HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) clinical record reviewed of a patient with suicidal ideation, whose death subsequently followed, the Hospital failed to ensure that patient's suicidal risk for harm was appropriately identified. As a result, the Condition of Participation (42 CFR 482.13) Patient Rights was not in compliance. This has the potential to affect the Hospital's current patient census of 77, for whom the suicide risk assessment tool is being used.

Findings include:

1. The Hospital failed to ensure that the suicide risk assessment (Columbia Suicide Severity Scale) was appropriate. (A-144 A)

2. The Hospital failed to increase the patient's monitoring, as required by the patient's actions. (A-144 B)

The immediate jeopardy began on 8/11/18 when Pt. #1's suicidal ideation continued. The Hospital failed to fully investigate, appropriately conduct a suicide risk assessment, and provide the necessary patient monitoring. Pt. #1 was admitted to the Hospital on 8/3/18 due to feeling depressed for weeks and having intense suicidal thoughts. Pt. #1 was placed on suicidal precautions (every 15 minutes monitoring) from 8/4/18 to 8/13/18. On 8/11/18 and 8/12/18, Pt. #1's suicidal ideation continued, however, Pt. #1 was kept on every 15 minutes monitoring. Subsequently, the patient attempted suicide, transferred to Hospital B and eventually died on 8/15/18.

An IJ was identified and announced on 8/31/18 at 12:36 PM, during a meeting with the President and the Chief Nursing Officer. The immediate jeopardy was not removed by the survey exit date of 8/31/18. No corrective actions were initiated.

A. Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) clinical record reviewed for a patient who attempted suicide while receiving treatment in the Hospital, the Hospital failed to ensure that the suicide risk assessment (Columbia Suicide Severity Scale) was appropriate.

Findings include:

1. On 8/28/18 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 25 year old female admitted to the Hospital on 8/3/18 with a diagnoses of of GAD (general anxiety disorder), MDD (major depressive disorder), and post-traumatic stress disorder (PTSD). Pt. #1 attempted suicide on 8/13/18, and was transferred to Hospital B and eventually died.

- The clinical record indicated that Pt. #1 was placed on suicide precautions (every 15 minutes monitoring) from 8/4/18 until 8/13/18 for location and behavior.

- On 8/8/18, E #6 (Registered Nurse) Progress Notes indicated, "(Pt. #1) had to be placed in therapeutic hold (physical intervention to restrain a patient) from 11:15 PM to 11:36 PM due to self-harming behavior and refusing to take medications ..."

- On 8/9/18 at 7:31 PM, MD #2 (Attending Psychiatrist) Progress Notes indicated, " ... (Pt. #1) had a very difficult evening yesterday ... refusing medication changes ... (Pt. #1) says she remains suicidal... Precautions: Suicide Precautions Continues ... Room Lockout (Used for safety, suicidal thoughts, self-injury ... patient remains in the milieu and is not permitted in their room. Patient is monitored by staff when entering their room or bathroom. Patient may not go off unit) until discontinued..."

- The clinical record included a physician's order for a room lockout from 8/9/18 to 8/10/18.

- The Progress Notes of MD #3 (Covering Psychiatrist) dated 8/11/18 at 9:48 AM was reviewed and included, " ... Discussed with ... staff ... (Pt. #1) ... Still feeling very depressed ... Thoughts of suicide come and go, 'mostly wishing that all of this is over' ...When she (Pt. #1) leaves here, has half formed ideas of suicide that she can do (overdose on meds, crash car, jump off building) ... Self-injured earlier this week ... Has had fleeting thoughts of self-harm ..." However, the suicide risk assessment (Columbia Suicide Severity Rating Scale/C-SSRS) by E #10 (Behavioral Health Associate) on 8/11/18 at 2:32 PM answered "No" (equivalent to 0 response) to the following questions: 1. Have you wished you were dead ... (Past 30 days)? 2. Have you actually had any thoughts of killing yourself? (Past 30 days); 3. Have you been thinking about how you might kill yourself? (Past 30 days). Pt. #1's suicide risk assessment score was scored as "Low Risk" and was kept on suicide precautions.

- On 8/11/18 at 11:17 PM, E #11 (Registered Nurse) documented, "(Pt. #1) endorsed SI (suicidal ideation)." However, a suicide risk assessment was not conducted to reflect a change from the previous suicide risk assessment that scored Pt. #1 as, "Low Risk" (not having thoughts of killing yourself). Pt. #1 remained on every 15 minutes monitoring.

- The Progress Notes of MD #3 on 8/12/18 at 11:32 AM (the day before Pt. #1's incident) included, " ... Discussed with ... staff ... (Pt. #1) seen. States that she (Pt. #1) is not doing any better than yesterday ... Has current thoughts of suicide ..." However, the suicide risk assessment by E #12 (Behavioral Health Associate) on 8/12/18 at 2:55 PM answered "No" to the following questions: 1. Have you wished you were dead ...? (Past 30 days) 2. Have you actually had any thoughts of killing yourself? (Past 30 days) ..." Pt. #1's suicide risk was scored as "Low Risk" and was kept on suicide precautions.

- The Progress Notes of E #1 (Registered Nurse/RN) dated 8/13/18 at 4:56 AM was reviewed and included, " ... Informed by (E #2/Behavioral Health Associate) that (Pt. #1) is in the bathroom during his rounds and is not responding to name call. Undersigned (E #1) went to check patient knocked and called out her name and there was no response, opened the bathroom and found patient kneeling on the floor with shower curtain wrapped around her neck facing the shower. Called for help... Code blue (medical emergency) and (Paramedic) was called. CPR (heart resuscitation) initiated ... (Paramedic) came took over and transported patient to (Hospital B) ..."

2. On 8/28/18 at approximately 10:00 AM, the Hospital's policy titled, "Suicide Risk and Precautions" reviewed (2/18) was reviewed and included, " ... There is an ongoing assessment of suicide risk while in treatment ...E. Signs and symptoms of suicide risk are documented in the medical record."

3. On 8/28/18 at approximately 10:15 AM, the Hospital's policy titled, "Behavioral Precautions" (undated) was reviewed and included, "... C-SSRS (Columbia Suicide Severity Scale)... Suicide Precautions... 5. Suicide risk is assessed daily by the RN (Registered Nurse)..."

4. On 8/29/18, the mandatory training provided to staff in April and May 2018 regarding "Columbia Suicide Severity Rating Scale (C-SSRS)" included, " ... Use of the C-SSRS scale directs interventions to foster patient safety ... Start assessment by saying ...At time of admission ask questions exactly as written, after admission, ask 'Since the last time you were asked' ... A risk level (low, medium, high will be recommended based on patient assessment ..."

5. On 8/29/18 at approximately 10:30 AM, The Columbia-Suicide Severity Rating Scale (screenshot document) was reviewed. The document indicated that an intervention that could be selected for suicide risk patients included, "Psychiatrist will order 1:1 level of monitoring to ensure patient is monitored at all times by staff.

6. On 8/29/18 at approximately 2:34 PM, an interview was conducted with E #7 (Behavioral Health Associate). When asked regarding the use of the suicide risk assessment after a patient's admission to the hospital, E #7 stated that the suicide risk assessment questions are asked the way the questions are displayed on the computer. E #1 said, "Within the last 30 days."

7. On 8/29/18 at approximately 3:00 PM, an interview was conducted with E #5 (Registered Nurse). E #5 said, that he (E #5) starts the assessment by saying, "At this time, right now (time of the assessment) ..." When asked about the most recent suicide risk assessment training or review from the Hospital, E #5 said, "Maybe in April ... June ..."

8. The Hospital's Root Cause Analysis with a report date of 8/13/18 was reviewed and included, "...At approximately 1:30 AM on 8/13/18, (Pt. #1)... was found by hospital staff in... bathroom... asphyxiate herslef (Pt. #1)using shower curtain... transported to (Hospital B Emergency Department)... admitted to ICU (Intensive Care Unit)... pronounced brain dead... 8/15/18... There were no identified deviations in process, protocols or environmental standards associated with the assessment of this case."

9. On 8/28/18 at approximately 12:24 PM, an interview was conducted with MD #2 (Attending Psychiatrist). MD #2 said, "I've known her (Pt. #1) since October 2016 ... She has been admitted many times ... struggled from mood disorder ... We had her (Pt. #1) on suicide precautions right away (upon admission) ... The entire length of time (referring to Pt. #1's admission until discharge), (Pt. #1) was on suicide precautions and was never discontinued ... That means checking on her every 15 minutes ... There was a time when (Pt. #1) was in lockout ..."

10. On 8/28/18 between 4:00 PM and 5:00 PM, an interview was conducted with E #8 (Chief Nursing Officer) and E #9 (President). E #8 and # 9 stated that the Hospital has conducted a Root Cause Analysis and did not find deviation in the Hospital's processes during the investigation.

11. On 8/29/18, between 8:00 AM and 9:00 AM, E #8 was interviewed. E #8 (Chief Nursing Officer) stated that staff were educated to perform suicide risk assessments two times per day (Day and Evening Shifts), as needed, and use the computer Columbia Suicide Severity Rating Scale to document. E # 8 said, "There is a disconnect from what the physician's notes and the staff suicide risk assessment." E #8 added that the suicide risk assessment tool is used for all patients admitted to the hospital. E #8 agreed that there should have been another suicide risk assessment completed based on E #11's documentation. E #8 added that there is no specific policy for the suicide risk assessment (C-SSRS).

12. On 8/29/18 at approximately 9:18 AM, an interview was conducted with MD #3. MD #3 said, I was covering for the group ... got sign-out from the outgoing physician ... I do factor in nurse's suicide risk assessment by talking to nurses ..." MD #3 verified that on 8/12/18, Pt. #1 had suicidal thoughts.

13. On 8/30/18 at approximately 2:45 PM, another interview was conducted with E #8. E #8 stated that the 1:1 monitoring (Patient is observable at all times. One staff member is located in the same room), is an intervention that could be selected for a suicidal patient whenever necessary.

B. Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) clinical record reviewed for a patient who attempted suicide while receiving treatment in the Hospital, the Hospital failed to increase the patient's monitoring, as required by the patient's actions.

Findings include:

1. On 8/28/18 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 25 year old female admitted to the Hospital on 8/3/18 with a diagnoses of of GAD (general anxiety disorder), MDD (major depressive disorder), and post-traumatic stress disorder (PTSD). Pt. #1 attempted suicide on 8/13/18, and was transferred to Hospital B and eventually died.

- The Progress Notes of MD #3 (Covering Psychiatrist) dated 8/11/18 at 9:48 AM was reviewed and included, " ... Discussed with ... staff ... (Pt. #1) ... Still feeling very depressed ... Thoughts of suicide come and go, 'mostly wishing that all of this is over' ...When she (Pt. #1) leaves here, has half formed ideas of suicide that she can do (overdose on meds, crash car, jump off building) ... Self-injured earlier this week ... Has had fleeting thoughts of self-harm ..."

- The Progress Notes of MD #3 on 8/12/18 at 11:32 AM (the day before Pt. #1's incident) included, " ... Discussed with ... staff ... (Pt. #1) seen. States that she (Pt. #1) is not doing any better than yesterday ... Has current thoughts of suicide ..."

2. On 8/28/18 at approximately 10:00 AM, the Hospital's policy titled, "Suicide Risk and Precautions" reviewed (2/18) included, " ... There is an ongoing assessment of suicide risk while in treatment ...E. Signs and symptoms of suicide risk are documented in the medical record."

3. On 8/29/18, the mandatory training provided to staff in April and May 2018 regarding "Columbia Suicide Severity Rating Scale (C-SSRS)" included, " ... Use of the C-SSRS scale directs interventions to foster patient safety ... Start assessment by saying ...At time of admission ask questions exactly as written, after admission, ask 'Since the last time you were asked' ... A risk level (low, medium, high will be recommended based on patient assessment ..."

4. On 8/29/18 at approximately 10:30 AM, The Columbia-Suicide Severity Rating Scale (screenshot document) was reviewed. The document indicated that an intervention that could be selected for suicide risk patients included, "Psychiatrist will order 1:1 level of monitoring (Patient is observable at all times. One staff member is located in the same room), to ensure patient is monitored at all times by staff.

5. On 8/29/18 at approximately 2:34 PM, an interview was conducted with E #7 (Behavioral Health Associate). When asked regarding use of suicide risk assessment after patient's admission to the hospital, E #7 stated that the suicide risk assessment questions are asked the way the questions are displayed on the computer. E #1 said, "Within the last 30 days."

6. On 8/29/18 at approximately 3:00 PM, an interview was conducted with E #5 (Registered Nurse). E #5 said, that he (E #5) starts the assessment by saying, "At this time, right now (time of the assessment) ..." When asked about the most recent suicide risk assessment training or review from the Hospital, E #5 said, "Maybe in April ... June ..."

7. On 8/30/18 at approximately 2:45 PM, another interview was conducted with E #8. E #8 stated that the 1:1 monitoring (Patient is observable at all times. One staff member is located in the same room), is an intervention that could be selected for a suicidal patient whenever necessary.