HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the right to receive care in a safe setting for one of one patient (Patient #8) in 09/2017 and eight unidentified patients at the time of survey.

1. Patient #8 had been admitted in 09/2017 with daily suicidal thoughts and reported a suicide attempt by overdose prior to admission. Two weeks into Patient #8's hospitalization, the patient used the hooks in a public bathroom to hang self. Patient #8 died.
2. At the time of survey, eight unidentified patients were surveyor observed to have unsupervised access to plastic ware that could be broken into sharp-edged pieces during a patient self-harm attempt.

Findings included:

1. Record review of Patient #8's Intake Integrated Assessment dated 09/01/17 at 1740 reflected the patient was admitted with self-harming and suicidal thoughts, decreased eating and sleeping. The patient had superficial lacerations on the left forearm from previous self-harm attempts.

Nursing Progress Notes dated 09/14/17 at 1325 reflected that Patient #8 "refused all groups...withdrawn and isolates."

Nursing Progress Notes dated 09/14/17 for the 1500 to 2300 shift reflected the patient was depressed, irritable, anxious, preoccupied, and felt very hopeless.

Nursing Notes dated 019/14/17 at 2230 reflected Patient #8 refused to take the evening medications. There was no evidence of a nursing assessment and/or intervention. Forty minutes later, at 2310 the mental health technician notified nursing staff that Patient #8 was "in the [the] hall bathroom with door locked...light on and no response from...[Patient #8]...unlocked [door] with a screw driver...patient found against [the] door...green ligature around neck and around hinge of bathroom door...unresponsive...color blue/gray..."

Patient #8's Physician Progress Notes dated and signed by Personnel #4 on 09/15/17 at 0830 reflected the patient was "...doing well...no suicidal...ideation..."

Patient #8's Physician Discharge Summary dated and signed by Personnel #3 on 09/15/17 at 0800 did not reflect the hanging incident the previous night.

During an interview on 10/12/18 at 1245, Personnel #6 stated Patient #8 had locked self in the bathroom, used a hook inside the bathroom and spandex tights for ligature to hang self.

A letter dated 09/15/17 reflected the Dallas County Medical Examiner's Office "was conducting an investigation into the death of...[Patient #8]."



2. Observations on the hospital's military unit on 10/12/18 at 1255 reflected eight patients ate their lunch meal in a dining room off the main hallway. Two persons with identification badges, identified later as nursing students by Personnel #6, had turned their backs to the patients and watched TV. A table close to the door to the hallway had a bin with plastic spoons accessible to patients. There was no staff in the room at that time which left patients with the potential to hide plastic ware as contraband for later use during a self-harm attempt.

On 10/12/18 at 1258, an unidentified male patient left the dining room and disposed of his plastic ware in the trash. The patient's actions were unobserved by staff.

During an interview on 10/12/18 at approximately 1315, Personnel #6 acknowledged the surveyor observation.

The US Department of Veterans' Affairs (VA) National Center for Patient Safety recommended an inpatient mental health environment with a care safety checklist that observed for objects with "sharp edges" potentially usable in patients' self-harm attempts (https://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp)