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Based on record review, interview and observation the hospital failed to prevent patients from commiting suicide through ligature in the facility. The cumulative effect of this systemic problem resulted in the facility's inability to ensure patients receive care in a safe setting. (A144)

Based on record review, observation, and interview the hospital failed to provide care in a safe setting to prevent patients from completing suicide in the facility. This failure resulted in the death of two (Patient #1 and #2) patients. This deficient practice has the potential to affect all patients receiving services at the facility. The facility census was 246.

Findings include:

According to Staff E on 02/25/20 at 12:52 PM there were 2 recent suicides on C-1 resulting in patient deaths within a 6-month period. Six months ago a patient hung himself with a sheet or sweatshirt and closed door. In the past month, a patient hung himself from the desk in the room.

1. Review of Patient #1's medical record completed on 02/25/20, revealed an admission date of 09/25/19. On admission Patient #1 was placed on every 5/15 minute checks due to suicide prevention per order dated 09/25/19, at 8:38 PM. An order dated 09/26/20, at 1:25 PM noted that the every 15 minute observation was discontinued. No other observation orders were noted in the medical record for Pt #1.

A psychiatry note dated 09/26/19, revealed Patient #1 was admitted on a psychiatric emergency admission (pink slip) due to severe suicide attempt. Patient #1 had overdosed on large amounts of Lamictal (Anticonvulsant used to treat seizures and bipolar disorder), Geodon (Antipsychotic used to treat schizophrenia and bipolar), and Seroquel (Antipsychotic used for schizophrenia, bipolar disorder, and depression). Patient #1 wrote suicide notes to multiple people and had been planning to attempt suicide for a couple weeks. Patient #1 was found unresponsive with empty pill bottles. A psychiatry note dated 09/27/19, stated Patient #1 currently denied suicidal and homicidal ideation. A psychology note dated 09/30/19, stated attempted to talk to Patient #1 for therapy session. Patient #1 politely noted that he had slept poorly and desired to continue taking a nap. Patient #1 requested that psychology re-schedule a meeting with her in the morning on 10/01/19. A psychiatry note dated 09/30/19, stated Patient #1 denied any current suicidal ideation. A psychiatry note dated 10/01/19, electronically signed at 1:05 PM stated Patient #1 denied any current suicidal ideation. No issues were noted with medication administration and psychiatric assessments.

A psychology note dated 10/01/19, revealed a therapy session with Patient #1 to "process suicide attempt, provide hope, and begin evaluating functional circumstances preceding the entrance to the hospital". "The C-SSR (Columbia Suicide Severity Rating Scaled) was not completed at present because it was already clear that Patient #1's risk outside the hospital is high and wanted Patient #1 to have the opportunity to process events without interruption. S: Patient #1 initiated the session by noting that he has no hope and asking what she is supposed to do. When questioned regarding suicidal ideation, she noted that "I'm not going to do anything while I'm locked up, but ...... what do you think will happen when I leave?" Patient #1 then noted that "I did everything right and I still did this, what hope should I have?' O: Patient #1 appeared to begin the session in a highly irritated and negative frame of mind. As the session progressed, this appeared to lessen as the sessions progressed until at the end of the session she laughed. A: Patient #1 continues to battle between feeling hopeless, worried about what will happen after the hospital, and desires to be transferred to Facility B. She appeared more positive at the end of the session - including laughing - and asked to stop the session after 70 minutes so she could join other patients outside. P: Patient #1 agreed to meet the following day, 10/02, to continue the conversation. Will update the team regarding his current functioning". No documentation was noted of the psychologist informing the physician or any other staff of the patient potentially being suicidal.

A nursing note dated 10/02/19, and electronically signed at 8:54 PM stated "D: Patient #1 was tearful and requested to speak to unit psychologist after going out for fresh air at 3:40 PM. Unit psychologist was with another patient. This staff offered to talk to Patient #1, which Patient #1 agreed. Patient #1 reported abandonment issues after her father's death. Patient #1 reported she separated herself after father's death. Patient #1 reports that she becomes attached to people easily/quickly and feels like everyone leaves her. Her roommate whom she became attached to, was recently discharged which further upset her and further reinforced issues of abandonment. Provided 1:1 verbal intervention to encourage Patient #1 to verbalize thoughts, feelings and concerns. Patient #1 reported she does not want to harm herself but just has abandonment issues. Offered Patient #1 music room, arts and crafts, TV, books or anything Patient #1 could think of that she enjoys. This staff spoke to her for 15 minutes and Patient #1 appeared like she was feeling better. Staff asked if there was anything else staff can do for her and Patient #1 said no and thanked staff for listening. Patient #1 ate dinner, then socialized with peers on the unit. Patient #1 was still up on the unit during 5:00 PM rounds".

"Social Learning Center personnel called and asked for patients for activities off the unit. As staff were walking toward Patient #1's bedroom to notify her of activities off the unit, Patient #1's roommate pointed out that a sheet was hanging off the door. Staff pulled the door open and Patient #1 fell on the floor with a sheet tied around her neck. A chair was also by the door. Code blue was called 5:32 PM and cardio pulmonary resuscitation (CPR) initiated at 5:33 PM. 911 was also called at 5:33 PM. Automatic External Defibrillator (AED) machine hooked up to patient and followed AED's instructions to continue CPR and give breaths. R: Patient #1 looked paled and was not conscious. The sheet around the neck was untied by staff. emergency medical technician (EMT) to hospital grounds at 5:46 PM and on unit C1 at 5:50 PM. Patient #1 left the unit with EMT at 6:05 PM with pulse and rhythm to University Hospital Bedford with 1 Northcoast Behavioral Health staff".

A therapeutic program worker (TPW) note dated 10/2/19, and electronically signed at 8:23 PM stated "after Patient #1 ate her dinner around 5 PM, she was talking on the phone with someone, after the conversation was over, Patient #1 appeared to be upset. She walked over to the day area and was talking to his peers. Around 5:30 PM patients were being gathered to attend an off unit group. When opening the door, it was a struggle and Patient #1 fell to the ground. A code was immediately called".

A psychiatry note dated 10/02/19, and electronically signed at 8:23 PM stated "this provider responded to the code blue called in at 5:32 PM. Arrived on the unit by which time nursing staff directed me to Patient #1's room across the end of the hallway. Patient #1 was lying on the floor unresponsive at the entry way with half of her body with head outside of the room and the rest in the room. No pulse was palpable. Vitals were not recordable. AED was connected and CPR was started at 5:33 PM and 911 was called in. Multiple cycles of CPR alternated with the Ambu bag insufflation and oxygen was connected. Patient #1 continued to remain unresponsive. Feeble pulse was palpable but no vitals recordable yet. AED did not indicate any shocks as there was not rhythm detected. EMT arrived on grounds at 5:46 PM and on to the scene at 5:50 PM. As pulse was not obtained and Patient #1 in Asystole, CPR was continued for next 15 minutes during CPR Intravenous epinephrine was given twice when pulse was recorded and heart beat was noticeable. Patient #1 was taken to UH Bedford ER for further stabilization and care. Nursing supervisor notified family of the incident".

2. Review of the medical record for Patient #2 completed on 02/26/20, revealed an admission date date of 02/11/20. On admission at 2:03 AM Patient #2 was placed on every 15 minute checks per physician order. On the initial psychiatric evaluation completed on 2/11/20, at 2:29, AM Brief Admit Note, history (hx) of present illness showed Patient #2 had limited formal past psych hx and was admitted on pink slip from St. Vincent for suicidal ideation. Pre-record, in the emergency department (ED) he was pacing, pressured speech, and obsessive/preoccupied thought process. Wife brought in for eval but wasn't available to speak with social worker (SW) for further collateral. Per record, Patient #2's in-law had reported the patient was suicidal or possibly made an attempt in January 2020, but Patient #2 and his spouse denied the in-law report. On admission to NBH, Patient #2 greatly minimizes any problems. He minimizes anxiety and insomnia, denies having a rope, denies any planed intent for suicide, denies suicidal ideation in past month, and lists kids as reason to live.

Review of the nursing, social work, and psychiatry progress notes for 02/11/20, no documentation was noted that Patient #2 stated he was suicidal or was showing signs of being suicidal. Review of the medical note dated 02/22/20, and electronically signed at 3:21 PM revealed "Patient #2 was found in his room, he had wrapped a sheet around his neck to hang himself and was unresponsive. The sheet was cut away".

A nursing note dated 02/11/20, at 6:18 PM stated "Patient #2 found in bedroom by the TPW with a sheet around his neck. Code blue was called at 2:21 PM and CPR initiated along with oxygen. 911 also initiated. Patient #2 was transferred out of facility by EMT staff at 2:39 PM per records. Social worker reportedly notified family".

Review of the rounding documentation showed Patient #2 was being observed every 15 minutes from 2:04 AM on 02/11/20 until 2:00 PM on 02/11/20. Patient #2 completed suicide attempt after the 2:00 PM observation and being found at 2:21 PM.

According to Staff A on 02/25/20 at 3:45 PM both Patient #1 and Patient #2 died at the receiving hospital.

According to Staff G located on C-1 on 02/25/20 at 1:26 PM the facility has been understaffed for a while and it's getting worse. It is very dangerous out here and one to one are budgetary.

Review of nursing huddle meeting completed 10/24/10 revealed there was a discussion about separating milieu and rounds. This stated "Milieu and Rounds are a separate assignment at all other psychiatric hospitals, we would like to follow this practice and separate the staff's assignments. No staff should complete the two at the same time. Separating milieu and rounds will guarantee that there are always at least 2 people out on the unit". No notation on what the responsibilities was noted for milieu person in this meeting.

Review of the audits of the separate milieu and rounding from December, 2019 through January, 2020 completed on 02/26/20 showed for unit C-1 that they did not have the appropriate milieu staff member three of the ten audits that were completed; for unit A-1 did not meet the appropriate milieu staff member five of thirteen audits that were completed; for B-1 did not meet the appropriate milieu staff member three of seven audits that were completed; for unit B-2 did not meet the appropriate milieu staff member zero of seventeen audits that were completed; for unit D-1 did not meet the appropriate milieu staff member six of ten audits that were completed; for unit C-2 did not meet the appropriate milieu staff member seven of eleven audits that were completed; for unit D-2 did not meet the appropriate milieu staff member two of five audits that were completed; for unit E-2 did not meet the appropriate milieu staff member one of eight audits that were completed; for unit E-3 did not meet the appropriate milieu staff member tow of nine audits that were completed. No documentation was noted if the person in the Milieu was constantly observing all the patients on the unit.

Observation of unit C-1 (location of Patient #1 and Patient #2 completion of suicide) completed on 02/25/20, at 1:10 PM revealed the surveyor could not visually see the patient door (ligature point) that opened into the corridor from the nurses station. Also during the 20 minutes on the unit no staff were noted walking through that corridor. Ligature points were also noted during the tour in the restrooms of the double rooms. There was noted gaps between the hand rails and walls of approximately a quarter of an inch.

Review of policy 02.10 Suicide Prevention completed on 02/26/20 revealed under section 10. "In hospitalized patients it is expected clinical practice: a. To observe patients for clues of harmful behaviors. b. To pay attention to changes in emotional state. c. To take note of patient's statements with suicidal or self-harm content. d. To take note of staff and/or other patient's reports patients voicing death wishes, suicidal thoughts and/or threats. e. To inform the unit RN and the physician of any indications of suicidal risk in patients". Under section 11. "Clinical Management of Suicidal Patients. b. Suicidal Precautions: 5) Observation of the patient levels: a) 1:1 observation. Shall be reserved for patients who are actively suicidal and/or at high risk of self-destructive or suicidal behavior. 1:1 observation where the patient must be watched, without interruption at all times, with documentation of this every fifteen minutes, recorded on the Special Observation Record, form #162. One staff member will be assigned to this duty (on rotation), and is expected to keep the patient under uninterrupted visual observation within 4 feet. b) Every five-minute observation shall be used for patients who are highly potentially suicidal and/or at moderate to high risk of self-destructive behavior. The patient must be observed at least once every five minutes, with the log completed at least every fifteen minutes. c) Every fifteen-minute observation shall be used for patients who are potentially suicidal and/or at moderate risk of self-destructive or suicidal behavior. The patient must be observed at least once every fifteen minutes".