HospitalInspections.org

Based on interview, record review, and observation, the facility failed to provide a safe environment for one (P#1) of 4 (P#1-4) patients who were on suicide precautions in the Behavioral Health Unit. This failed practice resulted in a successful suicide and places all current and future patients at risk for harm.
The findings are:

A. On 01/03/19 at 12:30 pm during a tour of the BHU and in conjunction with Staff #1, Staff #2, and Staff #3 interviews, revealed the patient was on q15 checks and placed on suicide watch precaution upon admission to the BHU due to suicide ideation.

B. On 01/03/19 at 12:30 pm during a tour of the BHU and in conjunction with Staff #1, Staff #2, and Staff #3 interviews, revealed the patient was placed in a paper gown while in the ED as per facility policy and assessment in the ED. Upon transfer, admission, and assessment in the BHU, he was changed into a cloth gown. The type of gown worn by the patient is based on the Psychological Assessment upon admission to the BHU. Patients with paper gowns are considered a higher risk for suicide.

C. On 01/03/19 at 12:30 pm during a tour of the BHU and in conjunction with Staff #1, Staff #2, and Staff #3 interviews, it was clarified that RN #7 was bringing the patient his scheduled medications and not requested medications as was stated in the hospital's in-house investigation document.

D. On 01/03/19 at 12:45 pm during interview, Staff #1, Staff #2 and Staff #3 stated P#1 hung himself while in the patient restroom on 11/03/18 between 1:58 pm and 2:08 pm. He was able to hang himself by tearing his hospital gown, wrapping it around his neck, and looping it over the corner of the inside bathroom door.

E. On 01/03/19 at 1:45 pm during interview, the QM confirmed RN #7 entered the patient's room on 11/03/18 for the scheduled q15 check at approximately 1:58 pm. She then exited the room and returned at approximately 2:08 pm to administer his scheduled medications and did not see him in his room. RN #7 went to look for him in the patient common areas, did not see him, returned to his room, and tried to open the bathroom door. She pulled on the bathroom door twice. With the first attempt, the door did not immediately open and she pulled harder on the door. The second attempt at pulling on the door, resulted in the patient falling from/off the door and onto the floor.

F. On 01/03/19 at 12:45 pm during interview, Staff #1, Staff #2 and Staff #3 stated at approximately 2:10 pm RN#7 removed the ligature from around the patient's neck and checked the patient for breathing. She called a Code Blue. The Code Team transferred the patient to the ED. The patient died en route and was pronounced dead in the Emergency Department.

G. On 01/03/19 at 12:45 pm the tour of the BHU and observation of patient rooms revealed that patients have the ability to hang themselves by using the (bathroom) doors as ligature points. The doors were heavy, had sharp edges, and opened by pulling outward. There were no piano hinges on any of the doors in the patient rooms.

H. On 01/03/19 during interview, the QM confirmed the on-duty staff did not follow facility policy or procedure. The QM stated, "no one on-duty that day remembers physically unlocking the bathroom for the patient. We didn't follow procedure. Nobody knew it [the bathroom door] was unlocked. Facility policy is that bathrooms in the patient rooms are supposed to be locked. Patients have to request the bathrooms be unlocked when they need to use the bathroom. Staff has to wait in the patient room until the patient is finished and then relock the bathroom door. Unfortunately, on the day of the incident there was human failure on our part and we did not follow procedure."

I. Record review of the following Presbyterian Hospital Policies confirmed facility policies and procedures were not followed:
a. BH (sic) Suicide Precautions, Reference Number BEH.CDS.306 dated 08/01/18, states "Procedure 2.b. Patient's bathroom door is to be locked at all times."
b. Presbyterian Hospital Policy: Patient Suicide Risk Prevention, Reference Number: PC.PDS.179, dated 07/10/18 states, "3. Immediate Safety Risk Assessment 3.1. If the patient's response indicates the patient is at risk for suicide, the following measures are initiated:...3.1.2. Measures will be implemented to create a safe environment for the patient. This may include, but are not limited to: clearing the room of hazards, removal of all paraphernalia associated with potential for self harm, , (sic) one-to-one observation, removal of personal belongings, initiation of other methods to protect the patient from self-harm."
c. Presbyterian Hospital Policy: Behavioral Health Standard Unit Precautions, Reference Number: BEH.CDS.209, dated 08/01/18 states, "Purpose: To promote the safety of all patients admitted to Behavioral Health Inpatient by mitigating risk factors and strengthening protective factors in the environment. To provide specific guidelines for staff assessment, observation and documentation of both the patient and the inpatient physical environment. Policy: Standard Unit Precautions are initiated when a patient is admitted to the Behavioral Health Units, unless the patient is placed on a higher level of precautions. Standard Unit Precautions include a staff assessment of the physical environment of each inpatient unit at the beginning of each shift, at a minimum, and more often, as required."