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Based on document review, record review, interview and observation, the hospital failed to protect and promote the rights of patients during their hospital stay. The findings are:

A. Based on document and record review, interview and observation the hospital failed to ensure that the triage area of the University Psychiatric Center - Psychiatric Emergency Services (PES) provided a safe environment for patients with suicidal ideation and intent. Two triage rooms did not have security air grilles and the PES failed to have policies and procedures in place on 11/22/11 to ensure that a suicidal patient was prevented from harming himself or others. The patient was able to use his shoelaces tied to an air grille to hang himself. This failure by the hospital to protect suicidal patients demonstrates the likelihood that another patient with suicidal ideation would not be protected from him/herself. (Refer to A 0144)

B. Based on document review, record review and interview, the hospital failed to ensure that psychiatric safety consultant recommendations made in October 2010 to improve the safety of secure triage rooms in the Psychiatric Emergency Services (PES) of the hospital's psychiatric facility had been carried out in a timely manner. On 11/22/11 at 0230 Patient #1 was able to use an air grille, which did not have the recommended security grille upgrade, to hang himself. This failure to ensure that hospital facilities were secure for patients with suicidal ideation demonstrates the likelihood that another patient with suicidal ideation might not be protected from him/herself or others.(Refer to A 0701)

Based on document and record review, interview and observation, the hospital failed to ensure that the triage area of the University Psychiatric Center - Psychiatric Emergency Services (PES) provided a safe environment for patients with suicidal ideation and intent. Two triage rooms did not have security air grilles and the PES failed to have policies and procedures in place on 11/22/11 to ensure that a suicidal patient was prevented from harming himself or others. The patient was able to use his shoelaces tied to an air grille to hang himself. This failure by the hospital to protect suicidal patients demonstrates the likelihood that another patient with suicidal ideation would not be protected from him/herself. The findings are:

A. On 11/21/11 Patient #1(P#1) was being treated at a drug/alcohol rehabilitation program. He verbalized suicidal ideation and was transferred by rehabilitation staff to the PES. The rehabilitation staff member advised the PES RN, who was doing triage, that the patient was expressing suicidal ideation.
B. RN#1 did a triage evaluation of the patient and documented in the Behavioral Health Form as follows under "BH Triage" performed at 19:17: "Suicidality: Acutely suicidal, History of suicidal gestures." The BH Triage continues: "Last Suicide attempt: 2 mo [months] ago - OD [drug overdose]." RN #1 triaged P#1 as a Level 1 in the PES triage classification system. A Level 1 status is assigned to any patient expressing suicide ideation. However, no member of the PES staff checked to ensure that P#1 did not have the means to harm himself or others. No search was done and he was allowed to keep his shoes with removable shoelaces.
C. P#1 was placed in Triage Room #2 where he remained unseen by a physician or qualified medical person for the next seven hours. The fact that P#1 was expressing suicidal ideation constituted an emergency medical condition and should have prompted the PES to ensure that he was protected and prevented from injuring or harming himself or others.
D. A PES RN note at 0230 on 11/22/11 states, "Pt. was found with a shoe lace tied around his neck and tied to the ceiling vent in room [triage] #2. Pt. was physically lifted up by Security and cut down immediately by PES staff. RRT [Rapid Response Team] notified and crisis team called. Pt. was pale and tremulous. VSS Pt. immediately placed on O2 [oxygen] per nasal cannula. O2 sat 98%, BP [blood pressure] 130/80; HR [heart rate] 120; Resp 28. Pt. transported via [local ambulance] to UHER [University Hospital Emergency Room] for medical clearance."
E. On 01/04/11 at 1:45 pm, the Acting Director of the PES stated during interview that no written policy or procedure for measures to be taken to protect suicidal patients was in effect prior to 11/28/11. He was then asked how the staff would know to remove any personal items from a suicidal patient. He said that this topic was covered in the PES employee orientation. He confirmed that no written policy or procedure for safety measures to be taken with suicidal patients existed prior to 11/22/11. He further stated that on 11/28/11 a new policy on Level 1 patient security and checklist was developed.
F. On 01/05/11 at 9:15 am, Mental Health Technician #2 was interviewed and asked if he had received any written policy or procedure on security measures on Level 1 patients. He stated that he had never seen a written policy on this topic. He also stated that nothing was ever mentioned about security measures for suicidal patients during his orientation in May 2011.
G. A root cause analysis (RCA) was done on this adverse patient event. The RCA revealed that a mental health technician (MHT) was supposed to be observing patients by video cameras located in each triage room. The RCA indicates that at the time P#1 was standing on a desk tying his shoelace through the air grille, the MHT was escorting a patient to one of the adult inpatient wards.

H. The hospital provided extensive documentation to demonstrate that it had immediately taken steps to remedy the lack of a suicide-proof grille over the air vents in the observation rooms. Among the documentation were two reports titled "Patient Safety Review - Final Report - October, 2010, for the University of New Mexico Psychiatric Center at 2600 Marble NE, Albuquerque, New Mexico." These two reports were provided by Behavioral Health Facility Consulting, LLC, a consulting firm with expertise in security in psychiatric facilities. One report was was dated October 2010 and the second was dated November 2011. [It should be noted that the hospital claims that it did not receive the draft report of the 2011 report until 11/23/11.] The October 2010 report states on page 12 under 4. UPC - Psychiatric Emergency Services[PES] item c.,"Triage Room #1 - It is suggested that the air grille be replaced with a security type grille." Item d., "Triage room #2 - It is suggested that the counter and flipper door unit be secured in place and the air grille be replaced."

On 01/05/12 at 2:15 pm an interview was done with three hospital employees involved with the physical plant. They were: Executive Director, Behavioral Health Finance, Executive Director, Facilities & Support Services, and a UNMH Facilities Planner, Analyst. These managers were asked to explain why the advice of their own consultant in October 2010 to replace the air grille in Triage Room #2 had not been done as of 11/22/11 when P#1 used the air grille to hang himself. Their response included the following reasons: (1) the hospital facilities & support services had developed an evaluation system to decide which work and improvements had the highest priority to be done and the air grille replacement was not given a high priority, (2) there were air flow concerns that needed to be resolved, (3) the cost of replacing the air grille was an issue.

They were then asked to explain how it could take over a year to resolve air flow issues. They had no answer. They were then asked how much it would cost to replace the one air grille and the surveyor was told that it would cost "$100 to $200 dollars."

The hospital provided a UNMH Capital Request dated 11/22/11 titled UPC PES Patient Safety. The description of the request outlined all of the recommendations made by the psychiatric safety consultant in both 2010 and 2011. Under Justification of Request, it states: "There was a patient safety review conducted on 10/19/10 by [a psychiatric safety consultant], Behavioral Health Facility Consulting, LLC. This project is needed to correct the patient safety issues identified in the PES area of the UPC."

Based on document review, record review and interview the hospital failed to ensure that psychiatric safety consultant recommendations made in October 2010 to improve the safety of secure triage rooms in the Psychiatric Emergency Services (PES) of the hospital's psychiatric facility had been carried out in a timely manner. On 11/22/11 at 0230 Patient #1 (P#1) was able to use an air grille, which did not have the recommended security grille upgrade, to hang himself. This failure to ensure that hospital facilities were secure for patients with suicidal ideation demonstrates the likelihood that another patient with suicidal ideation might not be protected from him/herself or others. The findings are:

A. A PES RN note at 0230 on 11/22/11 states, " Pt. was found with a shoe lace tied around his neck and tied to the ceiling vent in room [triage] #2. Pt. was physically lifted up by Security and cut down immediately by PES staff. RRT [Rapid Response Team] notified and crisis team called. Pt. was pale and tremulous. VSS Pt. immediately placed on O2 [oxygen] per nasal cannula. O2 sat 98%, BP [blood pressure] 130/80; HR [heart rate] 120; Resp 28. Pt. transported via [local ambulance] to UHER [University Hospital Emergency Room] for medical clearance."
B. The hospital provided extensive documentation to demonstrate that it had immediately taken steps to remedy the lack of a suicide-proof grille over the air vents in the observation rooms. Among the documentation were two reports titled "Patient Safety Review - Final Report - October, 2010, for the University of New Mexico Psychiatric Center at 2600 Marble NE, Albuquerque, New Mexico." These two reports were provided by Behavioral Health Facility Consulting, LLC, a consulting firm with expertise in security in psychiatric facilities. One report was was dated October 2010 and the second was dated November 2011. [It should be noted that the hospital claims that it did not receive the draft report of the 2011 report until 11/23/11.] The October 2010 report states on page 12 under 4. UPC - Psychiatric Emergency Services[PES] item c.,"Triage Room #1 - It is suggested that the air grille be replaced with a security type grille." Item d., "Triage room #2 - It is suggested that the counter and flipper door unit be secured in place and the air grille be replaced."

C. On 01/05/12 at 2:15 pm an interview was done with three hospital employees involved with the physical plant. They were: Executive Director, Behavioral Health Finance, Executive Director, Facilities & Support Services, and a UNMH Facilities Planner, Analyst. These managers were asked to explain why the advice of their own consultant in October 2010 to replace the air grille in Triage Room #2 had not been acted upon prior to 11/22/11 when P#1 used the air grille to hang himself. Their response included the following reasons: (1) the hospital facilities & support services had developed an evaluation system to decide which work and improvements had the highest priority to be done and the air grille replacement was not given a high priority, (2) there were air flow concerns that needed to be resolved, (3) the cost of replacing the air grille was an issue.

They were then asked to explain how it could take over a year to resolve air flow issues. They had no answer. They were then asked how much it would cost to replace the one air grille and the surveyor was told that it would cost "$100 to $200 dollars."

D. The hospital provided a UNMH Capital Request dated 11/22/11 titled UPC PES Patient Safety. The description of the request outlined all of the recommendations made by the psychiatric safety consultant in both 2010 and 2011. Under Justification of Request, it states: "There was a patient safety review conducted on 10/19/10 by [psychiatric safety consultant]. This project is needed to correct the patient safety issues identified in the PES area of the UPC."