Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 670093	(X3) Date Survey Completed 04/16/2019
Name of Provider or Supplier Aspire Hospital	Street Address, City, State 2006 South Loop 336 West, Suite 500, Conroe, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

A0144

PATIENT RIGHTS: CARE IN SAFE SETTING
CFR(s): 482.13(c)(2)

The patient has the right to receive care in a safe setting.

This STANDARD is not met as evidenced by:
Based on observation, review of medical records, and staff interviews, the facility failed to ensure that patients received psychiatric care in a safe setting. A. In 10 of 10 patients (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and #25) on suicide precautions, patoients were being placed in bedrooms and on a psychiatric unit that had multiple ligature risks. These ligature points could be used to attach material for the purpose of hanging or strangulation. B. In 10 of 10 patients (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and #25), patients were being assessed for suicide risk with two different suicide risk assessment tools during the admission process in the Intake Department. This resulted in contradictory suicide risk assessment findings. Such contradictory findings created confusion as to the actual suicidal risk of the patient. C. In 1 of 10 patients (patient #24), patients were being assessed as a "high" risk for suicide on the SADPERSONS assessment tool and not being placed on a 1:1 observation as is delineated in the facility's policies. D. In 1 of 20 patients (patient #26), patient was in bed with the bedroom door closed during a scheduled group time. This is contrary to the facility's observation policies by allowing patients in unobserved areas. E. In 20 of 20 patients (patients #2, 14, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, and #35), patients were placed in bedrooms and on a psychiatric unit with numerous screws that were not tamper resistant. Ten (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and#25) of these patients were on suicide precautions. Such hardware has the likelihood to be used by patients for self-harm. Findings: A. Patients on suicide precaution being placed in bedrooms on a psychiatric unit that had multiple ligature risks. During a tour of the adult psychiatric unit on 04/11/2019 at 08:30 - 12:30 PM, 16 of 16 bedrooms and adjoining bathrooms (room 100, 101, 102, 103, 105, 106, 107, 108, 202, 203, 204, 205, 206, 207, 208, and room 209) were observed to have the following ligature risks: 1. Toilets were not mounted flush to the wall and floor, creating a loopable hole gap between the toilet bowl and the wall that could be used as a tie off point; 2. The plastic cover over the toilet pipes was not enclosed at the bottom, giving patients access to the pipes; 3. The plastic cover over the toilet pipes had been altered to allow access to the button flush system and the electric eye that triggers the automatic flushing system. The two holes, each about two inches in diameter, created a new tie off point; and 4. Bedroom door handles were standard door handles and posed a ligature risk. New handles had not been installed. There were other ligature risks observed: 1. 2 of 16 bedrooms (rooms 107 and 209) had a door that lead from within the bedroom into a community shower room. The door handles on these two doors were had standard door handles and posed a ligature risk; 2. 3 of 16 lavatory sinks found in patient bathrooms (rooms 103, 206, and 209) were missing the side board to the right of the sink. The 13 other lavatory had the side board installed. Without the side board, it was possible to tie off onto the sink; and 3. 6 of 24 beds (room 100, 202, 203, 204, 205, and room 206) were not bolted to the floor. In addition to the ligature risks outlined above, numerous other ligature risks were observed on the psychiatric unit during the tour. These ligature risks included: The metal door handle attached to the metal plate or trim piece on the inside of the seclusion room was loose. This created a gap between the door handle and the metal plate, thus creating a ligature risk. In an interview with Staff A and Staff C on 04/11/2019 at 2:00 PM, they stated that the toilet pipes, three lavatory sinks, unbolted beds, and door handles were ligature risks. Observation of the bathroom in the lobby on 04/11/2019 at 8:45 AM showed the following ligature risks: 1. Standard door handle and hinges created tie off points; 2. The mirror had a ledge across the top that created a tie off point; and 3. The toilet was not mounted flush to the wall and floor, creating a loopable hole between the toilet bowl and the wall that could be used as a tie off point. In an interview with Staff A, Staff R, and Staff C on 04/11/2019 at 8:45 AM, they stated that the patients in the Intake Department awaiting admission or in the admission process utilize the bathroom in the lobby. They also stated that the bathroom had ligature risks. Record review of the Nursing Shift Report dated 04/11/2019 [not timed] showed patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and patient #25 to be on suicide precautions. Each patient was assigned to a bedroom: Patient #2 - room 203 Patient #14 - room 205 Patient #18 - room 204 Patient #19 - room 102 Patient #20 - room 105 Patient #21 - room 106 Patient #22 - room 108 Patient #23 - room 206 Patient #24 - room 207 Patient #25 - room 208 Record review of the medical records of the 10 patients on suicide precautions showed the following: Patient #2. Record review of the Physician's Admission Orders dated 03/18/2019 at 11:47 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions." Record review of the Psychiatric Evaluation dated 03/19/2019 at 10:06 AM by MD N showed, " ... 46-year-old female ... hit by a car on March 13th ... disorganized and illogical ... The day before her accident, ... stated she was going to heaven ... Previous suicide attempt ... impaired insight, loss of judgement ... Admission [diagnoses]: Schizophrenia ... Hit by car, SAH [subarachnoid hemorrhage] partially resorbed, odontoid fracture ... Discharge Criteria: No longer is a danger to self ..." Patient #14. Record review of the Physician's Admission Orders dated 04/08/2019 at 3:59 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions." Record review of the Psychiatric Evaluation dated 04/09/2019 at 1:30 PM by MD N showed, " ... 67-year-old male ... suicide attempt by overdose on multiple medications [including] ... 60 0.5mg Xanax ... impaired insight [and] ... judgement ... Admission [diagnoses] Major Depressive Disorder, recurrent, severe ... Suicidal thoughts ... Overwhelming anxiety ... Discharge Criteria: No longer a danger to self ... " Patient #18. Record review of the Physician's Admission Orders dated 04/08/2019 at 11:23 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions." Record review of the Psychiatric Evaluation dated 04/09/2019 at 2:23 PM by MD N showed, " ... 33-year-old female ... suicidal ideation with voices telling her to kill herself ... previous known suicide attempt ... impaired insight [and] ... judgement ...Admission [diagnoses]: Major Depressive Disorder, recurrent, severe, ... blind both eyes ... overwhelming anxiety ... Discharge Criteria: No longer a danger to self ..." Patient #19. Record review of the Physician's Admission Orders dated 04/06/2019 at 3:46 AM showed "Suicide Precautions" ordered by MD J for this 75-year-old male. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions." Record review of the Psychiatric Evaluation dated 04/06/2019 at 10:17 AM by MD P showed, " ... he wanted to leave the nursing home ... the patient wrapped his call light around his neck ... He denies any suicidal ideation, intent, or plan ... Unkempt appearance ... Impaired insight [and] ... judgement ... Admission [diagnoses]: Major Depressive Disorder, recurrent, severe. There is some concern that the patient is minimizing ... Alzheimer's ... Suicidal thoughts ... Discharge Criteria: No longer is a danger to self ..." Patient #20. Record review of the Physician's Admission Orders dated 04/08/2019 at 2:32 AM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions." Record review of the Psychiatric Evaluation dated 04/08/2019 at 8:29 AM by MD N showed, " ... 21-year-old male ... [admitted on an] Emergency Detention Warrant ... out of the hospital for one week ... Delusions ... One previous suicide attempt in May 2017 by overdose on 50 Benadryl ... Suicidal behavior. Threatening suicide (holding knife to his throat) ... Impaired insight. Lack of judgement ... Admission [diagnoses]: Moderate manic bipolar I disorder (with psychotic features), substance use, misuse, abuse (marijuana use disorder) ... Discharge Criteria: No longer is a danger to self ..." Patient #21. Record review of the Physician's Admission Orders dated 04/08/2019 at 4:36 AM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions." Record review of the Psychiatric Evaluation dated 04/08/2019 at 10:30 AM by MD N showed, " ... 58-year-old male ... reports worsening depression ... Suicidal behavior. Threatening suicide (holding gun in his lap) ... impaired insight [and] ... judgement ... Admission [diagnosis]: Major Depressive Disorder, recurrent, severe ... Discharge Criteria: No longer is a danger to self ..." Patient #22. Record review of the Physician's Admission Orders dated 04/09/2019 at 12:21 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions." Record review of the Psychiatric Evaluation dated 04/09/2019 at 2:41 PM by MD N showed, " ... 48-year-old female ... [reported] bad anxiety and panic attacks, couldn't sleep ... Previous known suicide attempt. Suicidal behavior ... Has insight, impaired judgement ... Admission [diagnoses]: Major Depressive Disorder, first episode, severe ... GAD [Generalized Anxiety Disorder] ... Discharge Criteria: No longer is a danger to self ..." Patient #23. Record review of the Physician's Admission Orders dated 04/09/2019 at 4:30 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions." Record review of the Psychiatric Evaluation dated 04/09/2019 at 3:21 PM by MD N showed, " ... 62-year-old female ... Has insight. Impaired judgement ... Denies suicidal ideation ... Admission [diagnoses]: Major Depressive Disorder, recurrent, severe, ... Opiate Use Disorder, severe ... Discharge Criteria: No longer is a danger to self ..." Patient #24. Record review of the Physician's Admission Orders dated 04/09/2019 at 3:34 PM showed "Suicide Precautions" ordered by MD N. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions." Record review of the Psychiatric Evaluation dated 04/09/2019 at 3:36 PM by MD N showed, " ... 60-year-old female ... 'I have a paranoid problem' ... Delusions ... Has insight. Impaired judgement ... Admission [diagnosis]: Moderate Manic Bipolar I Disorder ... Discharge Criteria: No longer is a danger to self ..." Patient #25. Record review of the Physician's Admission Orders dated 04/10/2019 at 2:48 AM showed "Suicide Precautions" ordered by MD J. There was no documentation in the Physician's Orders to discontinue the "Suicide Precautions." Record review of the Psychiatric Evaluation dated 04/10/2019 at 7:47 PM by MD J showed, " ... 23-year-old female ... admitted with psychosis and suicidal ideation. She is guarded and will not share the reasons of her depressive psychosis ... a strong history of mental illness ... with multiple psychiatric hospitalizations ... hearing voices and ... insomnia ... Previous known suicide attempt. Suicidal behavior. Threatening suicide ... Impaired insight. Impaired judgement ... Admission [diagnoses]: Schizoaffective Disorder, mixed; Substance Use, Misuse, Abuse (Marijuana Dependence) ... Discharge Criteria: No longer is a danger to self ..." B. Contradictory suicide risk assessments, all conducted during the admission process in the Intake Department. In an interview with Staff R (Intake RN) and Staff C on 04/11/2019 at 1:25 PM, both staff members stated two suicide risk assessment tools are completed by the intake RN during the admission process: a suicide risk rating tool and the SADPERSONS. Staff R stated that these two assessments are part of the "Patient Assessment Report". Staff C stated that the suicide risk rating tool was a tool provided by Staff G. Staff C stated she did not know where Staff G obtained the tool. Staff C also stated that the standard of care in suicide risk assessment requires that clinicians conduct thorough suicide risk assessments. Record review of the "Patient Assessment Report" showed two suicide risk assessments: (1) A suicide risk rating tool and; (2) SADPERSONS Suicide Assessment Scale. (1) A suicide risk rating tool. The name of the suicide risk rating tool was not indicated in the "Patient Assessment Report". The suicide risk rating tool showed 22 suicide risk indicators, each with a numerical value or weight. [The number in the parenthesis is the numerical value given to the indicator.] The first seven suicide risk indicators are LOW INTENSITY INDICATORS: Use of alcohol or drugs to excess, infrequently (1) Vague, fleeting thoughts of suicide with no plan or method (2) No means to complete suicide (1) No previous suicide attempts (0) No recent or significant loss in the past (0) In good physical health, few or no medical problems (0) Rampant hostility - aggressiveness (1) The next 15 (fifteen) suicide risk indicators are classified as HIGH INTENSITY INDICATORS: High anxiety or panic (7) Withdrawn or isolated (6) Few resources (6) Destructive coping strategies (7) Verbal statements of intent (10) Negative view of professional help in the past (7) Non-verbal behavior indicating self-destructive thoughts (8) Unstable lifestyle (8) Excessive use of alcohol or drugs (7) Specific suicide plan (10) Recent or significant loss(es) (8) Self-deprecating (7) Impulsive behavior (9) Hearing command hallucinations for self-harm (10) In poor health, numerous medical problems (6) Score total Score on combined low and high intensity indicators. Score 0-20 - Suicide risk is none - low (not verbalizing or suggesting suicidal ideation) Score 21-59 - Suicide risk low (occasional or fleeting suicidal ideation, no plan, will contract for safety) Score 60-79 - Suicide risk moderate (ongoing suicidal ideations [sic], vague plan, minimal insight, ambivalent about contracting Score 80-125 - Suicide risk high (ongoing suicidal ideations [sic], command hallucinations or clear intent with concrete plan) In an interview with Staff R (Intake RN) on 04/11/2019 at 01:25 PM, she stated that the suicide risk rating tool was "subjective" and the risk factors outlined on the tool were "open to interpretation." She also stated that some of the "Patient Assessment Report's do not have sufficient information, adding that she had found herself documenting more comprehensive assessments when she was handwriting the assessment as opposed to inputting the assessment into the computer. (2) SADPERSONS Suicide Assessment Scale. The SADPERSONS Suicide Assessment Scale has ten suicide risk indicators: male sex, older age, depression, previous attempt, ethanol abuse, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The score and risk scale: SCORE RISK 0-4 Low 5-6 Medium 7-10 High Record review of the Policy & Procedure, "Suicide Risk Assessment and Precautions," reviewed/revised February 1, 2019, showed: "Patients will be assessed for suicide risk using SADPERSONS as part of pre-admission screening and admission assessments ... Patients assessed to be at a heightened risk of suicide or self-injurious behaviors will be placed on suicide precautions commensurate with the assessed level of risk ... 1.0 SADPERSONS, a comprehensive assessment for suicide potential, suicide risk factors, suicidal ideation, planning, and protective factors are performed and documented on all patients during pre-admission screening and at the time of admission ..." Record review of "The Sad Truth About the SADPERSONS Scale: An Evaluation of its Clinical Utility in Self-Harm Patients" in the Emergency Medicine Journal, October 31, 2014, (E-published July 29, 2019) by K. Saunders, F. Brand, K. Lascelles, and K. Hawton showed: "SADPERSONS failed to identify the majority of those either requiring psychiatric admission or community psychiatric aftercare, or to predict repetition of self-harm. The scale should not be used to screen self-harm patients presenting to general hospitals. Greater emphasis should be placed on clinical assessment which takes account of the individual and dynamic nature of risk assessment." In an interview with Staff R on 04/11/2019 at 1:25 PM, she stated that each one of the suicide risk indicators on the SADPERSONS Suicide Assessment Scale have a numerical value of one point. She concluded by saying that the total score is calculated by totaling the number of suicide risk indicators that apply to the subject being evaluated. In an interview with Staff A and Staff C on 04/16/2019 at 4:50 PM, they stated suicide risk is assessed in the intake Department using two tools: a suicide risk assessment tool and the SADPERSONS. They also stated that these tools are not evidence-based. They concluded by saying that there had been discussion about discontinuing these two tools and using an evidence-based tool, such as the Columbia-Suicide Severity Rating Scale. Patient #2. Record review of Progress Note by Staff Y dated 03/15/2019 at 11:05 AM showed: "Patient was talking prior about going to the light and there is now possibility that she was trying to commit suicide prior to coming into the emergency room when she was found." Record review of the "Patient Assessment Report" by Staff Q dated 03/18/2019 at 11:52 PM showed: Patient #2 was escorted to the facility by police with "suicidal ideation, psychosis, schizophrenia ... Patient had packed her bags stating she was going to heaven. The following day patient was hit by hit-and-run driver." "Not cooperating." Historian: "Medical Record." She admitted to suicidal thoughts within the last 72 hours but would not discuss her plan. Staff Q asked Patient #2 to explain how and when a suicide attempt had been attempted in the past and then documented, "NA" [Not Applicable]. Mood: depressed, bland. Affect: flat, blunted, guarded, constricted, congruent with mood. Thought processes: psychosis, delusions, non-logical. Recent or current behaviors: depression, social withdrawal, isolative, impaired judgement, poor insight, paranoid thinking - "unable to fully assess as patient will not answer questions." "Recently hit by car sustaining SDH [subdural hematoma] and SAH [subarachnoid hemorrhage]." Suicide risk: "High" Record review of the suicide risk rating tool by Staff Q dated 03/18/2019 at 11:52 PM showed the suicide risk indicators: mild depression; no previous suicide attempts; in good physical health; few or no medical problems; withdrawn or isolated; destructive coping strategies; verbal statements of intent; and non-verbal behavior indicating self-destructive thoughts. Total score: 33. Suicide risk: Low Record review of SADPERSONS Suicide Assessment Scale by Staff Q dated 03/19/2019 at 12:20 AM showed the suicide risk indicators were depression and rational thinking loss. "Unsure if patient attempted suicide by walking into traffic." Total score: 2. Suicide risk: Low Patient #14. Record review of Comprehensive Assess[ment] - Psych Response Team by Staff U dated 04/05/2019 at 1:31 AM showed: " ... Patient made a lethal suicide attempt to overdose on multiple medications. His attempt was planned and a suicide note was left for his family. He has possible induced serious brain damage related to attempt ... denies attempt and lacks insight ... patient has a 1:1 sitter at bedside. 1:1 sitter should remain at bedside and have view of the patient at all times, including times when patient may need to use the restroom ... The patient's room should be made as psychiatrically safe as possible ... Medical staff was encouraged to be cognizant that every new individual who interacts with the patient has the ability to change the patient's mood, presentation, willingness to seek treatment. Even if family becomes present, a 1:1 sitter should still be present in the room." Record review of the Psychiatry Consult Note by Staff T dated 04/06/2019 at 1:21 PM showed: " ... Hx [history] of MDD [Major Depressive Disorder] and ADHD [Attention Deficit Hyperactivity Disorder ... S/P [Status post] overdose on multiple psych meds including benzos [benzodiazepines]. He was intubated for 3-4 days ..." Record review of the "Patient Assessment Report" by Staff V dated 04/08/2019 at 6:08 PM showed: " ... SA [suicide attempt] by OD [overdose] on meds." Patient #14 stated that he was separated from his wife which contributed to his depression. Staff V documented "NA" [not applicable] to the question, "Is patient experiencing psychotic features," Psychosis, "Harm to others risk, Detox and or withdrawal, Elopement risk, and Disposition issues and or plan. Suicide risk: "High" Record review of the suicide risk rating tool by Staff V dated 04/08/2019 at 6:08 PM showed the suicide risk indicators: mild to moderate anxiety; use of alcohol or drugs to excess, infrequently; destructive coping strategies; non-verbal behavior indicating self-destructive thoughts; specific suicide plan; recent or significant loss(es); and impulsive behavior. Total score: 45. Suicide risk: Low Record review of SADPERSONS Suicide Assessment Scale by Staff V dated 04/08/2019 at 6:08 PM showed the suicide risk indicators were male sex, older age, depression, previous attempt, organized plan, no spouse, and sickness. Total score: 6. Suicide risk: Medium Patient #18. Record review of the "Patient Assessment Report" by Staff W dated 04/08/2019 at 10:18 PM showed: " ... Visual hallucinations, suicidal, anxious ... suicidal thoughts in the last 72 hours ... delusions ... auditory hallucinations ..." Suicide risk: "High" Record review of the suicide risk rating tool by Staff W dated 04/08/2019 at 10:18 PM showed the suicide risk indicators: No previous suicide attempts; high anxiety or panic; withdrawn or isolated; few resources; destructive coping strategies; verbal statements of intent; unstable lifestyle; impulsive behavior; and in poor health, numerous medical problems. Total score: 59. Suicide risk: Low Record review of SADPERSONS Suicide Assessment Scale by Staff W dated 04/08/2019 at 10:18 PM showed the suicide risk indicators were depression, rational thinking loss, social supports lacking, and sickness. Total score: 4. Suicide risk: Low Patient #19. Record review of the "Patient Assessment Report" by Staff L dated 04/06/2019 at 7:06 AM showed: " ... wanted to leave nursing home so I made them think that I was crazy by putting the call light cord around my neck ... depression, hopelessness, helplessness, minimizes problems, anxiety, confusion" Suicide risk: "Moderate" Record review of the suicide risk rating tool by Staff L dated 04/06/2019 at 7:06 AM showed the suicide risk indicators: mild to moderate anxiety; few resources; destructive coping strategies; impulsive behaviors; and poor health, numerous medical problems. Total score: 30. Suicide risk: Low Record review of SADPERSONS Suicide Assessment Scale by Staff L dated 04/06/2019 at 7:06 AM showed the suicide risk indicators: male sex, older age, rational thinking loss, social supports lacking, no spouse, and sickness. Total score: 6. Suicide risk: Medium Patient #20. Record review of the "Patient Assessment Report" by Staff L dated 04/07/2019 at 9:17 PM showed: " ... depression, suicidal ideation, anxiety ... suicidal thoughts in the last 72 hours. Put knife to throat. Always has a plan ... 2017 overdose ... loss of energy, hopelessness, helplessness, feelings of worthlessness and guilt, mood swings, manic, impaired judgment, poor insight, paranoid thinking, insomnia ... brought in by EMS [Emergency Medical Services] ...found with a knife to his throat, had to be restrained by family ... a danger to himself and others ..." Suicide risk: Moderate Record review of the suicide risk rating tool by Staff L dated 04/07/2019 at 9:17 PM showed the suicide risk indicators: mild to moderate anxiety; mild depression; destructive coping strategies; unstable lifestyle; specific suicide plan; impulsive behavior. Total score: 38. Suicide risk: Low Record review of SADPERSONS Suicide Assessment Scale by Staff L dated 04/07/2019 at 9:17 PM showed the suicide risk factors: male sex, depression, rational thinking loss, and no spouse. Total score: 6. Suicide risk: Medium Patient #21. Record review of the "Patient Assessment Report" by Staff L dated 04/08/2019 at 4:45 AM showed: " ... depression, suicidal ideation, anxiety ... 'Times are getting harder. I just can't take it anymore' ... racing thoughts, had a gun in hand, but couldn't do it ... depression, loss of energy, low self-esteem, hopelessness, helplessness, feelings of worthlessness and guilt, impulsive, impaired judgment, anxiety, insomnia ... hearing voices ... visual hallucinations. Suicide risk: Moderate Record review of the suicide risk rating tool by Staff L dated 04/08/2019 at 4:45 AM showed the suicide risk indicators: high anxiety or panic; destructive coping strategies; specific suicide plan; impulsive behavior; and hearing command hallucinations for self-harm. Total score: 43. Suicide risk: Low Record review of SADPERSONS Suicide Assessment Scale by Staff L dated 04/08/2019 at 4:45 AM showed the suicide risk indicators: male sex, older age, depression, rational thinking loss, no spouse, and sickness. Total score; 6. Suicide risk: Medium Patient #22. Record review of the "Patient Assessment Report" by Staff V dated 04/09/2019 at 1:13 PM showed: " ... depression, suicidal ideation, anxiety ... brought in by family for taking 10 pills of Xanax two days ago in suicide attempt ... husband left for another woman ... depression, loss of energy, low self-esteem, hopelessness, helplessness, feelings of worthlessness and guilt, decreased concentration, impulsive, impaired judgement, minimizes problems, anxiety, panic attacks, insomnia ... Elopement risk - NA ... Disposition issues and or plan - NA ..." Suicide risk: "High" Record review of the suicide risk rating tool by Staff V dated 04/09/2019 at 1:13 PM showed the suicide risk indicators: no professional help in the past, or no positive experiences associated with this help; use of alcohol or drugs to excess, infrequently; high anxiety or panic; destructive coping strategies; non-verbal behavior indicating self-destructive thoughts; specific suicide plan; recent or significant loss(es) self-deprecating; and impulsive behavior. Total score: 57. Suicide risk: Low Record review of SADPERSONS Suicide Assessment Scale by Staff V dated 04/09/2019 at 1:13 PM showed the suicide risk indicators: depression, previous attempt, organized plan, and no spouse. Total score: 4. Suicide risk: low Patient #23. Record review of the "Patient Assessment Report" by Staff V dated 04/08/2019 at 6:23 PM showed: " ... opioid abuse, dependence ... chronic pain ... social withdrawal, isolative, impulsive, impaired judgement, poor insight, anxiety, insomnia ..." Suicide risk: NA Record review of the suicide risk rating tool by Staff V dated 04/08/2019 at 6:23 PM showed the suicide risk indicators: mild to moderate anxiety; no declarative statement; no non-verbal behavior indicating self-destructiveness; withdrawn or isolated; few resources; excessive use of alcohol or drugs, and impulsive behavior. Total score: 30. Suicide risk: Low Record review of SADPERSONS Suicide Assessment Scale by Staff V dated 04/08/2019 at 6:23 PM showed the suicide risk indicators: previous attempt, social support lacking, and no spouse. Total score: 3. Suicide risk: Low Patient #24. Record review of the "Patient Assessment Report" by Staff R dated 04/09/2019 at 12:15 PM showed: " ... bipolar disorder with suicidal ideation ... running from an abusive relationship ... manic and suicidal ... patient was minimizing ... has a history of alcohol intoxication as a suicide attempt ... hopelessness, helplessness, feelings of worthlessness and guilt ... impaired judgement, poor insight, anxiety, panic attacks, deterioration of ability to care for self, insomnia, decreased appetite ... " Suicide risk: "High" Record review of the suicide risk rating tool by Staff R dated 04/09/2019 at 12:15 PM showed the suicide risk indicators: mild to moderate anxiety; mild depression; no non-verbal behavior indicating self-destructiveness; use of alcohol or drugs to excess, infrequently; high anxiety or panic; few resources; unstable lifestyle; specific suicide plan; recent or significant loss(es); impulsive behavior; and in poor health, and numerous medical problems. Total score: 59. Suicide risk: Low Record review of SADPERSONS Suicide Assessment Scale by Staff R dated 04/09/2019 at 12:15 PM showed the suicide risk indicators: older age, depression, previous attempt, ethanol abuse, social supports lacking, organized plan, no spouse, and sickness. Total score: 8. Suicide risk: High Patient #25 Record review of the "Patient Assessment Report" by Staff X dated 04/10/2019 at 1:26 AM showed: " ... depression, suicidal ideation, psychosis ... racing thoughts, wants to hurt self ... prior suicidal attempts times two ... suicidal thoughts in the last 72 hours ... 'jump off a bridge' ... Attempted suicide in the past ... drank a bottle of fingernail polish on one [occasion]. Second [occasion] took bottle of Tylenol ... depression, loss of energy, hopelessness, social withdrawal, isolative, loss of interest in activities, decreased concentration, mood swings, manic, irritability, impaired judgement, minimized problems, assaultive, and hypersomnia ... Shadows and voices telling her to harm herself ... " Suicide risk: "High" Record review of the suicide risk rating tool by Staff X dated 04/10/2019 at 1:26 AM showed the suicide risk indicators: vague, fleeting thoughts of suicide with no plan or method; in good physical health, few or no medical problems; withdrawn or isolated; verbal statements of intent; unstable lifestyle; excessive use of alcohol or drugs; impulsive behavior; and hearing command hallucinations for self-harm. Total score: 52. Suicide risk: Low Record review of SADPERSONS Suicide Assessment Scale by Staff X dated 04/10/2019 at 1:26 AM showed the suicide risk indicators: depression, previous attempt, ethanol abuse, rational thinking loss, social supports lacking, and no spouse. Total score: 5. Suicide risk: Medium C. Patients with documented "high" risk for suicide were not placed on a 1:1 at the time of admission. Record review of the Policy & Procedure: "Comprehensive Interdisciplinary Patient Assessment" reviewed/revised February 1, 2019 showed: "The information obtained on initial preadmission screening includes: ... 1.1.3 Suicide/Homicide Risk via SADPERSON [sic] (score of 7 or above automatically generates a 1:1 status ...) " Record review of the Policy & Procedure: "Admission Procedure (Nursing)" reviewed/revised February 1, 2019 showed " ... 5.0 The admission interview includes: 1.1 An immediate review of the SADPERSONS assessment (a score of seven (7) or greater necessitates high risk precautions for the duration of the patient's hospitalization ..." Record review of SADPERSONS Suicide Assessment Scale for Patient #24 by Staff R dated 04/09/2019 at 12:15 PM showed the suicide risk indicators: older age, depression, previous attempt, ethanol abuse, social supports lacking, organized plan, no spouse, and sickness. Total score: 8. Suicide risk: High Record review of the Physician's Orders for Patient #24 dated 04/09/2019 at 03:34 PM showed "Suicide Precautions" ordered by Staff N (MD). A 1:1 was not ordered. In an interview with Staff C and Staff H on 04/11/2019 at 1:25 PM, they stated that patients assessed to be at high risk for suicide during the admission process need to be placed on a 1:1. D. Patient in bedroom with door closed. Record review of the Policy & Procedure: "Patient Observation Rounds," reviewed/revised December 31, 2018 showed: " ... 2.0 ... All patients will be excluded from their rooms or any private areas from 9:00 AM-3:00 PM ... 8.0 ... Bedroom doors are left open (except while patient is dressing or undressing) for additional observation and safety." Record review of the Policy & Procedure: "Levels of Patient Observation," reviewed/revised February 1, 2019 showed: " ... All patients will be strongly encouraged to stay out of their rooms from 9:00 AM - 12:00 PM where they can be better observed as well as to encourage participation in the clinical program ... All patients will be excluded from their rooms or any private areas from 9:00 AM-3:00 PM ..." Patient #26 was observed to be in her bedroom (room 100) reclining in her bed with the door closed during a tour of the psychiatric unit on 04/11/2019 at 9:30 AM. In an interview with Staff C on 04/11/2019 at 9:15 AM, she stated that patients are not to be in their bedrooms with the door closed. She also stated that there was no policy on keeping the bedroom door open when patients are in the room. E. Screws not tamper resistant. Record review of the Environmental Risk Assessment dated 03/01/2019 showed that non-tamper resistant screws had been identified as an environmental risk by leadership. During a tour of the adult psychiatric unit on 04/11/2019 at 08:30 - 12:30 PM, numerous screws were observed that were not tamper resistant. Non-tamper resistant screws were found on the metal kick plate on the bedroom doors, bedroom shelving, electrical outlet cover, and toilet paper holder. A 2½ inch screw was removed from the wall in rooms 105 and 204. In an interview with Staff A, Staff B, and Staff C on 04/11/2019 at 4:00 PM, they stated that they were aware that tamper resistant screws are to be used in patient care areas and are in the process of replacing the non-tamper resistant screws with those that are tamper resistant. F. Staff without identification badge. Record review of the Aspire Hospital Handbook [not dated], page 37, showed, "Badges ae a required part of the employee uniform. The ID [identification] badge provides a means of identification to help patients, visitors, and fellow employees identify Aspire Hospital, LLC employees ... " During a tour of the adult psychiatric unit on 04/11/2019 at 08:30 - 12:30 PM, Staff AA, a Mental Health Technician, was observed to have no identification badge visible. He pulled the badge out of his pocket. In an interview with Staff AA on 04/11/2019 at 1200, Staff AA stated the badge was broken. He also stated he knew he was supposed to be wearing his badge and would get it repaired immediately.