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Based on observation, record review, and interview, the facility failed to protect the rights to receive care in a safe environment for 1 of 10 patients (Patient #1).

Although physician ordered to be on constant staff observation, Patient #1 was left alone in the bathroom for approximately 12 minutes and attempted suicide by strangulation on 11/16/2024.

Cross Refer Tag A0144

Based on observation, record review, and interview, the facility failed to ensure that a safe environment was provided for 1 of 10 patients (Patient #1).

Although physician ordered to be on constant staff observation, Patient #1 was left alone in the bathroom for approximately 12 minutes and attempted suicide by strangulation on 11/16/2024.

Findings Included:

Patient #1's Inpatient Psychiatric Evaluation completed on 11/05/2024 at 12:29 AM reflected the following, " ...Date of Admission: 11/05/2024 ... Chief Complaint: 'I kind of, like, already attempted this week, I took 11 tab [tablets] of Tylenol. I have angry outbursts from mother I have history of self-harm' ...a 14-year-old female, was admitted to a recent suicide attempt by ingesting 11 Tylenol pills the previous day, which has resulted in dizziness, nausea, and weakness. She presented with a history of emotion and physical abuse. There is a pending CPS [child protective services] case going on the same matter. She said she does not want to stay with her mother in the same house and would like to go to a foster care ...Patient has feelings of depressed and low mood, helplessness, worthlessness, mid cycle waking up, anhedonia. Patient continues to have suicidal thoughts, and ideation but no plan ...She also disclosed a history of self-harm, specifically cutting, which she attributes to the various traumatic events in her life ...She also suffers from anxiety and panic attacks ...has been hospitalized for psychiatric reasons four times since September of this year, with each stay lasting about two weeks. She feels that these hospitalizations have not been helpful ...Diagnosis: Major depressive disorder severe recurrent without psychosis, Generalized anxiety disorder, Panic disorder, Post Traumatic stress disorder [PTSD], Relationship Distress with significant other ..."

Interdisciplinary Progress Note completed on 11/16/2024 11:55 AM reflected the following, "At 11:55 am code 100 called, Patient requested to use the restroom according to the PCA [patient care associate] and her door was opened which took her longer time than normal, the nurse walked into room and found patient laying on the floor with pillowcase wrapped around her neck. Patient had a nosebleed and was able to respond when lifting the patient head from the ground. Pt was very tearful and stated 'I was feeling sad and wanted to end it all.' Patient VS [vital signs] are WNL [within normal limits] ...Mom notified, patient is now placed on a 1:1 and is currently being sent out for further observation per Dr ..."

Inpatient Progress Note completed on 11/16/2024 at 11:37 AM reflected the following, " ...Patient presented with a history of attempting self-harm by strangulation using a pillowcase ...It was noted that she experienced dizziness and a nosebleed upon waking. The patient could not recall if she hit her head during the episodes. She mentioned that staff members found her and assisted her after she fainted. She had petechiae all over her neck. When discussing her current living situation, the patient expressed mixed emotions about not returning home and the possibility of moving to a residential care, but she herself is uncertain about its necessity ...Regarding her mental state, the patient conveyed a lack of excitement about her future and could not identify any activities or goals that she looks forward to as an adult. During the session, her cognitive function was assessed by asking her to perform a serial subtraction task, which she completed with some difficulty, indicating potential issues with concentration and focus ... Physical symptoms included persistent dizziness and headaches. It was recommended that she undergo a medical evaluation, possibly including a CT [computed tomography] scan ...It was decided to keep the patient on a 1-to-1 observation for her safety and to monitor her condition closely. Further medical evaluation and continued psychiatric care were planned to ensure comprehensive care ..."

Video Footage Review completed with the Director of Nursing and the Director of Quality on 11/21/2024 at 10:40 AM for the attempted suicide incident that occurred on 11/16/2024 with Patient #1:

11:39:21 Patient #1's room door was unlocked by Personnel #6 who waited outside the patient room with the door open so Patient #1 could go to the bathroom
11:39:28 Personnel #6 left Patient #1 in her room unattended to assist another patient
11:51:52 Personnel #7 and Personnel #6 entered Patient #1's room
11:52:20 Personnel #6 ran down the hall for assistance
11:54:00 Multiple staff members entered and exited Patient #1's room
11:54:32 Crash cart was brought to Patient #1's room
11:57:11 Personnel #13 [physician] entered Patient #1's room
12:00:36 Patient #1 left patient room and ambulated to the nurse's station in paper scrubs
12:09:35 Patient #1 stood at nurse's station drinking a cup of fluids
12:16:28 Patient #1 sat in day room area while her head was assessed by Personnel #7
12:18:00 Patient #1 remained sitting in day room, talking with Personnel #7 and Personnel #6
12:20:00 Patient #1 appeared to be sobbing/crying, supported by staff in day room
12:24:23 Personnel #12 [physician] moved Patient #1 to a private exam room
12:31:55 Patient #1 exited private exam room and returned to day room to sit in a chair with her legs drawn up, staff remained with Patient #1 until EMS [emergency medical services] arrived for transport, Patient #1 appeared calm and to be talking to staff
1:53:15 EMS arrived and prepared Patient #1 for transport
1:56:35 Patient #1 was placed on stretcher and left day room and facility

During an interview on 11/21/2024 at 10:40 AM, Personnel #4 stated the following, " ...On 11/16/2024, [Patient #1] was changed to line-of-sight observation level. She had asked to use her restroom in her room and the PCA unlocked her door and left the door open. The PCA got distracted by another patient having a panic attack and left [Patient #1] unattended for an extended period ... We identified that the PCA had [Patient #1] on line of sight on 11/16/2024 as ordered. The PCA led [Patient #1] to her room. Another patient was in distress and the PCA left [Patient #1] alone while she was on line of sight to assist the patient in distress. Th PCA took the distressed patient to the nurse and realized that [Patient #1] had been left unattended. The nurse and the PCA returned to [Patient #1]'s room and that is when they found her in the bathroom with a pillowcase around her neck ...A corrective action plan was developed and implemented for the incident that occurred on 11/16/2024 with [Patient #1]. The DON [director of nursing] developed the corrective action plan and is currently working on the retraining of all the staff."

During an interview on 11/21/2024 at 3:03 PM, Personnel #6 stated the following, " ...The day of the incident on 11/16, [Patient #1] asked me to go to the restroom. I took her to the restroom, and I did walk away. I told her to shut her bedroom door when she was finished. [Personnel #7] wanted to check to make sure she was ok and found [Patient #1] in the bathroom and she went into action. She told me to go get another nurse and the crash cart.

I knew that [Patient #1] was on line of sight and it was completely my fault for leaving her unattended for 12 minutes. I should have stayed with her no matter what. When I saw her in the bathroom, she [Patient #1] was sitting up and talking. They didn't have to use any ammonia or anything like that to wake her up. They didn't use anything from the crash cart. She didn't require any oxygen ..."

During an interview on 11/21/2024 at 3:20 PM, Personnel #7 stated the following, I was the nurse assigned to [Patient #1] on 11/16/2024 with [Personnel #6]. That morning [Personnel #6] let me know there was another patient having problems and needed medication. I wanted to check that patient's vital signs and when I got to [Patient #1]'s room, I asked [Personnel #6] why her door was open. I asked her why she wasn't with [Patient #1], and she told me because she felt like she needed to help the other patient having a serious panic attack. I ran into [Patient #1]'s room and found her on the floor of the bathroom. She was lying on the floor. I saw that she had something on her neck which ended up being a pillowcase. As soon as I started removing it, she responded immediately. She was awake and alert and immediately started crying. She was scared that she was in trouble. She did have a small amount of bleeding from her nose. We called a code and got the crash cart, but nothing was needed. She stood up and walked out of the bathroom. [Personnel #13] did come in briefly and assessed the situation and the patient was not in distress. [Personnel #12] is the doctor that did her full assessment after the incident."

Record review of the facility policy titled "Patient Bill of Rights" dated 07/2021 reflected the following, "Basic Rights for All Patients ...You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity ...You have the right to be free from mistreatment, abuse, neglect, and exploitation ..."

Record review of the facility policy titled "Levels of Observation and Precautions" dated 03/2024 reflected the following, " ...Line of sight observation: This level of observation is very restrictive and involves continuous visual monitoring at all times ...Staff must be within visual contact of the patient at all times ...When using the 'Special Bathing' area of the Hospital, staff will be required to monitor the patient inside the 'Special Bathing' area at all times ..."