July 26, 2014 STATEMENT OF DEFICIENCIES SOURCE: Centers for Medicare & Medicaid Services Based on records review and interviews, the hospital failed to ensure that a registered nurse effectively supervised the nursing care and appropriately evaluated the risk for self harm for 2 of 12 patients (Patient #1 and #8) in accordance withthe hospital's nursing policy. 1) Although aware of Patient #1's history of self-injurious behavior, nursing staff failed to implement safety measures adequate to prevent the patient from causing serious self-harm by attempting to strangle himself on 07/26/14. 2) On 09/23/14, nursing staff failed to implement safety measures that could have prevented Patient #8 from tying a knotted sheet to the door and around his neck that resulted in breathing problems after. Patient #8 had reported to nursing staff his intentions to use a sheet to commit suicide by hanging less than 24 hours earlier. Findings included: 1) Patient #1's comprehensive admission screening dated 07/26/14, at 00:10, reflected the patient suffered from psychosis with suicidal ideation after jumping through a glass window. Admission orders noted by nursing staff on 07/26/14, at 02:00, reflected suicide precautions for Patient #1. Suicide assessment dated by nursing staff on 07/26/14, at 02:15, noted "none." Nursing Notes dated 07/26/14, noted that at 05:40, Patient #1 was found on the floor of his patient room. He was "unconscious with long elastic bandage around [his] neck ...not breathing ..." Periorbital edema (swelling around eyes) and a "small amount of blood" were noted in the patient's mouth. The patient had "superficial abrasions" around his neck. ED Physician Record dated 07/26/14, at 06:30, noted Patient #1 presented with "self-strangulation..." from the hospital's behavioral health center. The patient was "...unconscious with difficulty breathing...was emergently intubated on arrival for respiratory distress and airway protection...blood pressure was 184/110 mmHg...in severe distress...ill-appearing." Diagnoses included Asphyxiation and Strangulation, Suicide Attempt, Hypoxic Brain Injury, and Respiratory Failure.
Hospital Employee #5 stated on 10/09/14, at 14:45, she "did not think ...[Patient #1] was actively suicidal and didn't impress me as a major threat" during the patient admission.