HospitalInspections.org

Based on record review, observation, and interview, the hospital failed to meet the Condition of Participation for Patients Rights.

Based on record review and interview, the hospital failed to provide a safe environment for 1 (P #1) of 20 (P #1 through #20) patients sampled by not placing P #1 on a higher level of monitoring and observation after P #1 consistently verbalized suicidal ideation (SI) with a plan to hang himself. This deficient practice caused actual harm to P#1 who subsequently attempted suicide and was transported to a medical facility #2 where P #1 died 4 days later (see Tag A144).

Based on record review and interview, the agency failed to obtain the required legal paperwork and inform the patient of his status (voluntary or involuntary) to involuntarily hold the patient who verbalized suicidal ideation with a plan to hang himself for 1 (P #1) of 10 (P #1-10) patient records reviewed. P #1 expressed the desire to leave the facility, but was held without the required legal documentation. P #1 was not provided with the information necessary to make an informed decision to refuse treatment. This failed practice resulted in significant harm leading to death.

Based on record review and interview, the agency failed to obtain the required legal paperwork and inform the patient of his status (voluntary or involuntary) to involuntarily hold the patient who verbalized suicidal ideation with a plan to hang himself for 1 (P #1) of 10 (P #1-10) patient records reviewed. P #1 expressed the desire to leave the facility, but was held without the required legal documentation. P #1 was not provided with the information necessary to make an informed decision to refuse treatment. This failed practice resulted in significant harm leading to death.

The findings are:


A. Record review reveals P#1 was a 37 year old male who was transported to the facility on 7/24/18 by law enforcement due to verbalizing suicidal ideation with a plan to hang himself. Prior to hospitalization, P#1 called the facility and spoke with an RN who noted that the patient stated during the call that he wanted to hang himself in his motel room. Patient hung up or was disconnected and law enforcement was notified by the RN. At the facility, P #1 was evaluated by the assessment and referral social worker and orders were written for an involuntary hold. After admission to the facility, patient was not able to leave voluntarily because the facility is a secured behavioral health hospital.

B. Record review of patient P #1's medical chart reveals P #1 did not sign any consents for admission and treatment. Review also indicates initial physician orders dated 7/24/18 at 7:38 pm state patient was on an "involuntary hold".

C. Record review of form "Consent for treatment" revised 1/26/18 reveals S #10 writing "Pt refused -on invol hold 7/25/18 19:38" (7:38 pm admission time). Dates were inconsistent on the admission document, but patient was admitted on 7/24/18.

D. On 8/31/18, at 8:31 am, during interview S#7 stated, "patient was voluntary, not on involuntary hold because he was seeking medication. Usually patients asking for treatment or meds (medication) are voluntary. I have to verify if he was put on involuntary because he wanted to leave (on 7/26/18 nurses notes state "patient wanted to leave").

E. On 8/31/2018, at 10:35 am, during interview S #8 stated, "I was on call when he was admitted, they (S#7) gave me the information that he threatened to leave and made threats against himself and I gave him an involuntary admission."

F. On 09/04/18, at 4:45 pm, during interview S#13 stated, "the involuntary hold starts at the time paperwork is faxed from [Name of Hospital] to the courts". S#13 confirmed, "we dropped the ball on this one. This is the first time that we missed legal paperwork." Staff #13 further confirmed that the facility failed to complete and fax the paperwork.

G. On 8/31/18 and 9/4/18 during interviews, multiple staff members stated that they did not know whether the patient was admitted as voluntary or involuntary hold.

Based on record review and interview, the hospital failed to provide a safe environment for 1 (P #1) of 20 (P #1 through #20) patients sampled by not placing P #1 on a higher level of monitoring and observation after P #1 consistently verbalized suicidal ideation (SI) with a plan to hang himself. This deficient practice caused actual harm to P#1 who subsequently attempted suicide and was transported to a medical facility #2 where P #1 died 4 days later. The findings are:


A. Record review of facility's Root Cause and Analysis regarding P#1 revealed the following: On 07/26/18 at approximately 1215, P#1's roommate saw P#1 on the floor and yelled for help, nursing staff who responded found P#1 unresponsive and laying behind his bedroom door with a pant leg loosely wrapped around his neck. A Code Blue was initiated and 911 was called. Cardiopulmonary resuscitation (CPR) was initiated by facility staff. Emergency Medical Services (EMS) arrived at 1222 (12:22 pm) and care was transferred. P#1 was transported to a local medical facility at 1250 (12:50 pm) with palpable pulse and assisted ventilation. On 07/30/18 at 1730 (5:30 pm), facility was notified that P#1 passed (died) at 1416 (4:00 pm) on 07/30/18.


B. Record review of P #1's "Integrated Assessment" dated 07/24/18 at 1745 (5:45 pm), completed in sections and at different times throughout the day by S#10, revealed the following:

1) On 07/24/18 at 12:15 pm, the date of admission, "[Name of P #1] contacted facility via phone stating [P #1] was suicidal with a plan to hang self." Facility called [name of] Police Department (PD) to conduct a welfare check on P #1. PD then brought P #1 to the facility for assessment on a voluntary basis.

2) During initial assessment phase, P #1 reports having "on-going suicidal ideation" with a current plan to hang self and an attempted suicide by overdose in November of 2017.

3) "Patient presents as extremely depressed and anxious" and states as a reason for being at the facility: "Always suicidal" and "ran out of meds (medications)."

4) "Patient stated always feeling suicidal every moment of the day." P#1 then went on to say, "Someone will lose their life b/c (because) you won't prescribe Subutex (substance that is commonly used to help people who are struggling with opioid dependence and addiction). [P#1] states the first thing [P #1] looks for in a hotel room is a place to hang self ...Patient appears to be in serious danger to self ; [P #1] is placed on an involuntary hold"

5) P #1 refused to answer several questions on the assessment.

6) P #1 was noted as being on an "involuntary hold" dated 07/24/18 at 1820 (6:20 pm).


C. Record review of "Suicide Precautions, Policy Number: 1000.91 revised: 1/14, reviewed on 2/17" revealed the following:

1) "Patients assessed to be at heightened risk of suicide as determined in the conclusion of either the Intake Assessment, Nursing Assessment, Psychiatric Evaluation or based on patient statements and /or behavior, will be placed on suicide precaution commensurate with the assessed level of risk."

2) Staff responsible for monitoring patients on suicide precautions shall maintain the patient in a safe environment and take measures to protect the patient from self harm.

3) low risk patients are placed on 15-minute checks: Moderate Risk to High Risk patient are placed on either Q5 minute watch (observation of patient every 5 minutes) or 1:1 (specific staff member is dedicated to 1:1 only and is assigned to remain within arms reach of the patient at all times).


D. On 08/24/18, at 4:00 pm, during an interview, S #5 acknowledged working on the unit during P #1's suicide attempt on 07/26/18. S #5 stated, "I believe [P #1] was on a suicide precaution - I wasn't sure."


E. On 08/30/18, at 3:15 pm, during interview, S #4 stated, she was the lead Mental Health Technician (MHT) on the overflow unit (where P #1 was placed). S #4 stated, her duties included "overseeing Q15 (visually assessing patient) checks, making sure floor is running safely, conducting searches, and multiple other tasks". When asked if P #1 was on suicide precaution, S #4 stated, "Yes I believe so. We are always monitoring the patients. Every single one of the patients was on Q15. It is tricky when there is high acuity." S #4 acknowledged that a doctor could order a one to one (one staff at arms length away from patient) precaution for patients if necessary.


F. On 08/30/18, at 4:23 pm, during interview, S #6 stated, "[Name of P #1] was angry about being here; [P #1] was a walk in; on voluntary basis. [P #1] was on suicide precaution: 15 minutes checks, so is everyone else. S #6 confirmed that [name of P #1] had a plan to hang himself".


G. On 08/31/18, at 8:31 am, during an interview, S #7 confirmed P #1 was a voluntary not involuntary patient. S #7 stated, "I have to verify if [name of P #1] was put on involuntary status". S #7 confirmed P #1 had stated several times being suicidal with a plan to hang self. S #7 confirmed he did not place P #1 on a higher level of suicide precaution.


H. On 08/31/18, at 9:42 am, during an interview, S #3 confirmed P#1 was on Q15. S #3 stated, "Everyone has 15 min checks." S #3 further stated, "[Name of P#1] was admitted on an involuntary hold."


I. On 09/04/18, at 10:10 am, during interview, S #3 stated nurses can initiate a one to one (one staff to one patient at arms length) and that P #1 was not on such precaution.


J. On 09/04/18, at 11:07 am, during interview, S #9 confirmed taking the call from P #1 before P #1 was admitted to the facility. S #9 stated, "I remember the most important things, [name of P #1] was telling me that [P #1] was suicidal and in a hotel crying and every time [P #1] walked into the hotel, [P #1] looked around to see where he could hang self. He sounded in distress and hung up on me. I called to have a welfare check".


K. On 09/04/18, at 11:25 am, during interview, S #10 stated P #1 said he is "always suicidal". P #1 told S #10,"Too bad someone is going to lose their life because of this." S #10 stated, patient seemed the most acutely suicidal patient I have see in the year I have worked here".


L. On 09/04/18, at 11:50 am, during interview, S #11 confirmed being P #1's therapist. S #11 stated, "[Name of P #1] came in and was very suicidal, very depressed, indicated that things were worse when S #11 met with [P #1] on 07/26/18 after treatment planning." S#11 stated, "I did not document information about [P #1's] worsening SI and did not tell a nurse [P#1] was worse".


M. Record review of P #1 medical chart from [medical facility #2] revealed the following:

1) P #1 arrived at [name of medical facility #2] on 07/26/18 at 12:55 pm, Emergency Medical Services (EMS) performing Cardiopulmonary resuscitation (CPR). P #1 was intubated (the process of inserting a tube, called an endotracheal tube [ET], through the mouth and then into the airway) and given 1 round of epi (Epinephrine, also known as adrenalin or adrenaline used to stimulate the heart) and 2 mg (milligrams) of Narcan (blocks the effect of opioids and reverses an overdose) en route.

2) P #1 was admitted to Intensive Care Unit (ICU) and at 14:55 (2:55 pm), was given the preliminary diagnosis (dx) of "Cardiac arrest, cause unspecified - due to respiratory asphyxiation from hanging".

3) History and Physical states, "Chief Compliant: Suicide Attempt".

4) P #1 was placed on a ventilator (machine designed to move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe).

5) P#1 became apneic (not breathing) after discontinuing ventilator and was declared brain dead 07/30/18 at 4:16 pm.

6) A note by attending physician dated 07/30/18 stated, "Suicidal attempt by possibly hanging himself or possibly drug overdose." It further stated, "discussed with [P #1] psychiatrist, who is not really clear what caused this...UDS (Urine analysis) was positive for benzodiazapines (a class of drugs primarily used for treating anxiety) and opiates...unclear whether these were administrated during resuscitation versus patient abusing medication."



Plan of Removal included the following:

Completion of a Root Cause Analysis regarding P#1's incident on 07/26/18 outlining indicators contributing to the incident and improvements to be made.

Annual training and orientation on revised policies and procedures provided to included: Suicide screening, Suicide Assessment/Reassessment, Risk Factors and High Risk Behaviors for Suicide, Monitoring a Patient at High Risk for Suicide, Suicide Precautions and Prevention, Safety and Environment Rounds, Discharge and Suicide Presentation/Safety Planning, and Post Discharge Follow-up.

Staff Sign-In sheet with a training agenda.

Record review of personnel files revealed confirmation of retraining. Interview with administrative personnel and facility staff confirmed training and policy changes as well as changes made to the policy specifically dealing with patient's "level of care."

Record review of sample patients admitted on 08/29/18 revealed implementation of Columbia-Suicide Severity Rating Scale (C-SSRS), which establishes a rating scale to assess the safety of a patient and the suicide risk associated for their care.

Record review of Suicide Level "buddy badge" lanyard system ensures monitoring for each patient's level of suicide risk (Low, Moderate, High). Leadership was given the authority to monitor staff to ensure they are wearing their badge at all times.

Observation of patients on 08/30/18 from 2:00 pm to 4:30 pm provided evidence of (14 of 14) patients (who were being monitored by facility staff) were out of their assigned rooms and assigned room doors were locked (preventing self-isolation). Patients were involved in therapy or being observed in time- out room.

Observation of patients on 09/04/18 from 2:30 pm to 4:30 pm provided evidence of (7 of 7) adult patients (being monitored by facility staff) who were out of their assigned rooms and their assigned room doors were locked (preventing self-isolation).

Record review of Ad Hoc Forms/ Policies Committee Agenda and Board of Governors agenda (both dated 08/16/18) revealed Suicide Prevention Plan indicators were discussed, and the new Suicide Prevention Plan policy was revised and accepted on 08/2018.

Record review of current patients revealed 3 (P #11, 14 and 20) out of 10 (P #11- P #20) current patients were high risk for Suicide on the C-SSRS and were placed on 15 minute checks and MD (Medical Doctor) to order special precautions for SI as needed.

Based on record review and interview, the nursing staff failed to 1) keep the interdisciplinary care plan current, 2) develop appropriate interventions, and 3) perform ongoing assessments of the patient's needs for 1 (P #1) of 10 patient records reviewed for patients diagnosed with Suicidal Ideation. The nursing plan of care should have been updated based on the admission status (voluntary vs. involuntary), patient's self-isolation, therapist observations, and patient's refusal to attend therapy sessions. This failed practice has the potential to result in substandard care not based on the patient's needs and in this instance resulted in death.


The findings are:


A. Record review of P #1's "Integrated Assessment" dated 07/24/18 at 1745 (5:45 pm), completed in sections and at different times throughout the day by S #10, revealed the following:

1) On 07/24/18 at 12:15 pm, the date of admission, "[Name of P #1] contacted facility via phone stating [P #1] was suicidal with a plan to hang self." Facility called [name of] Police Department (PD) to conduct a welfare check on P #1. PD then brought P #1 to the facility for assessment on a voluntary basis.

2) During initial assessment phase, P #1 reports having "on-going suicidal ideation" with a current plan to hang self and an attempted suicide by overdose in November of 2017.

3) "Patient presents as extremely depressed" and anxious and states as a reason for being at the facility: "Always suicidal" and "ran out of meds (medications)."

4) "Patient stated always feeling suicidal every moment of the day ...someone will lose their life b/c (because) you won't prescribe Subutex (substance that is commonly used to help people who are struggling with opioid dependence and addiction) ...[name of patient] states the first thing [P #1] looks for in a hotel room is a place to hang self ...Patient appears to be in serious danger to self ...he [P #1] is placed on an involuntary hold"

5) P #1 refused to answer several questions on the assessment.

6) P #1 was noted as being on an "involuntary hold" dated 07/24/18 at 1820 (6:20 pm).

B. Based on record review of physician "Admitting Orders" dated 07/24/18 at 2100 (9:00 pm), the patient was placed on Close Observation; 15 minute checks (q15).


C. Based on record review of "Visual Cue Notification" form dated 07/24/18 at 1938 (7:38 pm), the patient was "SI (suicidal with a plan to hang self)."


D. Record review of hospital policy number 1000.25 dated 5/17 states:

1) "Patients requiring more frequent observations will be provided with such, based on acuity and assessed risk. All staff will report noticeable or abrupt changes in behavior or mental status including: Self-isolation".

2) "1:1 may be ordered for patient on high risk suicide precautions or other ordered precautions. A dedicated staff member is assigned to remain within arms reach of the patient at all times".


E. Record Review of "Suicide Precautions" revised 1/14 reveals "Implementation and Communication of Special Precautions" reveals a registered Nurse may immediately increase the level of observation based upon assessment/re-assessment without a physician order, but may not lower a level of observation without a physician order."


F. Record review reveals P #1 consistently isolates himself:


1. Nursing notes dated 07/25/18 at 0600 (6:00 am) reveals "Patient isolates in his room, only out for meds (medications) and meals".


2. "Adjunctive Progress Note" 07/25/18 at 1030 (10:30 am therapy such as Yoga, Music Therapy or Artistry) reveals: "Patient did not attend".


3. Adjunctive Progress Note dated 07/25/18 at 1430 (2:30 pm) reveals: "Patient did not attend".


4. Nursing notes dated 07/26/18 at 0600 (6:00 am) states: "Nobody cares, the doctor doesn't care, nobody cares" and "walked away to room". RN (Registered Nurse) also notes "patient in his room, awake lying in bed reading before noon".


5. "Patient Observation Rounds" documentation for 07/25/18 reveals the patient was in his room except for 1 hr. (hour) during the 24 hr. period (he ate lunch and dinner in the cafeteria).


6. "Patient Observation Rounds" documentation for 07/26/18 reveals the patient was in his room on 07/26/18 from 0015 (12:15 am) till the code Blue was called (approximately 12:11 pm).


G. On 08/30/18 at 4:40 pm, during interview Staff # 6 stated that on 07/26/18 at 0730 (7:30 am) "patient did not go to breakfast, he stayed back".


H. On 08/30/18 from 2:00 pm through 4:30 pm and on 09/04/18 from 2:30 pm through 4:30 pm during periord of observation on 2 units, patients were out of their assigned rooms and their assigned room doors were locked (preventing self-isolation). Patients were involved in therapy or being observed in time-out room.





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I. Record review of (interdisciplinary care plan), section Specific intervention treatments/Therapies-Therapist section" 7/24/18 reveals:

1. Group therapy will be "1 times a day & 7 times per week to educate and process insight of problem behavior/s".

2. If patient is refusing to participate in Group the following will be provided: 1:1 (Individual Therapy).


J. Record review of the Therapy Program notes dated 07/25/18 and 07/26/18 at 9:30 am reveals: Patient did not attend and did not particpate in Group Therapy.


K. Record review of "Initial Treatment Plan" dated 7/26/18 reveals: "Treatment Team Response- Circle & date current level of functioning on scale below/rate progress towards goal/objectives (Goal completion, willingness, participation, investment in treatment)" reveals P #1 was rated "2 out of 10 with 1 being non-compliance and 10 being full compliance".


L. Record review of "Social Services/Therapy Progress Notes" 07/25/18 and 07/26/18 reveals: "Pt (patient) reported I don't know, all I know is I'm leaving this place worse then when I came in".


M. On 9/4/18 at 11:48 am during interview, S #11 stated "He came in very suicidal, well that's how he presented when he came in. I met with him for the treatment meeting. He was upset because he was ready but the doctor was not ready to let him leave. He was indicating that things are worse off then when he came in". When asked why he said he was worse, what did you do to revise the treatment plan? She did not have an answer. When asked about individual therapy, S #11 stated "we do not do individual therapy. Furthermore stating "I did not tell a nurse that he was worse."