HospitalInspections.org

Based on observation, interview, policy and procedure review, and documentation in 3 of 3 medical records reviewed of patients admitted to the behavioral health unit (BHU) (Patient #s 1, 2, and 3) it was determined that the hospital failed to ensure that practices for monitoring and observation to ensure patient safety were in accordance with clear and complete policies and procedures and complete patient assessments. Suicide Risk Assessments were incomplete or inconsistent with other assessments; monitoring and observation of patients was not individually planned and documented; policies and procedures related to observation did not contain clear instruction; and there were no written policies and procedures for practices related to "contracting for safety. Findings include:

1. The BHU Work Instruction titled "Assessment and Reassessment" dated as last revised "3/31/08" was reviewed. It included nursing staff responsibility for conducting patient assessments. It contained a requirement that the initial nursing assessment be completed within 4 hours of the patient's admission. It specified that nursing staff complete a "Suicide Risk Assessment" on each patient upon admission. "The purpose of the suicide risk assessment is to determine the patient's level of risk for self harm and to determine the level of observation needed on the unit."

2. The BHU Work Instruction titled "Special Observation" dated as last revised "1/12/08" was reviewed. This document reflected that "Special Observation Precautions are instituted to maintain the safety of patients who have demonstrated high risk behaviors." It contained the following definitions:
"Hourly Checks - All patients are routinely monitored, with documentation thereof, on at least an hourly basis";
"Close Observation (15-minute checks)...observed by a staff at least every 15 minutes, and the patient's behaviors are appropriately documented...";
"Line of sight...monitored through continuous, in person observation. The monitoring is documented...";
"One to One - Patient is within arms reach of the staff and is monitored through continuous, in person observation. The monitoring is documented...";

It contained "Instructions" which indicated that "The physician can order three levels of special observation for any patient who requires a level of monitoring other than routine any time during the admission, for the following types of high risk behaviors: Suicide, Assault, Elopement, Sexual Acting-Out, Self-Harm".

However, the only criteria which specified under what circumstances each defined special observation should be initiated was outlined under "Line-of-sight observation...for patients who have made a suicide attempt...during their current treatment in our facility, for patients who have made a serious suicide attempt (with intent to die) within 3 months of admission, for patients who have made 2 serious suicide attempts (with intent to die) at any time in their life". There were no criteria related to the other high risk behaviors identified as requiring "Line-of sight" observation.

The form titled "Patient Observation Record" referred to in this observation work instruction was reviewed. It was dated as "6/09" and reflected the following instruction: "Circle one: 30 min 15 min Line of Sight 1:1". The work instruction did not include definitions or criteria for "30 min" checks.

3. Documentation in the medical record reflected that Patient #1 had presented to the emergency department (ED) of the hospital on 09/20/10 at 1418. The dictated ED physician's report dated 09/20/10 reflected that the patient had been transferred from a hospital in a neighboring city where he/she "had been seen...with a several day history of increasing auditory hallucinations which are quite specific. [He/she] was mentioning suicide and is quite disturbed by [his/her] hallucinations, which [he/she] does not really talk to me about. [He/she] was placed on a hold and admitted to the hospital there for observation and then transferred here today..." The physician documented that the patient "has some vague thoughts of suicide. [He/she] was suicidal this morning apparently." The ED report reflected that the patient was seen by a social worker and that the physician discussed the case with the BHU Psychiatrist and the BHU Medical Director. As a result the patient was placed on a "2-physician hold" for admission to the BHU. The physician's "Impression" was documented as: "Schizoaffective disorder, Acute psychosis, Suicidal Ideation".

The dictated MSW psychosocial assessment dated 09/20/10 reflected that the patient "reports that the voices say that they hate [him/her] and they will not leave [him/her] alone and they are wanting [him/her] to end [his/her] life...[He/she] feels unsafe with [him/herself]...The patient had a plan for suicide although [he/she] was not willing to follow through with it...The patient has some suicidality although not a current plan right now. The patient is at high risk due to the ongoing voices, the lack of treatment for these voices, lack of support system and [his/her] desperation at wanting them to end."

An electronically generated document titled "Emergency Department Chart" dated 09/20/10 contained documentation by an RN and indicated that during the patient's stay in the ED he/she continuously monitored in the psychiatric emergency services area. The ED RN documented at the time of the patient's transfer from the ED to the BHU as "Condition at discharge - serious".

The medical record reflected that Patient #1 presented on the BHU on 09/20/10 at 1950. An electronically generated "Suicide Risk Assessment" dated 09/20/10 at 2014 reflected that the RN documented at that time the patient's "Intensity of Ideation: Mild; Frequency of Ideation: Sometimes; Accessibility of Means for Killing Self: Unable to Determine; Concreteness/Specificity of Plan(s): Unable to Determine; Lethality of Plan(s): Unable to Determine; Current Plan? No; Self-Harm Gestures? No; Attempts? Yes 2 PRIOR ATTEMPTS (OD AND CUTTING); Impulsivity: Unable to Determine; Deterrents to Suicide: Mild; Level of Risk: Low...Recommendations [none - blank]".

An electronically generated "Nursing assessment/evaluation" was documented by an RN at 2026. The documentation reflected that the patient denied auditory or command hallucinations at that time and "does contract for safety". There was no documentation which reflected what the content of that "contract" was. It was "noted in prior reports to have had 2 prior suicide attempts and [he/she] has a history of being a cutter and there are some old scars on [his/her] arms but no new one's...has a flat affect...behavior is strange...poor judgement, poor insight and [his/her] mood is angry..." The "Plan" was documented as "Administer medications and monitor for side effects/efficacy, Safety updates, No razors or anything sharp due to past cutting history."

There was no documentation by the RN which reflected the frequency and level of observation assessed to be appropriate to ensure the safety of the patient in accordance with the policies and procedures described above. There was no documentation by the RN which reflected that the patient's "2 PRIOR ATTEMPTS" had been assessed for "intent to die"as described in the "Special Observation" work instruction to ensure the appropriate level of observation was implemented. Although the BHU RN had been "unable to determine" 4 of the 10 criteria on the Suicide Risk Assessment and identified that the patient had "2 prior attempts", and although other assessors had identified the patient's risk as "high" and his/her condition "serious", the RN documented the level of risk as "low" and there were no "Recommendations" documented. Additionally, the nursing assessment "Plan" lacked the level of observation to be implemented.

Documentation on two "Patient Observation Record - 60 minutes" forms dated 09/20 and 09/21/10 reflected that BHU staff recorded observation of Patient #1 and 10 other patients on the BHU hourly, on the hour, beginning at 2000 on 09/20/10 through 1100 on 09/21/10.

During an interview on 10/6/10 at approximately 1310 the RN who admitted Patient #1 to the BHU on 09/20/10 stated that the initial nursing assessment was "incomplete" as the patient was "sleepy and groggy". The RN stated that he/she asked the patient if the patient was suicidal and the patient stated "no". The RN stated that he/she asked the patient "Can I have you contract for safety?". During the interview the RN was asked how levels of observation are determined. The RN answered the question by stating that patients are assigned to "hourly checks" unless otherwise indicated. The RN stated that he/she had a "gut feeling" that the patient was "okay" and required "no special watch". The RN did not specify or describe criteria which reflected knowledge of how the levels of observation were to be determined.

4. Documentation in the medical record reflected that Patient #2 had presented to the ED of the hospital on 09/19/10 at 1518. The dictated ED physician's report dated 09/19/10 reflected that the patient had been transferred from a hospital in a neighboring city where he/she had presented as result of a "suicide attempt by taking pills...". The report reflected that the patient had a history of depression and severe psychotic symptoms with multiple suicide attempts in the past...The patient was seen here on the 1st of this month after injecting turpentine into her left antecubital region requiring incision and drainage and removal of necrotic tissue." The report reflected that the patient had been admitted to the BHU in the past. The physician conferred with the BHU Psychiatrist and the patient was placed on a "2-physician hold" with a plan to admit to the BHU. The physician's "Impression" was documented as: "Bipolar disorder, Suicide Attempt".

An electronically generated "Intake Screening" document included an entry dated 09/19/10 which reflected that "Within the last 3 months...pt has jumped in front of a vehicle, injected terpintine (sic) into [his/her] arm and last night took a bottle of over the counter sleep aid."

The medical record reflected that Patient #1 presented on the BHU on 09/19/10 at 1745. An electronically generated "Suicide Risk Assessment" dated 09/19/10 at 1848 reflected that the RN documented at that time the patient's "Intensity of Ideation: Very Strong; Frequency of Ideation: Often; Accessibility of Means for Killing Self: Very accessible; Concreteness/Specificity of Plan(s): Very Specific pt bought a bottle of over the counter sleep aids and took a hundred h; Lethality of Plan(s): Lethal; Current Plan? No; Self-Harm Gestures? No; Attempts? Yes this is the 2nd, 1st time was trying to inject paint thinner into arm; Impulsivity: Impulsive; Deterrents to Suicide: Moderate; Level of Risk: High...Recommendations [none - blank]".

An electronically generated "Nursing assessment/evaluation" was documented by an RN at 1906. The documentation reflected that "skin check was performed...some scars visible on both of [his/her] arms...[he/she] had been a cutter in the past...Pt's mood is appropriate for the situation and [he/she] is very remorseful about what [he/she] did...has bright affect and seems to sincerely remorseful and doesn't know what made [him/her] try an attempt again. Pt denies suicidal ideations and denies any [auditory or visual hallucinations]. Pt contracts for safety." There was no documentation which reflected what the content of that "contract" was. The note continued and reflected that the patient reported to the RN that "drove [him/herself] to the store and bought some over the counter sleep aid and after [he/she] took about 100 pills, [he/she] then called 911 and asked for help and let them know what [he/she] had done...[he/she] knew all along that [he/she] wasn't going to be safe and [he/she] had come up with this plan all by [him/herself]...stitches on [his/her] left forearm from where [he/she] injected paint thinner and later had an I&D on (sic) were removed by ER, it look (sic) like it is still healing...willing to stick to a better plan to keep [him/herself] from doing this again...poor insight, poor self esteem and judgment is poor..." The "Plan" was documented as "Administer medications and monitor for side effects/efficacy, Safety updates, Encourage pt to attend groups, Encourage pt to discover new coping skills, Monitor pt per protocol, Engage pt in treatment at [BHU]." Although the nursing assessment "Plan" included "Monitor pt per protocol" there was no evidence of what "protocol" the RN was referring to and what that meant for this patient.

There was no documentation by the RN which clearly reflected the frequency and level of observation assessed to be appropriate to ensure the safety of the patient in accordance with the policies and procedures described earlier in these findings. There was no documentation by the RN which reflected that the patient's "multiple" identified suicide attempts had been evaluated for "intent to die" as described in the "Special Observation" work instruction to ensure the appropriate level of observation was implemented. Although the BHU RN had documented on the Suicide Risk Assessment that the patient's risk of a suicide attempt was "high" there were no "Recommendations" documented.

Documentation on two "Patient Observation Record - 60 minutes" forms dated 09/19 and 09/20/10 reflected that BHU staff recorded observation of Patient #2 and 10-11 other patients on the BHU hourly, on the hour, beginning at 1800 on 09/19/10 through 0700 on 09/20/10.

The patient had a documented history of multiple attempts of suicide and self-harm, including "cutting", and the Suicide Risk Assessment reflected that the patient's risk for suicide was high. However, an electronically generated Progress Note dated 09/20/10 at 0836 reflected that earlier that morning BHU staff had given the patient a disposable razor to use without supervision. There was no documentation by the RN which reflected that the patient had been assessed to be safe to use a razor without monitoring or observation.

5. Documentation in the medical record of Patient #3 reflected that the patient had been admitted to the BHU on 09/23/10 at 1425 on a "2-physician hold" as a result of a suicide attempt. The Suicide Risk Assessment documented by the RN reflected that the patient's risk was "moderate" and the nursing assessment "Plan" documented on 09/23/10 reflected the patient was to be monitored "per protocol". However, there was no evidence of what "protocol" the RN was referring to and what that meant for this patient.

There was no documentation by the RN which clearly reflected the frequency and level of observation assessed to be appropriate to ensure the safety of the patient in accordance with the policies and procedures described earlier in these findings.

During interview on 10/6/10 the BHU Manager stated that monitoring "per protocol" for this patient on that day meant every 15 minutes.

6. Although BHU assessment documentation reflected that patient #s 1, 2, and 3 "contracted for safety" there were no policies and procedures which identified or addressed that practice. During interviews on 10/6/10 with the Director of Behavioral Health Services and the BHU Manager it was confirmed that the practice of "contracting" with patients for safety was not addressed in policies and procedures. During an interview on 10/6/10 at approximately 0900 the BHU Psychiatrist stated that psychiatric literature does not support that "contracting" for safety necessarily prevents or predicts suicide.