HospitalInspections.org

Based on review of 1 of 1 clinical record, progress notes of a patient who committed suicide within 36 hours of discharge, did not identify significant progress the patient made from 2/5/10 when he said if he went home he would try suicide to 2/6/10 the day the patient was discharged and considered not a suicide risk.

FINDINGS:

1. Patient #1 attempted suicide by drinking a large amount of vodka and tying a trash bag tightly around his head/neck. He was found by his wife and taken by ambulance to a local hospital. From this local hospital, he was admitted under an emergency detention warrant (EDW) to this facility on January 26, 2010.

Patient expressed some form of suicide ideation , intent or plan every day of his hospital stay except date of discharge. He was discharged on February 6, 2010 and committed suicide on February 8, 2010.

Documentation regarding patient's mental status and suicide ideation during his eleven day stay included the following:

Tuesday 1/26/10:
"fears losing everything.....Doesn't see any way out except suicide and will attempt again if given the chance, has access to pills and also a gun".

Wednesday 1/27/10:
Nursing noted: "incredibly suicidal". MD note: "I'm determined to kill myself".

Thursday 1/28/2010:
"Suicidal ideation with thought and a plan". "Guarded about plan";

MD noted: "Still has suicide ideation" told MD: "I intend to do it".

Nursing noted: "Pt. states he's good at hiding his feelings and emotions".

Friday 1/29/10:
"continues to be suicidal". "Remains focused on harming himself". "Still depressed and suicidal".

Saturday 1/30/10:
M.D. noted: "Continues with suicide ideation". "I intend to do it". Nursing noted: "Suicide plan and intent". Individual therapy noted: "patient with suicide ideation and definite plan".

Sunday 1/31/10:
MD noted: "Mood worse today....He continues to have significant suicide ideation". Nursing also noted at 4:10 p.m. "still having suicide ideation".

Monday 2/1/10:
M.D. noted: "Suicide ideation continues to be severe and he states he intends to kill himself". nursing narrative noted "suicide thoughts".

Tuesday 2/2/10:
MD note: "Suicide ideation slightly decreased in intensity. Feels slightly more hopeful".

Nursing on 7-3 and 3-11 (at 3:30 p.m.) noted he had suicide ideation with "plan and intent". Later, 3-11 nursing at 9:00 p.m. noted: "patient denies SI at this time".

Individual Therapy/Case Management noted: "denies suicide ideation at this time. has brighter affect".

Wednesday 2/3/10:
MD noted: "He is a bit more depressed. The suicide ideas are present but diminished in intensity".

Nursing documented he continued with "suicide ideation".

Case management noted: "continues to deny suicide ideation BUT clarified that if he is charged......he will suicide and nothing anyone can do to stop him".

Thursday 2/4/10:
MD noted that patient reported suicide ideation present but decreased. Nursing on 7-3 and 3-11 shifts noted he had thought, plan, and intent to suicide.

During family therapy with wife present, patient "denied suicide ideation".

Friday 2/5/10:
MD noted: "Feeling more depressed today. Has increased suicide ideation. He feels that if he went home he would try suicide".

No remarks regarding suicide ideation documented by nursing, only that he was "very pleasant and in a good mood".

Saturday 2/6/10:
Nursing noted: "denies feeling depressed or with suicide ideation".
MD noted: "no suicidal thoughts". Patient discharged this day with appointment to continue with intensive outpatient therapy beginning 2/8/2010.

According to complaint letter, patient committed suicide on 2/8/2010.