28-year-old male patient presented to the Emergency Department (ED) for suicidal ideation. The patient was not medically cleared; therefore, was admitted to the Medical Surgical Unit for management of acute medical conditions. The provider ordered suicide precautions. The patient was unmonitored by a safety attendant or virtual sitter. The patient was found during hourly rounds with a shower head flexible hose wrapped abournd his neck. A code blue was called; however, resuscitation efforts failed.