HospitalInspections.org

Based on observation, interview, clinical record review, and documentation review, it was determined that the facility failed to protect and promote each patient's rights (Condition).

Findings include:

The facility did not ensure that 3 of 10 sampled patients received care in a safe setting. The following processes were not in place as identified at:

CFR 482.13(c)(2) Patient Rights Care in Safe Setting (Tag A144).

Based on interview, resident record review and documentation review, the facility failed to ensure Resident #1's family, and/or legal representative, was contacted following an incident that required transfer to another facility.

Findings include:

Patient #11 was a 53 year-old admitted to the hospital on 6/15/11, under a Legal 2000 (State of Nevada's involuntary civil commitment process) evaluation, with diagnoses including bipolar I disorder with depressed episode, intervertebral disc degeneration site, arthropathy, diabetes type II controlled, hypertension, pure hypercholesterolemia and personal history of allergy to medicinal agent.

A Nursing Progress Note, dated 6/16/11, noted staff and Patient #11 reported that a peer tackled the resident from behind. It was noted in the entry that Patient #11 had a history of lower back pain and had increased back pain, left leg and left thigh pain following the incident.

A physician's order was obtained on 6/16/11 at 1325 (1:25 PM), for transfer of Patient #11 to an ED (emergency department) at a local acute care hospital

It was noted in the Memorandum of Transfer, dated 6/16/11 at 1330, that the reason for transfer was left lower extremity and left femur pain.

It was noted in a Milieu Observation Note, dated 6/16/11 at 1440 (2:40 PM), that Patient #11 had called his wife, crying and wanting to leave. There was no evidence of documentation that revealed Patient #11 had informed his wife of the recent incident and pending transfer out to a local acute hospital.

It was noted in an Individual & Family Progress Note, dated 6/17/11, that "Pt's wife contacted." This note was the only documented evidence Patient #11's wife was contacted. The note detailed various outpatient appointments arranged for Patient #11 and to inform the resident's wife that Patient #11 was off the Legal 2000. No specific information detailing the incident that occurred on 6/16/11, which motivated the transfer to a local acute hospital for pain evaluation and treatment.

Review of the facility's policy and procedure for incident reporting, noted under Section C, the Risk Manager is responsible for informing all necessary parties of an incident, regardless of severity.

Review of the hand written incident report was conducted and noted that the assault occurred on 6/16/11 at approximately 1:15 PM. The description of the incident was explained by Employee #12. Patient #12 was standing in the northwest hallway, kicked off his shoes and ran over and tackled Patient #11 from behind, and the force took both residents over a dayroom chair.

Further review of the incident report noted that various facility staff were notified of the incident, as well as the ambulance company called to transport Patient #11. There was no documented evidence on the incident report that noted Patient #11's wife was contacted.

On 7/14/11 at 2:55 PM, Employee #7 indicated Patient #11's wife called the following day. She indicated the patient's wife was angry and claiming that she didn't receive a call from the facility concerning the incident on 6/16/11. Employee acknowledged, "...that fell through the cracks."

Based on staff interview, clinical record review, and policy review, the facility did not ensure that 3 of 10 patients received care in a safe setting (Patients: #1, #2, #3).

Findings include:

1. The facility reported that a patient incident occurred on 5/25/11, in which Patient #1 was found hanging from the shower by a sheet. The facility initiated CPR and she was taken to an emergency room via ambulance.

Patient #1 was admitted to the facility on a "Legal 2000" (State of Nevada's involuntary civil commitment process) on 05/17/11, with the diagnosis of schizoaffective disorder. The Legal 2000-R indicated that she was placed on involuntary status because "subject entered a doctor's office demanding to be given mediation because (someone) poisoned her she threatened to kill her self and said she was tired of living. She was very violent with officers upon contact."

A record review of the clinical record revealed that Patient #1 was placed on "Q 5" (every five minute) checks when she was admitted. She was then placed on "Q15" checks on 05/19/11. Her physician, Employee #6, was interviewed on 06/01/11 at 12:28 PM. Employee #6 indicated that Patient #1 was first put onto every 5 minute checks, and that after the staff had the opportunity to observe her behavior, the checks were changed to every 15 minutes. The physician indicated that prior to the suicide attempt, Patient #1 had a history of being non-compliant in taking her medications.

A document titled, "Acute Psychiatric Progress Note," dated 05/21/2011, indicated Patient #1 "states having no choice but to die" and she had suicidal thoughts. The "level of observation" listed was every 15 minute checks.

A note written by Patient #1, and dated 05/21/2011, stated, "I will soon to die. I don't want to die. But No. Choice... I love you everyone!".

On 06/01/2011, the facility provided an "Interoffice Memorandum" dated 01/05/2011. The document stated in part, "Patients at high risk for safety: self harm, suicidality, heightened risk of danger to self or others may be placed on Q 5 Observation."

Patient #1's 05/25/2011 observation sheet recorded that Patient #1 got up at 4:30 AM and went to the nurse's station. On subsequent checks she also spent time in her room and in the bathroom. A nursing note written at 6:30 AM indicated that Patient #1 "slept most of the night. Pt is demanding medication that is not scheduled until 0800. Nurses explained this to the pt, pt returned 15 minutes later requesting same medication." At 7:45 AM, she was observed to be in the day room.

On 06/01/11, Employee #1, the Chief Operating Officer, provided the policy titled, "Patient Observation and Milieu Progress Note." The document details how to perform surveillance to ensure the safety of the patients. The document stated in part, "Visually observe patients when behind closed bathroom doors by: Knocking on bathroom door, announce that they are stepping into the bathroom for rounds, open the door and visually observe the safety of the patient."

On 07/21/2011, the document, "Spring Mountain Treatment Center Policy & Procedure," dated 11/10, was reviewed. The document indicated that when a patient is on an every 15 minute observation level, staff should "maintain visual and verbal contact sufficient to monitor the patient's condition of a frequency level as ordered by the physician." The policy does not direct staff to visualize the environment. The Las Vegas Metropolitan Police Incident Report, dated 06/07/2011, stated that Patient #1 was found "hanging from the neck with a torn up sheet suspending her from a shower curtain tract that had Velcro hanging from it." Patient #1's "Patient Observation Rounds" record only her behavior and location. There was no evidence that her environment had been observed for items that were out of place, concealed, and normal or abnormal room presentation.

On 06/01/2011, Employee #5, a Registered Nurse and the Assistant Director of Nursing, was interviewed. Employee #5 indicated that he got to work at 7:30 AM on 05/25/11. Employee #5 indicated that between 7:30 AM and 8:00 AM, he saw Patient #1 in the day room. Employee #5 indicated that he later heard the code called and he then went to Patient #1's room. Employee #5 then indicated the first thing he saw was the Patient's nurse cutting the sheet that Patient #1 was hanging from. Employee #5 indicated that the staff began CPR, and he noticed the patient's lips were cyanotic.

On 06/01/11, Employee #3, the Registered Nurse assigned to care for Patient #1, was interviewed. Employee #3 indicated that on 05/25/11, she was administering medications to patients when she heard a code called. Employee #3 indicated that she saw Patient #1 hanging by a sheet and went to get scissors and cut the patient down. CPR was started.

On 06/01/11, Employee #4, was interviewed. Employee #4 indicated that he responded to the code and tried to take the sheet off of Patient #1, but could not, so he lifted her up while the nurse cut the sheet, and Employee #4 then lowered her to the floor. Employee #4 indicated he was assigned to wait outside for the ambulance and let the paramedics onto the unit. Employee #4 indicated that after the paramedics arrived, he took other patients outside.

On 06/01/11, Employee #2, the technician assigned to care for Patient #1 on 05/25/11, was interviewed. Employee #2 indicated that after making the 7:45 AM rounds, a male patient began to act out. Employee #2 wanted to redirect him, so she offered to take patients outside at 7:55 AM. Employee #2 indicated that she went to go invite Patient #1 outside and to do her safety check, and found the patient hanging from a sheet. Employee #2 indicated that she called a code and the nurse cut the patient down from the sheet.

Employee #6, the physician, indicated that she was on duty on 05/25/11, and that she got to work at 7:40 AM and was seeing patients when she heard someone yell for help. Employee #6 found Patient #1 unresponsive and "purple" in color. CPR was initiated. Patient #1 was ventilated with the ambu bag and Oxygen. Employee #6 indicated that staff twice tried to use the AED (automated external defibrillator), but the patient's rhythm was not shockable.

Employee #7, the risk manager, was interviewed on 06/01/11. Employee #7 indicated that she responded to patients when the code was called, and that she took patients outside and accounted for those patients. Employee #7 indicated that after the paramedics took Patient #1 out of the building, that the police conducted an investigation that took about three hours.

Employee #7 provided the document titled, "Patient Incident." The document summarized Patient #1's suicide attempt and staff response. The section, "Findings and Recommendations," indicated that "...the patient tied Velcro strips together and then tied a sheet with the Velcro ties. The patient removed a drawer from the wardrobe in order to stand on in order to reach the hanging sheet... Action: On May 25, 2011, the metal track that housed the Velcro strips was removed. Velcro strips were adhered to the shower enclosure and then onto the shower curtain. This allows for Velcro to Velcro in order to eliminate any hanging risk with weight bearing. Drawers on the wardrobes were removed on May 25, 2011."

Patient #1's clinical records at the acute care facility to which she was transferred were reviewed. A "Consultation Report," dated 05/27/2011, stated, "Patient presented to (facility's emergency room) where at that time patient was in cardiac arrest...patient had not been exhibiting any brain stem reflexes." The assessment on the document stated, "we strongly suspect permanent anoxic brain injury. Prognosis appears quite poor..."


2. This complaint was originally a self report submitted by the facility. On 06/06/2011, the facility submitted a document titled, "Patient Incident." The document indicated that Patient #2's mother had informed the facility that Patient #2 was dead. Subsequent investigation indicated that the cause of death was hanging and the manner of death was suicide. After a record review of Patient #2's clinical record, the self report was changed to a complaint. On 06/21/2011, an onsite investigation was conducted.

Patient #2, a 17 year old female, was readmitted to the facility on 05/02/2011. Her "Comprehensive Assessment Tool" listed the presenting problem as "Pt (Patient) transported by mother. Mother reports daughter was caught stealing sleeping pills at Smith's and told loss prevention as an attempt to complete suicide." The document listed her history of illness to include social withdrawal irritability, poor impulse control, and aggression. Her history describes cutting herself, bingeing and purging, punching walls, rebellious behavior, and obsessive thoughts in regard to "dying."

Patient #2's "Adolescent Nursing Assessment," dated 05/02/2011, stated that the patient "...explained she has a 'general dislike for life', and that she had suicidal ideation with a plan to overdose on sleeping pills, and had cut herself with an exacto knife." Her "Psychosocial Assessment" also indicated that she had recently been sexually abused.

The facility's Policy and Procedure titled, "Provision of Care Plan" (policy number PC.138), dated August 2009, described the Adolescent Treatment Program that Patient #1 was admitted to on 05/02/2011. The description included "the treatment of adolescents, ages 12 through 17, with primary psychiatric diagnoses...the program operates 24 hours per day; seven days per week in an acute care setting." On 05/06/2011, Patient #2 was discharged from the inpatient program.

On 05/09/2011, Patient #2 was admitted to the facility's "Partial Hospitalization Program (PHP). Policy and Procedure PHP.16, dated August 2010, described the program. "The Partial Hospitalization Program is designed for patients who will benefit from a structure (sic), supervised treatment setting...The program consists of intensive programming Monday through Friday."

Patient #2's "Safety Crisis Plan," dated 05/09/2011, described her goals for healthy behavior, warning signs, triggers, coping skills, and a list of people to call. Her goals included "take my meds, exercise, eat well, stretch, no cutting." The call list included 911 and 1-800-SUICIDE (784-2433). The document also stated that Patient #2 "reports he/she does not have access to prescription medications for use other than as prescribed or access to weapons, lethal medications, and/or other means of self harm." The document was signed by her support person and a staff member, but the patient had not signed the document.

A "Health History Nursing Assessment Update" for Patient #2, dated 05/09/2011, listed the "changes that have occurred since inpatient Nursing Assessment" as "none".

Patient #2's clinical record indicated that she received two daily medications with the "indications for use" listed as "mood" (the medications were Prozac and Seroquel).

Patient #2's "Brief Psychiatric Re-Evaluation," dated 05/09/2011, stated, "She purged once a day on the weekend...She reports thoughts of suicide 'I was so close' references past attempt. Unable to list reason she's still alive...feels 'suicidal' in that she can't achieve goal."

An "Individual & Family Progress Note," dated 05/10/2011, stated, "Pt admitted to purging 1 x 1 day ... Pt said that she thinks that 'things happen for a reason' so can't explain why she is still alive." A "Weekly Nursing Note," dated 05/10/2011, documented that Patient #2 "admits to thoughts of death and feels hopeless."

An "Individual & Family Progress Note," dated 05/12/2011, stated, "Mom reports continued concern over pt's education and eating disorder... scheduled family session onsite for ... 5/18."

An "Individual & Family Progress Note" for Patient #2, dated 05/13/2011, indicated "pt was also given workbook activities surrounding body image and the entire self harm workbook."

An "Individual & Family Progress Note," dated 05/17/2011, documented that Patient #2 "Reports that she has had thoughts of cutting but hasn't b/c (because) 'nothing to cut with' and 'scissors isn't sharp enough'... Pt says that she sometimes still thinks that she wants to die & have 'eternal sleep'...Pt admit to sneaking out last night & not getting home until 4 AM."

An "Individual & Family Progress Note" for Patient #2, dated 05/18/2011, indicated that she had discussed her sexual abuse. "Pt admitted to purging last night... will complete 10 schools & 10 reasons to live by next (treatment) team..."

Patient #2's "Multi-Disciplinary Daily Flow Sheet," dated 05/20/2011, indicated that she "reluctantly committed to the group to do 'whatever it takes' to stay off of drugs & alcohol not self harm, & not purge this wknd." The summary stated, "Pt continuing to have a difficult time getting any significant period of time where she doesn't either have suicidal thoughts, self harm, or purge...she said she had gone years w/o (without) being able to go a whole night w/o doing 'something'."

A "Weekly Nursing Note," dated 05/24/2011, documented that Patient #2 "...has sad affect. She states she last purged 05/20/11. Patient cut yesterday. Pt continues to have poor self body image. Pt reports thoughts of suicide with plan to hang herself in the closet. Pt snuck out of the house 2 nights ago... Patient has made minimal effort to complete tx (treatment) work regarding 10 reasons to live." The document stated, "Mood: (Use Patient Quotes) 'sad'." This note identified both "thoughts" of suicide and a "plan" to commit the act of suicide.

On 06/21/2011, Employee #9, the Director of Clinical Services, a psychologist, was interviewed if Patient #2's thoughts of suicide by hanging herself were a red flag. Employee #9 indicated that thoughts of suicide and plans to commit suicide were different, so that when thoughts are expressed by patients, staff would ask questions about whether there were issues that would keep the patient from suicide. Employee #9 also indicated that she would find out whether a patient was "future oriented," and had plans for their future. On 06/21/2011, the facility provided the document titled, "Suicide Risk in Adolescents." The document stated in part: "... Inquiry should include suicide plans ("If you were to kill yourself, how would you do it?")..."

Employee #8, a Marriage and Family Therapist, was interviewed on 06/21/2011. Employee #8 indicated during every treatment team meeting, Patient #2 was asked if she was thinking of hurting herself. The therapist indicated that when Patient #2 talked about hanging herself in the closet, she asked the patient what kept her from killing herself, and the patient stated that she did not want to hurt her parents.

On 06/21/2011 at 1:00 PM, Employee #1, the Chief Operating Officer, was interviewed if Patient #2's statements on 05/24/2011 about hanging herself would be a red flag. Employee #1 indicated that she would consider this suicidal statement a red flag and that she does not know why the staff working with Patient #2 did not. Employee #1 further indicated that the expectation would be that the patient would be reassessed that day by the physician. A review of Patient #2's "Assessments and Evaluations" in her clinical record indicated that the most recent assessment was conducted on 05/09/2011.

An "Individual & Family Progress Note" for Patient #2, dated 05/24/2011, stated, "Pt said that she cut herself yesterday - had a bad day. Pt. reports feeling very sad 'just don't like who I am"... Pt. said that she has had thoughts about suicide (hanging herself in the closet) but doesn't do it b/c (because) she doesn't want her parents to find her hanging. She said that yesterday she couldn't think of reasons to live." A "Psychiatric Progress Note," dated 05/24/2011, indicated that a team meeting was held. The note further stated that Patient #2 reported feeling "really sad lately" and documented that she continued to experience suicidal ideation with "desire to hang self in the closet. Doesn't act due to (illegible) on family. Gets SAT scores back (illegible) - She has future plans - signed up for the next test."

A 05/27/2011 "Multi-Disciplinary Daily Flow Sheet" for Patient #2 indicated that weekend safety was discussed and that "Pt completed recovery safety plan but struggled a bit in doing so b/c she said that she doesn't think she has a problem. While she was very reluctant to sign commitment to good weekend behavior, she did sign."

An "Individual & Family Progress Note" for Patient #2, dated 05/31/2011, documented that a treatment team meeting was held. "Pt. reports 'worst weekend ever' says that she purged like she 'used to' (2 x daily). Pt. says that she really wants to get better but that she still is 'thinking sad'... Pt. says that she wanted to cut all weekend but she didn't."

A "Weekly Nursing Note", dated 05/31/2011, stated "Pt reports having the worst weekend ever. She reports purging 2 x/day. Pt states is constantly sad. Pt's affect is flat. Mood: (Use Patient Quotes) 'sad'."

A "Psychiatric Progress Note", dated 05/31/2011, documented Patient #2's mood as "still sad."

An "Individual & Family Progress Note" for Patient #2, dated 06/01/2011, stated, "Also talked (with pt about homework assignments. She said that didn't like the self harm one much but will continue working on the others and meet (with) therapist tomorrow to discuss progress."

An "Individual & Family Progress Note" dated 06/03/2011, for Patient #2, stated, "Mom took lock off bathroom door and turned toilet off on pt's bathroom (has to use mom's)." On 06/21/2011, Employee #8, a Marriage and Family Therapist, was interviewed. Employee #8 clarified that she spoke to the mother about safety and privacy concerns. The therapist further indicated that she reassured the patient's mother that her daughter's safety was important and that it was all right to remove the door lock.

A "Multi-Disciplinary Daily Flow Sheet," dated 06/03/2011, indicated that Patient #2 attended a Process Group. The document stated, "...Another peer told pt that he was afraid for her. Pt. (reluctantly) agreed not to cut self this wknd." The summary of this report stated, "Pt seemed to realize this week that she is very 'other focused' and doesn't feel like she has reasons to live other than for other people..."

The facility submitted a self report to Health Care Quality and Compliance on 06/06/2011. The document stated that the transporter for the facility went to pick up Patient #2 and take her to the program. At that time, "...he was told by police that the patient would no longer require the facility's services." Patient #2's physician later "received a phone call from the patient's mother stating that the patient had died and that the mother had been instructed by the coroner's office to contact the facility. No information was obtained regarding cause of death at that time."


3. Patient #3 was admitted to the facility on 05/30/2011 at 3:40 PM, with the diagnosis of mood disorder. On 07/07/2011, his clinical record was reviewed. A Progress Note, dated 05/30/2011, indicated that Patient #3 was admitted with a sad and flat affect, and was oriented to person, place, and time. He was assessed by a nurse, and then introduced to the group. The note stated that at 4:05 PM, a peer (Patient #4) "ran up to patient striking him in the nose." First Aide was provided. Patient #3's Memorandum of Transfer document that he was transferred to the emergency room at 4:20 PM for a facial fracture.

Patient #4 was admitted to the facility on 05/15/2011, with diagnoses that included paranoid schizophrenia and asthma. On 07/07/2011, Patient #4's clinical record was reviewed. Patient #4's Restraint/Seclusion Order/Record, dated 05/23/2011, indicated that at 5:25 PM, Patient #4 "hit male peer 2 times in head" when he was in the gym. At that time, he was not allowed back into the gym.

Patient #4's Restraint/Seclusion Order/Record, dated 05/27/2011, indicated that at 4:45 PM, Patient #4 "attacked peer throwing punches & hitting him." At that time, his treatment plan was modified to reflect that Patient #4 was placed on 1:1 monitoring by staff and that he was to be separated from peers by ten feet. The document stated that the patient's perception of the incident was that a peer was "picking on him." The staff's perception was that the patient had been "taunted by peer since previous day."

Patient #4's Restraint/Seclusion Order/Record, dated 05/27/2011, noted that at 6:00 PM, Patient #4 "hit the wall and had physical altercation with female peers."

Patient #4's Physician's Order Sheet, dated 05/27/2011, stated 1 on 1 precaution with a 10 foot separation was ordered for him.

Patient #4's Restraint/Seclusion Order/Record, dated 05/30/2011, indicated that at 4:05 PM, Patient #4 was responding "to internal stimuli, ran up to peer and punched him in the nose."

On 07/07/2011 at 11:00 AM, Employee #1, the Chief Operating Officer, was interviewed. Employee #1 indicated that Employee #10, the Mental Health Technician assigned to maintain the 1 on 1 precautions for Patient #4 had not returned to work for family reasons. Employee #1 further stated that the facility would conduct written counseling when he returned. Employee #1 provided the Corrective Action Notice that she planned to give to Employee #10. The Notice stated:

"We have viewed these events on the surveillance video. On 5/30/11 you were assigned to a patient on a 1:1."

From the "Patient Observation Rounds Expectations and Acknowledgement Training,"
When assigned to a patient who is on increased level of observation (i.e.; constant observation, 1:1, arms length, line of sight, etc.), I will:
-Remain close enough to the patient to assure the patient's safety is maintained at all times.
-Not engage in other activities that divert my attention, such as reading, (other than observation rounds information, conversing with other patients of staff members about non-related rounds issues, etc.

You were observed further than an arms length from your assigned patient. The patient walked out of the dayroom and you followed the patient. The patient then turned around and walked back into the dayroom and walked towards another patient on the other side of the room. You did not follow the patient back across the room and did not maintain a 'no further than an arms length' distance from your assigned patient. Your assigned patient then punched another patient in the face. The purpose of a 1:1 is to assure patient safety, your failure to follow procedure created an un-safe environment."

Based on interview and record review, the facility did not provide outpatient services that met the needs of 1 of 10 sampled patients (Patient #2). (Condition)

Findings include:

On 05/09/2011, Patient #2 was admitted to the facility's "Partial Hospitalization Program (PHP). Facility's Policy and Procedure PHP.16, dated August 2010, described the program as, "The Partial Hospitalization Program is designed for patients who will benefit from a structure (sic), supervised treatment setting...The program consists of intensive programming Monday through Friday."

Patient #2's "Safety Crisis Plan", dated 05/09/2011, described her goals for healthy behavior, warning signs, triggers, coping skills, and a list of people to call. Her goals included "take my meds, exercise, eat well, stretch, no cutting." The call list included 911 and 1-800-SUICIDE (784-2433). The document also stated that Patient #2 "reports he/she does not have access to prescription medications for use other than as prescribed or access to weapons, lethal medications, and/or other means of self harm." The document was signed by her support person and a staff member, but the patient had not signed the document.

A "Health History Nursing Assessment Update" for Patient #2, dated 05/09/2011, listed the "changes that have occurred since inpatient Nursing Assessment" as "none".

Patient #2's clinical record indicated that she received two daily medications with the "indications for use" listed as "mood" (the medications were Prozac and Seroquel).

Patient #2's "Brief Psychiatric Re-Evaluation, dated 05/09/2011, stated, "She purged once a day on the weekend...She reports thoughts of suicide 'I was so close' references past attempt. Unable to list reason she's still alive...feels 'suicidal' in that she can't achieve goal."

An "Individual & Family Progress Note," dated 05/10/2011, stated, "Pt admitted to purging 1 x 1 day ... Pt said that she thinks that 'things happen for a reason' so can't explain why she is still alive." A "Weekly Nursing Note," dated 05/10/2011, documented that Patient #2 "admits to thoughts of death and feels hopeless."

An "Individual & Family Progress Note," dated 05/12/2011, "Mom reports continued concern over pt's education and eating disorder... scheduled family session onsite for ... 5/18."

An "Individual & Family Progress Note" for Patient #2, dated 05/13/2011, stated, "pt was also given workbook activities surrounding body image and the entire self harm workbook."

An "Individual & Family Progress Note," dated 05/17/2011, documented that Patient #2 "Reports that she has had thoughts of cutting but hasn't b/c (because) 'nothing to cut with' and 'scissors isn't sharp enough'... Pt says that she sometimes still thinks that she wants to die & have 'eternal sleep'...Pt admit to sneaking out last night & not getting home until 4 AM."

An "Individual & Family Progress Note," for Patient #2, dated 05/18/2011, indicated that she had discussed her sexual abuse. "Pt admitted to purging last night... will complete 10 schools & 10 reasons to live by next (treatment) team..."

Patient #2's "Multi-Disciplinary Daily Flow Sheet," dated 05/20/2011, stated that Patient #2 "reluctantly committed to the group to do 'whatever it takes' to stay off of drugs & alcohol not self harm, & not purge this wknd." The summary stated, "Pt continuing to have a difficult time getting any significant period of time where she doesn't either have suicidal thoughts, self harm, or purge...she said she had gone years w/o (without) being able to go a whole night w/o doing 'something'."

A "Weekly Nursing Note," dated 05/24/2011, documented that Patient #2 "has sad affect. She states she last purged 05/20/11. Patient cut yesterday. Pt continues to have poor self body image. Pt reports thoughts of suicide with plan to hang herself in the closet. Pt snuck out of the house 2 nights ago... Patient has made minimal effort to complete tx (treatment) work regarding 10 reasons to live." The document stated, "Mood: (Use Patient Quotes) 'sad'." This note identified both "thoughts" of suicide and a "plan" to commit the act of suicide.

On 06/21/2011, Employee #9, the Director of Clinical Services, a psychologist, was interviewed if Patient #2's thoughts of suicide by hanging herself were a red flag. Employee #9 indicated that thoughts of suicide and plans to commit suicide were different, so that when thoughts are expressed by patients, Employee #9 would ask questions about whether there were issues that would keep the patient from suicide. Employee #9 also indicated that she would find out whether a patient was "future oriented," and had plans for their future. On 06/21/2011, the facility provided the document titled "Suicide Risk in Adolescents." The document stated in part: "... Inquiry should include suicide plans ("If you were to kill yourself, how would you do it?")..."

Employee #8, a Marriage and Family Therapist, was interviewed on 06/21/2011. Employee#8 indicated during every treatment team meeting, Patient #2 was asked if she was thinking of hurting herself. The therapist stated that when Patient #2 talked about hanging herself in the closet, she asked the patient what kept her from killing herself, and the patient indicated that she did not want to hurt her parents.

On 06/21/2011 at 1:00 PM, Employee #1, the Chief Operating Officer, was interviewed if Patient #2's statements on 05/24/2011, about hanging herself would be a red flag. Employee #1 indicated that she would consider this suicidal statement a red flag and that she does not know why the staff working with Patient #2 did not. Employee #1 further indicated that the expectation would be that the patient would be reassessed that day by the physician. A review of Patient #2's "Assessments and Evaluations" in her clinical record indicated that the most recent assessment was conducted on 05/09/2011.

An "Individual & Family Progress Note" for Patient #2, dated 05/24/2011, stated, "Pt said that she cut herself yesterday - had a bad day. Pt. reports feeling very sad 'just don't like who I am"... Pt. said that she has had thoughts about suicide (hanging herself in the closet) but doesn't do it b/c (because) she doesn't want her parents to find her hanging. She said that yesterday she couldn't think of reasons to live." A "Psychiatric Progress Note," dated 05/24/2011, indicated that a team meeting was held. The note further stated that Patient #2 reported feeling "really sad lately" and documented that she continued to experience suicidal ideation with "desire to hang self in the closet. Doesn't act due to (illegible) on family. Gets SAT scores back (illegible) - She has future plans - signed up for the next test."

A 05/27/2011 "Multi-Disciplinary Daily Flow Sheet" for Patient #2 stated that weekend safety was discussed and that "Pt completed recovery safety plan but struggled a bit in doing so b/c she said that she doesn't think she has a problem. While she was very reluctant to sign commitment to good weekend behavior, she did sign."

An "Individual & Family Progress Note" for Patient #2, dated 05/31/2011, documented that a treatment team meeting was held. "Pt. reports 'worst weekend ever' says that she purged like she 'used to' (2 x daily). Pt. says that she really wants to get better but that she still is 'thinking sad'... Pt. says that she wanted to cut all weekend but she didn't."

A "Weekly Nursing Note," dated 05/31/2011, stated, "Pt reports having the worst weekend ever. She reports purging 2 x/day. Pt states is constantly sad. Pt's affect is flat. Mood: (Use Patient Quotes) 'sad'." A "Psychiatric Progress Note," dated 05/31/2011, documented Patient #2's mood as "still sad."

An "Individual & Family Progress Note" for Patient #2, dated 06/01/2011, stated, "Also talked (with pt about homework assignments. She said that didn't like the self harm one much but will continue working on the others and meet (with) therapist tomorrow to discuss progress."

An "Individual & Family Progress Note," dated 06/03/2011, for Patient #2, stated, "Mom took lock off bathroom door and turned toilet off on pt's bathroom (has to use mom's)." On 06/21/2011, Employee #8, a Marriage and Family Therapist, was interviewed. Employee #8 clarified that she spoke to the mother about safety and privacy concerns. The therapist further indicated that she reassured the patient's mother that her daughter's safety was important and that it was all right to remove the door lock.

A "Multi-Disciplinary Daily Flow Sheet," dated Friday, 06/03/2011, indicated that Patient #2 attended a Process Group. The document stated, "...Another peer told pt that he was afraid for her. Pt. (reluctantly) agreed not to cut self this wknd." The summary of this report stated, "Pt seemed to realize this week that she is very 'other focused' and doesn't feel like she has reasons to live other than for other people..."

Patient #2 was discovered on 06/06/2011, after she committed suicide by hanging.