HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to:
*Have a physician assessment for one of one patient (5) prior to starting an antidepressant medication for a diagnosis of depression who committed suicide.
*Document a discussion regarding a code status change for one of one patient (5) who committed suicide.
Findings include:

1. Review of patient 5's medical record revealed:
*He had been admitted on 3/29/15.
*He had surgery on 3/30/15 for a fractured hip.
*On 4/3/15 physician assistant certified (PAC) A ordered Zoloft (an antidepressant medication for depression) at 6:40 p.m.
*The Zoloft had been recorded as given at 6:53 p.m.
*No documentation of a comprehensive assessment regarding the patient's mood or behavior, and why the antidepressant had been ordered from the nursing staff or medical staff.
*No further documentation after 4/4/15 at 2:00 a.m. from RN F stating the patient was "guarded".

Review of the providers investigation report summary of patient 5's suicide incident revealed:
*RN G saw and talked to him on 4/4/15 between 8:00-8:10 a.m. She told him she would return later with his medication.
*She returned to his room between 8:20-8:25 a.m. and found him hanging from a ceiling lift with a gait belt wrapped around his neck.
*She had pushed the code blue light, but realized his status had changed to do not resuscitate
*Patient 5 was deceased.

Interview on 4/8/15 at 1:00 p.m. with PAC A revealed:
*She had received a phone call from patient 5's nurse stating the patient and daughter had requested an antidepressant, because he was feeling a little down.
*The nurse had reported patient 5 had used an antidepressant after his heart surgery, because he had been a little depressed then.
*She had not seen or assessed the patient for suicidal thoughts that night, because she had been on call and had a busy night with six pages of phone calls.
*She had not asked if he had stated any suicidal thoughts. The nurse had not expressed if he had any significant moods or behaviors.
*She had been unsure if there was a protocol for ordering antidepressants.

Interview on 4/8/15 at 1:10 p.m. with the vice president of quality, safety, and risk management revealed there had been no policy for assessing a patient with depression prior to the initiation of antidepressant orders.



18560

2. Review of patient 5's medical record revealed:
*An internal medicine progress note by physician D dated 4/3/15 at 10:15 a.m.
-"Pt (patient) is resting comfortably in bed in denies any new complaints."
-"Code status - Full Code."
*An order by physician D dated 4/3/15 at 11:33 a.m. regarding code status.
-"Allow natural death/dnr (do not resuscitate)."
*No physician's note regarding his discussion with patient 5 on why he had requested the code status change at this time.
*No documentation of the discussion between patient 5 and registered nurses (RN) E, RN C, and RN B about changing his code status at this time.
*No documentation as to why patient 5 wanted his code status changed now.
*No documentation of the nurse's discussion with physician D regarding patient 5 wanting to change his code status.

Interview on 4/8/15 at 10:03 a.m. with RN B revealed:
*On 4/3/15 RN E, RN C, and her had done bedside report with patient 5 in his room.
*Patient 5's full code status had been mentioned.
*Patient 5 asked what the code status meant, and after it had been explained he stated he had not known that was what it was.

Interview on 4/8/15 at 1:25 p.m. with physician D revealed:
*On 4/3/15 he had visited twice with patient 5.
*After his first visit he had been at the nursing counter and a nurse had told him patient 5 wanted to change his code status.
*He again visited with patient 5 and asked if he had any questions about code status.
*He explained what his current code status was.
*He stated patient 5 clearly stated "No - I don't want those things. Do not resuscitate me."
*He then ordered patient 5's code status change.

Interview on 4/9/15 at 11:00 a.m. with the vice president of quality, safety, and risk management and the vice president of patient care revealed they were looking at how physicians documented their discussions with patients regarding code status.

Review of the provider's August 2011 Code Blue - Order for Resuscitation policy revealed "Any clarifications or modifications made to the patient directive should be documented in the patient's medical record."

Review of the provider's 3/26/15 Medical Staff Rules and Regulations revealed "A decision to not resuscitate a patient should involve the following procedure:
A. If possible, the decision not to resuscitate should be discussed with the patient, the patient's surrogate and/or family, and other involved members of the medical and nursing staff.
B. Documentation of the decision to not resuscitate should be as follows:
1. The physician should document in the progress note:
a) Statement of the patient's competency to make this health-care decision.
b) Justification for the DNR order.
c) Summary of discussions with the patient, surrogate, family, and staff."

Based on record review and interview, the provider failed to:
*Appropriately evaluate and assess one of one patient (5) who had been started on an antidepressant for a diagnosis of depression and committed suicide approximately thirteen hours after the first dose was administered.
*Appropriately assess and follow-up for two of two patients (6 and 11) who verbalized feelings of self-harm or harm to others without previous diagnosis of emotional or behavior problems.
*Document a discussion regarding changing of code status with one of one patient (5) who committed suicide.
Findings include:

1. Review of patient 5's medical record revealed:
*He had been admitted on 3/29/15.
*He had surgery on 3/30/15 for a fractured hip.
*On 4/3/15 physician assistant certified (PAC) A ordered Zoloft (an antidepressant medication for depression) at 6:40 p.m.
*The Zoloft had been recorded as given at 6:53 p.m.
*No documentation of a comprehensive assessment of depressive symptoms from nursing or medical staff regarding why the antidepressant had been ordered.

Interview on 4/8/15 at 10:03 a.m. with registered nurse (RN) B revealed:
*She had started her job in March 2015 and was still in training.
*She had been training with RN C on 4/3/15.
*She had cared for patient 5 on 4/2/15 and on 4/3/15.
*On 4/3/15 a young female family member of patient 5 (relationship unknown) had approached her and requested an antidepressant for him. She had told RN B she had not seen him that depressed in the past.
*She had not been aware of any protocol for ordering antidepressants.
*She called the on-call physician, who had been PAC A, to request the antidepressant.
*Neither RN B nor PAC A had asked the extent of patient 5's depression or if he had self-harm or suicidal thoughts.
*PAC A had asked what the patient had taken for depression in the past, but it was not known.
*RN B had asked patient 5 if he felt depressed. "He didn't say yes. He just didn't think he was going to be able to get up and moving again."

Interview on 4/8/15 at 3:30 p.m. with RN C revealed:
*She had been training RN B on 4/3/15.
*She had not cared for patient 5 prior to 4/3/15.
*RN B had called the physician for an antidepressant. RN B had told her later she had gotten the antidepressant order.
*When questioned if she would have done anything differently, she stated she would have asked the patient what was going on or what he was thinking.

Review of patient 5's medical record revealed:
*On 4/3/15 at 8:00 p.m. RN F documented:
-"He seems depressed. He stated he isn't feeling like himself."
-"Has a flat affect and showing no emotion at this time. Will continue to monitor. Guarded".

Interview on 4/8/15 at 9:35 a.m. with RN F revealed:
*She had worked the night of 4/3/15.
*She had been given report that patient 5 had started on an antidepressant.
*She had sat at the nurses' station beside his door and had observed him hourly.
*When asked what 'guarded' had meant, she stated it meant he was not really expressive; he was hesitant in telling her how he was.
*She had asked what it meant that he was not feeling himself, but he had not answered.
*She had reported the onset of patient 5's depression to RN G when she took over his care on 4/4/15 at 7:45 a.m.

Interview on 4/9/15 at 11:00 a.m. with the vice president of quality, safety, and risk management and the vice president of patient care revealed:
*There was no policy regarding assessing a patient prior to getting orders for antidepressant medication.
*They agreed depression would have been a change in a patient's status.

Review of the provider's April 2014 Interdisciplinary Assessment/Reassessment policy revealed a reassessment was to have been performed by a qualified nurse when the patient's condition changed or as needed at the professional judgement of the nurse.



18559

2a. Review of patient 6's medical record revealed:
*He had been admitted on 12/17/14.
*An admission assessment had been performed on 12/17/14 at 12:51 a.m. included the following:
-He answered yes to the question do you want to hurt self or others.
-He answered no to the question admitted with emotional or behavioral diagnosis.
*No documentation at the time of the admission assessment to clarify his answers.
*A care management medical/surgical (CM Med/Surg) assessment was performed on 12/17/14 at 10:48 a.m. and noted no interventions for mental health or psychosocial interventions were needed at this time.
*No documented suicide risk assessment, physician's orders, or interventions for suicide risk between the time of the two assessments.

b. Review of patient 11's medical record revealed:
*He had been admitted on 1/27/15.
*An admission assessment had been performed on 1/27/15 at 12:51 p.m. included the following:
-She answered yes to the question do you want to hurt self or others.
-She answered no to the question admitted with emotional or behavioral diagnosis.
*A physical assessment was performed on 1/27/15 at 4:51 p.m. with a psychosocial comment the patient was pleasant and cooperative.
*A CM Med/Surg assessment performed on 1/28/15 at 12:30 p.m. noted no interventions for mental health or psychosocial interventions were needed at this time.
*No documented suicide risk assessment, physician's orders, or interventions for suicide risk between the time of the two assessments.

c. Review of the provider's January 2012 Suicide Risk Assessment, Care Management, and Precautions policy revealed:
*"All patients admitted as inpatients will be asked if the patient is currently experiencing feelings of hopelessness and/or depression that make the patient want to hurt themselves or others.
*If the patient answers yes, the nurse will contact the provider to discuss suicide risk and obtain order for suicide precautions protocol."

d. Interview on 4/9/15 at 11:50 a.m. with the vice president of patient care regarding patients 6 and 11 revealed:
*There had been no additional suicide risk documentation in the patients' medical records.
*A suicide risk assessment should have been triggered when the patients answered yes to the question about wanting to hurt themselves or others.
*She was not sure why the suicide risk assessment had not triggered, but she would look into it.



18560

3. Review of patient 5's medical record revealed:
*An internal medicine progress note by physician D dated 4/3/15 at 10:15 a.m. stated:
-"Pt (patient) is resting comfortably in bed in denies any new complaints."
-"Code status - Full Code."
*No documentation by RN B, RN E, or RN C regarding patient 5 asking what his code
status meant.
*No documentation of a nurse discussing with physician D his request to change his code status.
*No documentation as to why he was asking about his code status at that time.
*An order by physician D dated 4/3/15 at 11:33 a.m. changing patient 5's code status to "Allow natural death/dnr (do not resuscitate)."
*No documentation by physician D of his discussion regarding code status with him nor why he requested to change his status at that time.

Interview on 4/8/15 at 10:03 a.m. with RN B revealed:
*On 4/3/15 RN E, RN C, and her had done bedside report with patient 5 in his room.
*Patient 5's full code status had been mentioned.
*Patient 5 asked what the code status meant.
*After the code status had been explained to him he stated he had not known that was what it was.

Interview on 4/8/15 at 1:25 p.m. with physician D revealed:
*On 4/3/15 he had visited twice with patient 5.
*After his first visit he had been at the nursing counter, and a nurse had told him patient 5 wanted to change his code status.
*He again visited with patient 5 and asked if he had any questions about code status.
*He explained what code status was.
*He stated patient 5 clearly stated "No - I don't want those things. Do not resuscitate me."
*He then ordered patient 5's code status changed.

Interview on 4/9/15 at 11:00 a.m. with the vice president of quality, safety, and risk management and the vice president of patient care revealed the nurses' conversation with patient 5 regarding his code status and the communication to his physician should have been documented in his medical record.

Based on observation, interview, and manufacturer's manual review, the provider failed to evaluate the ceiling hoist system as a potential suicide risk hazard for one of one ceiling hoist system used. Findings include:

1. Observation on 4/7/15 at 4:40 p.m. with the director of orthopedic, neurology, and surgery (ONS) departments and the vice president of quality, safety, and risk management of a ceiling hoist system in a patient room on the ninth floor revealed:
*The hoist was a Guldmann GH2-F flexible lifting module.
*The hoist was permanently mounted on a H frame which had been cemented into the ceiling.
*The hoist had a traveling trolley that operated along the short end of the H frame.
*The traveling trolley moved back and forth across the bed and up and down the bed.
*Attached to the traveling trolley was a hoist module.
*Attached to the hoist module was a lifting hanger for attaching a lifting sling.
*Attached to the hoist module was a hand control.
*The hand control raised or lowered the lifting hanger.
*There was a red cord attached to the hoist module that stopped the hoist from being raised or lowered.
*In order to reactivate the hoist after the red cord had been pulled a person had to reach up and reset the red cord at the unit.
*The hoist was usually stored in the upper corner of the H frame.
*The lifting hanger was usually stored in the up position closest to the hoist module.
*The hand control was usually stored around the hoist.

Further observation on 4/9/15 at 10:05 a.m. with the director of risk management and assistant director of ONS revealed:
*The hoist was usually stored in the upper corner of the H frame with the power on.
*The power remained on to ensure the battery continued to charge.
*In order to reattach the red cord a person would need to be at least five feet five inches tall.
*Most of the patient floor rooms had the hoist systems in place.
*The hoist systems had been in place since for at least five years if not longer.

Interview on 4/9/15 at 11:00 a.m. with the vice president of quality, safety, and risk management, and the vice president of patient care revealed the ceiling hoist systems:
*Had been installed as patient rooms had been remodeled.
*Had been evaluated for infection control with one lift used per patient bed.
*Had been evaluated for safety of transferring patients and for the safety of staff members.
*Had not been evaluated as a potential suicide risk hazard.

Review of the manufacturer's manual revealed the hoist "should be stored with the emergency stop activated to consumption of battery power."

Based on record review, interview, and policy review, the provider failed to:
*Have a physician assessment for one of one patient (5) prior to starting an antidepressant medication for a diagnosis of depression who committed suicide.
*Document a discussion regarding a code status change for one of one patient (5) who committed suicide.
Findings include:

1. Review of patient 5's medical record revealed:
*He had been admitted on 3/29/15.
*He had surgery on 3/30/15 for a fractured hip.
*On 4/3/15 physician assistant certified (PAC) A ordered Zoloft (an antidepressant medication for depression) at 6:40 p.m.
*The Zoloft had been recorded as given at 6:53 p.m.
*No documentation of a comprehensive assessment regarding the patient's mood or behavior, and why the antidepressant had been ordered from the nursing staff or medical staff.
*No further documentation after 4/4/15 at 2:00 a.m. from RN F stating the patient was "guarded".

Review of the providers investigation report summary of patient 5's suicide incident revealed:
*RN G saw and talked to him on 4/4/15 between 8:00-8:10 a.m. She told him she would return later with his medication.
*She returned to his room between 8:20-8:25 a.m. and found him hanging from a ceiling lift with a gait belt wrapped around his neck.
*She had pushed the code blue light, but realized his status had changed to do not resuscitate
*Patient 5 was deceased.

Interview on 4/8/15 at 1:00 p.m. with PAC A revealed:
*She had received a phone call from patient 5's nurse stating the patient and daughter had requested an antidepressant, because he was feeling a little down.
*The nurse had reported patient 5 had used an antidepressant after his heart surgery, because he had been a little depressed then.
*She had not seen or assessed the patient for suicidal thoughts that night, because she had been on call and had a busy night with six pages of phone calls.
*She had not asked if he had stated any suicidal thoughts. The nurse had not expressed if he had any significant moods or behaviors.
*She had been unsure if there was a protocol for ordering antidepressants.

Interview on 4/8/15 at 1:10 p.m. with the vice president of quality, safety, and risk management revealed there had been no policy for assessing a patient with depression prior to the initiation of antidepressant orders.



18560

2. Review of patient 5's medical record revealed:
*An internal medicine progress note by physician D dated 4/3/15 at 10:15 a.m.
-"Pt (patient) is resting comfortably in bed in denies any new complaints."
-"Code status - Full Code."
*An order by physician D dated 4/3/15 at 11:33 a.m. regarding code status.
-"Allow natural death/dnr (do not resuscitate)."
*No physician's note regarding his discussion with patient 5 on why he had requested the code status change at this time.
*No documentation of the discussion between patient 5 and registered nurses (RN) E, RN C, and RN B about changing his code status at this time.
*No documentation as to why patient 5 wanted his code status changed now.
*No documentation of the nurse's discussion with physician D regarding patient 5 wanting to change his code status.

Interview on 4/8/15 at 10:03 a.m. with RN B revealed:
*On 4/3/15 RN E, RN C, and her had done bedside report with patient 5 in his room.
*Patient 5's full code status had been mentioned.
*Patient 5 asked what the code status meant, and after it had been explained he stated he had not known that was what it was.

Interview on 4/8/15 at 1:25 p.m. with physician D revealed:
*On 4/3/15 he had visited twice with patient 5.
*After his first visit he had been at the nursing counter and a nurse had told him patient 5 wanted to change his code status.
*He again visited with patient 5 and asked if he had any questions about code status.
*He explained what his current code status was.
*He stated patient 5 clearly stated "No - I don't want those things. Do not resuscitate me."
*He then ordered patient 5's code status change.

Interview on 4/9/15 at 11:00 a.m. with the vice president of quality, safety, and risk management and the vice president of patient care revealed they were looking at how physicians documented their discussions with patients regarding code status.

Review of the provider's August 2011 Code Blue - Order for Resuscitation policy revealed "Any clarifications or modifications made to the patient directive should be documented in the patient's medical record."

Review of the provider's 3/26/15 Medical Staff Rules and Regulations revealed "A decision to not resuscitate a patient should involve the following procedure:
A. If possible, the decision not to resuscitate should be discussed with the patient, the patient's surrogate and/or family, and other involved members of the medical and nursing staff.
B. Documentation of the decision to not resuscitate should be as follows:
1. The physician should document in the progress note:
a) Statement of the patient's competency to make this health-care decision.
b) Justification for the DNR order.
c) Summary of discussions with the patient, surrogate, family, and staff."

Based on record review and interview, the provider failed to:
*Appropriately evaluate and assess one of one patient (5) who had been started on an antidepressant for a diagnosis of depression and committed suicide approximately thirteen hours after the first dose was administered.
*Appropriately assess and follow-up for two of two patients (6 and 11) who verbalized feelings of self-harm or harm to others without previous diagnosis of emotional or behavior problems.
*Document a discussion regarding changing of code status with one of one patient (5) who committed suicide.
Findings include:

1. Review of patient 5's medical record revealed:
*He had been admitted on 3/29/15.
*He had surgery on 3/30/15 for a fractured hip.
*On 4/3/15 physician assistant certified (PAC) A ordered Zoloft (an antidepressant medication for depression) at 6:40 p.m.
*The Zoloft had been recorded as given at 6:53 p.m.
*No documentation of a comprehensive assessment of depressive symptoms from nursing or medical staff regarding why the antidepressant had been ordered.

Interview on 4/8/15 at 10:03 a.m. with registered nurse (RN) B revealed:
*She had started her job in March 2015 and was still in training.
*She had been training with RN C on 4/3/15.
*She had cared for patient 5 on 4/2/15 and on 4/3/15.
*On 4/3/15 a young female family member of patient 5 (relationship unknown) had approached her and requested an antidepressant for him. She had told RN B she had not seen him that depressed in the past.
*She had not been aware of any protocol for ordering antidepressants.
*She called the on-call physician, who had been PAC A, to request the antidepressant.
*Neither RN B nor PAC A had asked the extent of patient 5's depression or if he had self-harm or suicidal thoughts.
*PAC A had asked what the patient had taken for depression in the past, but it was not known.
*RN B had asked patient 5 if he felt depressed. "He didn't say yes. He just didn't think he was going to be able to get up and moving again."

Interview on 4/8/15 at 3:30 p.m. with RN C revealed:
*She had been training RN B on 4/3/15.
*She had not cared for patient 5 prior to 4/3/15.
*RN B had called the physician for an antidepressant. RN B had told her later she had gotten the antidepressant order.
*When questioned if she would have done anything differently, she stated she would have asked the patient what was going on or what he was thinking.

Review of patient 5's medical record revealed:
*On 4/3/15 at 8:00 p.m. RN F documented:
-"He seems depressed. He stated he isn't feeling like himself."
-"Has a flat affect and showing no emotion at this time. Will continue to monitor. Guarded".

Interview on 4/8/15 at 9:35 a.m. with RN F revealed:
*She had worked the night of 4/3/15.
*She had been given report that patient 5 had started on an antidepressant.
*She had sat at the nurses' station beside his door and had observed him hourly.
*When asked what 'guarded' had meant, she stated it meant he was not really expressive; he was hesitant in telling her how he was.
*She had asked what it meant that he was not feeling himself, but he had not answered.
*She had reported the onset of patient 5's depression to RN G when she took over his care on 4/4/15 at 7:45 a.m.

Interview on 4/9/15 at 11:00 a.m. with the vice president of quality, safety, and risk management and the vice president of patient care revealed:
*There was no policy regarding assessing a patient prior to getting orders for antidepressant medication.
*They agreed depression would have been a change in a patient's status.

Review of the provider's April 2014 Interdisciplinary Assessment/Reassessment policy revealed a reassessment was to have been performed by a qualified nurse when the patient's condition changed or as needed at the professional judgement of the nurse.



18559

2a. Review of patient 6's medical record revealed:
*He had been admitted on 12/17/14.
*An admission assessment had been performed on 12/17/14 at 12:51 a.m. included the following:
-He answered yes to the question do you want to hurt self or others.
-He answered no to the question admitted with emotional or behavioral diagnosis.
*No documentation at the time of the admission assessment to clarify his answers.
*A care management medical/surgical (CM Med/Surg) assessment was performed on 12/17/14 at 10:48 a.m. and noted no interventions for mental health or psychosocial interventions were needed at this time.
*No documented suicide risk assessment, physician's orders, or interventions for suicide risk between the time of the two assessments.

b. Review of patient 11's medical record revealed:
*He had been admitted on 1/27/15.
*An admission assessment had been performed on 1/27/15 at 12:51 p.m. included the following:
-She answered yes to the question do you want to hurt self or others.
-She answered no to the question admitted with emotional or behavioral diagnosis.
*A physical assessment was performed on 1/27/15 at 4:51 p.m. with a psychosocial comment the patient was pleasant and cooperative.
*A CM Med/Surg assessment performed on 1/28/15 at 12:30 p.m. noted no interventions for mental health or psychosocial interventions were needed at this time.
*No documented suicide risk assessment, physician's orders, or interventions for suicide risk between the time of the two assessments.

c. Review of the provider's January 2012 Suicide Risk Assessment, Care Management, and Precautions policy revealed:
*"All patients admitted as inpatients will be asked if the patient is currently experiencing feelings of hopelessness and/or depression that make the patient want to hurt themselves or others.
*If the patient answers yes, the nurse will contact the provider to discuss suicide risk and obtain order for suicide precautions protocol."

d. Interview on 4/9/15 at 11:50 a.m. with the vice president of patient care regarding patients 6 and 11 revealed:
*There had been no additional suicide risk documentation in the patients' medical records.
*A suicide risk assessment should have been triggered when the patients answered yes to the question about wanting to hurt themselves or others.
*She was not sure why the suicide risk assessment had not triggered, but she would look into it.



18560

3. Review of patient 5's medical record revealed:
*An internal medicine progress note by physician D dated 4/3/15 at 10:15 a.m. stated:
-"Pt (patient) is resting comfortably in bed in denies any new complaints."
-"Code status - Full Code."
*No documentation by RN B, RN E, or RN C regarding patient 5 asking what his code
status meant.
*No documentation of a nurse discussing with physician D his request to change his code status.
*No documentation as to why he was asking about his code status at that time.
*An order by physician D dated 4/3/15 at 11:33 a.m. changing patient 5's code status to "Allow natural death/dnr (do not resuscitate)."
*No documentation by physician D of his discussion regarding code status with him nor why he requested to change his status at that time.

Interview on 4/8/15 at 10:03 a.m. with RN B revealed:
*On 4/3/15 RN E, RN C, and her had done bedside report with patient 5 in his room.
*Patient 5's full code status had been mentioned.
*Patient 5 asked what the code status meant.
*After the code status had been explained to him he stated he had not known that was what it was.

Interview on 4/8/15 at 1:25 p.m. with physician D revealed:
*On 4/3/15 he had visited twice with patient 5.
*After his first visit he had been at the nursing counter, and a nurse had told him patient 5 wanted to change his code status.
*He again visited with patient 5 and asked if he had any questions about code status.
*He explained what code status was.
*He stated patient 5 clearly stated "No - I don't want those things. Do not resuscitate me."
*He then ordered patient 5's code status changed.

Interview on 4/9/15 at 11:00 a.m. with the vice president of quality, safety, and risk management and the vice president of patient care revealed the nurses' conversation with patient 5 regarding his code status and the communication to his physician should have been documented in his medical record.