HospitalInspections.org
Bringing transparency to federal inspections
MEMORIAL MEDICAL CENTER
PATIENT RIGHTS
Tag No.: A0115
Based on record review, interviews, and observation, the hospital failed to protect patients from neglect, and by failing to closely monitor a patient with documented suicidal ideation, did not provide care in a safe setting (refer to A144).
The cumulative effect of the systemic deficient practices resulted in the hospital's inability to ensure the safety of patients.
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on record review, observation, and interviews, the hospital failed to provide care in a safe setting by failing to perform regular 15-minute checks by unit personnel to confirm patients' safety and welfare. This deficient practice caused actual harm to the patient by allowing the patient time to successfully commit suicide.
The findings are:
A. Record review of the facility medical record for Patient #1 revealed that Patient #1 was admitted to the facility on 04/21/16 with a diagnosis of major depression and suicidal ideation. The patient was placed on visual checks by staff every 15 minutes by standing order. Patient #1 refused to eat, drink and/or take medication. Patient #1 was found on 04/24/16 in the bathroom, with bathroom door closed, a bed sheet wrapped around the top corner of the door and stuck into the side between the door and door jamb, with the other end tied around his neck.
B. Review of the facility's Policy for Suicide Precautions dated March 2015 revealed the following protocol: "Suicide precaution status: A. Patients admitted following a suicide attempt will be considered at high risk. For these patients, suicide precaution status will be initiated upon arrival to [the facility]."
C. Video review revealed Staff #8 did not conduct checks every 15 minutes on patients as required per the facility's standing order.
D. On 05/03/16 at 9:15 am during interview, Staff #8 stated she had been with the facility for about 6 years and had worked off and on in the behavioral health unit. Staff #8 also stated she did not make any 15-minute checks within the hour prior to the incident. Staff #8 further stated that she documented checks every 15 minutes after the incident knowing she hadn't checked on the patient. Staff #8 stated she did some of the checks on the shift but not all.