HospitalInspections.org

Based on observation, review of medical records and policies, and interviews with administrative and clinical staff, the facility failed to safeguard and uphold the rights of adolescent patients in the facility. Failure to do so resulted in:

A. Two adolescent patients were not assessed daily for suicide risk even after the facility determined that a daily suicide risk assessment needed to be performed. The first patient was a 14-year-old male, admitted into the facility following a suicide attempt by jumping from a second story balcony. He also had a history of self-mutilation by neurotic excoriations and cutting with a knife. The second patient was a 17-year-old male, admitted into the facility following an automobile vs. pedestrian collision. He made a suicide attempt by suffocation with a plastic bag in his bedroom while confined to a wheelchair.

B. As part of the Suicide Risk Assessment, nurses documented the degree of suicide risk to be low, moderate, or high for two adolescent patients. There was no clearly defined criteria for making this determination by RN and LVN staff members. Administrative staff reported that there was no validated and reliable tool in use to define the degree of suicide risk.

C. Staff members (comprised of RNs and LVNs) documented that a patient was on "close observation." Administrative staff reported that "close observation" was not an accepted level of precaution and that there was no policy that outlined the use of this term. It was also reported that some staff members confused "close observation" with "one-on-one" precautions.

D. The policy, "Suicide Precautions," neither referenced nor provided instruction on completion of a suicide risk assessment. Administrative staff reported that there was no policy to provide guidance to the nurse for the completion of the Suicide Risk Assessment.

Cross reference: CFR 483.21 A0144 Patient Rights

Based on observation, review of medical records and policies, and interviews with administrative and clinical staff, the facility failed to provide care in a safe setting for adolescent patients. Failure to do so resulted in:


A. 2 of 2 adolescent patients (patient #1 and patient #3) were not assessed daily for suicide risk even after the facility determined that a daily suicide risk assessment needed to be performed. Patient #1, a 14-year-old male, was admitted into the facility post a suicide attempt by jumping from a second story balcony. He also had a history of neurotic excoriation and self-mutilation by cutting with a knife. Patient #3, a 17-year-old male, was admitted following an automobile vs. pedestrian collision. He made a suicide attempt by suffocation with a plastic bag in his bedroom while confined to a wheelchair.


Findings:

Record review of World Psychiatry - Official Journal of the World Psychiatric Association, 2017 Feb; 16(1): 28-29, "Suicide Risk Assessment: Tools and Challenges," by Maria A. Oquendo, MD, PhD and Joel A. Bernanke, MD (Columbia University of Psychiatry) showed: "The World Health Organization estimates that over 800,000 people die by suicide each year, and for each suicide as many as 20 more individuals have attempted suicide. The assessment and management of suicide risk is considered a core competency for psychiatrists. Risk assessment and management is best conceptualized as a process - not a single event - that includes structured evaluation, intervention, and reassessment ..."


Patient #1.

Record review of Pediatric Psychiatry Consultation Note by Staff E (MD) dated 3/26/2019 at 1:26 PM and modified on 3/26/2019 at 3:53 PM showed, Patient #1 was a 14-year-old ninth-grade male with a past psychiatric history of depression and attention deficit hyperactivity disorder [ADHD]. He had jumped from a second story balcony in a suicide attempt. He also had a history of self-mutilation in the form of cutting. He had two past inpatient psychiatric hospitalizations.

Record review of Orthopedic Surgery Trauma Consultation Note by Staff D (MD) dated 3/25/2019 at 6:29 PM showed, B closed calcaneus [mid heel bone] fractures with skin at risk, a right talus [ankle] fracture, and left tibia [larger bone between knee and ankle] and fibula [larger bone between knee and ankle] fractures. To operating room on 3/25/2019 urgently for closed reduction and percutaneous pin B calcaneus fractures and inter-medullary nailing left tibia with complex regional pain syndrome left distal tibia.

Record review of Neuropsych Initial Consult by Staff C (MD) dated 4/1/2019 at 10:41 AM showed a failed suicide attempt. In addition, the patient described commentary type hallucinations that told him they knew everything about him and "other bad stuff." These stopped about a year ago after the Abilify was started. He had a history of self-injurious behavior characterized by cutting on the anterior aspect of his upper arms with a knife. He stated he otherwise excoriated (dermatillomania) his arms with his nails.

Record review of the Suicide Risk Assessment showed the following items:

a) Suicide Ideation

b) Suicide Plan

c) Describe Plan

d) Acute Signs

e) Feelings of Hopelessness

f) Previous Suicide Attempts

g) History Family Suicide

h) History Panic Disorder

i) History Recent Loss

j) History Substance Use

k) Substance Use

l) Hallucinations

m) Impulse control Description

n) Patient Appearance

o) Loss of Daily Functioning

p) Suicide Risk Degree

q) Suicide Risk Precautions

r) Physician Notified of Suicide Risk

s) Psychologist Notified of Suicide Risk


In an interview with Staff B on 6/11/2019 at 9:35 AM, she stated, Patient #1 was admitted on 3/29/2019. He was discharged on 4/10/2019 for surgery and readmitted on 4/19/2019. He was discharged home on 5/13/2019.

Record review of suicide risk assessments for Patient #1 showed a suicide risk assessment on 3/29/2019 by Staff Y. There was no suicide risk assessment for 3/30, 3/31, and 4/1.

In an interview with Staff A and B on 6/11/2019 at 9:35 AM, they stated that during an annual survey by DNV surveyors on 4/2/2019 it was determined that a daily suicide risk assessment would be conducted by the nursing staff for Patient #1.

Record review of Patient #1's medical record for his second admission (from 4/19/2019 through 5/13/2019) showed no daily suicide risk assessments.

In an interview with Staff B on 6/11/2019 at 2:45 PM, she stated:

1) She did not know why the suicide risk assessments were not done on Patient #1 from 4/19/2019 through 5/13/2019 (his treatment dates following surgical intervention).

2) Daily suicide risk assessments should have been done on Patient #1.

3) There was not a policy on the completion of a suicide risk assessment but she was working on a policy.

4) She was looking for an evidence-based suicide risk assessment, such as the Columbia - Suicide Risk Rating Scale.



Patient #3.

Record review of History and Physical by Staff K (NP) dated 3/21/2019 at 10:49 showed Patient #3 was a 17-year-old transfer from another facility where he was treated for fractures sustained during an automobile vs. pedestrian motor vehicle accident. He had multiple severe lower extremity fractures.

Record review of Psychological Consultation Note by Staff H (PhD) dated 4/8/2019 at 5:21 PM showed: As Patient #3 progressed and encountered more potential triggers associated with his accident, "he will be closely monitored for any associated changes in his mood or behavior."

Record review of Psychological Consultation Note by Staff H (PhD) dated 4/18/2019 at 6:11 PM showed a code was called to Patient #3's room. Patient #3 was discovered with one arm tied to his chair and with the other was attempting to tighten a plastic bag around his neck. Staff removed items from the room that could be potentially used for self-harm.

Record review of Psychological Consultation Note by Staff H (PhD) dated 4/23/2019 at 5:52 PM showed Patient #3 had been upset with his grandmother during her visit. He wrapped a bag around his neck and attempted to take a photo to send to his grandmother to "make her feel sorry" when staff intervened.

Record review of Neuropsychiatry Progress Note by Staff C (MD) dated 4/25/2019 at 2:236 PM showed a review of Patient #3's suicidality and ongoing risk for self-harm. "It was clear that his interaction with his grandmother should, in no way, have precipitated a behavioral response of this nature." A safety contract was discussed.

In an interview with Staff B on 6/11/2019 at 2:45 PM, she stated that it was decided by the administrative staff to increase the assessment of suicide risk on Patient #3 from once every 24 hours to once each shift. She also stated that there was no policy for this change but a new policy would be developed.

Record review of the Suicide Risk Assessment by various nurses showed that a suicide risk assessment was not performed by nursing staff each shift for Patient #3. One suicide risk assessment was performed for five days: 4/18, 4/19, 4/23, 4/29, and 5/5/2019. On 4/29/2019 at 9:00 PM Staff Q did not perform a suicide risk assessment, but documented, "Patient off suicide [precautions]."



B. As part of the Suicide Risk Assessment, the degree of suicide risk was determined for 2 of 2 adolescent patients (patient #1 and patient #3) to be low, moderate, or high without any clearly defined criteria for making this determination by 12 of 16 staff (staff O, Q, R, S, T, U, X, Y, Z, AA, EE, and staff FF).

Findings:

Record review of the suicide risk assessment in the medical record of Patient #1 and Patient #3 does not list any criteria (or gauges) the nurse can use in the determination of the degree of suicide risk.

Record review of the suicide risk assessments for Patient #1 showed the following entries for the suicide risk degree:

3/29/2019 at 2:12 PM entry by Staff Y: low

4/2/2019 at 8:50 PM entry by Staff M: low

4/3/2019 at 12:00 PM entry by Staff EE: low

4/6/2019 at 9:00 AM entry by Staff FF: low

4/7/2019 at 9:00 AM entry by Staff FF: low

4/9/2019 at 9:00 AM entry by Staff R: low


Record review of the suicide risk assessments for Patient #3 showed the following entries for the suicide risk degree:

4/18/2019 at 4:48 PM entry by staff U: high

4/19/2019 at 3:20 PM entry by Staff U: moderate

4/20/2019 at 7:45 AM entry by Staff Q: moderate

4/20/2019 at 7:19 PM entry by Staff Y: moderate

4/21/2019 at 9:00 AM entry by Staff Z: moderate

4/21/2019 at 9:00 PM entry by Staff AA: moderate

4/22/2019 at 9:00 AM entry by Staff X: moderate

4/22/2019 at 9:00 PM entry by Staff S: moderate

4/23/2019 at 9:00 AM entry by Staff R: moderate

4/24/2019 at 9:00 AM entry by Staff R: moderate

4/24/2019 at 9:00 PM entry by Staff T: moderate

4/25/2019 at 9:00 AM entry by Staff R: moderate

4/25/2019 at 9:00 PM entry by Staff T: moderate

4/26/2019 at 7:25 AM entry by Staff O: moderate

4/26/2019 at 9:00 PM entry by Staff Q: moderate

4/27/2019 at 9:00 AM entry by Staff O: moderate

4/27/2019 at 9:00 PM entry by Staff Q: moderate

4/28/2019 at 9:00 PM entry by Staff Q: moderate

5/1/2019 at 10:13 PM entry by Staff S: moderate

5/5/2019 at 3:12 PM entry by Staff U: low

5/9/2019 at 9:00 AM entry by Staff Y: low


In an interview with Staff B on 6/11/2019 at 2:45 PM, she stated that there was no validated and reliable tool in use to define the degree of suicide risk. She also stated that she had asked the nursing staff to NOT rate the degree of suicide risk (low, moderate, or high) because of the subjectivity of that determination.



C. 8 of 16 staff members (staff O, P, Q, R, S, T, U, and staff FF) documented on the suicide risk assessments for Patient #1 and Patient #3 that the patients were on "close observation" though "close observation" was not an accepted level of precaution.

Findings:

Record review of the suicide risk assessment for Patient #1 dated 4/9/2019 at 9:00AM by Staff FF showed: Precautions: Close Observation.

Record review of the suicide risk assessments for Patient #3 showed that Close Observation was documented as a precaution on:

4/23/2019 at 9:00 AM entry by Staff R

4/24/2019 at 9:00 AM entry by Staff R

4/24/2019 at 9:00 PM entry by Staff T

4/25/2019 at 9:00 AM entry by Staff R

4/25/2019 at 9:00 PM entry by Staff T

4/26/2019 at 7:25 AM entry by Staff O

4/26/2019 at 9:00 PM entry by Staff Q

4/27/2019 at 9:00 AM entry by Staff O

4/27/2019 at 9:00 PM entry by Staff Q

4/28/2019 at 9:00 PM entry by Staff Q

4/29/2019 at 9:00 AM entry by Staff O

4/30/2019 at 9:00 PM entry by Staff P

5/1/2019 at 10:13 PM entry by Staff S

5/5/2019 at 3:12 PM entry by Staff U


In an interview with Staff B on 6/11/2019 at 2:45 PM, she stated that there was no policy that outlined use of this term "Close Observation," and that some staff members confused the term "close observation" with "one-on-one" precautions. She also stated that the appropriate level of education and training needed to be done with staff on this issue and a policy needed to be developed.



D. The policy, "Suicide Precautions," neither references nor provides instruction on completion of a suicide risk assessment. There is no policy for the Suicide Risk Assessment.

Findings included:

In an interview with Staff B on 6/11/2019 at 2:45 PM, she stated that the policy, "Suicide Precautions," was developed as a result of the annual DNV survey, April, 2019.

Record review of the policy, "Suicide Precautions," issued 4/2019 showed: I. Purpose:

To provide guidelines to be followed when screening for potential suicide risks, as well as the appropriate plan of care if they are identified ...

II. Policy:

It is our policy to screen all patients over the age of five (5) years who:

a) Have a history of prior suicidal attempts,

b) Formally diagnosed major depressive disorder, with or without psychotic ideation

c) Those who exhibit new signs or symptoms of major depressive disorder, with or without psychotic ideation accompanied by suicidal thoughts or expressions of the wish to harm him or herself ...

As part of the pre-admission evaluation and criteria review before admission, all patients who are actively suicidal or in crisis will be denied admission until they are not an imminent risk of harming themselves and psychiatrically stable, unless they have significant medical conditions which would prevent them from being admitted to a psychiatric facility under their current licensure. For crisis that occur during hospitalization, the patient may be transferred to a licensed psychiatric hospital if they are accepted and can be managed medically in such a facility.

III. Procedure:

At the time of admission, if there is a history of suicidal attempt or the patient is exhibiting symptoms of suicidal thoughts or ideation, self-harm, or depression, the licensed clinical staff will perform a suicide risk assessment (only patients over the age of 5 years) ... Suicide precautions will be implemented immediately once the need is determined ...

In an interview with Staff B on 6/11/2019 at 2:45 PM, she stated a policy will be developed for the evidence-based Suicide Risk Assessment that will be initiated by the facility.