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A complaint (GA00146642) survey was conducted on 1/14/15, based on record review, and interview the Governing Body failed to assure that policy and procedures related to searching to include removal of potential objects that could be used for self-harm such as hose and medications, for one (1) patient (#4) of ten (10) sampled patients which resulted in an attempted SI while under the care of the facility which resulted in patient #4 being transferred to Acute Care facility and requiring mechanical ventilation to maintain respiratory support.

Cross reference to for details:
482.13 Patient Rights
482.13(c)(2) Patient Rights: Care in Safe Setting
482.23 Nursing Services

Based on record reviews and interviews the facility failed to assure for one (1) patient (#4) of ten (10) sampled patients recieved care in a safe environment related to a known suicide ideation patient, seeking care to prevent self-harm.

Cross reference for details:
482.13(c)(2 ) -Patient Rights: Care in Safe Setting

Based on record reviews, and interviews the facility failed to assure and follow their own policy and procedures related to searching to include removal of potential objects that could be used for self-harm such as hose and medications, for one (1) patient (#4) of ten (10) sampled patients which resulted in an attempted SI while under the care of the facility which resulted in patient #4 being transferred to Acute Care facility and requiring mechanical ventilation to maintain respiratory support.

Findings include:


First Admission on 9/24/2015:
Record review of patient #4 revealed the 58 year old patient was transported by private vehicle to the facility's Emergency Department (ED) on 9/23/2014 at 9:31 p.m. with complaints of recurrent depression and suicidal ideation (SI); and admitted to the psychiatric unit on 9/24/2014.

Review of the ED Nursing Continuation notes by RN #6 on 9/23/2014 at 10:24 p.m. revealed the patient arrived stating depression with suicidal thoughts and a plan to drive somewhere in a car and overdose, that had overdosed in the past with post traumatic stress disorder (PTSD) and bipolar; was compliant with medications; denied homicidal ideation (HI) and hallucinations; denied alcohol, drug, and nicotine use; had depressed mood, flat affect, poor eye contact, and clear speech.

Review of the history and physical conducted by MD #2 on 9/24/2014 at 12:35 a.m. revealed the patient presented voluntarily to the facility with suicidal ideation; stated that he/she wanted to take too many medications and cause harm to self; and, was unable to provide any medical history other than that. The patient was arousal from sleep, and answered questions intermittently, but stated that he/she did not want to answer questions the MD asked.

Review of Physician orders dated 9/24/2014 by MD #2 included admission to inpatient behavioral health services, every fifteen (15) minute observations, suicide precautions, and fall risk.

Physician progress notes dated 9/24/2014 by MD #2 revealed the patient experienced depression, SI, bipolar, and post traumatic stress disorder (PTSD)

Review of documentation by RN #4 revealed that a body search had occurred on 9/24/2014 at 1:53 a.m., and no sharps were found.

The form included a notation that a small container with at least 10 different kinds of loose pills, numbering 50-75, were discovered in the patient's suitcase, and had been sent to the pharmacy.
On 9/24/2014, RN #5 verified by signature that he/she had searched the patient's clothes, personal items, and luggage (for drugs, items containing alcohol, or harmful articles such as knives, guns, etc)

Nursing admission notes on by RN #4 9/24/2014 at 2:41 a.m. revealed the patient was admitted to the unit; was drowsy and frequently drifting off to sleep while nurse attempted to perform assessment; nurse was unable to obtain signatures on paperwork; patient admitted to having depression for three weeks, and denied SI; judgement and insight were poor.

On 9/24/2014 at 6:08 a.m., RN #4 noted that he/she had attempted to awaken the patient to administer, morning medications, but the patient continued to be very drowsy; would wake slightly, open eyes, then return to sleep; sternal rub aroused the patient slightly; patient answered question with one word, then returned to sleep; cold cloth was applied to the patient's face, which did not awaken the patient enough to take AM medications; MD #2 was notified, who stated that the patient was about that way on examination in the ED.

On 9/24/2014 at 6:10 AM, RN #4 phoned MD #2 again, and this time a computed tomography scan (CT scan) was ordered.

On 9/24/2014 at 8:10 a.m., a day shift RN noted that upon initial contact with the patient, the patient was noted unresponsive to stimuli-sternal rub, pinching, and calling name; pupils were unresponsive to light; respirations were 16 per minute with pauses; blood sugar was 140; blood pressure was unattainable with manual cuff; the rapid action team (RAT) and MD were notified; the MD ordered the patient be transferred to the critical care unit (CCU); the patient's daughter was notified; an assessment was not performed due to the nature of the circumstances.

Review of Short Stay Report by MD # 1 on 9/24/2014 at 7:50 AM revealed the patient was found unresponsive to sound, pain, and deep sternal rub at 7:00 AM. On evaluation; it was difficult to obtain a blood pressure (BP); respirations were 16; oxygen saturation was 95%; blood glucose 143. A faint systolic BP of 40 was obtained by the RAT using a doppler. Due to the patient's acute distress, it was felt that perhaps the patient had not disclosed an overdose of blood pressure medication, since the patient was on several BP medications at the time. It was also noted that the patient had not been administered any medications on the unit because he/she arrived in a drowsy state, but was verbal and communicative.

Review of a Discharge Summary on 9/26/2014 at 4:03 PM by MD #9 revealed the patient was transferred to the intensive care unit (ICU), underwent volume resuscitation and intubation (placement of tube into airway to assist with breathing), and followed closely. Post extubation, the patient stated that he/she did not remember the events that led up to the respiratory arrest and altered mental status; and, was not sure of how many medications he/she took prior to being admitted to the hospital. A urine drug screen performed on 9/24/2014 was positive for benzodiazepines (psychoactive drug used to treat anxiety, insomnia, agitation, seizures, muscle spasms, and alcohol withdrawal) and opiates (narcotic pain reliever); and, this was the likely culprit of the patient's sudden symptoms of respiratory failure. The patient responded well to treatment, and the plan was to transfer patient back to the psychiatric floor pending evaluation and acceptance by psychiatry.

Second Admission:
Review of Physician's Orders written by MD #9 on 9/27/2014 at 3:47 PM, revealed an order to admit the patient to psych floor under the services of psychiatric attending MD.

Review of Nursing Documentation on 10/2/2104 at 7:45 a.m. revealed RN documentation that the patient had told MD #1 that he/she had placed a stocking sock around his/her throat the previous night in attempt to kill self; marks around neck were noted; patient was placed on 1:1 for suicide precautions; room was searched and items removed.

Review of the Discharge Summary by MD #1 on 10/6/2014 at 10:36 a.m. revealed the patient had had multiple suicide attempts since the 1980s and frequent psychiatric admissions; when the patient was admitted to the hospital, he/she was groggy after an overdose and was admitted to the fourth floor; patient stated that he/she had hidden a nylon inside of his/her socks and put it around his/her throat and then refused to give the nylon up until he/she received a barium swallow for perceived severe stricture in throat and inability to swallow things.

During an telephone interview with MD #2 on 1/15/2014 at 3:15 PM in the conference room, it was revealed that the MD recalled the patient; that the patient did not have any "red flags"; the physical examination and laboratory studies were okay; the morning the patient was found unresponsive, the MD had ordered a computed tomography scan (CT scan) to assure the unresponsiveness was not due to a medical problem because the toxicology screen performed in the ED had been negative. In regards to ordering suicide precautions on the patient, the MD explained that he/she assumed that there was a system in place to prevent self injurious behavior, such as body checks for objects, sharps, etc, and, that they would monitor the patient more closely.

During a telephone interview with RN #4 on 1/15/15 at 8:15 PM, the RN revealed that he/she recalled the patient; recalled performing a body search; when he/she first saw the patient, he/she was wearing 2 gowns, which was kind of bulky; the RN had searched under the patient's arms and in all body folds (excluded cavity search); because the patient was really drowsy, the search was performed while lying down in bed; the RN did not perform a clothing search; the RN had discovered the patient would not awaken for 7:00 AM medication; the scheduled medication was not administered because the RN did not feel comfortable due to the patient being so drowsy; the RN took the patient's vital signs and phoned the MD; the MD informed the RN that the patient would not answer his/her questions either, and ordered a CT scan; the RN later learned the patient had taken pills; the RN believed the patient had taken them earlier because the patient was so sleepy on admission to the unit, but was talking; the patient later told different stories about when the pills were taken; the patient attempted self harm with panty hose on a different date.

Review of facility policy Search Processes, approved 10/2009, revealed that as a means of ensuring safety, searches would be conducted of patients, patient's belongings, and patient areas during indicated situations; personal searches are standard procedures regularly done on admission of all new patients without exception; personal body searches are performed by a staff member of the same sex as the patient when possible, and in a location that insures patient privacy; if a same sex staff member was unavailable, a nurse would be present; items considered illegal, dangerous or hazardous to patient safety would be removed and secured by nursing staff and in accordance with hospital policy; these items include any medications, non-prescription drugs, and any potentially hazardous objects (for example, weapons, sharps, glass containers, small appliances, and similar items).Patients would also have personal belongings searched. On admission all personal belongings brought to the hospital by the patient would be searched; valuables, outside medications, sharp objects or other items not allowed would be either sent home with a family member or processed as valuables or dangerous objects pursuant to hospital policy

A complaint (GA00146642) survey was conducted on 1/14/15, based on record review, and interview the Nursing Service failed to assure policy and procedures related to searching to include removal of potential objects that could be used for self-harm such as hose and medications, for one (1) patient (#4) of ten (10) sampled patients which resulted in an attempted SI while under the care of the facility which resulted in patient #4 being transferred to Acute Care facility and requiring mechanical ventilation to maintain respiratory support.

Cross reference to for details:
482.12 Governing Body
482.13 Patient Rights
482.13(c)(2) Patient Rights: Care in Safe Setting