HospitalInspections.org

Based on review of facility documents, medical records (MR), observation, and staff interview (EMP), it was determined the facility failed to ensure the safety of a patient admitted to the Behavioral Health Unit with suicidal thoughts and actions (MR1).

Findings Include:

Review of the facility policy "Procedure for Securing Belongings," last reviewed March 3, 2014, revealed "Purpose: To provide safety for the patient, other patients, and personnel. Persons Affected: All inpatient psychiatry staff Policy: The policy of Procedure for Securing Belongings is to ensure proper documentation and dispensation of patient belongings. ... Responsibilities: All inpatient psychiatry staff is responsible for securing patient personal belongings. Procedure: 1. All patient belongings are to be brought onto the unit by the admitting person and brought into the nurse's station to secure them. ... 3. When patients are admitted from the Outpatient clinic, escort the patient to their assigned room and have the patient change in to hospital garb. Take belongings to Nurses station to be checked. Reassure the patient that this routine is per unit protocol to ensure patient safety. Place any items that the patient may not keep with him/her in the patient's belongings box in the nursing station. ... 4. Secure all sharp objects, aerosol cans, electrical appliances, belts, cords, all plastic bags, wire clothes hanger, etc. for the patient's safety. 1. Sharp Objects - Nail file (metal), scissors, knives, nail clippers, knitting needles/crochet hooks. Razors - an order must be written for a patient to use a disposable razor independently. Patients without a written order allowing use of a razor may do so under direct supervision of staff. 2. Lighters and all tobacco products. 3. Glass objects or containers 4. Denture Cleaners - i.e. Efferdent 5. Mirrors - Including mirrors contained in compacts and suitcases 6. Jewelry - with very strong chains 5. Place belongings in nurse's station in proper belonging box; place name on box. ..."

Review of the facility policy "Observation Levels," last reviewed March 12, 2014, revealed "Observation Levels These levels will be used for all patients according to their need for observation due to suicidal potential, acting out behavior, elopement risk, or fall risk. On admission, the adult patient will be placed on Level B Close Observation or Level B by the admitting physician. Adolescent patients will be placed on a Level B1. Treatment Team determines changes in observation. ... Observation Levels: Level B Close - observe every 15 minutes Level B Close - Fall Risk (Danville Campus only) ... Level B, BF, - observe every 30 minutes Adolescent Levels B1 and B2 - observe every 30 minutes documentation of the patient's observation level occurs at the beginning of each shift. By documention [sic] of the observation level, it is understood that the observation times are followed throughout the shift as determined by the ordered observation level. ... Nightshift staff completes rounds on the unit observing all patients according to the ordered observation level. Documentation of these rounds occurs on a Patient Observation Checklist. Each round is initialed on the form by the staff person who has completed the round. ..."

Review of the facility policy "Evaluation of Patient's Suicide Risk," last reviewed March 12, 2014, revealed "Purpose: To evaluate patient's suicide risk. ... Procedure: Evaluation of Patient's Suicide Risk 1. On admission the RN [registered nurse] will assess the following: Orientation Identifiable Stressors Presence of Suicidal Ideation Previous suicide attempt and if so, by what means Access to means to harm self Family history of suicide ... 3. Based on admitting provider assessment and RN assessment, the patient is assigned to either observation level B or B Close. Room Assignment is also determined at this time. 4. Treatment Team makes a Dangerous to Self/Others Assessment (DTSOA) to determine patient's risk. 5. Suicide ideation is assessed by nursing staff at least twice a day. 6. Treatment Team updates DTSOA as patient's condition changes. 7. Treatment Team is updated to reflect patient's change in condition as needed."

Review of MR1 on November 7, 2014, revealed nursing documentation dated October 28, 2014, that the patient presented with increased depression, anxiety and thoughts of suicide, MR1 did not have a plan but did have thoughts of hurting self. Additional review of MR1 revealed emergency department (ED) physician documentation that MR1's history included bipolar disorder, numerous admissions to the behavioral health unit, is in an intensive day treatment program, was taken off Abilify (antipsychotic medicine) and Remeron (antidepressant) the previous day, feels as though cannot do this anymore and sees themselves wrapping a car around a tree.

Continued review of MR1 revealed attending physician documentation dated October 29, 2014, indicating this patient would awake in a panic, was afraid of going through the change alone, and has been depressed for weeks. Further review revealed a phone conversation with MR1's spouse indicating MR1 felt unsafe, would like to be straightened out, MR1 was anxious on the Abilify and Remeron, was switched back to Lithium (antipsychotic medicine) and felt better, and that MR1 was in Intensive Outpatient therapy. Continued review revealed MR1 has had multiple suicide attempts, including overdose and hanging, and that MR1's suicide risk was assessed to be severe.

Continuing review of MR1 revealed nursing documentation dated November 4, 2014, indicating staff entered patient's room at 6:05 AM to administer medications; patient was not in bed, patient found slumped over against bathroom door, and was unresponsive. MR1 was transferred to intensive care and placed on a ventilator.

Review of MR1's Multidisciplinary Treatment Plan revealed this patient was put on B-close supervision due to elopement risk on October 29, 2014. The patient reviewed and signed the treatment plan on the same day.

Interview with EMP2 and EMP4 on November 7, 2014, revealed MR1 had 10 admissions to the behavioral health unit since January 2014, and was previously a patient at a psychiatric long term care facility. EMP2 and EMP4 confirmed MR1 was on every 15 minute checks for elopement.

Continued interview with EMP2 and EMP4 revealed MR1 contracted for safety and did not have any suicidal intentions. EMP7 was assigned every 15 minute checks for MR1. The patient was checked at 5:45 AM and was flushing the commode in the bathroom. Further interview revealed the patient was due for medication at 6:00 AM. EMP8 entered the patient's room and found the patient hanging from the bathroom door. EMP2 and EMP4 revealed the patient had taken a duffle bag that had two handles, opened the bathroom door, placed one handle over the top outer part of the door, put their head through the second handle, bent at the knees and was found slumped over, hanging from the open bathroom door.

Interview of EMP9 at 1300 on November 7, 2014, revealed EMP9 worked the shift of the incident with MR1. EMP9 stated they were a nursing assistant and worked on the BHU for 7 years. EMP9 stated MR1 was on 15 minute checks. EMP9 stated MR1 was usually asleep when checks were completed. EMP9 stated that on November 4, 2014, they saw and heard a call light at the end of the hall. EMP9 then heard EMP8 call for help. EMP9 entered MR1's room and saw MR1 hanging from the bathroom door using a duffle bag with two straps. EMP9 stated they assisted EMP8 in lifting MR1 and removing the strap from MR1's neck. EMP9 then ran to the nurses' station to call a code. EMP9 stated duffle bags were allowed on the BHU.

Interview with EMP10 at 1305 on November 7, 2014 revealed EMP10 was working at the time of the incident with MR1. EMP10 has worked on the BHU for 6 years. EMP10 stated MR1 usually slept through the night. EMP10 stated they were charge nurse on November 4, 2014. EMP10 stated they were at the nurse's station when EMP9 ran to the desk and said to call a code. EMP10 stated EMP7 took the code cart to MR1's room. When EMP10 arrived at MR1's room the nursing supervisor was on the scene. EMP10 stated they took over administering compressions until the code team arrived. EMP10 confirmed duffle bags with straps were allowed on the BHU prior to this event.