HospitalInspections.org

Based on medical record review, staff interviews, review of incident reports and policies and procedures, and review of video and e-mail, the facility failed to meet the Condition of Participation for Patient Rights. The findings were:

Review of the medical record, incident reports, e-mail, video, and policies and procedures and staff interview showed staff did not provide a safe environment for 1 of 6 sample residents (#1) who were at moderate or higher risk for suicide (A144). The environment failed to minimize risks for suicide and staff did not provide adequate supervision for patient #1, who completed suicide in the facility. The seriousness of the outcome resulted in the determination that the Condition of Participation for Patient Rights was not met.

Based on medical record review, staff interviews, review of incident reports and policies and procedures, and review of video and e-mail, the facility failed to meet the Condition of Participation for Nursing Services. The findings were:

Review of the medical record, incident reports, e-mail, video, and policies and procedures and staff interview showed staff did not provide adequate supervision for 1 of 6 sample residents (#1) who were at moderate or higher risk for suicide (A395). Staff failed to implement 15 minute checks for patient #1, who completed suicide in the facility. The seriousness of the outcome resulted in the determination that the Condition of Participation for Nursing Services was not met.

Based on medical record review, staff interviews, and review of incident reports, the facility failed to meet the Condition of Participation for Physical Environment. The findings were:

Review of the medical record, incident reports, and policies and procedures and staff interview showed the environment was not safe for 1 of 6 sample residents (#1) who were at moderate or higher risk for suicide (A701). A door in the patient's room did not contain hinges which were designed to minimize hanging, and the patient completed suicide. The seriousness of the outcome resulted in the determination that the Condition of Participation for Physical Environment was not met.

Based on observation, medical record review, staff interviews, review of incident reports and policies and procedures, and review of video and e-mail, the facility failed to provide a safe environment for 1 of 6 sample residents (#1) who were at moderate or higher risk for suicide. The environment failed to minimize risks for suicide and staff did not provide adequate supervision for patient #1, who completed suicide in the facility. The findings were:

1. Review of the psychiatric admission note showed patient #1 was admitted on 5/1/18 as an involuntary patient. The patient stated he had attempted an overdose. The diagnostic impression was Schizoaffective disorder, bipolar type and the Columbia Suicide Severity Ratings Scale (C-SSRS) screen completed 5/1/18 was a score of 25, which was moderate level of risk. Review of the 5/9/18 C-SSRS (lifetime level of risk) showed the patient had three previous attempts of suicide (overdose, jump in front of train, and hang self in prison). The patient scored a "11" which was moderate risk. Review of physician orders showed on 5/1/18 the patient was ordered 15 minute observations. Review of incident reports and progress notes showed on 6/18/18 the patient requested to take a shower. Further review showed on 6/18/18 at 6:45 PM a staff member knocked on the door to the patient's room, but s/he did not answer. When the staff person entered the room, she saw the patient hanging from the door into the tub room by a sheet. The patient was hanging from a sheet that s/he had tied around the top hinge bracket of the door (into the tub room). Staff provided emergency care and called Emergency Medical Services. The patient was transported to the hospital where s/he was pronounced dead. The following concerns were identified:
a. Review of video with the Risk and Performance Improvement Manager and the Director of Nursing (DON) on 6/20/18 at 3:08 PM showed on 6/18/18 at 5:30 PM security went into the patient's room to open up the tub room, then left. At that time, mental health technician (MHT) #1 was assigned 15 minute checks (observations) of patients on the hall. At 5:41 PM, 5:56 PM, 6 PM, 6:10 PM, and 6:17 PM MHT #1 was observed to be in the hallway outside of the patient's room, but was never observed to peek into the patient's room or call out to the patient. At 6:36 PM another staff member knocked on the door, and then entered. She screamed and called out for assistance.
b. During an interview on 6/20/18 at 3:08 PM the Risk and Performance Improvement Manager and DON stated MHT #1 did not follow the facility's policy regarding 15 minute observations. They stated the staff person is supposed to visualize the patient, which this staff person did not do. On 6/20/18 at 2:10 PM the Risk and Performance Improvement Manager stated from 5:30 PM to 6:30 PM (an hour) the staff person assigned 15 minute observations did not do any checks on the patient during that time.
c. Review of the facility's policy "Special Observations" (revised September 2017) showed "Q-15 Minute Checks 1. Patients and their immediate environment will be visually checked for safety or specific behavioral indications ordered to be observed for treatment purposes."
d. Observation of the patient's room (rm 321) on 6/20/18 at 3:50 PM revealed the door to the tub room was a wooden door with 3 hinges. Interview with registered nurse (RN) #1 at that time revealed she was the nurse who responded that night. She stated the patient was hanging from a sheet from the top hinge of the door into the tub room. Observation at that time revealed the door to the patient's room had a small window, but that it was covered. Interview with the Risk and Performance Improvement Manager on 6/21/18 at 10:47 AM revealed the windows were usually covered for patient privacy, and would have been covered when staff were doing 15 minute checks.
e. Interview with the maintenance director on 6/21/18 at 10:27 AM revealed about 8 or 9 years ago most of the doors in the unit were changed from wooden doors with 3 hinges to metal doors which incorporated a "hospital hinge" (one continuous hinge) to reduce ligature risks. When asked why the door into the tub room in the patient's room was not replaced, he stated that because of other risks inside the tub room, the door remained locked. When it was pointed out that the door was unlocked and open when patients used the shower in the tub room, he replied "Well, they do 15 minute checks."
f. According to the "2006 Guidelines for Design and Construction of Health Care Facilities," The Facility Guidelines Institute, Chapter 2.3 Psychiatric Hospitals, "...(4) Door hinges (a) Door hinges shall be designed to minimize points for hanging (i.e., cut hinge type)."
g. Interview with physician #1, who was the patient's psychiatrist, on 6/21/18 at 11:25 AM revealed the patient was at moderate risk for suicide. He stated the patient had told him s/he wouldn't commit suicide in the facility, but "they surprise you." He stated "they need to make rooms suicide proof...those doors are not suicide proof; they need to get rid of those."
h. During an interview on 6/20/18 at 2:10 PM, the risk and quality manager stated since the incident, both tub room doors were locked and were not in use. She also stated all nursing staff received an e-mail to educate them about 15 minute checks and not using the tub rooms. Review of a copy of the e-mail dated 6/19/18 showed "end rooms with the bathtub needs to remain locked...The areas which need to be locked are the wooden doors with hinges- They need to be locked at all times. The patients will need to utilize another peer shower if they are located in these rooms." Observation on 6/21/18 at 8:42 AM showed the tub rooms to rooms 321 and 322 were locked. Further observation at that time showed the patient in room 322 was told s/he couldn't use the tub room, and needed to use another peer's shower. Observations during the survey on 6/20/18 and 6/21/18 verified staff were completing 15 minute observations in accordance with facility policy.

Based on observation, medical record review, staff interviews, review of incident reports and policies and procedures, and review of video and e-mail, the facility failed to provide adequate supervision for 1 of 6 sample patients (#1) who were at moderate or higher risk for suicide. Staff did not perform 15 minute checks on patient #1, who completed suicide in the facility. The findings were:

1. During an interview on 6/21/18 at 10:47 AM the Risk and Performance Improvement Manager stated nurses made assignments at the beginning of the shift, including 15 minute observations and any 1:1s. She stated mental health technicians (MHTs) were supervised by nurses.

2. Review of the psychiatric admission note showed patient #1 was admitted on 5/1/18 as an involuntary patient. The patient stated he had attempted an overdose. The diagnostic impression was Schizoaffective disorder, bipolar type and the Columbia Suicide Severity Ratings Scale (C-SSRS) screen completed 5/1/18 was a score of 25, which was moderate level of risk. Review of the 5/9/18 C-SSRS (lifetime level of risk) showed the patient had three previous attempts of suicide (overdose, jump in front of train, and hang self in prison). The patient scored a "11" which was moderate risk. Review of physician orders showed on 5/1/18 the patient was ordered 15 minute observations. Review of incident reports and progress notes showed on 6/18/18 the patient requested to take a shower. Further review showed on 6/18/18 at 6:45 PM a staff member knocked on the door to the patient's room, but s/he did not answer. When the staff person entered the room, she saw the patient hanging from the door into the tub room by a sheet. The patient was hanging from a sheet that s/he had tied around the top hinge bracket of the door (into the tub room). Staff provided emergency care and called Emergency Medical Services. The patient was transported to the hospital where s/he was pronounced dead. The following concerns were identified:
a. Review of video with the Risk and Performance Improvement Manager and the Director of Nursing (DON) on 6/20/18 at 3:08 PM showed on 6/18/18 at 5:30 PM security went into the patient's room to open up the tub room, then left. At that time, MHT #1 was assigned 15 minute checks (observations) of patients on the hall. At 5:41 PM, 5:56 PM, 6 PM, 6:10 PM, and 6:17 PM MHT #1 was observed to be in the hallway outside of the patient's room, but was never observed to peek into the patient's room or call out to the patient. At 6:36 PM another staff member knocked on the door, and then entered. She screamed and called out for assistance.
b. During an interview on 6/20/18 at 3:08 PM the Risk and Performance Improvement Manager and DON stated MHT #1 did not follow the facility's policy regarding 15 minute observations. They stated the staff person is supposed to visualize the patient, which this staff person did not do. On 6/20/18 at 2:10 PM the Risk and Performance Improvement Manager stated from 5:30 PM to 6:30 PM (an hour) the staff person assigned 15 minute observations did not do any checks on the patient during that time.
c. Review of the facility's policy "Special Observations" (revised September 2017) showed "Q-15 Minute Checks 1. Patients and their immediate environment will be visually checked for safety or specific behavioral indications ordered to be observed for treatment purposes."
d. During an interview on 6/20/18 at 2:10 PM, the risk and quality manager stated since the incident, both tub room doors were locked and were not in use. She also stated all nursing staff received an e-mail to educate them about 15 minute checks and not using the tub rooms. Review of a copy of the e-mail dated 6/19/18 showed "end rooms with the bathtub needs to remain locked...The areas which need to be locked are the wooden doors with hinges- They need to be locked at all times. The patients will need to utilize another peer shower if they are located in these rooms." Observation on 6/21/18 at 8:42 AM showed the tub rooms to rooms 321 and 322 were locked. Further observation at that time showed the patient in room 322 was told s/he couldn't use the tub room, and needed to use another peer's shower. Observations during the survey on 6/20/18 and 6/21/18 verified staff were completing 15 minute observations in accordance with facility policy.

Based on observation, review of the medical record and incident reports, and staff interview, the facility failed to ensure the environment was safe for 1 of 6 sample residents (#1) who were at moderate or higher risk for suicide. A door in the patient's room did not contain hinges which were designed to minimize hanging, and the patient completed suicide. The findings were:

1. Review of the psychiatric admission note showed patient #1 was admitted on 5/1/18 as an involuntary patient. The patient stated he had attempted an overdose. The diagnostic impression was Schizoaffective disorder, bipolar type and the Columbia Suicide Severity Ratings Scale (C-SSRS) screen completed 5/1/18 was a score of 25, which was moderate level of risk. Review of the 5/9/18 C-SSRS (lifetime level of risk) showed the patient had three previous attempts of suicide (overdose, jump in front of train, and hang self in prison). The patient scored a "11" which was moderate risk. Review of physician orders showed on 5/1/18 the patient was ordered 15 minute observations. Review of incident reports and progress notes showed on 6/18/18 the patient requested to take a shower. Further review showed on 6/18/18 at 6:45 PM a staff member knocked on the door to the patient's room, but s/he did not answer. When the staff person entered the room, she saw the patient hanging from the door into the tub room by a sheet. The patient was hanging from a sheet that s/he had tied around the top hinge bracket of the door (into the tub room). Staff provided emergency care and called Emergency Medical Services. The patient was transported to the hospital where s/he was pronounced dead. The following concerns were identified:
a. Observation of the patient's room (rm 321) on 6/20/18 at 3:50 PM revealed the door to the tub room was a wooden door with 3 hinges. Interview with registered nurse (RN) #1 at that time revealed she was the nurse who responded that night. She stated the patient was hanging from a sheet from the top hinge of the door into the tub room.
b. Interview with the maintenance director on 6/21/18 at 10:27 AM revealed about 8 or 9 years ago most of the doors in the unit were changed from wooden doors with 3 hinges to metal doors which incorporated a "hospital hinge" (one continuous hinge) to reduce ligature risks. When asked why the door into the tub room in the patient's room was not replaced, he stated that because of other risks inside the tub room, the door remained locked. When it was pointed out that the door was unlocked and open when patients used the shower in the tub room, he replied "Well, they do 15 minute checks."
c. According to the "2006 Guidelines for Design and Construction of Health Care Facilities," The Facility Guidelines Institute, Chapter 2.3 Psychiatric Hospitals, "...(4) Door hinges (a) Door hinges shall be designed to minimize points for hanging (i.e., cut hinge type)."
d. Interview with physician #1, who was the patient's psychiatrist, on 6/21/18 at 11:25 AM revealed the patient was at moderate risk for suicide. He stated the patient had told him s/he wouldn't commit suicide in the facility, but "they surprise you." He stated "they need to make rooms suicide proof...those doors are not suicide proof; they need to get rid of those."
e. During an interview on 6/20/18 at 2:10 PM, the risk and quality manager stated since the incident, both tub room doors were locked and were not in use. She also stated all nursing staff received an e-mail to educate them about 15 minute checks and not using the tub rooms. Review of a copy of the e-mail dated 6/19/18 showed "end rooms with the bathtub needs to remain locked...The areas which need to be locked are the wooden doors with hinges- They need to be locked at all times. The patients will need to utilize another peer shower if they are located in these rooms." Observation on 6/21/18 at 8:42 AM showed the tub rooms to rooms 321 and 322 were locked. Further observation at that time showed the patient in room 322 was told s/he couldn't use the tub room, and needed to use another peer's shower.