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Based on observation, record review, and interviews with key staff on March 16-19, 2010, it was determined that the psychiatric hospital failed to protect and promote each patient's rights, including failure to provide a safe environment. This resulted in an Immediate Jeopardy to patients served by this psychiatric hospital.

Findings include:

Patient Information

Patient A's 'Comprehensive Exam' dated February 27, 2010 stated under 'Current Concerns' that Patient A was a 51 year-old admitted with increased depression for one month and increased suicidal ideation.

Patient A's 'Psychiatric Evaluation' dictated on February 28, 2010 stated that Patient A had "an increasing period of depression and hopelessness with significant suicidal ideation and plan to overdose on medications and drive somewhere where [spouse] could not find [him/her]."

The Admission Order form stated that Patient A would be on 15 minute checks.

The initial 'Plan of Care - Master Treatment Plan' was completed on March 1, 2010. It stated that the focal problem was "plan to od [overdose] and drive where [spouse] cannot find [her/him]."

In the nursing note dated March 1, 2010, Patient A was noted to have stated, "If I leave here with just doing the same thing and I only feel good for a month than I won't make it back again."

Further review of Patient A ' s medical record indicated that Patient A was focused on ECT throughout his/her hospitalization. There was documented evidence that the patient became " enraged " when the scheduled ECT was postponed by the ECT Physician for concerns related to Patient A ' s past medical history.

Documentation in Patient A ' s medical record indicated that upon postponement of the ECT, Patient A became increasingly angry, isolative, anxious, emotionally disregulated, and had made suicidal gestures when he/she was found in his/her room tying sheets together and verbalizing the desire to die. Patient A was placed on involuntary status on March 8, 2010 when he/she asked to leave and it was determined that Patient A was impulsive and not safe to be discharged.

Failure to Ensure a Safe Environment

The 'Levels of Observation' form dated March 11, 2010 documented that Patient A was at the Nurses Station at 14:30 and 14:45.

During a telephone interview on March 18, 2010 at 8:50 AM, the LPN stated, "The patient left the nursing station at 2:45 PM on March 11, 2010 and went to [his/her] room. [He/She] was very upset. [Patient A] had a heated discussion on the phone with someone. [He/She] was upset about that and [he/she] walked hastily back to [his/her] room." He stated that he was on his way to follow Patient A because he was concerned when "I met [the Psychiatrist] in the hall."

A Progress Note that was written by [the Psychiatrist] dated March 11, 2010 at 17:45 stated, "I returned to [Patient A's] room and knocked on the door and entered....[Patient A] was not in [his/her] bedroom. I noticed that the door to [his/her] bathroom was closed and there appeared to be fabric coming out of the top part of the door. {His/Her] bathroom door was locked. I notified staff, who unlocked the door and found [Patient A] hanging from a shower curtain. The staff immediately administered CPR as [he/she] was found not to be breathing or have a pulse. A Code Blue was called. We called 911, who came and transported [Patient A] to [receiving hospital] for further treatment."

During an interview on March 19, 2010 at 1040, [Psychiatric Technician 3] indicated that he had returned from a break at 2:50pm. [Psychiatric Technician 3] stated, " [Psychiatrist] called me to the patient ' s room and I went as fast as I could. Psychiatrist pointed out cloth top of bathroom door. I tried to open [the door] but it was hard. Didn ' t open the door easily. I tried to use the key and turned it right and left. Finally, I pulled out the door. Heard a loud thud. Patient facing down, perpendicular to me. "

The 'Event Note' dated March 11, 2010 stated, "1455 found pt face down with shower curtain wrapped around [his/her] neck. Removed curtain, rolled pt over, pt purpleish blue with no carotid pulse. Pulled pt out of bathroom and positioned [him/her] to begin CPR. I started compressions and [Psychiatric Technician 1] did breaths. We did approx. four cycles before the code cart arrived. No carotid pulse, [Psychiatric Technician 1] and I contiued CPR while oral airway installed, I contiued with compressions switching off with [RN2] while [Coordinator of Infection Prevention and Control] installed a nasal canular. [Coordinator of Infection Prevention and Control] hooked up the AED while I did compressions and [Coordinator of Infection Prevention and Control ] applying the O2. [Coordinator of Infection Prevention and Control] did suction with some success. [Nurse Manager] replaced me. Rescue arrived."

A 'Narrative for Police Officer' was obtained on March 18, 2010 from the Westbrook Police Department, this narrative included the following: "One of the staff members involved [Psychiatric Technician 1] stated, that he had contact with [Patient A] minutes prior to the incident. At around 1440 hrs, [Psychiatric Technician 1] states that [Patient A] approached the nurses station and asked [Psychiatric Technician 1] 'you got a gun.' [Psychiatric Technician 1] didn't respond to [his/her] question but asked [him/her] if [he/she] needed something. [Patient A] then stated to him that [he/she] would like to make a phone call....[Psychiatric Technician 1] states that [Patient A] only talked for a few minutes on the phone then went down to [his/her] room. [Psychiatric Technician 1] states that about 10 minutes later, [Psychiatrist] summonsed him and the other staff to [Patient A's] room. [Psychiatric Technician 1] stated that [Psychiatric Technician 2] struggled with the door before it would open. [Psychiatric Technician 1] states he observed what appeared to be a shower curtain around [Patient A's] neck. [His/Her] lips were purple and [he/she] had no pulse when checked."

The 'Discharge Summary' from the receiving hospital stated, "[Patient A] was found this afternoon hanging from a shower rod....CT scan of [his/her] head showed extensive cerebral edema. There were no obvious abnormalities noted in [his/her] neck...The family expressed a desire to withdraw support given [his/her] poor prognosis and ongoing decline. We withdrew support and [he/she] passed away at 9:25." This document listed the cause of death as "hanging."

Failure to Implement Safety Plan Following Incident

During an interview with the Director of Professional Development & Performance Excellence, Risk Manager Coordinator, Interpreter Services on March 16, 2010 at 12:50 PM, she stated that since Patient A's suicide, "we have not really changed anything, no policies, procedures, or processes." She continued that "we did discuss at a meeting on March 12th the need to revise the policy on bathroom doors." She stated that none of these minutes were typed. "We decided to wait to complete the RCA and not make hasty decisions."

The draft minutes from the Critical Incident Debriefing held on March 12, 2010, stated that one of the discussion topics was "immediate actions to prevent similar occurance." The minutes documented the discussion as "[Director of Professional Development & Performance Excellence, Risk Manager Coordinator, Interpreter Services] asked if there were any immediate actions that should be taken to prevent similar occurances. None recommended, [Director of Professional Development & Performance Excellence, Risk Manager Coordinator, Interpreter Services] questioned if the bathroom doors on Adult Services should be locked except when in use. [Chief Medical Officer] did not feel this was necessary given the fact that there have not been similar incidents and recommended we wait until the RCA was conducted to determine if this is an appropriate action. [Nurse Manager] felt this would not have prevented the event as the patient would have requested to use the bathroom and staff would have opened the door. [Program Director Adult Services] supported that she did not feel this was necessary. The doors are locked when clinically indicated."

An Interim Safety Plan was requested from the hospital on March 16, 2010. The Surveyors received the Interim Safety Plan at 7:30 PM.

Based on observation, record review, and interviews with key staff on March 16-19, 2010, it was determined that the psychiatric hospital failed to protect and promote each patient's rights, including failure to provide a safe environment. This resulted in an Immediate Jeopardy to patients served by this psychiatric hospital.

Findings include:

Patient Information

Patient A's 'Comprehensive Exam' dated February 27, 2010 stated under 'Current Concerns' that Patient A was a 51 year-old admitted with increased depression for one month and increased suicidal ideation.

Patient A's 'Psychiatric Evaluation' dictated on February 28, 2010 stated that Patient A had "an increasing period of depression and hopelessness with significant suicidal ideation and plan to overdose on medications and drive somewhere where [spouse] could not find [him/her]."

The Admission Order form stated that Patient A would be on 15 minute checks.

The initial 'Plan of Care - Master Treatment Plan' was completed on March 1, 2010. It stated that the focal problem was "plan to od [overdose] and drive where [spouse] cannot find [her/him]."

In the nursing note dated March 1, 2010, Patient A was noted to have stated, "If I leave here with just doing the same thing and I only feel good for a month than I won't make it back again."

Further review of Patient A ' s medical record indicated that Patient A was focused on ECT throughout his/her hospitalization. There was documented evidence that the patient became " enraged " when the scheduled ECT was postponed by the ECT Physician for concerns related to Patient A ' s past medical history.

Documentation in Patient A ' s medical record indicated that upon postponement of the ECT, Patient A became increasingly angry, isolative, anxious, emotionally disregulated, and had made suicidal gestures when he/she was found in his/her room tying sheets together and verbalizing the desire to die. Patient A was placed on involuntary status on March 8, 2010 when he/she asked to leave and it was determined that Patient A was impulsive and not safe to be discharged.

Failure to Ensure a Safe Environment

The 'Levels of Observation' form dated March 11, 2010 documented that Patient A was at the Nurses Station at 14:30 and 14:45.

During a telephone interview on March 18, 2010 at 8:50 AM, the LPN stated, "The patient left the nursing station at 2:45 PM on March 11, 2010 and went to [his/her] room. [He/She] was very upset. [Patient A] had a heated discussion on the phone with someone. [He/She] was upset about that and [he/she] walked hastily back to [his/her] room." He stated that he was on his way to follow Patient A because he was concerned when "I met [the Psychiatrist] in the hall."

A Progress Note that was written by [the Psychiatrist] dated March 11, 2010 at 17:45 stated, "I returned to [Patient A's] room and knocked on the door and entered....[Patient A] was not in [his/her] bedroom. I noticed that the door to [his/her] bathroom was closed and there appeared to be fabric coming out of the top part of the door. {His/Her] bathroom door was locked. I notified staff, who unlocked the door and found [Patient A] hanging from a shower curtain. The staff immediately administered CPR as [he/she] was found not to be breathing or have a pulse. A Code Blue was called. We called 911, who came and transported [Patient A] to [receiving hospital] for further treatment."

During an interview on March 19, 2010 at 1040, [Psychiatric Technician 3] indicated that he had returned from a break at 2:50pm. [Psychiatric Technician 3] stated, " [Psychiatrist] called me to the patient ' s room and I went as fast as I could. Psychiatrist pointed out cloth top of bathroom door. I tried to open [the door] but it was hard. Didn ' t open the door easily. I tried to use the key and turned it right and left. Finally, I pulled out the door. Heard a loud thud. Patient facing down, perpendicular to me. "

The 'Event Note' dated March 11, 2010 stated, "1455 found pt face down with shower curtain wrapped around [his/her] neck. Removed curtain, rolled pt over, pt purpleish blue with no carotid pulse. Pulled pt out of bathroom and positioned [him/her] to begin CPR. I started compressions and [Psychiatric Technician 1] did breaths. We did approx. four cycles before the code cart arrived. No carotid pulse, [Psychiatric Technician 1] and I contiued CPR while oral airway installed, I contiued with compressions switching off with [RN2] while [Coordinator of Infection Prevention and Control] installed a nasal canular. [Coordinator of Infection Prevention and Control] hooked up the AED while I did compressions and [Coordinator of Infection Prevention and Control ] applying the O2. [Coordinator of Infection Prevention and Control] did suction with some success. [Nurse Manager] replaced me. Rescue arrived."

A 'Narrative for Police Officer' was obtained on March 18, 2010 from the Westbrook Police Department, this narrative included the following: "One of the staff members involved [Psychiatric Technician 1] stated, that he had contact with [Patient A] minutes prior to the incident. At around 1440 hrs, [Psychiatric Technician 1] states that [Patient A] approached the nurses station and asked [Psychiatric Technician 1] 'you got a gun.' [Psychiatric Technician 1] didn't respond to [his/her] question but asked [him/her] if [he/she] needed something. [Patient A] then stated to him that [he/she] would like to make a phone call....[Psychiatric Technician 1] states that [Patient A] only talked for a few minutes on the phone then went down to [his/her] room. [Psychiatric Technician 1] states that about 10 minutes later, [Psychiatrist] summonsed him and the other staff to [Patient A's] room. [Psychiatric Technician 1] stated that [Psychiatric Technician 2] struggled with the door before it would open. [Psychiatric Technician 1] states he observed what appeared to be a shower curtain around [Patient A's] neck. [His/Her] lips were purple and [he/she] had no pulse when checked."

The 'Discharge Summary' from the receiving hospital stated, "[Patient A] was found this afternoon hanging from a shower rod....CT scan of [his/her] head showed extensive cerebral edema. There were no obvious abnormalities noted in [his/her] neck...The family expressed a desire to withdraw support given [his/her] poor prognosis and ongoing decline. We withdrew support and [he/she] passed away at 9:25." This document listed the cause of death as "hanging."

Failure to Implement Safety Plan Following Incident

During an interview with the Director of Professional Development & Performance Excellence, Risk Manager Coordinator, Interpreter Services on March 16, 2010 at 12:50 PM, she stated that since Patient A's suicide, "we have not really changed anything, no policies, procedures, or processes." She continued that "we did discuss at a meeting on March 12th the need to revise the policy on bathroom doors." She stated that none of these minutes were typed. "We decided to wait to complete the RCA and not make hasty decisions."

The draft minutes from the Critical Incident Debriefing held on March 12, 2010, stated that one of the discussion topics was "immediate actions to prevent similar occurance." The minutes documented the discussion as "[Director of Professional Development & Performance Excellence, Risk Manager Coordinator, Interpreter Services] asked if there were any immediate actions that should be taken to prevent similar occurances. None recommended, [Director of Professional Development & Performance Excellence, Risk Manager Coordinator, Interpreter Services] questioned if the bathroom doors on Adult Services should be locked except when in use. [Chief Medical Officer] did not feel this was necessary given the fact that there have not been similar incidents and recommended we wait until the RCA was conducted to determine if this is an appropriate action. [Nurse Manager] felt this would not have prevented the event as the patient would have requested to use the bathroom and staff would have opened the door. [Program Director Adult Services] supported that she did not feel this was necessary. The doors are locked when clinically indicated."

An Interim Safety Plan was requested from the hospital on March 16, 2010. The Surveyors received the Interim Safety Plan at 7:30 PM.