HospitalInspections.org

Based on document review, observation, and interview, the facility failed to provide care in a safe setting for 1 of 10 patients (Patient 1) and failed to verbally report an inpatient suicide within 24 hours of occurrence in 1 of 1 (Patient 1).

The cumulative effort of this systemic problem resulted in the hospitals inability to promote Patient Rights in a safe setting.

Based on document review, interview, and observation, the facility failed to provide care in a safe setting for 2 of 10 patients (Patients 1 and 4) medical records reviewed and the facility failed to verbally report an inpatient suicide within 24 hours of occurrence in 1 of 1 (Patient 1) medical records reviewed.

Findings include:

1. Facility policy titled, Patient Bill of Rights, Policy #149, approval date 04/18/2025, under V. Procedure, 6. Provision of care in a safe setting.

2. Facility policy titled Contraband Search, Policy #: PM2-177, approved 08/03/2016, under II. Definitions, 4. Contraband search must be completed by ED staff prior to bringing the patient into any inpatient unit. Under III. Procedure Contraband Search - Body and Personal Adult Psychiatric Unit, under 4. Ask or assist patient to remove all clothing., under 9. Search personal items: A. Clothing examples: shoes, socks, belts, hems, waistbands, pockets, soles, heels, and lining.

3. Facility policy titled Patient Observation Levels, Policy #: PM2-522, approved 04/09/2025, under IV. Procedure, 7. The patient's room door must remain open at all times unless safety concerns or isolation precautions require otherwise.

4. Review of Patient 1's medical record indicated the following:
a. The patient presented to the Emergency Room (ER) on 04/19/2025 for possible suicide attempt and the patient was placed on suicide precautions in the ER; medical record lacked documentation of a contraband search.
b. On 04/19/2025, the patient was admitted to the psychiatric unit at 4:40 p.m. and at 6:59 p.m., the patient was found in the patient's bathroom with a self-inflicted injury by hanging.

5. Review of Patient 4's medical record indicated the following:
a. The patient presented to the ER on 04/14/2025 for suicidal ideations and the patient was placed on suicide precautions.
b. Medical record lacked documentation of a contraband search in the ER.

6. Review of Incident Report of event dated 04/19/2025 for patient 1 indicated the charge nurse entered the patient bathroom, found patient hanging by string and patient was unresponsive. The incident report indicated the patient suffered from an anoxic brain injury, terminally weaned, and passed on April 24, 2025.

7. Video observation on 05/08/2025 at approximately 11:20 a.m of 04/19/2025 indicated patient 1's window blind remained closed from approximately 4:36 p.m. to approximately 6:57 p.m. and the room door did not remain open at all times during the same time period.

8. Interview with N1 (Registered Nurse) on 05/07/2025 at approximately 12:38 p.m. confirmed they were assigned patient 1 on 04/19/2025 in the ER. N1 confirmed patient 1 was not asked to remove their gym shorts under the paper scrubs and the gym shorts remained on the patient when they were transferred to the psychiatric unit.

9. Interview with A2 (Risk Management Director) on 05/07/2025 at approximately 1:02 p.m. confirmed the facility did not verbally report the patient's death to the state department of health.

10. Interview with N2 (Registerd Nurse) on 05/07/2025 at approximately 4:00 p.m. confirmed patient 1 had black underwear/shorts on under their paper scrubs and indicated the shorts were not removed and remained on the patient.

11. Interview with A3 (Senior Director of Nursing) on 05/08/2025 at approximately 10:40 a.m. confirmed patients 1 and 4's MR lacked documentation of the contraband search.

Based on document review and interview, nursing services failed to obtain provider orders for 1:1 observation for 5 of 10 (Patients 1, 6, 7, 8, and 10) medical records reviewed.

Findings include:

1. Facility policy titled Patient Observations Levels, Policy #: PM2-522, approved 04/09/2025, under IV. Procedure, 2. Provider order is required for initiation of observation.

2. Review of Patient 1's medical record indicated the following:
a. The patient presented to the Emergency Room (ER) on 04/19/2025 and the patient was placed on 1:1 observation by nursing at 1:45 p.m.
b. Medical record lacked documentation of a provider order for 1:1 observation.

3. Review of Patient 6's medical record indicated the following:
a. The patient presented to the ER on 04/14/2025 and the patient was placed on 1:1 observation by nursing at 5:00 p.m.
b. Medical record lacked documentation of a provider order for 1:1 observation.

4. Review of Patient 7's medical record indicated the following:
a. The patient presented to the ER on 04/12/025 and the patient was placed on 1:1 observation by nursing at 12:07 a.m.
b. Medical record lacked documentation of a provider order for 1:1 observation.

5. Review of Patient 8's medical record indicated the following:
a. The patient presented to the ER on 04/30/25 and the patient was placed on 1:1 observation by nursing at 2:30 p.m.
b. Medical record lacked documentation of provider order for 1:1 observation.

6. Review of Patient 10's medical record indicated the following:
a. The patient presented to the ER on 04/25/25 for suicidal ideations and the patient was placed on 1:1 observation by nursing at 10:45 p.m.
b. Medical record lacked documentation of provider order for 1:1 observation.

7. Interview with A3 (Senior Director of Nursing) on 05/08/2025 at approximately 10:40 a.m. confirmed that patients 1, 6, 7, 8, and 10's MR lacked documentation of the provider order for 1:1 observation.