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Based on review of Patient #1's clinical record, review of the Hospital's action plan and interviews with the Director of the Psychiatric Unit, the Risk Manager,the Psychiatric Unit's Educator, Case Manager and Mental Health Associates (MHA) #1 and #7, the Hospital failed to ensure that corrective actions, developed in response to multiple suicide attempts by Patient #1, were developed and implemented in a timely manner.

Findings include:

The Psychiatric Adult Comprehensive Assessment (Assessment), dated 11/7/12, indicated that Patient #1's diagnoses included: post-traumatic stress disorder (PTSD) and generalized anxiety disorder (GAD) with several near-lethal suicide attempts.

Suicide attempt #1:

The Physician Note, dated 11/9/12, indicated that Patient #1 suffered from a chronic recurring shoulder dislocation that was reduced. The Physician Note indicated that a sling was applied to be worn for 3 weeks.

The ED Nursing Continuation Note, dated 11/15/12, indicated that Patient #1 was admitted to the Psychiatric Unit.

The Physician Orders, dated 11/19/12 at 10:45 A.M., indicated that 1:1 observations were discontinued and 5 minute checks were initiated.

The Policy/Procedure titled Safety Checks, reviewed 6/20/12, indicated that when safety checks were performed, the observer must visualize the patient, ensure the patient was breathing, observe physical status and monitor the environment for hazards.

The Nurse Event Note, dated 11/19/12 at 5:00 P.M., indicated that Patient #1 was found in his/her room with the sling used to support the right arm tightly wrapped around his/her neck.

Surveyor #1 interviewed the MHA #1 (who conducted the 5 minute checks on 11/19/12) on 12/17/12 at 2:05 P.M. MHA #1 said just prior to the event, she entered Patient #1's room and Patient #1 was lying in his/her bed with eyes closed. MHA #1 said Patient #1 had a blanket up to his/her chin, was breathing evenly without distress and his/her skin color was good. MHA #1 said she left Patient #1's room to continue rounding and several minutes later Patient #1's roommate ran up to her and said Patient #1 was asking for help. MHA #1 said she went back to Patient #1 and noted his/her eyes were still closed, but his/her breathing was gurgly. MHA #1 said she pulled down the blanket and observed the sling wrapped tightly around Patient #1's neck. MHA #1 said the nurse came and a Code (emergency code to activate team for cardiopulmonary resuscitation) was initiated.

The Nurse Event Note, dated 11/19/12 at 5:00 P.M., indicated that Patient #1 had normal vital signs, but was wheezing when the Code Blue was called. The Nurse Event Note indicated that Patient #1 was prophylactically intubated and discharged to the Intensive Care Unit for observation.

The Nursing Note, dated 11/21/12, indicated that Patient #1 was extubated and re-admitted to the Psychiatric Unit.

Surveyor #1 interviewed the Director of the Psychiatric Unit with the Psychiatric Unit Educator present. The Director said when Patient #1 returned to the Psychiatric Unit, his/her sling was discontinued. The Director said Patient #1 was required to sleep with the covers below the neckline and certain undergarments that could be used adversely were removed at night.

The Constant Observation Sheets, dated 11/21/12 to 12/3/12, indicated that Patient #1 was maintained on 1:1 observations.

The Nursing Shift Notes, dated 11/21/12 to 12/3/12, indicated that Patient #1 did not verbalize or act upon thoughts of suicidal ideation.

Suicide Attempt #2:


The Nursing Event Note (Note), dated 12/3/12 at 7:06 P.M., indicated that at 3:35 P.M., Patient #1 requested to take a shower and obtained the necessary items to take to the shower. The Note indicated that a privacy screen was placed in front of the door to the shower room. The Note indicated that Patient #1 was singing and when the singing stopped, the 1:1 observer checked on Patient #1 and found found him/her with a top tied around his/her neck, head against the wall and slumped in the corner of the shower.

Surveyor #1 interviewed the 1:1 observer assigned to Patient #1 (MHA #7) on 12/20/12 at
2:15 P.M. MHA #7 said while Patient #1 was taking a shower, she stood in the corridor outside the privacy screen. MHA#7 said that she could not see the patient showering. MHA #7 said that after the singing stopped, she looked behind the shower curtain and found Patient #1 seated on the shower floor with a black cloth tied around his/her neck.

The Nurse Event Note, dated 12/3/12, indicated that a Rapid Response was called. The Nurse Event Note indicated that Patient #1's breathing was shallow and he/she was intubated prophylactically and discharged to the Intensive Care Unit.

The Discharge Summary, dated 12/4/12, indicated that Patient #1 was re-admitted to the Psychiatric Unit.

Physician Orders, dated 12/4/12 and 12/5/12, included: 1:1 observation arm's length 24 hours a day and 5 minute checks by a nurse, no access to sharps, arms above cover during sleep, observation in the bathroom, head and feet must be visible at all times when in the shower and no supplies in his/her possession when in the shower.

The Policy/Procedure titled Constant Observation, reviewed 7/20/12, indicated that the observer must be able to visualize the patient at all times

Suicide attempt #3:

The Case Manager Note, dated 12/12/12 at 2:50 P.M., indicated that the Case Manager observed Patient #1 with another patient who was rubbing Patient #1's hands.

Surveyor #1 interviewed the Case Manager on 12/20/12 at 2:40 P.M. The Case Manager said she observed Patient #1 seated on the floor in the lounge with another patient (Patient #4) seated on the floor facing Patient #1. The Case Manager said the 1:1 observer was seated on the sofa observing Patient #1, but Patient #1 had his/her back to the observer. The Case Manager said Patient #4 was rubbing Patient #1's hand and that Patient #1 had his/her palm opened. The Case Manager said she reminded Patient #1 and Patient #4 of the Unit's no-touch policy and they stopped. The Case Manager said she did not observe Patient #1 holding anything.

The Nurse Event Note, dated 12/12/12 at 6:15 P.M., indicated that Patient #1 was noted to have dilated pupils, drooping eyes, his/her legs were shaking and he/she was having difficulty focusing. The Nurse Event Note indicated that a Rapid Response was called and Patient #1 admitted to taking 2 Suboxone (medication used to treat opioid dependence) tablets obtained from another patient which was verified by a witness (unknown). The Nurse Event Note indicated that Rapid Response was called and Patient #1 was discharged to the Intensive Care Unit for observation.

The Director of the Psychiatric Unit said an immediate investigation was conducted and determined that another patient who was a voluntary admission had brought in Suboxone via a body cavity and somehow there was a handoff of the medication. The Director said that the patient, who was a voluntary admission, was administratively discharged that evening.

The Discharge Summary, dated 12/13/12, indicated that Patient #1 was discharged from the Intensive Care Unit and returned to the Psychiatric Unit on 12/14/12.

Physician Orders, dated 12/13/12, included all previous restrictions, no touching other patients and to be a distance of 10 feet from patients.

Plan of correction:

Interview with the Director of the Psychiatric Unit and Psychiatric Unit Educator indicated that an investigation was conducted. The Director said opportunities for improvement were identified and a corrective action plan was developed.

Surveyor #1 reviewed the Hospital's action plan. At the time of the Survey, the Hospital had not fully implemented the following:

1) Identification of levels of intensity for patients on 1:1 or 5 minute checks to include high or moderate risk or fall risk levels. (Although the order form was developed it had not been implemented).
2) Modify the shower to enable constant observation of a patient's head/feet; a partial shower curtain was installed where previously a full shower curtain was in place (completed).
3) Development of a suicide risk assessment tool (developed, but not yet implemented)
4) Auditing of safety checks for completion (in process and ongoing with disciplinary actions for noncompliance).
5) Re-education of staff regarding the safety check policies. The Educator said she had been meeting with each staff as they were assigned to checks/observations, but had not documented the education or obtained signatures to indicate re-education was provided.
6) Establishment of a policy regarding use of splints/braces/ace bandages on the Unit (not yet developed).

Based on review of Patient #1's clinical record and the Constant Observation Policy and interviews with the Director of the Psychiatric Unit, Psychiatrist #1, Psychiatrist #2 and Mental Health Associate (MHA) #7, the Hospital failed to ensure that Patient #1 was constantly observed 1) during a shower which resulted in an attempted suicide and 2) during a patient to patient contact which was followed by Patient #1 taking medication not prescribed for him/her.

Findings include:

Please refer to A-0286 for Patient #1's information.

The Observers did not ensure that Patient #1 was completely visible during peer interactions at all times.