HospitalInspections.org

Based on interview and document review the hospital 's Psychiatric Emergency Services (PES) failed to identify that patient #1 (P#1) had an emergency medical condition based on verbalized suicidal ideation. The PES did not provide further medical examination and treatment as required to stabilize the medical condition. The PES failed to protect and prevent patient #1 from injuring or harming himself or others. After a seven-hour wait without being seen by a physician, P#1 used his shoelaces to hang himself in an observation room. This failure by the PES staff to identify an emergency medical condition and protect suicidal patients demonstrates the likelihood that other patients with suicidal ideation would not be protected from him/herself. The findings are:
A. On 11/21/11 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.
C. P#1 was placed in Observation 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. 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 #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 Albuquerque 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 stated 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.