FF, MHT stated that Patient #33 eloped during a smoke break on 02/15/12. Staff FF stated that he was really busy and he admitted documenting the patient was actually in the facility. Staff FF was unaware of the patient's elopement until the day after the elopement. Staff FF stated that additional staff would help at times.

12. During an interview on 10/03/12 at 10:05 AM, Staff W, Psychiatrist, stated that the patient (#33) was bipolar and became distraught when he found out he was going back to jail after discharge. Staff W stated that the patient was clever and created the appearance of sleeping in bed to allude the staff.

13. Observation on 10/03/12 at 10:38 AM showed the patio area consisted of an area about 20-feet by 20-feet with a concrete patio surrounded by a 10-foot wooden fence. While standing inside the facility at the patio doorway, two corners of the outside area could not be visualized (creating a place for patients to hide).

Patient #33 never returned to the hospital.

The facility failed to reassess involuntary Patient #33 for potential elopement risk after being informed the patient would be returning to jail after his discharge.

14. Review of Nurse Practitioner notes dated 06/21/12 for Patient #42, showed the patient was admitted to the ITU unit on 06/20/12 with a diagnosis of schizophrenia (characterized by paranoia and by seeing/hearing things).

15. Review of Nurses' Notes dated 06/22/12, at 4:10 AM, showed Patient #42 was pacing the floor (could be an elopement risk factor).

16. Review of the initial Social Work assessment dated 06/22/12, showed Patient #42 had been depressed and increasingly agitated. The patient's goals were to go home as soon as possible (could be an elopement risk factor).

17. Review of Nurses' Notes dated 06/22/12, at 9:42 PM, showed Patient
#42 felt she was ready for discharge.

18. Review of physician's orders dated 06/23/12, at 2:00 PM, showed Patient #42 was transferred to the adult side of the unit (utilized for less intensive, more stable patients) with anticipated discharge in two days.

19. Review of Nurses' Notes dated 06/23/12, at 7:08 PM, showed Patient #42 was anxious and told the staff several times, "It would only take one hit and I could knock her out (referring to peer)." The patient was loud and provoking and threatening towards her peers.

20. Review of Nurses' Notes dated 06/23/12, at 10:19 PM, showed Patient #42 was missing when the 9:00 PM patient 15-minute rounds were conducted.

21. Record review of an Event report dated 06/23/12, showed that other patients saw Patient #42 elope through the unit exit door into the main hospital hallway. The report showed a nurse was distracted when her key got stuck in the unit's door lock with the door in the open position and the patient walked out the open door. The patient then walked out the front door of the facility when an ambulance was bringing another patient through the door.

The nurse failed to observe and stop an unescorted patient from leaving a locked unit, who then left the building. The facility also failed to reassess Patient #42 after she exhibited anxious behavior and the desire to be discharged.

22. Review of Nurses' Notes dated 06/24/12, at 7:46 AM, showed Patient
#42 returned to her family home. The patient never returned to the hospital.

23. During a telephone interview on 10/04/12 at 1:40 PM, Staff DD, Medical Director, stated that if the nursing assessment shows a patient is an elopement risk, the patient should be confined to the ITU unit. Staff DD stated that patients typically don't speak of elopement so prediction of elopement is difficult and elopement precautions were usually not in place. Staff DD stated staff did not inform him of the elopement regarding Patient #42.

24. During observation on 10/01/12 at 3:37 PM showed on the Adult/ITU unit, each patient room had regular round doorknobs, and three regular hinges. These were a potential looping/hanging hazard.
-The sink in each patient room had regular paddle-type or round faucet handles. Suicidal patients could potentially use the faucet handles as looping hazard, increasing the potential for hanging.
-Two patient-use telephones located in the hallway had cords approximately 18-30 inches long, which could create looping/hanging hazards.

Twenty-three of the 43 patients on the combined unit were on suicide precautions. Patients were allowed access to items which were looping/hanging hazards.

25. Review of a facility policy titled, "Suicide Risk Monitoring Tool For patients at Risk For Suicide/Self-Harm," dated 09/11, showed the following:
-It shall be the policy to create an environment of care that will foster the accurate identification and successful management of patients who are at an increased risk for suicide or self destructive behaviors.
-The suicide Risk Monitoring Tool will be the standard tool used by licensed registered nurses and clinical social workers on the inpatient units to evaluate all patients deemed to be at risk for self-harm.
-Although the patient will be rated with a numerical rating, direct observation of the patient and the lethality of method/plan can increase the level of observation and care required for the patient. The numerical rating is not intended to replace the assessment and judgment of the skilled clinician. The registered nurse/licensed clinical social worker shall have the authority to move the patient to a higher level of risk assessment until evaluated by the physician and a determination is made.
-The minimum frequency for completing the suicide assessment tool will be every 24 hours (on patients assessed as a low risk).
-Patients who exhibit a sudden or significant change in mental status, including level of depression, agitation, or level of anxiety will have a reassessment accomplished to determine the need for continued, increased or decreased observation.
-Reassessments shall be documented in the medical record.
-An initial suicide risk assessment will be performed on each patient when they present to the ComPAS Department (area where screening for admission takes place) using the Intake Psychiatric Assessment form and the suicide risk Monitoring Tool. The Suicide Risk Monitoring Tool is a stand-alone form developed to assist in determining the possible suicide risk a patient may present.

For individuals determined to be at a low risk (score 0-2):
a. Place on 15 minute checks.
b. Contraband search of valuables and other belongings will be performed at a minimum of once on the day shift and once on the evening shift and the night shift as indicated by patient admission to the hospital or at staff's discretion. The contraband search will be accomplished in accordance with each individual unit's contraband list.
c. Completion of the suicide risk assessment tool once every 24 hours.
d. Documentation per shift in the progress notes related to the status of the patient.

For individuals determined to be at a medium risk (score 3-5):
a. Place on 15 minute checks or close observation depending on the degree of lethality involved with the patient and as specified by the physician's order
b. Contraband search of valuables and other belongings will be performed at a minimum of once on the day shift and once on the evening shift and the night shift as indicated by patient admission to the hospital or at staff's discretion.

For individuals determined to be at a higher risk (score 6-9):
a. Place on 15 minute checks, close observation, or 1:1 status depending on the degree of lethality involved with the patient and as specified by the physician's order.
b. Contraband search of valuables and other belongings will be performed at a minimum of once on the day shift and once on the evening shift and the night shift as indicated by patient admission to the hospital or at staff's discretion. The contraband search will be accomplished in accordance with each individual unit's contraband list.
c. Reassessment with the suicide Risk Monitoring Tool every shift during hospitalization.
d. Documentation per shift in the progress notes related to the status of the patient.

26. Record review of Patient #43's Psychosocial Assessment dated 01/30/12, showed the patient was admitted 01/30/12 because, "I want to kill myself," and for electroconvulsive therapy (ECT-a treatment for depression consisting of delivery of a short electric current to the brain). The patient had a history of seven to eight recent suicide attempts (mostly by hanging). This was the fifth psychiatric hospitalization in six months. The patient stated she would attempt suicide during this hospitalization by using a sheet over a doorknob and hanging herself. The patient also stated that she knew she had 15-minutes between patient checks to accomplish this hanging [a strong advance message to staff to monitor for suicide attempt]. The anticipated treatment for this patient included family contact, coordination of care, discharge planning and referral to community resources.

27. Review of the admission physician orders, dated 01/30/12, at 4:15 PM, showed staff were to monitor Patient #43 using standard 15-minute patient checks.

28. Review of a Nurses' Note dated 01/30/12, at 9:21 PM, showed Patient #43 thought of suicide.

Review of a Nurses' Note dated 01/31/12, at 6:18 AM showed Patient #43 remained on standard 15-minute patient checks.

29. Review of a Social Worker assessment dated 01/31/12, at 5:18 PM, showed Patient #43 had attempted to hang herself at 11:00 AM earlier that day (less than 24-hours after admission).

30. Review of a facility internal investigation of the suicide attempt, dated 01/31/12, showed the following:
-Staff GG made normal 15-minute rounds and found Patient #43 on the floor with one sleeve of a sweater around her neck and the other sleeve wrapped around a door knob;
-The patient told Staff GG that she had been telling people (staff) for days that she was suicidal and no one listened;
-The patient placed on one-on-one status and transferred to the ITU, after the patient attempted suicide.

31. Review of a physician's order dated 01/31/12, at 2:00 PM, showed after the hanging attempt, the physician transferred Patient #43 to the ITU side of the unit and placed the patient on one-to-one observation status (staff to be within an arms length of the patient at all times).

32. During an interview on 10/04/12 at 10:13 AM, Staff GG, MHT, stated that Patient #43 had been very attention seeking that day, wanting the MHT to remain with her all day. Staff GG stated that she found the patient later that day on the floor of her room with one end of a sweater wrapped around her neck and the other end wrapped around the room doorknob.

Facility staff failed to review and/or consider Patient #43's history and current assessment, failed to reassess the patient and place the patient on an appropriate monitoring status based on the risk factors presented.

33. Review of facility policies titled, "Contraband, use of the Metal Detector Wand for Search," and "Control of Contraband," revised 06/12 showed the following:
-This is to ensure patients do not retain items that can be used to harm the patient or others;
-Admissions staff to ask patients to remove items from their pockets;
-Coins, nail clippers, nail files, pocket knives, and other sharp objects, hairpins, earrings, and studs are considered contraband;
-Items restricted to [from] patient areas include medications, any string, drawstring, shoestring or any corded item;
-Staff to make environmental rounds twice daily to observe for contraband.
-Upon admission, staff will issue to the patient and family a list of the items not allowed in the patient areas. Patients will be instructed to send restricted items home with family, placed in their vehicle or have hospital personnel lock the items in their closet or safe until the patients discharge. Patients refusing to cooperate with the search will remain with staff until an inspection for contraband takes place.
-A second check for contraband items will take place during the nursing assessment on the inpatient unit.
-Family and visitors shall comply with contraband policies, and appraising staff of items brought in.
-Staff will make environmental rounds twice a day to observe for contraband.

34. Review of Patient #41's psychiatric report, dated 11/26/11, showed the patient was admitted to the Adult unit on 11/25/11 with a diagnosis of bipolar mood disorder and severe depression with suicidal thoughts. The patient's judgment and insight was fair. The patient had a history of suicide attempts.

35. Review of the triage assessment, dated 11/25/11, showed Patient #41 felt she needed to die and had been noncompliant with medications. The patient had taken six milligrams (mg) of Xanax (an anti-anxiety medication, the typical maximum daily dose is four mg) at home and drank two glasses of wine. The patient fell asleep and when she woke she attempted to cut herself with scissors.

36. Review of the initial psychiatric evaluation, dated 11/25/11, showed Patient #41 was severely depressed, was an imminent risk to harm self or others, and could not be treated in a less restrictive environment. The patient was on a 15-minute patient observation status.

37. Review of a physician's progress note, dated 11/27/11, showed Patient #41 was feeling "hopeless," and anxious.

38. Review of Nurses' Note dated 11/28/11, at 10:14 PM, showed Patient
#41 had earlier in the shift approached a nurse and said she was having a panic attack and the nurse did not help her. The patient couldn't sleep because of anxiety and she stated she didn't feel safe in her room.

39. Review of the patient's Observation Flowsheet (documentation of 15-minute patient rounds) dated 11/29/11, showed Patient #41 was on standard monitoring (patient rounds every 15-minutes).

40. Review of Nurses' Note dated 11/29/11, at 2:24 PM, showed Patient
#41 admitted she had eight Xanax pills hidden in a small pocket of her running pants (note did not say where/how the patient got the pills.)

41. Review of a Risk Management Report dated 11/29/11, at 2:51 PM, showed Patient #41 had barricaded the door to her room and was found standing on a chair in the shower. The patient had a length of ribbon around her neck and was attempting to hang herself on 11/29/11 at 12:15 PM.

42. Review of the Patient #41's Observation Flowsheet dated 11/29/11, after the attempt of suicide, showed the patient was placed on one-to-one observation.

43. Review of physician's orders dated 11/29/11, at 12:25 PM, showed Patient #41 was transferred to ITU, and placed on close observation (patient to be within the line of sight of staff), after an attempt of suicide.

44. Review of a physician's progress note dated 11/30/11, showed Patient #41 had been stashing pills in her bed.

Facility staff failed to review and/or consider the patient's history and reassess the patient based on statements made by the patient. Staff failed to place the patient on an appropriate monitoring status based on the risk factors presented. The staff also failed to conduct thorough environmental rounds and/or observation of patient medication consumption.

45. Review of Patient #39's medical record showed:
- The patient was admitted on 12/20/11 due to drug overdose.
- The was allowed to use the gym bathroom unattended, while staff observed other patients "shooting baskets".
- Patient found lying on the gym bathroom floor with a shoe string (considered contraband) around her neck on 12/26/11 at 3:15 PM.
- Patient was pulling the shoe string tightly around her neck.
- Patient placed on routine 15-minute checks.

46. Record review of the facility investigation showed Patient #39 obtained the shoestring from the roommates slippers.

The facility staff failed to remove contraband from the roommate's slippers.

47. Record review showed only one contraband check for Patient #39 at admission on 12/20/11. The record failed to contain documentation of environmental rounds twice a day (per facility policy) to observe for contraband.

48. Review of Patient #35's medical record showed:
- Patient admitted on 09/03/12 with suicidal thoughts and a history of cutting self.
- Patient suicide risk score was 6 (high risk score) on admission.
- Patient stated that she had anxiety and felt like killing herself.
- Patient was placed on routine 15-minute checks.
- Patient found in her room with two strings (considered contraband) tied together and wrapped around her neck in attempted self harm/suicidal gesture at 9:57 PM on 09/03/12.
- Record review showed contraband check on admission.
- Review of facility investigation showed the patient had hidden strings in her underwear.

The facility failed to adequately check Patient #35 for contraband on admission.

49. During an interview on 10/04/12 at 2:30 PM, Staff D, RN, unit director stated maybe the facility should initially place a patient in a gown for contraband checks.

50. Record review of discharged Patient #40's medical chart showed the patient was admitted to the facility on 01/20/12 with complaints of mood disorder and suicide attempt.

51. Record review of Patient #40's Psychiatric Evaluation dated 01/21/12 showed he was transferred from a local hospital after he stabbed himself multiple times in the chest. The patient was adamant that he was not going to kill himself in the hospital, but said he was willing to talk to staff about it.

52. Record review of the patient's Suicide Risk Monitoring Tool Intake Assessment dated 01/20/12 showed staff assessed Patient #40 at high risk for suicide.

53. Record review of the Contraband Checklist dated 01/20/12 showed Patient #40 arrived in gowns.

54. Record review of Patient #40's Physician Orders showed the following:
-On 01/20/12 at 7:50 PM the physician ordered the patient placed on one-to-one status.
-On 01/21/12 at 11:09 AM the physician wrote an order to have the patient in line of sight of staff while awake, can d/c (discontinue) one-to-one.
-On 01/28/12 at 5:12 AM the physician ordered to place the patient on one-to-one.
-On 01/28/12 at 10:45 AM the physician ordered to continue one-to-one sitter.

55. Record review of the patient's Behavioral Health Progress Notes showed staff documented the following:
- On 01/26/12 Patient #40 said, "What's the point of being alive?" Patient had ruminative (repetitively focusing on the symptoms of distress, and on its possible causes and consequences) thoughts, depressed, hopeless and poor energy. Positive suicide ideation with thoughts of wishing he was dead. Insight and judgment poor. Depression-severe.
- On 01/28/12 at 10:18 AM severe depression, hopeless and helpless. Positive suicide ideation. Patient was found last evening with strings of gown tied around his neck. He verbalizes a little regret for this now, but still suicide risk. Suicide attempt last night-remains high risk.

56. Record review of the facility's investigation showed the following:
-On 01/27/12 Patient #40 appeared disheveled and mood was described as depressed with flat affect, but still positive. Staff noticed a change in his behavior, he was jovial and joking. He had asked for a chair and puzzles and staff answered his request.
-On 01/28/12 at 5:30 AM the MHT made a random check on the patient and found him sitting in a chair with two gowns wrapped around his neck. When the patient saw staff he pulled the gowns tighter. The patient later stated to the MHT he heard her coming down the hall and thought he had enough time to attempt suicide, but the MHT changed her routine and interrupted his suicide attempt. The patient was placed on one-to-one status.

57. Record review of Patient #40's Observation Flowsheet dated 01/28/12 from 4:30 AM to 5:30 AM showed staff documented the patient was awake in bed.

On 01/20/12 at 11:09 AM the physician wrote an order for Patient #40 to be in line of sight of staff while awake. Staff did not document line of sight for the patient from 4:30 AM to 5:30 AM when he was awake in bed.

58. Record review of Patient #40's medical chart showed no documentation of the patient's nursing suicide assessment tool for the following dates: 01/26/12, 01/27/12, 01/28/12 or 01/29/12.

59. During an interview on 10/04/12 at 1:25 PM, Staff C, Quality and Performance Improvement, RN, stated she could not find the nursing suicide assessment tool for Patient #40 for 01/26/12, 01/27/12, 01/28/12 or 01/29/12.


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