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Based on review of Patient #7, Patient #8 and Patient #1's clinical records and interviews with the Adult Psychiatric Treatment Unit (APTU) Manager and the Performance Improvement (PI) Coordinator, the Hospital was not in compliance with the Condition of Participation of QAPI because:
A) the Hospital failed to investigate Patient #7 and Patient #8's suicide attempts and
B) the Hospital failed to implement corrective actions developed in response to the investigation of Patient #1's suicide attempt in a timely manner.

Findings include:

A)
PATIENT #7: The Progress Note, dated 2/1/12 at 11:25 P.M., indicated that Patient #7 was found in a locked bathroom. The Progress Note indicated that Patient #7 opened the bathroom door for the APTU staff and was found with a shower curtain tied tightly around his/her neck. The Progress Note indicated that the shower curtain was immediately removed and there were no injuries.

The Hospital did not investigate Patient #7's suicide attempt.

Please refer to A-0286 for further information.


PATIENT #8: The Progress Note, dated 3/14/12 and untimed, indicated that Patient #8 wrapped the cord from his/her continuous positive air pressure machine (C-PAP) around his/her neck. The Progress Note indicated that the cord was removed and there were no injuries.

The Hospital did not investigate Patient #8's suicide attempt.

Please refer to A-0286 for further information.


B) The Discharge Summary, dated 10/11/12 at 7:41 P.M., indicated that Patient #1 was found unresponsive in his/her bed. The Discharge Summary indicated that Patient #1 later told staff that he/she had taken Klonopin and Oxycodone.

Surveyor #1 and Surveyor #2 interviewed the APTU Manager at 9:40 A.M. on 12/26/12. The APTU Manager said the Hospital conducted an investigation and identified opportunities for improvement that were not implemented at the time of the survey.

Please refer to A-0286 for further information.

Based on review of Patient #7, Patient #8 and Patient #1's clinical records, review of the Adverse Event Policy and interviews with the Adult Psychiatric Treatment Unit (APTU, a secure unit) Manager and the Performance Improvement (PI) Coordinator, the Hospital failed to: A) investigate the suicide attempts of Patient #7 and Patient #8 and B) implement corrective actions developed in response to the investigation of Patient #1's suicide attempt in a timely manner.

Findings include:

A) The Policy/Procedure titled Adverse Event, effective 8/24/09, indicated that adverse events are to be analyzed and appropriate and consistent action must be taken in response to each adverse event.

Surveyor #1 reviewed the APTU's Incident Report Log for 2012 and selected 2 suicide attempts that occurred on the APTU (Patient #7 and Patient #8).

PATIENT #7:

The Emergency Service (ES) Comprehensive Assessment, dated 1/22/12, indicated that Patient #7 presented to the Hospital's Emergency Department (ED) with suicidal ideation, feelings of hopelessness, helplessness, lack of motivation and inability for self-care. The ES Assessment indicated that Patient #7's medical history history included suicidal attempts, self-injurious behaviors and previous psychiatric admissions. The ES Assessment indicated that Patient #7 had not received any treatment or care for his/her psychiatric disorders for the previous year. The ES Assessment indicated that Patient #7's level of risk for self harm was moderate. The ES Assessment indicated that Patient #7 was medically cleared and Patient #7 agreed to respite placement for mood stabilization, medication management and linkage to outpatient services for ongoing care.

The Emergency Medicine Note, dated 1/24/12, indicated that Patient #7 returned to the ED with suicidal ideation. The Emergency Medicine Note indicated that the risk of harm to self was severe. The Emergency Medicine Note indicated that Patient #7 was medically cleared and admitted to the APTU.

Surveyor #1 and Surveyor #2 interviewed the APTU Manager at 9:40 A.M. on 12/26/12. Surveyor #1 and Surveyor #2 reviewed the Policy/Procedure titled Management of the Suicidal Patient, effective 2/9/11. The Manager said and the Policy indicated that any staff member could make a determination regarding the frequency of safety checks verses constant observation. The Manager said that the decision for frequency of safety checks was based on the patient's presentation at the time of the staff member's interaction with the patient.

The Policy/Procedure titled Safety Rounds, effective 2/8/11, indicated that the staff assigned to perform the rounds were required to: 1) observe for signs of life (breathing, skin color and absence of distress), 2) identify the patient's location, 3) record what the patient was doing at the time of the observation and note the patient's affect, behavior and attitude.

The Progress Note, dated 1/25/12 at 11:50 P.M., indicated that during the evening, Patient #7 locked him/herself in a bathroom and superficially scratched him/herself with his/her nails. The Progress Note indicated that Patient #7 was placed on 5 minute safety checks.

The Physician Progress Note, dated 1/28/12 at 3:12 P.M., indicated that Patient #7 said that on the previous day, he/she had thoughts of harming him/herself and planned to break a window to cut him/herself, but did not follow through with the plan given the lack of means. Patient #7 remained on 5 minute safety checks.

The Progress Note, dated 1/29/12 at 10:15 P.M., indicated that Patient #7's affect was either depressed or anxious. The Progress Note indicated that during rounding, Patient #7 was found seated in the bathroom rocking his/herself. Patient #7 remained on 5 minute safety checks.

The Physician Progress Note, dated 1/30/12 at 11:59 A.M., indicated that Patient #7 said he/she felt angry, sad, useless and disgusting. The Physician Progress Note indicated that Patient #7 felt suicidal with a plan to strangle him/herself. Patient #7 remained on 5 minute safety checks.

The Progress Note, dated 1/31/12 at 11:10 P.M., indicated that Patient #7 said he/she heard voices, was isolative and at one point hid in the bathroom. Patient #7 remained on 5 minute safety checks.

The Physician Progress Note, dated 2/1/12 at 12:50 P.M., indicated that Patient #7 was observed in the bathroom. The Physician Progress Note indicated that Patient #7 said he/she was constantly hearing voices telling him/her to kill him/herself and had thought of hurting him/herself with a fork. Patient #7 remained on 5 minute safety checks.

The Evening Shift Checks and Rounds Sheet, dated 2/1/12 from 11:00 P.M. to 11:30 P.M., indicated that for a 30 minute period, Patient #7 was located in the bathroom during each 5 minute safety check.

The Progress Note, dated 2/1/12 at 11:25 P.M., indicated that Patient #7 was found in a locked bathroom. The Progress Note indicated that Patient #7 opened the bathroom door for the APTU staff and was found with a shower curtain tied tightly around his/her neck. The Progress Note indicated that after the suicide attempt, Patient #7 was placed on 1:1 observation.

The Physician Progress Note, dated 2/2/12 at 3:38 P.M., indicated that Patient #7 stated that he/she stayed in the bathroom for awhile trying to figure out how to kill him/herself. The Physician Progress Note indicated that Patient #7 stated he/she was interrupted a few times by staff checking on him/her. However, Patient #7 managed to figure out when he/she was not going to be seen.

Surveyor #1 and Surveyor #2 interviewed the APTU Manager at 9::40 A.M. on 12/26/12. The APTU Manager said that he was not the manager at the time of Patient #7's suicide attempt. The APTU Manager said he could not provide the investigation or corrective actions related to Patient #7's suicide attempt.

Surveyor #1 interviewed the PI Coordinator at 2:15 P.M. on 12/26/12. The PI Coordinator said she was supposed to receive a quarterly report that included aggregate data of the APTU's patient incidents. The PI Coordinator said the quarterly report allowed the her to review incidents and/or identify trends. The PI Coordinator said that from January, 2012 to October, 2012, she did not receive the APTU's quarterly reports because the reporting system was not functioning properly. The PI Coordinator said that as a result, she was not aware of Patient #7's suicide attempt.

The Hospital did not investigate Patient #7's suicide attempt to determine if there were opportunities to improve patient safety on the APTU.


PATIENT #8:

The Emergency Medicine Note, dated 2/27/12, indicated that Patient #8 presented to the Emergency Department with suicidal/homicidal ideation and worsening chronic depression. The Emergency Medicine Note indicated that Patient #8's medical history included obstructive sleep apnea treated with C-PAP and electroconvulsive therapy (ECT, a method of administering shock treatments under controlled conditions to treat severe depression) for chronic depression. The Emergency Medicine Note indicated that Patient #8 was medically cleared and admitted to the APTU.

Physician Orders, dated 2/28/12, included use of the C-PAP machine and 5 minute safety checks.

The Progress Note, dated 3/14/12 and untimed, indicated that Patient #8 was anxious/agitated about an impending scheduled ECT treatment. The Progress Note indicated that at 11:10 A.M., Nurse #3 medicated Patient #8 with Ativan and left the room. Nurse #3 was gone only 1-2 minutes and informed the treatment team of Patient #8's agitation. The Progress Notes indicated that the team immediately went to Patient #8's room and found Patient #8 with the cord from the C-PAP machine wrapped around his/her neck. The Progress Note indicated that the cord was immediately removed and there was no evidence of injury or airway compromise. The Progress Note indicated that Patient #8 was immediately placed on 1:1 observation.

Surveyor #1 and Surveyor #2 interviewed the APTU Manager at 9::40 A.M. on 12/26/12. The APTU Manager said that he was not the manager at the time of Patient #8's suicide attempt. The APTU Manager said he could not provide the investigation or corrective actions related to Patient #8's suicide attempt.

Surveyor #1 interviewed the PI Coordinator at 2:15 P.M. on 12/26/12. The PI Coordinator said she was supposed to receive a quarterly report that included aggregate data of the APTU's patient incidents. The PI Coordinator said the quarterly report allowed the her to review incidents and/or identify trends. The PI Coordinator said that from January, 2012 to October, 2012, she did not receive the APTU's quarterly reports because the reporting system was not functioning properly. The PI Coordinator said that as a result, she was not aware of Patient #8's suicide attempt.

The Hospital did not investigate Patient #8's suicide attempt to determine if there were opportunities to improve patient safety on the APTU.


B) The Emergency Medicine Note, dated 10/9/12 at 8:55 P.M., indicated that Patient #1 was brought to the Hospital's ED following a suicide attempt. The Emergency Medicine Note indicated that Patient #1's medical history included depression, post-traumatic stress disorder, history of self harm and bipolar disorder. The Emergency Medicine Note indicated that labs were done to rule out substance ingestion. Patient #1 was evaluated by the Crisis Team.

The Clothing/Valuables List from the ED, dated 10/9/12, indicated that Patient #1's valuables included a stuffed elephant.

The Progress Note, dated 10/10/12 at 7:50 P.M., indicated that Patient #1 was admitted to the APTU.

The Valuables and Belongings List from the APTU, dated 10/10/12 at 8:02 P.M., included a stuffed animal.

Surveyor #2 interviewed MHC #1 at 2:45 P.M. on 12/26/12. MHC #1 said that during the search of Patient #1's belongings, she inspected the stuffed elephant's legs, body and trunk for sharps. MHC #1 said that no sharps were found, but a small battery pocket in the animal contained a rosary and tube of chapstick which were removed from Patient #1's possession. MHC #1 said that Patient #1 was allowed to keep the stuffed animal.

The Physician Discharge Summary, dated 10/11/12 at 7:41 P.M., indicated that, at approximately 6 P.M., the fire alarm sounded on the APTU. The Discharge Summary indicated that when the alarm sounded, Patient #1 failed to come out of his/her room. The Discharge Summary indicated that Patient #1 was found unresponsive in his/her bed. The Discharge Summary indicated that a Code Blue was called, Patient #1 was stabilized and transferred to the Neurological Intensive Care Unit. The Discharge Summary indicated that Patient #1 later told staff that he/she had taken Klonopin and Oxycodone. The Discharge Summary indicated that Patient #1's family said that Patient #1 had a history of hiding substances in his/her body cavity.

The Hospital conducted an investigation and developed corrective actions that included: 1) reinforcement of the importance of safety checks with staff, 2) review of the safety checks sheet to determine if separate sheets would be used for 5 and 15 minute safety checks to improve readability and accuracy, 3) review of the procedure for inspection of personal belongings at intake to emphasize the importance of a thorough inspection and 4)changing the Search and Safety Check procedure to reflect that stuffed animals were no longer allowed on the APTU.

Surveyor #1 and Surveyor #2 interviewed the APTU Manager at 9:40 A.M. on 12/26/12. The APTU Manager said he had spoken with the APTU staff individually about no longer allowing stuff animals on the APTU, but he did not document that the discussions occurred. The APTU Manager said that the other corrective actions had not been implemented at the time of the survey.

The Hospital failed to implement corrective actions developed in response to Patient #1's suicide attempt that would improve patient safety and minimize the recurrence of suicide attempts on the APTU.

Based on review of Patient #7's clinical record, review of the Management of the Suicidal Patient and Safety Rounds Policies and interviews with the Adult Psychiatric Treatment Unit (APTU) Manager, the Hospital failed to institute additional safety measures to address Patient #7's continued presentation of suicidality and depression.

Findings include:

Please refer to A-0286 for Patient #7's information.

Although 5 minute safety checks were performed, the APTU staff failed to institute additional safety measures to address Patient #7's continued presentation of suicidality and depression from 1/25/12 until his/her suicide attempt on 2/1/12.