HospitalInspections.org

Based on interviews, review of facility policies and procedures and record reviews, the facility:
- failed to provide a safe environment for one patient (#1) on the Behavioral Health Services Unit who was at risk for suicide; and
- failed to follow Physician's orders for patient (#1) who was on close observation precautions but allowed to enter and remain in their bedroom, without staff monitoring in order to prevent or minimize potential harm.

The severity and cumulative effect of the systemic practices resulted in an Immediate Jeopardy situation, representing the hospital's failure to have a consistent patient monitoring practice in place, which may have prevented the self-inflicted hanging/strangulation and death of Patient (#1). The facility census was 28.

The Administrator was notified of the Immediate Jeopardy on 11/14/10 and it was considered abated at the time of exit with an acceptable plan.

Refer to A-144 for deficiency.

Based on interviews, review of facility policies and procedures and record reviews, the facility failed to provide a safe environment for one patient (#1) on the Behavioral Health Services Unit who was at risk for suicide; and failed to follow Physician's orders for patient (#1) who was on line of site precautions but allowed to enter and remain in their bedroom, without staff monitoring which would have prevented or minimized potential harm. The facility census was 28.

1. Medical record review showed Patient #1 was admitted to the facility on 11/09/10 at 4:00 PM for worsening depression and suicidal ideation.

The History and Physical (H&P) dated 11/09/10 showed the patient had a history of depression, irritability, mood swings, poor sleep and anxiety disorder with low self-esteem. The symptoms continued to worsen due to the patient's ongoing alcohol and cocaine abuse and socials stressors which included not being able to visit his/her 2 year old daughter.

The H&P described the patient as alert and oriented, cooperative, unkempt and disheveled. The physician described Patient #1 as sad, dysphoric, occasionally tearful speech, but coherent and goal directed. The patient denied any suicidal ideation, intent to harm himself/herself and/or homicidal ideations at that time. He/she also denied any intent to harm his/her friend, who called police after the patient tried to hurt him/her. The patient's insight and judgment was documented as guarded.

Assessment/Plan:
Admit the patient for further evaluation and stabilization.
The patient will be closely monitored for his/her safety and will be involved in the therapeutic milieu.
For his/her depression, we will start Celexa (an antidepressant) 20 mg daily.
A risk benefit analysis was done and informed consent was obtained.
The patient will be placed on the alcohol withdrawal protocol and monitored closely for his/her alcoholism.

2. Record review of the Physician's Orders - Adult Mental Health Initial Care Orders dated 11/09/10 at 5:20 PM showed the following (in part):
Direction/Purpose Treatment/Educate Patient On: Meds [medications] to treat Illness; s/s [signs and symptoms] of depression, relaxation techniques, coping skills mgmt [management]
Observation level: CO (constant observation)
Special Precautions: Suicide/Self Harm; Violence to others; Withdrawal (alcohol withdrawal)
Orders signed by the Physician on 11/10/10 at 10:00 AM showed an order for Celexa (an antidepressant) 20 mg (milligrams) po (by mouth) q HS (every night).

3. Review of the facility's close observation policy entitled "Patient Intervention Status," revised 1/10 showed in part:
Purpose: To provide safety of patient through observation, assessment, and intervention.

Suicide
Close Intervention Criteria - imminent risk, making verbal threats, intent without available means or plan, unable to maintain personal safety without supervision, history of poor impulse control or history of harming self while in treatment.

Homicide or threat of violence
Close Intervention Criteria - potential for imminent risk to others, needs frequent intervention and redirection, needs ongoing support, utilizing department resources and needs ongoing support to maintain control, history of poor impulse control

Close Intervention Status: 1 staff for 4 patient ratio
Staff always has the patients' within eyesight and is accessible to intervene when necessary for patients who are placed on close intervention status. Staff has the ability to provide assessment and intervention for up to three close intervention patients. The staff with the patient must be constantly available to intervene with the patient and provide interventions as indicated.


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4. During an interview on 11/13/10 at 10:30 AM, the Chief Nursing Officer (CNO) stated he/she learned during the facility's Root Cause Analysis investigation the following information:
The patient transferred from Heartland Regional Medical Center to St Luke's Northland Hospital Smithville on 11/09/10 at 4:00 PM.
On 11/10/10 between 11:15 and 11:55 AM, the patient verbalized to the Licensed Psychiatric Therapist that he/she felt better and no longer had suicide thoughts.
The Patient saw the Physician 1-1 ? hours (11:00-11:30 AM) prior to his/her death on 11/10/10 and reported to him/her that he did not have suicide thoughts. The patient requested a flu and pneumonia vaccine from the Pharmacist during a group session on 11/10/10 between 11:00-11:15 AM and the Pharmacist wrote orders (per vaccine protocol) for the patient to receive the vaccines at 11:15 AM. Record review also revealed the patient received the vaccines as ordered (vial dated 08/10/10) and the 11/10/10 at 11:15 AM order showed Staff took the order off on 11/10/10 at 11:30 AM.

5. During an interview on 11/13/10 at 1:35 PM, CNO stated he/she would expect a Mental Health Technician (MHT) to know where his/her patients were at all times. CNO stated the Licensed Psychiatric Therapist (LPT) told him/her patient #1 attended Release Prevention group session held in the dining room, but left the session at 11:55 AM. No one saw patient #1 after he/she left the group session at 11:55 AM until 12:20 PM (25 minutes later), at which time Staff found him/her hanging in his/her room.

CNO stated a construction team worked outside of patient #1's room at the time of his/her suicide. He/she stated the plastic used in the construction prevented Staff at the nurses'
station from visually seeing the patient's room.

CNO stated MHT #C called Patient #1's name after he/she did not see him/her in the dining room at 12:15 PM, but he/she did not answer. MHT #C went into patient's room to look for him/her and found him/her on the floor hanging against the wall at 12:20 PM. MHT #C called Registered Nurse (RN Staff #A) for assistance and she/he found Patient #1 hanging in his/her room from a string torn from a gown and wedged behind a wall suction bracket. RN Staff #A cut the patient's gown string, called a code and began resuscitation on the patient, but did not revive him/her.

CNO stated MHT #B reported he/she went to lunch and told RN Staff #C that he/she was leaving for lunch. (Note: MHT #B wrote a statement on 11/15/10 and stated he/she completed rounds at 11:30 AM, set the rounding board down on the nurses' station and informed RN Staff #C at 11:40 AM that he/she was going to lunch. Also Note: RN Staff #C wrote a statement on 11/15/10 and stated he/she did not recall any MHT telling him/her that he/she was going to lunch).

6. Note: The facility failed to follow the practice of Close Intervention monitoring for observing patients at all times. Based on the above statements, MHT #B thought he/she passed his/her patient to the RN Staff #C, while RN Staff #C stated he/she did not recall MHT #B passing the patients to him/her. The patients assigned to MHT #B went from 11:40 AM to 12:20 PM (40 minutes) without anyone being responsible for them and monitoring them. Interview on 11/13/10 at 1:35 PM with CNO indicated he/she would expect a MHT to know where his/her patients were at all times and if all MHTs were unavailable, an RN would take responsibility for the patients.

7. CNO reported MHT #B returned to the floor from lunch around 12:20 PM and noticed Patient #1's rounding sheet had not been initialed for 12:00 PM and 12:15 PM. MHT #B initialed the rounding sheet even though he/she went to lunch during those times. (Note: MHT #B admitted to facility's staff that he/she falsified the rounding sheet by initialing it during the period of time he/she had lunch).

8. During interview on 11/13/10 at 1:35 PM, CNO stated the facility did not have a specific policy regarding MHT Staff handing patients off to other MHT Staff and RNs when MHTs were not available to cover for another MHT. Management expected MHT Staff to pass their patients off to another MHT or RN and they just followed that practice.

9. During an interview on 11/13/10 at 11:25 AM, MHT #D stated that he/she did not work the day of the suicide, but stated rounds should be done every 15 minutes even though they were not rigid. MHT #D stated each patient should be physically located. He/she stated Staff should tell someone when they leave the floor and the receiving person was expected to take over the rounds. MHT #D stated a close observation consisted of observation in which the patient must be in view at all times.

10. During interview on 11/13/10 at 1:20 PM, RN Staff #A stated he/she worked the day of the patient's suicide and was assigned to the patient on the day of the suicide. She/he left for lunch around 12:20 PM and was barely on the elevator when MHT B came to the desk and said the patient in Room 206 didn't look good. RN Staff #A stated he/she went into the room and the patient stood with his/her back against the wall with a string (which had been torn from a gown) around his/her neck and wedged behind a wall plate. She/he stated he/she cut the string and the patient stood still slumped against the wall; he/she called a code and pulled him/her flat on the floor. Resuscitation was unsuccessful.

11. During an interview on 11/13/10 at 11:15 AM, MHT Staff #E stated he/she was not scheduled to work on the day of the suicide, but was called in to assist after the death of the patient. She was the facility's Lead Mental Health Technician and conducted training for the facility.

She/he stated she/he conducted rounds every 15 minutes and sometimes 10, depending on the patients and the situation. He/she stated when rounding, the MHTs should use the monitoring sheet to document the time they saw the patient, the patients' where about and what they were doing at each time of her/his rounds. He/she stated they needed to put their initial by each patient's name to acknowledge they physically saw the patient at that time. She/he stated rounding to her/him meant physically putting her/his eyes on the patient. She/he stated if her/his patients were asleep at time of rounding and/or if it was during the night with lights off, she used a flashlight to shine in their face to make sure they were in bed and were doing fine. He/she stated if patients were not in their room, she/he physically looked for them until she/he found them. He/she stated rounding to her/him meant making sure patients were safe and their environments were safe. He/she stated during rounding/monitoring checks, he/she ensure the patients do not need anything, answered their questions if they had some and assisted them if they needed assistance with anything. She/he also stated Physicians and Therapist were good about letting them know when patients were being seen by them.

MHT Staff #E stated prior to her/him leaving the floor for breaks, lunch or for whatever reason, she/he always let another Staff know so they could check/cover her/his patients for her/him. She/he stated that was the expected thing to do. She/he stated the number of MHTs scheduled depended on the acuity level of the patients. Generally the shift consisted of at least 3-5 MHTs scheduled, but that depended on the number of patients needing one-on-one.

12. Based on interviews on 11/13/10 between 11:00 and 3:00 PM, the CNO, MHT #A and MHT #E all stated rounding should be conducted at least every 15 minutes, patients should be physically located if they are not in view at the time of rounding and Staff should tell someone when they leave the floor and the receiving person is expected to take over the rounds. The CNO stated he/she would expect Staff to know where their patients were at all times.

13. During correspondence with CNO on 12/01/10 at 6:22 PM, he/she stated the MHTs worked under the direction of the RNs and on 11/10/10, the facility had three RNs and three MHTs scheduled to work with patients not receiving 1:1 intervention. He/she stated the three MHTs worked with all three RNs to complete assigned duties of admitting patients, monitoring patients on rounds and assisting with other assigned duties. He/she stated the MHTs passed off their rounds to other MHTs when they needed to and if all MHTs were busy, they passed off rounding to an RN. He/she stated the RNs had certain patients assigned to them and RN Staff #C had responsibility for patient #1. Based on the correspondence received, the RNs provided direction to all of the MHTs and no particular RN had responsibility over any particular MHT.

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