HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.
Based on review of the clinical record, policies/procedures, hospital documentation, observation, and interviews with staff, for 1 of 10 patients (Patient #1), the hospital failed to ensure that a patient who expressed suicidal ideation's and had made self-injurious gestures was adequately assessed and/or was not provided with adequate nursing supervision and/or neglected to ensure the patient's safety by not providing a safe environment that resulted in harm when the patient made a suicide attempt by hanging in his/her bedroom using an article of clothing attached to a window lock.


Please refer to A144 and A145

Based on review of the clinical record, policies/procedures, hospital documentation, observation, and interviews with staff for 1 of 10 patients (Patient #1), the hospital failed to ensure that a patient who expressed suicidal ideation's and had made self-injurious gestures was adequately assessed and/or was not provided with adequate nursing supervision and/or neglected to ensure the patient's safety by not providing a safe environment that resulted in harm when the patient made a suicide attempt by hanging in his/her bedroom using an article of clothing attached to a window lock. The findings include:


a. Review of the clinical record identified Patient #1 was admitted involuntarily to the hospital on 8/16/13 after expressing suicidal ideation's with the intent to hang him/her-self. Patient #1's diagnosis included major depression, generalized anxiety disorder and somatoform disorder (physical complaints that result in treatment being sought or that results in significant impairment). Patient #1 indicated he/she had chronic muscle pain which was the cause for his/her suicidal thoughts. Interview with MD #1 on 8/26/13 at 11:00 AM identified that Patient #1's chronic muscle pain had been assessed on multiple occasions prior to admission that included physical examinations and laboratory blood work that did not identify a medical reason for the pain. MD#1 identified that his/her observation of Patient #1's behaviors and mannerisms did not correlate with the muscular pain that the patient reported. However, due to Patient #1's continued complaints of muscular pain, a medical consult was ordered on 8/20/13.


Patient #1 had a history of multiple suicidal attempts that included overdosing on medications, alcohol poisoning, and attempts at strangulation. Vegetative symptoms included insomnia, anergia (decreased energy), a poor appetite and decreased concentration. An initial psychiatric evaluation was conducted on admission and Patient #1 was assessed as a low suicide risk. Patient #1 reported he/she did not want to harm him/herself, but reported that strangulation was a form of relief from the muscle pain. Physician's orders dated 8/16/13 directed an observation status of every five minutes.

A treatment plan dated 8/19/13 identified that Patient #1 had a history of suicidal attempts by strangulation stating "I choke myself until I pass out to get a moment of freedom from pain." Although the patient's goal was to remain safe, and interventions included monitoring every 5 minutes, the treatment plan neglected to address the patient's environment as it relates to strangulation hazards.

Review of a nurse's note dated 8/18/13 at 1:00 PM identified Patient #1 was observed with pajamas around his/her neck. Although the nurse's note indicated Patient #1 was using the pajama as a scarf, the facility failed to conduct a comprehensive suicidal nursing assessment after the incident in accordance with the facilities suicidal guidelines (policy). In addition, the clinical record failed to identify that the physician was notified of the suicidal gesture on 8/18/13 when it occurred.


A Physician's order dated 8/19/13 at 11:00 AM directed an increase in psychoactive medications and blood work to rule out a thyroid condition.

A nurse's note dated 8/19/13 at 2:45 PM indicated Patient #1 was again observed with pajamas around his/her neck and self-inflicted skin scratches from a plastic knife. The clinical record including nurse's and physician notes failed to identify the area of the body that was scratched. The clinical record failed to identify that nursing conducted a comprehensive assessment following the self injurious scratching and using pajama pants around the neck in accordance with the facilities suicidal guidelines (policy). The clinical record also failed to identify that a physician was notified of the suicidal gestures on 8/19/13 when they occurred.

Review of physician progress notes dated 8/20/13 identified Patient #1's responsible party indicated he/she was convinced there was a medical basis for the pain that Patient #1 was experiencing. Further review of the progress note identified and the responsible party would not take Patient #1 home until a diagnosis was made as he/she worried that the patient would "end up dead " otherwise.

Psychiatry notes dated 8/20/13 identified a 1:1 observational level was discussed with the patient due to his/her recent suicidal gestures, however Patient #1 reported that he/she was not feeling suicidal but wanted to "feel" some physical pain other than body pain. Physician's orders dated 8/20/13 at 1:00 PM directed the addition of an antidepressant, a benzodiazepine trial for anxiety, and a consult with a medical physician related to the body pain. MD#1 discussed Patient #1 using a rubber band (typically used around a wrist and snapped) as a deflection mechanism to deter self-injurious behavior.

On 8/20/13, Patient #1 was reassessed and continued to be identified as a low suicide risk "due to safety of hospital." Although the patient was already on five minute checks, the psychiatrist thought the patient was on fifteen minute checks and ordered five minute observational checks with a room assignment to continue in front of the nurse's station. Interview with Psychiatrist #1 on 8/26/13 at approximately 11:00 AM identified that despite thinking he/she was changing Patient #1's status to five minute checks, he/she felt that every 5 minute checks remained appropriate and would not have placed the patient on continuous observation based on his/her assessment.

Interview and review of the clinical record with Mental Health Worker (MHW) #1 on 8/27/13 identified that on 8/21/13 at 4:58 AM, Patient #1 was awake and calm in his/her room and at 5:03 AM Patient #1 was observed in his/her room in front of the window not responding to staff. MHW #1 moved closer to the window and found Patient #1 hanging from a ligature point i.e. "latch" attached to the window with pajama bottoms. Patient #1 was removed from the window, placed on the floor with the absence of respirations and a pulse. An emergency code was activated and cardiopulmonary resuscitation (CPR) was initiated immediately. A pulse was palpated at approximately 5:15 AM. The emergency medical service (EMS) arrived at 5:20 AM, continued life saving measures and transported Patient #1 to an acute care hospital.

Although the hospital conducted a yearly environmental risk assessment in 2013 prior to the incident, the hospital failed to identify the potential for the window latch as a hanging hazard. The "latch" had originally been placed to minimize elopement risk and had been in place for many years. The "latch" on the window was positioned approximately five feet from the floor, was painted the same color as the the window trim and extended out approximately one inch. Subsequent to this incident, the facility conducted an environmental assessment and removed all ligature points from the patient windows that were identified as a hazard, prior to 8/22/13.


On 8/20/13 from 11:00 PM until 8/21/13 at 7:00 AM, three patients were on five minute checks and fourteen patients were on fifteen minute checks.

On 8/21/13 from 5:00 AM to 5:03 AM, MHW #1 was alone on the adolescent unit while the RN and a MHW were on their breaks.

Interview with Nurse Manager #1 on 8/26/13 at 2:10 PM identified that a licensed nurse should have been on the unit with two mental health workers at all times. Nurse Manager #1 could not identify why the hospital staffing protocol was not followed. Further interview with Nurse Manager #1 indicated although five minute checks were documented as ordered insufficient staffing resulted in an unsafe environment.


The hospital guideline (policy) for suicidal assessment directed in part the mental health professional would address the patient's immediate safety and develop interventions to further guide the care of the patient. Important domains of a suicide assessment are three areas of focus; intent to die, the severity of ideation, and the degree of planning. Assessment questions would include but are not limited to; how serious on a scale of one to ten do you want to die? Are there things or people in your life that keep you from trying to kill yourself? How often do you have these thoughts? How long do the thoughts last? Are the thoughts increasing in intensity and frequency? How likely is it you could actually carry out the plan to kill yourself? Have you done anything to put the plan in action? Can you stop yourself from killing yourself?

The hospital policy for client observation levels directed in part in the absence of medical staff, a registered nurse may initiate special observation (five minute or one to one observation), and notify medical staff immediately to obtain an order, and to further assess the client for additional clinical considerations.

The hospital patient care manual directed in part the registered nurse would assess and re-assess each patient throughout hospitalization. Data is collected according to the patient's immediate condition or need. Data may include, but was not limited to the patient's ability to remain safe and not be a danger to oneself.


Observation and tour of the pediatric/adolescent unit on 8/27/13 between 4:30 AM and 5:15 AM identified a census of fourteen combined pediatric/adolescent patients. One registered nurse and four mental health workers were assigned to the unit. One adolescent patient was on a one to one observational status. Upon arrival to the unit, the registered nurse was on her break and the unit was unattended by a licensed staff member. Interview with Nurse Supervisor #2 on 8/27/13 at 4:40 AM identified the nursing supervisor did not cover any hospital unit when the registered nurse was on break and/or unavailable.

Based on review of the clinical record, policies/procedures, hospital documentation, observation, and interviews with staff for 1 of 10 patients (Patient #1), the hospital neglected to provide psychiatric care and services to ensure that a patient who expressed suicidal ideation's and had made self-injurious gestures were adequately assessed and/or provided with adequate nursing supervision and/or provided a safe environment that resulted in harm when the patient made a suicide attempt by hanging in his/her bedroom using an article of clothing attached to a window lock. The finding included:


a. Review of the clinical record identified Patient #1 was admitted involuntarily to the hospital on 8/16/13 after expressing suicidal ideation's with the intent to hang him/her-self. Patient #1's diagnosis included major depression, generalized anxiety disorder and somatoform disorder (physical complaints that result in treatment being sought or that results in significant impairment). Patient #1 indicated he/she had chronic muscle pain which was the cause for his/her suicidal thoughts. Interview with MD #1 on 8/26/13 at 11:00 AM identified Patient #1's chronic muscle pain had been assessed on multiple occasions prior to admission that included physical examinations and laboratory blood work that did not identify a medical reason for the pain. MD#1 identified that his/her observation of Patient #1's behaviors and mannerisms did not correlate with the muscular pain that the patient reported. However, due to Patient #1's continued complaints of muscular pain, a medical consult was ordered on 8/20/13.


Patient #1 had a history of multiple suicidal attempts that included overdosing on medications, alcohol poisoning, and attempts at strangulation. Vegetative symptoms included insomnia, anergia (decreased energy), a poor appetite and decreased concentration. An initial psychiatric evaluation was conducted on admission and Patient #1 was assessed as a low suicide risk. Patient #1 reported he/she did not want to harm him/herself, but reported that strangulation was a form of relief from the muscle pain. Physician's orders dated 8/16/13 directed an observation status of every five minutes.

A treatment plan dated 8/19/13 identified that Patient #1 had a history of suicidal attempts by strangulation stating "I choke myself until I pass out to get a moment of freedom from pain." Although the patient's goal was to remain safe, and interventions included monitoring every 5 minutes, the treatment plan neglected to address the patient's environment as it relates to strangulation hazards.

Review of a nurse's note dated 8/18/13 at 1:00 PM identified Patient #1 was observed with pajamas around his/her neck. Although the nurse's note indicated Patient #1 was using the pajama as a scarf, the facility failed to conduct a comprehensive suicidal nursing assessment after the incident in accordance with the facilities suicidal guidelines (policy). In addition, the clinical record failed to identify that the physician was notified of the suicidal gesture on 8/18/13 when it occurred.


A Physician's order dated 8/19/13 at 11:00 AM directed an increase in psychoactive medications and blood work to rule out a thyroid condition.

A nurse's note dated 8/19/13 at 2:45 PM indicated Patient #1 was again observed with pajamas around his/her neck and self-inflicted skin scratches from a plastic knife. The clinical record including nurse's and physician notes failed to identify the area of the body that was scratched. The clinical record failed to identify that nursing conducted a comprehensive assessment following the self injurious scratching and using pajama pants around the neck in accordance with the facilities suicidal guidelines (policy). The clinical record also failed to identify that a physician was notified of the suicidal gestures on 8/19/13 when they occurred.

Review of physician progress notes dated 8/20/13 identified Patient #1's responsible party indicated he/she was convinced there was a medical basis for the pain that Patient #1 was experiencing. Further review of the progress note identified the responsible party would not take Patient #1 home until a diagnosis was made as he/she worried that the patient would "end up dead " otherwise.

Psychiatry notes dated 8/20/13 identified a 1:1 observational level was discussed with the patient due to his/her recent suicidal gestures, however Patient #1 reported that he/she was not feeling suicidal but wanted to "feel" some physical pain other than body pain. Physician's orders dated 8/20/13 at 1:00 PM directed the addition of an antidepressant, a benzodiazepine trial for anxiety, and a consult with a medical physician related to the body pain. MD#1 discussed with Patient #1 using a rubber band (typically used around a wrist and snapped) as a deflection mechanism to deter self-injurious behavior.

On 8/20/13, Patient #1 was reassessed and continued to be identified as a low suicide risk "due to safety of hospital." Although the patient was already on five minute checks, the psychiatrist thought the patient was on fifteen minute checks and ordered five minute observational checks with a room assignment to continue in front of the nurse's station. Interview with Psychiatrist #1 on 8/26/13 at approximately 11:00 AM identified that despite thinking he/she was changing Patient #1's status to five minute checks, he/she felt that every 5 minute checks remained appropriate and would not have placed the patient on continuous observation based on his/her assessment.

Interview and review of the clinical record with Mental Health Worker (MHW) #1 on 8/27/13 identified that on 8/21/13 at 4:58 AM, Patient #1 was awake and calm in his/her room and at 5:03 AM Patient #1 was observed in his/her room in front of the window not responding to staff. MHW #1 moved closer to the window and found Patient #1 hanging from a ligature point i.e. "latch" attached to the window with pajama bottoms. Patient #1 was removed from the window, placed on the floor with the absence of respirations and a pulse. An emergency code was activated and cardiopulmonary resuscitation (CPR) was initiated immediately. A pulse was palpated at approximately 5:15 AM. The emergency medical service (EMS) arrived at 5:20 AM, continued life saving measures and transported Patient #1 to an acute care hospital.

Although the hospital conducted a yearly environmental risk assessment in 2013 prior to the incident, the hospital failed to identify the potential for the window latch as a hanging hazard. The "latch" had originally been placed to minimize elopement risk and had been in place for many years. The "latch" on the window was positioned approximately five feet from the floor, was painted the same color as the the window trim and extended out approximately one inch. Subsequent to this incident, the facility conducted an environmental assessment and removed all ligature points from the patient windows that were identified as a hazard, prior to 8/22/13.


On 8/20/13 from 11:00 PM until 8/21/13 at 7:00 AM, three patients were on five minute checks and fourteen patients were on fifteen minute checks.

On 8/21/13 from 5:00 AM to 5:03 AM, MHW #1 was alone on the adolescent unit while the RN and a MHW were on their breaks.

Interview with Nurse Manager #1 on 8/26/13 at 2:10 PM identified that a licensed nurse should have been on the unit with two mental health workers at all times. Nurse Manager #1 could not identify why the hospital staffing protocol was not followed. Further interview with Nurse Manager #1 indicated although five minute checks were documented as ordered insufficient staffing resulted in an unsafe environment.


The hospital guideline (policy) for suicidal assessment directed in part the mental health professional would address the patient's immediate safety and develop interventions to further guide the care of the patient. Important domains of a suicide assessment are three areas of focus; intent to die, the severity of ideation, and the degree of planning. Assessment questions would include but are not limited to; how serious on a scale of one to ten do you want to die? Are there things or people in your life that keep you from trying to kill yourself? How often do you have these thoughts? How long do the thoughts last? Are the thoughts increasing in intensity and frequency? How likely is it you could actually carry out the plan to kill yourself? Have you done anything to put the plan in action? Can you stop yourself from killing yourself?

The hospital policy for client observation levels directed in part in the absence of medical staff, a registered nurse may initiate special observation (five minute or one to one observation), and notify medical staff immediately to obtain an order, and to further assess the client for additional clinical considerations.

The hospital patient care manual directed in part the registered nurse would assess and re-assess each patient throughout hospitalization. Data is collected according to the patient's immediate condition or need. Data may include, but was not limited to the patient's ability to remain safe and not be a danger to oneself.

The Condition of Participation for Nursing Services has not been met.

Based on a review of the clinical record, policies/procedures, facility documentation, observation, and interviews, for 1 of 10 patients (Patient #1), reviewed for suicidal ideation and had made self-injurious gestures the hospital failed to adequately assessed and/or provided appropriate nursing supervision and/or failed to ensure adequate staffing to promote a safe environment resulting in harm when the patient made a suicide attempt by hanging in his/her bedroom using an article of clothing attached to a window lock. The finding included:

Please see A392

Based on a review of the clinical record, policies/procedures, hospital documentation, observation, and interviews, for 1 of 10 patients (Patient #1), reviewed for suicidal ideation and who had made self-injurious gestures, the hospital failed to ensure that the patient was adequately assessed and/or provided appropriate nursing supervision and/or failed to ensure adequate staffing to promote a safe environment resulting in harm when the patient made a suicide attempt by hanging in his/her bedroom using an article of clothing attached to a window lock. The finding included:


Review of the hospital's census on 8/20/13 from 11:00 PM until 7:00 AM on 8/21/13 was as follows; five pediatric patients and seventeen adolescent patients. Two pediatric patients were on five minute checks and three pediatric patients were on fifteen minute checks. On the adolescent unit, three adolescent patients were on five minute checks and fourteen patients were on fifteen minute checks.


Review of the hospital's staffing pattern with Nurse Manager #1 on 8/26/13 at 2:00 PM identified that one registered nurse and three mental health workers were required for a census of twenty two or less. On 8/20/13 from 11:00 PM until 7:00 AM on 8/21/13 one registered nurse and three mental health workers were assigned to the pediatric/adolescent unit.


Interview with RN #1 on 8/27/13 who was assigned to the unit identified that he/she usually took a break from 4:00 AM to 5:00 AM, however on 8/21/13, did not go to break until 4:30 AM (with permission from the nursing supervisor). Interview with Nurse Supervisor #1 on 8/26/13 at 10:00 AM indicated he/she covered all units of the hospital and did not stay on any one unit to cover the licensed staff during their meal times. MHW #2 left the unit from 5:00 to 6:00 AM for break and MHW #3 was covering the pediatric section of the unit (which is attached to the adolescent unit). From 5:00 AM to 5:03 AM, MHW #1 was alone on the adolescent unit.


Review of the clinical record identified Patient #1 was admitted involuntarily to the hospital on 8/16/13 after expressing suicidal ideation's with the intent to hang him/her-self. A Physician's order dated 8/16/13 directed an observation status of every five minutes.


Interview and review of the clinical record with MHW #1 on 8/27/13 identified on 8/21/13 at 4:58 AM Patient #1 was awake and calm in his/her room. At 5:03 AM Patient #1 was observed in his/her room in front of the window not responding to staff. MHW #1 moved closer to the window and found Patient #1 hanging from a ligature point i.e."latch" attached to the window with pajama bottoms. Patient #1 was removed from the window, placed on the floor with the absence of respirations and a pulse. An emergency code was activated and cardiopulmonary resuscitation (CPR) was initiated immediately. A pulse was palpated at approximately 5:15 AM and the emergency medical service (EMS) arrived at 5:20 AM, continued life saving measures and transported Patient #1 to an acute care hospital.


Interview and review of the staffing pattern with Nurse Manager #1 on 8/26/13 at 2:10 PM identified a licensed nurse should have been on the unit with two mental health workers at all times and Nurse Manager #1 could not identify why the hospital staffing protocol was not followed. Further interview with Nurse Manager #1 indicated although five minute checks were documented as ordered insufficient staffing resulted in an unsafe environment.


Observation and tour of the pediatric/adolescent unit on 8/27/13 between 4:30 AM and 5:15 AM identified a census of fourteen combined pediatric/adolescent patients. One registered nurse and four mental health workers were assigned to the unit. One adolescent patient was on a one to one observational status. Upon arrival to the unit, the registered nurse was on her break and the unit was unattended by a licensed staff member. Interview with Nurse Supervisor #2 on 8/27/13 at 4:40 AM identified the nursing supervisor did not cover any hospital unit when the registered nurse was on break and/or unavailable.