HospitalInspections.org

Based on interview, review of policies and procedures, and medical record review it was determined the hospital failed to implement suicide precautions and maintain a safe environment for 1 of 10 sampled patients, (Patient 5).

Findings include:

During the survey it was revealed that on 7/3/15 at 10:48 am Patient 5 had been found by staff in the Mental Health Unit "hanging on the bathroom door by a bedsheet." Despite emergency interventions and transfer to the ICU, the patient expired on 7/7/15.

Review of hospital policies determined the hospital had adopted a variety of policies specific to the mental health unit, including policies "Scope of Care: Mental Health Unit," "Suicide Prevention," and "Safety in the Mental Health Unit." According to policy "Safety in the Mental Health Unit" safety checks are to be conducted "..minimally every 15 minutes for every patient..." Review of those policies revealed that hospital staff had failed to fully implement policy "Safety in the Mental Health Unit" while providing care to Patient 5.

Review of Patient 5's medical record revealed that he/she had been admitted to the hospital Mental Health Unity (MHU) on the evening of 7/2/15 following referral form the County jail for "psychiatric evaluation and medical clearance." The patient had initially been placed on "Level 1 Suicide Precautions," including "every 15 minute checks."

Patient 5's medical record reflect that on 7/3/15 at approximately 9:30 am an "Initial Intake Assessment" was completed by Physician F. Based on that assessment Level 1 Suicide Precautions, including 15 minute checks, were to remain in place.

That same record indicates that on 7/3/15 Patient 5 was provided medication at 10:19 am, and was again observed by staff "on side of bed" at 10:26 am. Those same records indicate that Patient 5 was not observed again until 10:48 am, 22 minutes later, when he/she was found "hanging on the bathroom door by a bedsheet."

In interview on 8/25/15 at 1:30 pm Witnesses A and B acknowledged that the facility had failed to fully implement hospital policy "Safety in the Mental Health Unit." Hospital staff had failed to complete "every 15 minute safety checks" as planned. The facility failed to maintain a safe environment for Patient 5, as required.

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