HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure that patients were provided care in a safe environment, free from self-harm.

Failure to protect patients from self-harm places patients at risk for serious physical harm and death.

Findings included:

Failure to implement effective policies and procedures to care for suicidal patients, keep suicidal patients safe, and prevent patient elopement.

Cross Reference: A-0144

Due to the severity of deficiency under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET.

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Item #1 Suicide Monitoring

Based on observations, interviews, and record reviews, the hospital failed to appropriately monitor and prevent patient elopement for 1 of 1 patients reviewed (Patient #1).

Failure to ensure care in a safe environment by monitoring and preventing the elopement of suicidal patients risks violation of patient rights, serious injury, or death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Suicide Screening and Risk Mitigation in Non-Psychiatric Departments," PolicyStat ID 16083101, last approved 11/20/24, showed the following:

a. The Columbia Suicide Severity Rating Scale (C-SSRS) screening tool will be completed on admission for all patients 12 and older by nursing staff or a licensed provider.

b. All patients who are identified as low risk for suicide must have close observation.

c. All patients who are identified as moderate risk must have a constant observer.

d. All patients who are identified as high risk must not be left alone, and a 1:1 observer will be initiated.

e. To decrease monitoring levels to close observation or no observation, a mental health professional, attending physician, or licensed provider must assess and document their recommendation for the reduced monitoring.

f. The nurse will complete the C-SSRS daily shift screen for patients who were previously low, moderate, or high risk at least twice each calendar day.

Document review of the hospital's patient handout titled, "Patient Rights and Responsibilities," last revised 01/13/25, showed that all patients have the right to receive care in a safe setting.

2. Investigator #1, Investigator #2, the Quality Assurance Registered Nurse (Staff #101), and the Director of Women's and Children's Services (Staff #102) reviewed Patient #1's medical record. The review showed the following:

a. On 02/25/25 at 7:15 PM, Patient #1 returned to the Emergency Department (ED) 2 hours after discharge from a previous hospitalization for an intentional overdose of 72 prescription fluoxetine (a medication used to treat depression) pills. At 8:16 PM, the Columbia Suicide Severity Rating Scale (C-SSRS) showed that the patient was at high risk for suicide. A 1:1 observer was initiated, and the provider was notified. On 02/26/25 at 9:50 AM, the patient was evaluated by a psychiatrist who documented that the patient needed around-the-clock supervision. On 02/26/25 at 7:41 PM, the patient was assessed by a pediatric hospitalist who admitted the patient and ordered a 1:1 observer. The patient was admitted to a dedicated behavioral health room with a 1:1 observer on the 3-South Pediatric unit on 02/26/25 at 8:21 PM.

b. On 03/07/25 at 1:00 PM, the patient self-harmed by hitting their head against the wall and punching themselves in the face. On 03/10/25 at 12:15 PM, the patient ran past their 1:1 observer, out of the unit, and into an elevator where the patient began cutting their arm and neck with a tack before hospital staff stopped the patient. On 03/11/25 at 10:44 PM, the patient attempted to stab themselves in the eye after taking supplies from a cart. On 03/12/25, the patient was observed attempting to remove curtain hooks from the ceiling. On 03/13/25, the patient made statements of running away and self-harm, then punched themselves in the head and tried to stab themselves in the eye with a power plug. That same day, remote visual monitoring began and continued concurrently with the 1:1 observer.

c. On 03/17/25, the patient made multiple statements about wanting to leave, attempted to walk out of their room, and when stopped by the nurse, they tried to grab items from the nurse's pockets. The patient then threatened to jump from their bed. Later that same day, the patient unplugged their remote visual monitor and made statements of wanting to stab themselves in the eye, threatened to punch their 1:1 observer, and ended up spitting on their 1:1 observer. On 03/19/25, the patient was showering and was observed shoving a shower cap down their throat until they coughed it out. On 03/26/25, the patient was observed writing a note that stated they would make everyone think they were okay and not depressed, then hang themselves, cut their veins, or jump off a high building.

d. On 04/04/25, documentation showed that the remote visual monitoring was discontinued; however, there was no evidence of a provider or mental health provider assessment or documentation of recommendations for the reduced monitoring.

e. On 04/08/25, documentation showed that the 1:1 observation was discontinued; however, there was no evidence of a provider or mental health provider assessment or documentation of recommendations for the reduced monitoring.

f. On 04/09/25, nursing notes showed that the patient was found standing on the counter in their room and made statements of feeling isolated, lonely, and confined. The patient remained shut in the room with no call light or television remote and few personal belongings.

g. Security footage showed that on 04/13/25 at 5:30 PM, the patient walked off the unit and entered the elevator. At 5:46 PM, security footage showed the patient on the 4th level of the hospital parking garage. Security reports showed that at 6:03 PM, security officers located the patient, and immediately after, the patient was observed jumping over the edge of the parking garage. The patient suffered non-survivable injuries and died 2 hours later in the hospital ED.

3. On 04/28/25 at 4:55 PM, Investigator #1 interviewed Staff #102. Staff #102 stated that the discussion to discontinue Patient #1's 1:1 observation did not include the leadership of the unit.

4. On 04/28/25 between 3:25 PM and 4:15 PM, Investigator #1 interviewed pediatric nurses who were involved in Patient #1's care (Staff #103, #104, and #105). Staff #103, Staff #104, and Staff #105 all stated that they were concerned about the discontinuation of Patient #1's 1:1 observation and were not included in the decision-making process to discontinue the 1:1 observation. Staff stated that nursing staff and security staff implemented a door alarm to alert them if the patient attempted to exit their room.

5. On 04/30/25 at 9:30 AM, Staff #101 and Staff #102 confirmed the investigators' findings of the missing provider or mental health professional assessments and documented recommendations for Patient #1's reduced monitoring levels on 04/04/25 and 04/08/25.

Item #2 Missing Child Alert

Based on interviews, record reviews, and policy review, the hospital failed to implement policies and procedures to ensure staff notified security dispatch immediately following the discovery of a missing pediatric patient at high risk for suicide for 1 of 1 patients reviewed (Patient #1).

Failure to activate emergency responses without delays puts patients at risk for physical and psychological harm, potential adverse outcomes, or death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Missing Child (previously known as Amber Alert)," PolicyStat ID 18044172, last approved 04/28/25, showed the following:

a. The missing child alert system is a hospital-wide overhead page to alert staff of a potential missing or abducted child or actual missing or abducted child.

b. Upon discovery of a missing child, staff will call the security dispatch number and identify that there is a missing child and the location. Security will notify the operator who will overhead page "Missing Child."

c. If a description of the missing child is available, the operator will overhead page the descriptors and a house-wide search will begin.

d. All available staff throughout the hospital will immediately check all adjacent main hallways and exit areas to and from their department or unit. Staff will remain at the exits and observe for anyone who is accompanied by a child or anyone attempting to leave the building with a child.

2. The investigators reviewed the medical record of Patient #1. The review showed the following:

a. On 02/25/25 at 7:15 PM, Patient #1 returned to the ED 2 hours after discharging from a previous hospitalization due to a suicide attempt by intentional overdose of fluoxetine. On 02/26/25 at 8:21 PM, the patient was transferred to the 3-South pediatric unit as a social admit while waiting for suitable placement with around-the-clock supervision. The patient had episodes of attempts at self-harm or actual self-harm on 03/07/25, 03/10/25, 03/11/25, 03/13/25, 03/17/25, and 03/19/25.

b. On 03/10/25, the patient attempted to elope from the hospital. On 03/13/25 and 03/17/25, the patient made statements and threats of eloping from the hospital.

c. On 03/26/25, the patient had written a suicide plan that stated they would make everyone think they were okay and not depressed, then hang themselves, cut their veins, or jump off a high building.

3. The investigators reviewed security documents and video of Patient #1's elopement from the hospital. The review showed that on 04/13/25 at 5:30 PM, the patient walked off the unit and entered the elevator. At 5:34 PM, nursing staff noted that Patient #1 was not in their room. At 5:44 PM, 11 minutes later, a "Missing Child" alert was activated. At 5:46 PM, security footage showed Patient #1 on the 4th level of the hospital parking garage. At 6:03 PM, security officers located the patient in the garage and witnessed Patient #1 jump off the edge and fall from the 4th floor to the ground. The patient was transported to the ED and was pronounced dead 2 hours later.

4. On 04/28/25 at 4:25 PM, Investigator #1 interviewed a pediatric nurse (Staff #105). Staff #105 stated that multiple caregivers and other members of Patient #1's treatment team would often take the patient for walks or to the gym without communicating this to the patient's nurse. Staff #105 stated that the delay in activating the "Missing Child" alert occurred because 3-South pediatrics staff believed the patient was with another staff member, so they checked the unit before activating the alert.

Item #3 Columbia Suicide Severity Risk Scale (C-SSRS)

Based on interviews, record reviews, and policy review, the hospital failed to ensure staff completed focused nursing assessments for 4 of 8 patients who were identified to have suicidal ideation (SI) during their hospitalization (Patients #1, #2, #3, and #4).

Failure to perform focused suicide risk assessments places patients at risk for inadequate monitoring, poor outcomes, physical harm, and death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Suicide Screening and Risk Mitigation in Non-Psychiatric Departments," PolicyStat ID 16083101, last approved 11/20/24, showed the following:

a. The Columbia Suicide Severity Rating Scale (C-SSRS) screening tool will be completed on admission for all patients 12 and older by nursing staff or a licensed provider.

b. The nurse will complete the C-SSRS daily shift screen for patients who were previously low, moderate, or high risk at least twice each calendar day.

2. The investigators reviewed the medical records of 4 discharged and 4 current patients. The review showed the following:

Patient #1

On 02/25/25 at 7:15 PM, Patient #1 returned to the ED 2 hours after discharging from a previous hospitalization due to a suicide attempt by intentional overdose of fluoxetine. A C-SSRS was completed at 8:16 PM and showed high risk for suicide. On 02/26/25 at 8:21 PM, the patient was transferred to the 3-South pediatric unit as a social admit while waiting for suitable placement with around-the-clock supervision. On 04/13/25 at 5:30 PM, the patient eloped from the hospital and ended their life by jumping off the 4th story of the hospital's parking garage. Between the patient's admission time and the time of their elopement from the hospital, the patient was missing 64 out of 92 C-SSRS screenings.

Patient #2

On 04/18/25 at 10:31 PM, Patient #2 was admitted to the neurology unit after a suspected seizure. The patient was assigned a 1:1 observer for behavioral reasons. The patient did not receive an initial C-SSRS admission screening until 04/22/25 at 9:15 AM, when they scored low risk. On 04/27/25, the patient scored a moderate risk. Between the patient's admission time and 04/29/25, the patient was missing 18 out of 21 C-SSRS screenings.

Patient #3

On 03/14/25 at 3:59 PM, Patient #3 was admitted to the intensive care unit after a suicide attempt by intentional overdose. At 9:13 PM, the patient received their initial C-SSRS admission screening and scored as a high risk. Between the patient's admission time through 04/29/25, the patient was missing 88 out of 88 C-SSRS screenings.

Patient #4

On 04/18/25 at 1:55 PM, Patient #4 was admitted to the hospital for medical reasons. On 04/18/25 at 2:27 PM, the patient received their admission C-SSRS screening and scored as a moderate risk. Remote visual monitoring was initiated immediately and continued through 04/29/25. Between the patient's admission time through 04/29/25, the patient was missing 1 out of 22 C-SSRS screenings.

3. At the time of the review, the Quality Assurance Registered Nurse (Staff #101) and the Director of Women's and Children's Services (Staff # 102) confirmed the missing C-SSRS screenings. Staff #102 stated that the hospital expects that patients at risk for suicidal ideation receive 2 daily C-SSRS screenings.

Item #4 MD Assessment/Justification

Based on interviews, record reviews, and policy review, the hospital failed to ensure providers assessed and documented their recommendation for downgrading suicidal monitoring for 2 of 8 patients who were identified to have suicidal ideation (SI) during their hospitalization (Patients #1 and #3).

Failure to perform assessments and provide recommendations for downgrading monitoring places patients at risk for inadequate monitoring, poor outcomes, physical harm, and death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Suicide Screening and Risk Mitigation in Non-Psychiatric Departments," PolicyStat ID 16083101, last approved 11/20/24, showed the following:

a. The Columbia Suicide Severity Rating Scale (C-SSRS) screening tool will be completed on admission for all patients 12 and older by nursing staff or a licensed provider.

b. All patients who are identified as low risk for suicide must have close observation.

c. All patients who are identified as moderate risk must have a constant observer.

d. All patients who are identified as high risk must not be left alone, and a 1:1 observer will be initiated.

e. To decrease monitoring levels to close observation or no observation, a mental health professional, attending physician, or licensed provider must assess and document their recommendation for the reduced monitoring.

Patient #1

2. Investigators reviewed hospital documents, security video, and the medical record for Patient #1. The review showed the following:

a. On 02/25/25 at 7:15 PM, Patient #1 returned to the ED 2 hours after discharging from a previous hospitalization due to a suicide attempt by intentional overdose of fluoxetine. At 8:16 PM, the Columbia Suicide Severity Rating Scale (C-SSRS) showed that the patient was at high risk for suicide. A 1:1 observer was initiated, and the provider was notified. On 02/26/25 at 9:50 AM, the patient was evaluated by a psychiatrist who documented that the patient needed around-the-clock supervision. On 02/26/25 at 7:41 PM, the patient was assessed by a pediatric hospitalist who admitted the patient and ordered a 1:1 observer. On 02/26/25 at 8:21 PM, the patient was transferred to the 3-South pediatric unit.

b. On 03/13/25, the patient made statements of running away and self-harm, and then punched themselves in the head and tried to stab themselves in the eye with a power plug. That same day, remote visual monitoring began and continued concurrently with the 1:1 observer.

c. On 04/02/25, the last documented medical provider assessment, a pediatric hospitalist note showed that the plan was to continue suicide and self-harm precautions.

d. On 04/04/25, documentation showed that the remote video monitoring was discontinued; however, there was no evidence of a provider or mental health provider assessment and no documentation of recommendations for the reduced monitoring.

e. On 04/08/25, a pediatric psychiatrist's note showed that the patient acknowledged that they lacked the full ability to manage their suicidal and self-harm thoughts and behaviors without restrictive measures and close supervision around their triggers. The provider documented that the patient's family was not able to provide appropriate supervision of the patient, and the plan was to continue pursuing long-term residential treatment.

f. On 04/08/25, documentation showed that the 1:1 observation was discontinued; however, there was no evidence of a provider or mental health provider assessment and no documentation of recommendations for the reduced monitoring. Nursing staff and security staff implemented a door alarm to alert them if the patient attempted to exit their room.

g. Security footage showed that on 04/13/25 at 5:30 PM, the patient walked off the unit and entered the elevator. At 5:34 PM, nursing staff noted that Patient #1 was not in their room, and after an 11-minute delay, a "Missing Child" alert was activated. At 5:46 PM, security footage showed Patient #1 on the 4th level of the hospital parking garage. At 6:03 PM, security officers located the patient in the garage and witnessed Patient #1 jump off the edge and fall from the 4th floor to the ground. The patient was transported to the ED and was pronounced dead 2 hours later.

Patient #3

3. Medical record review showed that on 03/14/25 at 3:59 PM, Patient #3 was admitted to the intensive care unit after a suicide attempt by intentional overdose. At 9:13 PM, the patient received their initial C-SSRS admission screening and scored as a high risk. No mitigating interventions were initiated until a 1:1 observation order was placed for impulsive behavior on 03/17/25 at 10:33 AM. On 03/18/25 at 8:12 AM, the 1:1 observer was pulled for other duties and did not resume until 7:00 PM that same day. There was no evidence of a provider or mental health provider assessment, and no documentation of recommendations for the reduced monitoring.

On 03/22/25 at 8:45 AM, the 1:1 observer was discontinued, and remote visual monitoring was started. There was no order for the downgrade, no evidence of a provider or mental health provider assessment, and no documentation of recommendations for the reduced monitoring. On 03/24/25 at 3:35 PM, the 1:1 observer order was discontinued by a nurse.

4. On 04/30/25 at 9:30 AM, the Quality Assurance Registered Nurse (Staff #101) and the Director of Women's and Children's Services (Staff #102) verified the missing provider assessments and documentation.