HospitalInspections.org

Based on review of Hospital policies, Hospital incident reports for 2011, clinical records, and staff interview, it was determined that the Hospital failed to ensure that patients' rights were protected, which would potentially affect 18 patients on suicide precautions as of 12/13/11. The cumulative affect of these systemic practices resulted in the Hospital's inability to ensure compliance with COP 482.13 Patient Rights.

Findings include:

1. For 4 of 14 (Pt #10, 12, 14, and 15) sampled patients on suicide precautions in 2011, the Hospital failed to ensure patients were properly monitored, and not allowed to harm themselves. Refer to A 144A.

2. For 1 of 1 patient (Pt. #15) who attempted suicide on a non-behavioral unit, the Hospital failed to ensure sentinel events were investigated. Refer to A 144B.

A. Based on review of Hospital policy, Hospital incident reports for 2011, clinical records, and staff interview, it was determined that for 5 of 14 (Pts. #1, 10, 12, 14, and 15) sampled patients on suicide precautions in 2011, the Hospital failed to ensure patients were properly monitored and not allowed to harm themselves.

Findings include:

1. Hospital policy entitled, "Suicide Precautions," with Hospital revision date 8/2010, reviewed on 12/13/11 at approximately 9:15 AM required, " Process: 1. On admission, all patients will be assessed for suicidal ideations and history. 2. The staff will initiate appropriate measures to protect the patient from his/her own actions...3. Suicide Precautions will be initiated and potentially dangerous items will be reviewed (i.e. sharp objects, strings, bells, broken glass etc.)...9. If an actual attempt has been made an order will be obtained for 1:1 suicide precautions. One staff is assigned to closely observe and monitor the patient every shift."

2. Hospital policy entitled, "Close Observation or 1:1 Observation in the Non-Behavioral Health Areas," with effective date 8/2010, reviewed on 12/14/11 at approximately 11:00 AM required, "..Process: 4. The following is completed for patients requiring 1:1 observations (those who have suicidal ideation, attempted suicide or intentional overdose) 4.1 Upon admission, the patient will be searched for potentially dangerous items (i.e...sharp objects)..4.2 Physical environment should be evaluated to see if additional precautions are indicated...4.5 Patients on 1:1 should never be left alone unsupervised. Bathroom door should remain open while caring for personal needs."

3. Hospital policy entitled, "Valuables and Belongings of Patient," with Hospital revision date 8/2011, reviewed on 12/14/11 at approximately 9:00 AM required, "..10. Items put in the contraband closet are those considered to be dangerous to self and others. This includes:.Sharp objects (scissors, razors, can....Valuables At Discharge: 1. Valuables must be recounted in the presence of the patient..."

4. The Hospital's Incident Reports for year 2011 were reviewed on 12/13/11 at approximately 10:00 AM. The reports identified the following: Pt. #1 as a suicide attempt, Pt #10 as a self inflicted injury, Pt #12 as a suicide attempt, Pt #13 as a suicide attempt, Pt #14 as a self inflicted injury, and Pt #15 as a suicide attempt.

5. On 12/13/11 between 9:45 AM and 10:45 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 20 year old male, admitted on 11/30/11, with a diagnosis of Paranoid Schizophrenia. Pt. #1's emergency room physician's assessment dated 11/30/11, indicated hearing voices and " ...a bit out of control, not suicidal ..." Pt. #1 was "medically cleared" and admitted to the Psychiatric Behavioral Unit on the 14th Floor on 11/30/11 at 1:20 PM.

A physician's telephone order dated 11/30/11 at 3:30 PM, included suicide precautions. Pt. #1's observation monitoring sheets included that monitoring every 15 minutes began on 11/30/11 at 2:45 PM and was consistently completed until 12/4/11 at 10:00 AM. However, Pt. #1's observation monitoring sheets dated 11/30/11 and 12/1/11 did not indicate the type of precautions that Pt. #1 had ordered, suicidal precautions.

A nursing note dated 12/4/11 at 10:30 AM, included that Pt. #1 was found, by Hospital staff, hanging on the bathroom [door] by a bed sheet, at which time a code blue (resuscitating measures) was initiated, but Pt. #1 was pronounced dead at 10:46 AM.

6. The clinical record of Pt #10 was reviewed on 12/14/11 at approximately 11:00 AM. Pt #10 was a 60 year old male admitted on 5/13/11 with a diagnosis of Major Depression. A physician's order dated 5/13/11 at 7:10 PM required that Pt #10 was to be placed on suicide, fall, and 1:1 precautions on admission. Nursing documentation dated 5/14/11 at 7:00 PM included, "Noted patient screaming loud around 6:20 (PM ) when checked patient actively bleeding on his left wrist. Pt verbalized, 'I cut myself with plastic knife and I want to kill myself..." Pt #10's monitoring checks dated 5/14/11 included that Pt #10 was on 1:1 and staff was in his room at the time of the incident.

7. The clinical record of Pt #12 was reviewed on 12/14/11 at approximately 11:00 AM. Pt #12 was a 35 year old female admitted on 10/23/11 with a diagnosis of Bipolar Disorder. A physician's order dated 10/23/11 at 10:30 PM required that Pt #12 was to be placed on close observation, suicide and 1:1 precautions on admission. Nursing documentation dated 10/23/11 at 11:55 PM included, "Pt tied pillow case around her neck. Team RN found her this way in her wash room..." Pt #12's every 15 minute round checks dated 10/23/11 included that Pt #12 was not placed on 1:1 until 12:00 AM (1.5 hours after ordered), instead of upon admission as ordered.

8. The clinical record of Pt #14 was reviewed on 12/14/11 at approximately 11:00 AM. Pt #14 was a 25 year old female admitted on 6/6/11 with a diagnosis of Major Depression. A physician's order dated 6/6/11 at 10:30 AM required that Pt #14 was to be placed on close observation and suicide precautions on admission. On 6/6/11 at 11:40 AM an order was written to transfer Pt #14 to the 12 th floor (Medical Psych) for CPAP (Continuous Positive Airway Pressure) (assistive breathing device) usage. Pt #14's Valuable Checklist dated 6/6/11 did not include that Pt #14 had a tube of toothpaste on admission. Nursing documentation dated 6/7/11 at 8:00 PM included, "...Pt cut herself on the left wrist using a plastic toothpaste tube.." The clinical record lacked documentation that a physician's order for 1:1 observation was obtained following the self inflicted injury, as required by policy.

9. The clinical record of Pt #15 was reviewed on 12/14/11 at approximately 11:15 AM. Pt #15 was 22 year old male admitted on 11/6/11 to the 8th floor medical unit with a diagnosis of Suicide Attempt, Tylenol Overdose. A physician's order dated 11/7/11 at 12:55 PM required Pt #15 to be placed on 1:1 and suicide precautions. Nursing documentation dated 11/11/11 at 2:25 PM included, "Pt was found by sitter in patient's bathroom attempting to hang himself...Pt had contusion on pt's throat area but no active bleeding."

10. The above findings were confirmed by the Director of Behavioral Health and Director of Medical-Surgical Telemetry during an interview on 12/14/11 at approximately 11:30 AM. During the interview, the Director stated that the Hospital does not have a policy regarding 1:1 Precautions however, 1:1 Precautions require "face to face within arms length at all times."


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B. Based on review of Hospital policy, incident reports, clinical records, peer review, a request for corrective action, and staff interview, it was determined, that for 1 of 1 Patient (Pt. #15) who attempted suicide on a non-behavioral unit, the Hospital failed to ensure sentinel events were investigated.

Findings include:

1. On 12/13/11 at 1:30 PM, Hospital policy, No. 100.85, titled, "Adverse/Sentinel Events" with Hospital revision date 3/2011, reviewed on 12/13/11 at approximately 1:30 PM, defined an Adverse Sentinel Event as "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof ..."

2. On 12/14/11 between 10:00 and 11:30 AM, the incident reports for 6 actual or potential suicide attempts made in the Hospital in 2011 were reviewed. Pt. #15 was on the Medical Surgical floor (8th floor) with the diagnoses of Suicide Attempt, Tylenol Overdose. A physician's order dated 11/7/11 required that Pt #14 was to be placed on suicide and 1:1 precautions. Pt. #15 had a one to one sitter, yet attempted to hang himself in the bathroom on 11/11/11 at 2:20 PM.

3. On 12/14/11 at 2:00 PM, the clinical record for Pt. #15 was reviewed. Pt. #15 was a 22 year old male, admitted on 11/6/11, for a Suicide Attempt by Overdose. a physician's order dated 11/7/11 at 1:00 AM, included, "...place on one to one, Suicide Precaution..." Nursing notes dated 11/11/11 at 2:25 PM, included, "Patient was found by sitter in Patient's toilet attempting to hang himself using the shower cord [call light cord]... Patient had a contusion on patient's throat area..."

4. On 12/14/11 at 3:00 PM, a peer review dated 11/14/11, related to Pt. #15 was reviewed. The peer review recommended a 1 to 1 sitter for suicidal patients and no more than 1 patient per sitter "sitter was monitoring 2 patients at the same time". Pt. #15 was being monitored 1 to 1 and still was able to attempt suicide.

5. A request was made to review corrective actions initiated by the Hospital related to Pt. #15's serious suicide attempt. The Hospital failed to provide a sentinel event for review, and did not identify significant corrective actions to reduce further suicide attempts in the non-behavioral health units.

6. These findings were confirmed by the Director of Medical Surgical Telemetry on 12/15/11 at 12:00 PM.

A. Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 7 of 8 (Pt #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed of patients on Suicide Precautions, the Hospital failed to ensure patients were monitored on appropriate precautions as ordered.

Findings include:

1. Hospital policy entitled, "Patient Rounds," with Hospital revision date 1/2011, reviewed on 12/13/11 at approximately 11:00 AM required, "Process: 1. The staff member assigned to rounds is responsible for: 1.1 Visibly locating every patient on the unit and indicating so on the rounds every 15 minutes. 1.4 Assuring special orders/instructions regarding precautions are being carried out i.e.: Close Observation, Suicide Precautions...3. Record the observations on the Patient's Precautions Flow Sheet."

2. Hospital policy entitled, "Suicide Precautions," with Hospital revision date 8/2010, reviewed on 12/13/11 at approximately 11:00 AM required, "Process:..2. The staff will initiate appropriate measures to protect the patient from his/her own actions based on an assessment. 3. Suicide precautions will be initiated and potentially dangerous items will be reviewed...7. A staff member is assigned to check every 15 minutes, making direct contact with the patient. Documentation is made on the 15 minute observation form..."

3. On 12/13/11 between 9:45 AM and 10:45 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 20 year old male, admitted on 11/30/11, with a diagnosis of Paranoid Schizophrenia. Pt. #1's emergency room physician's assessment dated 11/30/11, included hearing voices and "...a bit out of control, not suicidal ..." Pt. #1 was "medically cleared" and admitted to the Psychiatric Behavioral Unit on the 14th Floor on 11/30/11 at 1:20 PM.

A physician's telephone order dated 11/30/11 at 3:30 PM, included suicide precautions. Pt. #1's observation monitoring sheets included that monitoring every 15 minutes began on 11/30/11 at 2:45 PM and was consistently completed until 12/4/11 at 10:00 AM. However, Pt. #1's observation monitoring sheets, dated 11/30/11 and 12/1/11, lacked documentation that Pt. #1 was monitored on suicidal precautions as ordered.

A nursing note dated 12/4/11 at 10:30 AM, included that Pt. #1 was found by Hospital staff hanging on the bathroom [door] by a bed sheet at which time a code blue (resuscitating measures) was initiated, but Pt. #1 was pronounced dead at 10:46 AM.

4. The clinical record of Pt #2 was reviewed on 12/13/11 at approximately 9:30 AM. Pt #2 was a 55 year old male admitted on 12/9/11 with a diagnosis of Acute Psychosis. A physician's order dated 12/9/11 at 9:08 AM required that Pt #2 was to be placed on suicide and close observation precautions. The every 15 minute rounding sheets, dated 12/09 to 12/13/11, lacked documentation that Pt #2 was monitored on suicide precautions as ordered.

5. The clinical record of Pt #3 was reviewed on 12/13/11 at approximately 9:45 AM. Pt #3 was 44 year old male admitted on 12/2/11 with a diagnosis of Schizoaffective Disorder. A physician's order dated 12/2/11 at 7:30 PM required that Pt #3 was to be placed on suicide and close observation precautions. The every 15 minute rounding sheets, dated 12/2/11 to 12/13/11, lacked documentation that Pt #3 was monitored on suicide precautions as ordered.

6. The clinical record of Pt #4 was reviewed on 12/13/11 at approximately 10:00 AM. Pt #4 was a 47 year old male admitted with a diagnosis of Schizophrenia. A physician's order dated 12/11/11 required that Pt #4 was to be placed on suicide precautions. The every 15 minute observation sheet for Pt #4, dated 12/13/11, lacked documentation that Pt #4 was monitored on suicide precautions as ordered.

7. The clinical record of Pt #5 was reviewed on 12/13/11 at approximately 10:00 AM. Pt #5 was a 33 year old male admitted on 12/9/11 with a diagnosis of Schizoaffective Disorder. A physician's order dated 12/9/11 required that Pt #5 was to be placed on fall and suicide precautions. The every 15 minute observation sheet for Pt #5, dated 12/13/11, lacked documentation that Pt #5 was monitored on suicide precautions as ordered.

8. The clinical record of Pt #6 was reviewed on 12/13/11 at approximately 10:15 AM. Pt #6 was a 59 year old male admitted on 12/3/11 with a diagnosis of Bipolar Disorder. A physician's order dated 12/3/11 required that Pt #6 was to be placed on suicide precautions. The every 15 minute observation sheet for Pt #6, dated 12/13/11, lacked documentation that Pt #6 was monitored on suicide precautions as ordered.

9. The clinical record of Pt #7 was reviewed on 12/13/11 at approximately 10:15 AM. Pt #7 was a 36 year old male admitted on 12/6/11 with a diagnosis of Schizoaffective Disorder. A physician's order dated 12/6/11 required that Pt #7 was to be placed on Assault and Suicide Precautions. The every 15 minute observation sheet for Pt #7, dated 12/13/11, lacked documentation that Pt #7 was monitored on suicide precautions as ordered.

10. The above findings were verified with the Director of Behavioral Health during an interview on 12/13/11, at approximately 11:45 AM.

11. An interview was conducted with the Director of Behavioral Health on 12/15/11 at approximately 11:00 AM. During the interview, the Director stated that it is the night shift staff's responsibility to prepare 15 minute observational sheets for all patients. Furthermore, he stated that all patients are on every 15 minute checks and require face to face, unless it is a 1:1 patient.