HospitalInspections.org

Based on observations, record review, staff interviews, reviews of facility internal investigation, review of video tape of the Special Care Unit (SCU) and review of facility policies and procedures, the facility failed to provide patient care in a safe setting. This failure resulted in finding the Condition of Participation for Patient Rights out of compliance. 2 of 8 sampled patients (Patients 1 and 3) failed to have safety monitoring rounds made every 10 minutes per facility policy for SCU. Both Patients 1 and 3 had attempted suicide as the reason for admission to the SCU. Patient 1 successfully committed suicide by hanging self in room on SCU shortly after admission on 5/11/10. On 5/19/10 Video surveillance tape review of Patient 3's room on 5/15/10 demonstrated every 10 minute rounds were still not being made as per facility immediate action plan after the death of Patient 1. Tour on 5/19/10 in the Emergency Department found plastic red sharps boxes on the counters that had openings big enough for a patient's hand to access used needles and glass vials. The sharps boxes also allowed items to be easily emptied by turning the box upside down. Psychiatric patients are often in the rooms with these boxes without supervision. These findings presented an immediate threat to the health and safety of all patients on the SCU (capacity 13 patients) and all potential patients in the Emergency Department. The hospital Administrator was notified of the Immediate Jeopardy on 5/19/10 at 4:35 PM. The facility census was 158. See also A0144.

Based on observations, record review, staff interviews, reviews of facility internal investigation, review of video tape of the Special Care Unit (SCU) and review of facility policies and procedures, the facility failed to provide patient care in a safe setting. These findings resulted in determination that the Standard for Privacy and Safety was out of compliance. 2 of 8 sampled patients (Patients 1 and 3) failed to have safety monitoring rounds made every 10 minutes per facility policy for SCU. Both Patients 1 and 3 had attempted suicide as the reason for admission to the SCU. Patient 1 successfully committed suicide by hanging self in room on SCU shortly after admission on 5/11/10. On 5/19/10 Video surveillance tape review of Patient 3's room on and 5/15/10 demonstrated every 10 minute rounds were still not being made as per facility immediate action plan after the death of Patient 1. Tour on 5/19/10 in the Emergency Department found plastic red sharps boxes on the counters that had openings big enough for a patient's hand to access used needles and glass vials. The sharps boxes also allowed items to be easily emptied by turning the box upside down. Psychiatric patients are often in the rooms with these boxes without supervision. These findings presented an immediate threat to the health and safety of all patients on the SCU (capacity 13 patients) and all potential patients in the Emergency Department. The hospital Administrator was notified of the Immediate Jeopardy on 5/19/10 at 4:35 PM. The facility census was 158. See also A0144.

Based on observations, record review, staff interviews, reviews of facility internal investigation, review of video tape of the Special Care Unit (SCU) and review of facility policies and procedures, the facility failed to provide psychiatric intensive care in a safe setting. 2 of 8 sampled patients (Patients 1 and 3) failed to have safety monitoring rounds made by staff every 10 minutes per facility policy for SCU. Both Patients 1 and 3 had attempted suicide as the reason for admission to the SCU. Patient 1 successfully committed suicide by hanging self in room on SCU shortly after admission on 5/11/10. On 5/19/10 Video surveillance tape review of Patient 3's room on 5/15/10 demonstrated every 10 minute rounds were still not being made as per facility immediate action plan after the death of Patient 1. Tour on 5/19/10 in the Emergency Department found plastic red sharps boxes on the counters that had openings big enough for a patient's hand to access used needles and glass vials. The sharps boxes also allowed items to be easily emptied by turning the box upside down. Psychiatric patients are often in the rooms with these boxes without supervision. These findings presented an immediate threat to the health and safety of all patients on the SCU (capacity 13 patients) and all potential patients in the Emergency Department. The hospital Administrator was notified of the Immediate Jeopardy on 5/19/10 at 4:35 PM. The facility census was 158. Findings are:

A. Review of facility policy titled "Special Care Unit" last review date of 11/06 states the SCU is used for those "patients whose safety and ability to control their behaviors and care for themselves is in question." The SCU "provides the patient with the specific external boundaries, minimal stimulation, and close proximity to the nursing station, thus providing the optimum care and maintaining the safety of patients and staff." Indications for admission include "To provide very close observation to the patient who refuses or is unable to commit to their safety or to staying on the unit." The 13 bed unit is a locked unit with all private rooms. Cameras monitor the hallway and dining/day room area and can be utilized to monitor patient rooms as well. Monitors are located in the nursing station of the SCU and in the Security office near the Emergency Room.

Review of facility Behavioral Services policy titled "Suicidal Patient Care" last review date of 4/09 states "All mental health patients will be evaluated upon admission by a registered nurse with regards to a risk assessment including suicidal thought content ...". The policy further states under the section titled "Suicide Precautions" that a 'One-on-one staff member is assigned to do direct visual observation and to stay at an arm's length of the patient AT ALL TIMES." The policy includes an example of a patient considered to be at immediate risk to act out on suicidal thoughts and feelings as one who "is relaying a detailed suicide plan threatening to kill or harm him/herself with diminished ability to redirect, or has made an overt suicide attempt." For patients on "Suicide Evaluation" the patient is at risk to act out suicidally as evidenced by any one or combination of behaviors/ thoughts including a patient that has made "verbalization of suicidal feelings, threats or plans" and/or has made "superficial self mutilatory actions, (i.e. scratching self on the arms or hands)." Patients on the Special Care Unit are per policy to have nursing rounds made at "10 minute intervals".

B. Medical record review revealed Patient 1 arrived in the Emergency Room by rescue squad on 5/11/10. Police came with the patient and completed Emergency Protective Custody (EPC) papers for Patient 1 for being "Dangerous to Self". Police report review revealed the patient's employer called police concerning Patient 1. Police found the patient behind the store bleeding from both wrists. Patient 1 told the police "wished ...used a sharper knife, this was too dull" and "I should have done this at home." The Triage Registered Nurse (RN) assessment completed by RN-A is documented at 8:16 PM. The Emergency Physician noted the patient is depressed and has self- inflicted lacerations both wrists. The patient told the Physician he had "been depressed for a long time and is [sic] felt worse lately and took a box cutter and attempt to cut his wrists." Physical exam noted the wrist lacerations were horizontal across the wrist with the left measuring about 5 cm (centimeters) and 2 cm on the right wrist. The patient refused to allow the physician to suture the lacerations but did allow Derma bond for closure. The Physician noted the patient's mood and affect to be flat and depressed.

Nursing documentation in the Emergency Department at 8:31 PM by RN-A fails to indicate the patient has a nursing "Suicide Assessment" completed or suicide precautions implemented. The notes state the patient "denies wanting to hurt himself. Cutting on wrists he said was an accident. He was at work when this happened. Asked what he was cutting since it was an accident. The pt [patient] stated that "I should have used something sharper". The next nursing documentation is at 10:12 PM when the patient was transported with Security and belongings.

Physician orders dated 5/11/10 at 9:40 PM were taken as verbal orders by RN-B, a Behavioral Health Assessment Center nurse from the Emergency Department (ED). The ED has a 6-bed Behavioral Health Assessment area. Patient 1 was not in that area of the ED; however, the nurses from that unit help coordinate inpatient placement of Psychiatric Patients. RN-B confirmed during a phone interview on 5/19/10 at 11:30 AM that she did not see or evaluate the patient. RN-B stated she called the psychiatrist and got orders based on the ED nurse's report. RN-B stated she did call the SCU charge RN, RN-C, and told her the patient had cut himself and was an EPC. RN-C told RN-B the unit was ready to accept the patient. RN-B then gave the charge nurse the phone number of the ED nurse, RN-A, to get report on Patient 1. Documentation titled "Verbal Report Notes" taken at 5/11/10 at 9:25 PM identify the patient's self-inflicted injuries and statement that it was an accident and "should have used sharper one". Charge RN-C documented the patient has "Possible suicidal ideation. Worried about getting fired from job". Risk factors included "Suicidal Ideations" Box on document checked as "yes". Physician orders included under area titled "Precautions: [check marked] Suicide Evaluation; Elopement Precautions; Assault Precautions; Precautions per ICU Protocol. Under the section titled "Problems" the nurse noted "Potential for self Harm" with interventions listed as admit to SCU, check suicidal ideation every shift, "Keep safe, monitor behaviors & thought process."

The medical record fails to include an admission nursing assessment. The only nursing note after transfer to the SCU is at 10:40 PM by staff RN on 5/11/10 stating the Behavioral Service Technicians (BSTs) "were making rounds on SCU et found pt in room with knotted sheet around neck suspended from closed door. At this time they called for help, code blue called. CPR [Cardiopulmonary Resuscitation] initiated. Pt was not breathing no pulse at this time, color purple, code team arrived. Code concluded at 2258." The code blue resuscitation was unsuccessful and the patient died.

C. Facility record review of the facility investigation notes and interviews completed the night of Patient 1's death on 5/11/10 and the next day 5/12/10 revealed multiple failures of staff failing to provide a safe environment of care for Patient 1 in the ED on admission and on the SCU. The ED nurse failed to complete a suicide risk assessment and failed to accurately document the patient's behaviors in the ED which included his "hovering over the sharps [red sharps box] in ED" concerns he had taken a needle out of the sharps box leading to a second search in the ED. The attempts he made to leave the ED. The SCU charge nurse was told he had "passive SI [suicidal ideation]". The charge nurse on SCU was off the unit and did not assign the admission of Patient 1 to another RN on the unit. BST staff brought the patient to the unit, did vitals and asked the patient if he wanted to go to his room. The patient chose to go to his room and was escorted to the door of the room by the BST. The 2 BSTs on duty in SCU confirmed they did not do environmental rounds on the room Patient 1 was assigned to as it was empty and locked prior to his arrival. The BSTs failed to follow unit policy to do environmental rounds their shift to ensure all rooms are secure. Part of securing the rooms includes being sure the bathroom doors and closets are locked in each room of the SCU. Patient 1's room was not secured which allowed him access to the closet where he used the hinges to hold a knot he put in a sheet he used to hang himself. Policy for admission to SCU also includes staff direction that patients are not allowed to leave the day area in visual sight of staff until assessed by the RN. The rounds sheet used to document patient rounds made by the 2 BSTs to check on patients for safety every 10 minutes were documented for Patient 1. The rounds sheet noted the patient was in his room at 10:20 PM, 10:30 PM 10:40 PM, 10:50 PM and every 10 minutes after his death until the rounds sheet ends at 11:20 PM.

Staff interview on 5/18/10 at 10:00 AM with RN-F, the Adult Behavioral Health Services Operations Director, revealed that during the investigation the Security tapes of the unit were viewed and clearly identified, with video cameras at both ends of the SCU halls, that none of the staff checked on Patient 1 for "40 minutes" prior to his being found hanging in his room. RN-F also stated that the video camera in the patient's room "was not on." RN-F related administrative staff were on the unit after the incident on 5/11/10 and on 5/12/10 implemented a short term Action Plan which included staff retraining on the SCU and ED to address the problems with patient safety that were identified. Further interview with RN-F at 2:00 PM on 5/18/10 revealed all SCU closet doors were permanently screwed shut on 5/12/10, staff had to sign acknowledgement of retraining, top sheets were removed on SCU and replaced with a thicker blanket, and spot checks were being done to ensure rounds were completed.

Staff interview with RN-G, ED Operations Director on 5/19/10 at 10:40 AM confirmed the nursing ED notes for Patient 1 on 5/11/10 do not adequately reflect the patient's status which included his wanting to leave, sharps container activities and statements. RN-G confirmed the ED RN did not complete the suicide assessment. On 5/12/10 RN-F stated an email was put on the ED system that comes up on the computer when staff log in. Staff can click acknowledgement without reading it. The email included staff reeducation on Patient Safety in the ED. The memo included directing staff to do a suicide risk assessment and "if the patient is High or Moderate Risk, the every 15 minute safety checks are to be started immediately in the ED." RN-G confirmed that email was the only communication tool used and that there was not any formal training or meetings with charge nurses or ED staff on the changes. RN-G stated that on 5/17/10 (first day of survey) she realized staff had questions and started doing in-person education and 100% chart audits. The staff directive failed to ensure patients at high risk of suicide were monitored continually by staff in the ED to ensure patient safety in an unsecure busy ED environment. RN-G brought one of the red sharps containers used in the ED rooms to the interview. The red container has a clear plastic top that slides open to reveal a 2 inch X 5.5 inch opening. The red box fits inside a dog dish base that is glued to the counter in the ED exam rooms. RN-G stated that these boxes are used because the larger vials won't go into the more secure swinging door opening sharps containers that are kept on the wall in the ED exam rooms. The red boxes on the counter easily allow an adult or child's hand to obtain biohazard dangerous items from the box top or to tip it upside down and shake items out.

D. Random observation of security tapes of SCU that are dated and time stamped in real time were viewed to verify compliance with completion of safety rounds on 5/19/10 at 3:50 PM. RN-F, Operations Director Adult Behavioral Services viewed the tapes and compared them with the rounds documentation. Video surveillance tape was viewed after staff re-education was completed on 5/12/10. On 5/14/10 rounds from 6:00 PM - 12:30 AM on 5/15/10 were selected for viewing. Room 421, Patient 3's room was clearly seen in the video. Record review revealed Patient 3 was an EPC admit to SCU 5/6/10 after a suicide attempt with a knife causing an 8 inch laceration. On 5/14/10 Patient 3 was on Self harm Suicide Evaluation, Elopement precautions and Assault precautions. The rounds sheet dated 5/15/10 identified Patient 3 by first name and room number noting the patient was sleeping on rounds at 12:00 AM and 12:10 AM. Observation of the video tape revealed no rounds were made from 11:50 PM on 5/14/10 until 12:18 AM on 5/15/10. Patient 3, at risk of suicide, was not observed for 28 minutes. Again rounds were not done and rounds records falsified by SCU staff. After observing the video RN-F stated "staff continue to have problems getting rounds done every 10 minutes and falsifying rounds records." RN-F stated she "was not aware the problem continued until I saw the video today - my spot checks since 5/11/10 were OK but did not identify we still had a problem." Failure to do rounds per policy gives suicidal patients opportunity to engage in self harm/suicidal behaviors undetected by staff. This finding revealed that Immediate Jeopardy (IJ) to the health and safety of patients' conditions still existed in the 13 bed SCU on 5/19/10.

Observation tour of the ED on 5/19/10 at 4:05 PM with RN-G, Operations Director of ED, revealed cupboard doors in exam rooms 3 (Exam room used for Patient 1), 4, 5, 6, 7, 12, 13 that are made of glass and cannot be locked. RN-G confirmed unsafe red sharps containers with the sliding tops remained in 17 exam rooms of the ED. Observation confirmed the red box is easily lifted off the countertop dog dish holder. When the top sliding closure was opened and the box tipped upside down 3 used syringes, needles and a glass syringe vial easily fell out onto the table height counter. RN-G related that psychiatric patients are often in the main ED exam rooms as the Behavioral Assessment Center area of the ED is often full. RN-G stated that new sharps containers were ordered but would not arrive until 5/20/10. Presence of the unsecure/unsafe red sharps containers in the ED exam rooms placed patients/visitors in the ED exam rooms at Immediate Jeopardy.

E. The facility developed a new Action Plan to address the IJ conditions on 5/19/10. Observations in the ED on 5/20/10 at 1:40 PM revealed all unsafe red sharps boxes had been removed from patient areas. Review of 3 ED patient records found suicide risk assessments were completed. Constant observation of those identified at high suicidal risk was verified through surveyor observation and record review. Observation confirmed every 10 minute rounds are done on SCU. Observations 5/20/10 from 2:15 - 2:40 PM confirmed rounds are also being done and environmental checks for safety are completed on the Adult and Adolescent psychiatric units as well. The IJ was abated on 5/20/10 at 5:05 PM.

Based on observations, record review, staff interviews, reviews of facility internal investigation, review of video tape of the Special Care Unit (SCU) and review of facility policies and procedures, the facility failed to ensure psychiatric nursing care and supervision was provided to ensure the safety of suicidal patients in the Emergency Department and 13 bed SCU. 2 of 8 sampled psychiatric patients failed to have adequate nursing assessment and or supervision to ensure their safety (Patients 1 and 3). Suicide risk assessment and monitoring was not done by the Emergency Department (ED) on admission post-suicide attempt for Patient 1. Patient 1 successfully committed suicide by hanging after transfer and admission to the SCU on 5/11/10. The patient was not assigned or assessed by any of the 3 professional nurses present after admission to the SCU. Professional staff of the SCU also failed to adequately supervise non-licensed nursing staff to ensure rounds and safety checks were done on the SCU. Observations on 5/19/10 of videotaped rounds on 5/15/10 found the staff on SCU failed to make rounds for 28 minutes on Patient 3 who was on suicide evaluation status. Due to the serious nature of these findings, the Condition of Participation for Nursing Services was not met. The facility census was 158. See also A0395.

Based on observations, record review, staff interviews, reviews of facility internal investigation, review of video tape of the Special Care Unit (SCU) and review of facility policies and procedures, the facility failed to ensure psychiatric nursing care and supervision was provided to ensure the safety of suicidal patients in the Emergency Department and 13 bed SCU. 2 of 8 sampled psychiatric patients failed to have adequate nursing assessment and or supervision to ensure their safety (Patients 1 and 3). Suicide risk assessment and monitoring was not done by the Emergency Department (ED) on admission post-suicide attempt for Patient 1. Patient 1 successfully committed suicide by hanging after transfer and admission to the SCU on 5/11/10. The patient was not assigned or assessed by any of the 3 professional nurses present after admission to the SCU. Professional staff of the SCU also failed to adequately supervise non-licensed nursing staff to ensure rounds and safety checks were done on the SCU. Observations on 5/19/10 of videotaped rounds on 5/15/10 found the staff on SCU failed to make rounds for 28 minutes on Patient 3 who was on suicide evaluation status. Due to the serious nature of these findings the Standard: Staffing and Delivery of Care was not met. The facility census was 158. See also A0395.

Based on observations, record review, staff interviews, reviews of facility internal investigation, review of video tape of the Special Care Unit (SCU) and review of facility policies and procedures, the facility failed to ensure psychiatric nursing care and supervision was provided to ensure the safety of suicidal patients in the Emergency Department and 13 bed SCU. 2 of 8 sampled psychiatric patients failed to have adequate nursing assessment and or supervision to ensure their safety (Patients 1 and 3). Suicide risk assessment and monitoring was not done by the Emergency Department (ED) on admission post-suicide attempt for Patient 1. Patient 1 successfully committed suicide by hanging after transfer and admission to the SCU on 5/11/10. The patient was not assigned or assessed by any of the 3 professional nurses present after admission to the SCU. Professional staff of the SCU also failed to adequately supervise non-licensed nursing staff to ensure rounds and safety checks were done on the SCU. After the death of Patient 1 the facility put an Action Plan in place which included staff retraining and monitoring. Observations of videotaped rounds on 5/19/10 found the staff on SCU failed to make rounds for 28 minutes on Patient 3 who was on suicide evaluation status. The facility census was 158. Findings are:

A. Medical record review revealed Patient 1 arrived in the Emergency Room by rescue squad on 5/11/10. Police came with the patient and completed Emergency Protective Custody (EPC) papers for Patient 1 for being "Dangerous to Self." Police report review revealed the patient's employer called police concerning Patient 1. Police found the patient behind the store bleeding from both wrists. Patient 1 told the police "he wished he used a sharper knife, this was too dull" and "I should have done this at home." The Triage Registered Nurse (RN) assessment completed by RN-A is documented at 8:16 PM. The Emergency Physician noted the patient is depressed and has self- inflicted lacerations both wrists. The patient told the Physician he had "been depressed for a long time and is [sic] felt worse lately and took a box cutter and attempt to cut his wrists." Physical exam noted the wrist lacerations were horizontal across the wrist with the left measuring about 5 cm (centimeters) and 2 cm on the right wrist. The patient refused to allow the physician to suture the lacerations but did allow Derma bond for closure. The Physician noted the patient's mood and affect to be flat and depressed.

Nursing documentation in the Emergency Department at 8:31 PM by RN-A fails to indicate the patient has a nursing "Suicide Assessment" completed or suicide precautions implemented. The notes state the patient "denies wanting to hurt himself. Cutting on wrists he said was an accident. He was at work when this happened. Asked what he was cutting since it was an accident. The pt [patient] stated that "I should have used something sharper". The next nursing documentation is at 10:12 PM when the patient was transported with Security and belongings.

Physician orders dated 5/11/10 at 9:40 PM were taken as verbal orders by RN-B, a Behavioral Health Assessment Center nurse from the Emergency Department (ED). The ED has a 6-bed Behavioral Health Assessment area. Patient 1 was not in that area of the ED; however, the nurses from that unit help coordinate inpatient placement of Psychiatric Patients. RN-B confirmed during a phone interview on 5/19/10 at 11:30 AM that she did not see or evaluate the patient. RN-B stated she called the psychiatrist and got orders based on the ED nurses report. RN-B stated she did call the SCU charge RN, RN-C, and told her the patient had cut himself and was an EPC. RN-C told RN-B the unit was ready to accept the patient. RN-B then gave the charge nurse the phone number of the ED nurse, RN-A, to get report on Patient 1. Documentation titled "Verbal Report Notes" taken at 5/11/10 at 9:25 PM identify the patient's self inflicted injuries and statement that it was an accident and "should have used sharper one". Charge RN-C documented the patient has "Possible suicidal ideation. Worried about getting fired from job". Risk factors included "Suicidal Ideations" Box on document checked as "yes". Physician orders included under area titled "Precautions: [check marked] Suicide Evaluation; Elopement Precautions; Assault Precautions; Precautions per ICU Protocol". Under the section titled "Problems" the nurse noted "Potential for self Harm" with interventions listed as admit to SCU, check suicidal ideation every shift, "Keep safe, monitor behaviors & thought process."

The medical record fails to include an admission nursing assessment. The only nursing note after transfer to the SCU is at 10:40 PM by staff RN on 5/11/10 stating the Behavioral Service Technicians (BSTs) "were making rounds on SCU et found pt in room with knotted sheet around neck suspended from closed door. At this time they called for help, code blue called. CPR [Cardiopulmonary Resuscitation] initiated. Pt was not breathing no pulse at this time, color purple, code team arrived. Code concluded at 2258 [10:58 PM]." The code blue resuscitation was unsuccessful and the patient died.

B. Staff telephone interview on 5/19/10 at 9:10 AM with ED RN-A revealed the following regarding the nursing care of Patient 1 on 5/11/10 in the ED: Patient was in Room 3 of the main ED. He was very vague regarding his medications when asked. RN-A stated she would question Patient 1 and he would not answer and "never gave good eye contact." When she unwrapped his wrists he told her "should have used a sharper one". After measuring and cleaning the wounds on his wrist she stated "he kept coming out and she redirected him to stay in the room." Patient 1 told the police it was an accident and "he wanted to go home." RN-A explained to the patient he was an EPC and will be kept 72 hours. The patient complained about the cost. Patient 1 told her he was using a box cutter and again repeated "I should have used a sharper one."
RN- A stated that was caring for 2 other patients in Rooms 4 and 5 while also trying to watch Patient 1. She said hospital Security came up and did a security check of the patient and helped him into scrubs. The scrub bottoms fit and had a string closure. The scrub tops did not fit so the patient was allowed to wear his own polo shirt with a pocket. The patient used the phone and again was redirected back to his room. The patient repeated to RN-A that he wanted to go home. RN-A stated she felt "he was trying to leave the dept. [department]." RN-A then stated "I kept a close eye on him and saw him in our cupboard where 4X4 [gauze dressings] are kept in the room. He got some and wrapped the tape measure around the 4X4s he had put on his wrist." She stated "he had blood everywhere and she redirected him to stay out of the cabinet. RN-A redressed the wounds and told Patient 1 to leave them alone". He then tried to leave the room again and use the phone. After returning to the room she saw Patient 1 "leaning against the counter over the sharps box." RN said she wanted Security to come and watch him but they were busy and could only stay about 2 minutes. RN-A said she tried to walk by his room about every 2 minutes. About 5 minutes after this she walked by the room and found the patient "looking in the sharps box". She again called Security but they were unable to stay with the patient. RN-A then went to the Behavioral Health Assessment Center of the ED and asked them to take the patient telling them "he gets into things and I can't sit with him as I have 2 other patients." The Behavioral Health nurse called the psychiatrist and got orders to admit to SCU. She stated she gave report to the 4th floor [SCU]. She told them "he had gotten into the cupboard, was hanging around the sharps and to watch him." When the Behavioral Services Technician (BST) arrived about 5 minutes later, RN-A "told her she was not sure if he got into sharps." RN-A failed to ensure Patient 1 was assessed for suicidal ideation and failed to implement constant 1:1 monitoring of the suicidal high risk patient who was exhibiting unsafe behaviors in an unsecured environment. RN-A's documentation failed to include the patient's unsafe behaviors and need for constant supervision.

C. Staff interview with staff nurse RN-H on 5/19/10 at 1:00 PM revealed the following regarding Patient 1's admission and staffing on 5/11/10: When the patient arrived on SCU RN-H stated the charge nurse was doing change of shift report off the unit. RN-H stated that when the charge nurse was off the unit she was in charge. Patient 1 was the 3rd admission to the SCU since RN-H's arrival at 5:00 PM. The second admit was with the Transitional Care RN in a conference room on the unit. The Transitional Care RN assists with admissions on the psychiatric units. RN-H was aware Patient 1 was coming up from the ED. RN stated that when the charge nurse left for report she told her to "put a chart together for the second admit." RN-H was in the Plexiglas nurses station when Patient 1 arrived on the unit with the techs. She saw them doing his vital signs and then "I went back to documentation." RN stated the charge RN "did not assign me to do [name of Patient 1]'s admit." "RN-H did not see the BSTs take the patient to his room." RN-H stated the next time she saw the patient was when the techs discovered Patient 1 with a noose around his neck.

RN-H stated that when a patient comes to the unit the "RN assesses as quick as possible." The BSTs start with the patient immediately. The BST does a checkin process including a search for contraband before the patient comes on the unit. Once on the unit the BST get the vital signs, height and weight. She stated they "try to keep patients out in open areas until assessed." RN-H stated she was "not surprised techs allowed the patient to go to his room, it was late, pts get tired and we try to provide supportive care." RN-H related that unoccupied rooms such as the one Patient 1 was assigned to are to be kept locked on the unit. All rooms are to be checked for safety by techs at the beginning of the shift and the end of the shift. These checks include unoccupied rooms. RN-H stated that part of ensuring that rooms are secure is to "check that the bathroom and closet door are locked." RN further related that the unit was busy but staff was experienced and staffing was adequate on 5/11/10.

D. Review of facility policy titled "Special Care Unit" last review date of 11/06 states the SCU is used for those "patients whose safety and ability to control their behaviors and care for themselves is in question." The SCU "provides the patient with the specific external boundaries, minimal stimulation, and close proximity to the nursing station, thus providing the optimum care and maintaining the safety of patients and staff." Indications for admission include "To provide very close observation to the patient who refuses or is unable to commit to their safety or to staying on the unit." The 13-bed unit is a locked unit with all private rooms. Cameras monitor the hallway and dining/day room area and can be utilized to monitor patient rooms as well. Monitors are located in the nursing station of the SCU and in the Security office near the Emergency Room.

Review of facility Behavioral Services policy titled "Suicidal Patient Care" last review date of 4/09 states "All mental health patients will be evaluated upon admission by a registered nurse with regards to a risk assessment including suicidal thought content ...". The policy further states under the section titled "Suicide Precautions" that a 'One-on-one staff member is assigned to do direct visual observation and to stay at an arm's length of the patient AT ALL TIMES." The policy includes an example of a patient considered to be at immediate risk to act out on suicidal thoughts and feelings as one who "is relaying a detailed suicide plank threatening to kill or harm him/herself with diminished ability to redirect, or has made an overt suicide attempt." For patients on "Suicide Evaluation" the patient is at risk to act out suicidally as evidenced by any one or combination of behaviors/ thoughts including a patient that has made "verbalization of suicidal feelings, threats or plans" and/or has made "superficial self mutilatory actions, (i.e. scratching self on the arms or hands)." Patients on the Special Care Unit are per policy to have nursing rounds made at "10 minute intervals."

E. Facility record review of the facility investigation notes and staff interviews completed the night of Patient 1's death on 5/11/10 and the next day, 5/12/10, revealed multiple failures of staff failing to provide a safe environment of care for Patient 1 in the ED on admission and on the SCU. The ED nurse failed to complete a suicide risk assessment and failed to accurately document the patient's behaviors in the ED which included his "hovering over the sharps [red sharps box] in ED" concerns he had taken a needle out of the sharps box leading to a second search in the ED. The attempts he made to leave the ED. The SCU charge nurse was told he had "passive SI [suicidal ideation]". The charge nurse on SCU was off the unit and did not assign the admission of Patient 1 to another RN on the unit. BST staff brought the patient to the unit, did vitals and asked the patient if he wanted to go to his room. The patient chose to go to his room and was escorted to the door of the room by the BST. The 2 BSTs on duty in SCU confirmed they did not do environmental rounds on the room Patient 1 was assigned to as it was empty and locked prior to his arrival. The BSTs failed to follow unit policy to do environmental rounds their shift to ensure all rooms are secure. Part of securing the rooms includes being sure the bathroom doors and closets are locked in each room of the SCU. Patient 1's room was not secured which allowed him access to the closet where he used the hinges to hold the knot in a bed sheet which he then used to hang himself. Policy for admission to SCU also includes staff direction that patients are not allowed to leave the day area in visual sight of staff until assessed by the RN. The rounds sheet used to document patient rounds made by the 2 BST ' s to check on patients for safety every 10 minutes were documented for Patient 1. The rounds sheet noted the patient was in his room at 10:20 PM, 10:30 PM 10:40 PM, 10:50 PM and every 10 minutes after his death until the rounds sheet ends at 11:20 PM.

Staff interview on 5/18/10 at 10:00 AM with RN-F, the Adult Behavioral Health Services Operations Director, revealed that during the investigation the Security tapes of the unit were viewed and clearly identified, with video cameras at both ends of the SCU halls, that none of the staff checked on Patient 1 for "40 minutes" prior to his being found hanging in his room. RN-F also stated that the video camera in the patient's room "was not on." RN-F related administrative staff were notified and on the unit after the incident on 5/11/10. On 5/12/10 implemented a short term Action Plan which included staff retraining on the SCU and ED to address the problems that were identified. Further interview with RN-F at 2:00 PM on 5/18/10 revealed staff had to sign acknowledgement of retraining, and spot checks were being done to ensure rounds were completed.

Staff interview with RN-G, ED Operations Director on 5/19/10 at 10:40 AM confirmed the nursing ED notes for Patient 1 on 5/11/10 do not adequately reflect the patient's status which included his wanting to leave, sharps container activities and statements. RN-G confirmed the ED RN did not complete the suicide assessment. On 5/12/10 RN-F stated an email was put on the ED system that comes up on the computer screen when staff log in. Staff can click acknowledgement without reading it. The email included the staff reeducation on Patient Safety in the ED as part of the facility Action Plan. The memo included directing staff to do a suicide risk assessment and "if the patient is High or Moderate Risk, the every 15 minute safety checks are to be started immediately in the ED." RN-G confirmed that email was the only communication tool used and that there was not any formal training or meetings with charge nurses or ED staff on the changes. RN-G stated that on 5/17/10 (first day of survey) she realized staff had questions and started doing in-person education and 100% chart audits. The staff directive failed to ensure patients at high risk of suicide were monitored continually by staff in the ED to ensure patient safety in an unsecured busy ED environment. During the interview the every 15 minute safety checks were discussed with RN-G. RN-G confirmed that to ensure patient safety "high risk suicidal patients should be in line of sight for safe care in the ED."

F. Random observation of security tapes of SCU that are dated and time stamped in real time were viewed to verify compliance with completion of safety rounds on 5/19/10 at 3:50 PM. RN-F, Operations Director Adult Behavioral Services was also present for the viewing of the tapes and compared them with the rounds documentation. Video surveillance tape was viewed after staff re-education was completed on 5/12/10. On 5/14/10 rounds from 6:00 PM - 12:30 AM on 5/15/10 were selected for viewing. Room 421, Patient 3's room was clearly seen in the video. Record review revealed Patient 3 was an EPC admit to SCU 5/6/10 after a suicide attempt with a knife causing an 8 inch laceration. On 5/14/10 Patient 3 was on Self harm Suicide Evaluation, Elopement precautions and Assault precautions. The rounds sheet dated 5/15/10 identified Patient 3 by first name and room number noting the patient was sleeping on rounds at 12:00 AM and 12:10 AM. Observation of the video tape revealed no rounds were made from 11:50 PM on 5/14/10 until 12:18 AM on 5/15/10. The patient at risk of suicide was not observed by unit staff for 28 minutes. Once again safety rounds were not done and rounds records falsified by SCU staff. During the 28 minutes the rounds were not done the video showed a patient requiring security assistance in the day hall. The nursing staff failed to manage the unit milieu to ensure patient safety on the unit while other staff was busy with an out of control patient. After observing the video RN-F stated "staff continue to have problems getting rounds done every 10 minutes and falsifying rounds records." RN-F stated she "was not aware the problem continued until I saw the video today - my spot checks since 5/11/10 were OK but did not identify we still had a problem." Failure to do safety rounds per policy gives suicidal patients opportunity to engage in self harm/suicidal behaviors undetected by staff.

Based on record review of 1 of 1 death record (Patient 1), staff interview and facility policy review the facility failed to ensure the Organ Procurement Organization (OPO) was notified in a timely manner. The total sample was 8. The facility census was 158. Findings are:

A. Record review revealed Patient 1 died while on the Special Care Unit. The patient was pronounced at 10:58 PM on 5/11/10. The record reveals the OPO was not notified of the death until 5/12/10 at 5:48 AM, 6 hours and 50 minutes after death.

B. Staff interview with the Chief Nursing Officer on 5/18/10 at 10:40 AM related that the patient's death was a coroner's case and that was the reason for the delay.

C. Review of facility policy titled "Organ, Tissue, and Eye Donation" last revised date 9/07 states that the notification is to be "within 1 hour of cardiac death."