HospitalInspections.org

Based on document review and interview the facility failed to ensure patients' right to receive care in a safe environment as evidenced by:

The failure to ensure air-exchange vents were tamper-proof and/or did not hold the weight of fifty or more pounds.

The failure to remove or deny access to articles (I.e. eight-foot call cord), which could provide an avenue to self-inflict harm.

The failure to perform observations, as prescribed by the physician, in order to maintain the patients' right to safety .

The facility's failure to protect patients resulted in the death of one patient (Patient #7).

The findings include:

Patient #7 had two admissions to the facility for self-inflicted abdominal stab wounds (October 2013 and December 26, 2013).

A physician deemed Patient #7 safe for access to an eight-foot call cord after the patient denied suicidal ideation (December 26 - 29, 2013). The patient was placed on low level suicide precautions requiring documented observation every fifteen minutes.

Various staff document Patient #7 remained suicidal, had a change in affect/emotion, expressed hopelessness and dismissed supportive recommendations from December 30, 2013 - January 1, 2014. Staff allowed Patient #7 to retain access to the eight-foot call cord. On January 1, 2014 from 11:45 a.m. to approximately 12:20 p.m., staff failed to maintain observations every fifteen minutes. At approximately 12:20 p.m. on January 1, 2014 Patient #7 was found hanging from an air exchange vent in his/her room. Patient #7 had utilized the eight-foot call cord to hang him/herself.

Based on observations, document review, and interviews the facility failed to provide care in a safe setting. The facility staff failed to remove a means for self-inflicted harm (an eight-foot call cord) and to prevent the death for one of seven patients included in the survey sample (Patient #7).

The findings included:

Observations and interviews were conducted on January 15, 2014 at approximately 10:05 a.m., with Staff #2 and Staff #3, during the tour of the medical behavioral unit (MBU). Staff #3 explained prior to January 1, 2014, the air exchange vent in the patient's rooms were accessible. Staff #3 reported Patient #7 hung him/herself by attaching a long call cord to the air exchange vent.

Review of Patient #7's electronic medical record (EMR) revealed the patient had been admitted to the facility on December 19, 2013 after a self-inflicted stabbing to his/her abdomen. Patient #7 had been deemed stable for transfer to the facility's MBU on December 26, 2013. Review of the physician documentation for December 26, 2013 revealed Patient #7 complained of increased abdominal pain from using the short call cord and requested a longer call cord. The physician documentation for December 27, 2013 and December 28, 2013 revealed the patient denied suicidal ideation, remained on one to one observations with staff, and his/her request for a longer call cord was granted. Physician documentation on December 29, 2013 revealed Patient #7's visual one to one observation by staff was discontinued and the patient was placed on low level suicide precautions requiring documented observation every fifteen minutes.

On December 30, 2013 Staff #27's documented that Patient #7 "... remains suicidal...denies intent to hurt [him/herself] on unit. ..." Documentation on December 30, 2013 by Staff #21 detailed Patient #7's "negative view", dismissing supportive recommendations. The evening of December 30, 2013 nursing documented Patient #7's affect had changed and he/she was "acting suspiciously." Patient #7 was allowed to keep the eight-foot call cord, in spite of expressing suicidal ideation.

Staff #27 documented on December 31, 2013 that Patient #7 was "...resistant, remains discouraged and hopeless ... tearful ... depressed mood ... affect congruent [to mood] ..." On December 31, 2013, Staff #30 documented Patient #7 had avoidant eye contact, was "dishelved", with "poor" insight, "poor" judgment, and the patient reported he/she was "not going to last once discharged." Staff #24 attempted to perform an evaluation on December 31, 2013 and documented Patient #7 stated, "I don't want to waste your time." Staff #24 documented that Patient #7 reported having nothing to live for after discharge. After meeting with Patient #7 on December 31, 2013, Staff #21 documented the patient was "...hopeless about the future." Although Patient #7 expressed suicidal ideation staff did not confiscated or deny his/her access to the eight-foot call cord.

Documentation on January 1, 2014 at 12:03 p.m., by Staff #26 revealed Patient #7 was reclusive to room most of the day with the lights off. Staff #26 documented Patient #7 contracted for safety agreeing not to harm him/herself. Patient #7's EMR revealed the patient was found on January 1, 2014, after he/she had hung his/herself with the long call cord, he/she had attached to the air exchange vent in his/her room.

Review of the Environment safety checks from December 28, 2013 through January 1, 2014 revealed staff documented the assessment had been completed, the patient had been deemed safe. During December 28, 2013 through January 1, 2014, staff continued document "Observed by staff at ALL times" on the Environmental safety checks; although the physician had discontinued the order for Patient #7's one to one status.

Review of the facility's training power point "... Reassess the patient, based on suicide level, documenting on an ongoing basis by the interdisciplinary team ... Complete and document environmental safety checks, at least every 12 hours, while patient is on suicide precautions ... Do not rely on the tool to tell you if a patient is a suicide risk. There is no substitute for therapeutic relationship with your patient ... Based on current literature, asking patients to contract for safety is no longer recommended ... Contracting for safety (having the patient promise not to harm him or herself) has not been shown to reduce or prevent suicidal or self-harm behavior, ... Suicide Precautions : Low Risk ... Interventions[:] The patient will be observed by staff a minimum of every 15 minutes ... Nursing staff will document every 12 hours that the patient's environment is safe. Nursing staff shall assure that patients placed on SP [Suicide Precautions]: Low Risk are able to participate in normal activities of daily living and be observed by staff who will report to the physician or nurse practitioner if the patient expresses and/or exhibits more intense signs of suicidal behavior."

An interview was conducted on January 16, 2014 at 11:00 a.m., with Staff #29. Staff #29 reported prior to the event on January 1, 2014, "To have the longer call cord you had to be off all suicide risk, no expression of suicidal ideation, couldn't be a risk to self or others ..." Staff #29 reported after the event on January 1, 2014, "Everyone gets a short cord."

An interview was conducted on January 16, 2014 at 11:15 a.m., with Staff #25. Staff #25 reported the Environmental safety check documentation of "Observed by staff at ALL times" equaled "being on a one to one observation." Staff #25 reported in order to have access to the longer call cords, "You'd have to be off suicide precautions and no suicidal ideations ... and if I didn't trust what you were saying it would be the short cord ..."

An interview was conducted by telephone on January 16, 2014 at 1:00 p.m., with Staff #20. Staff #20 acknowledged Staff #11 had reported Patient #7's suspicious behaviors to him/her on December 30, 2013 and passed on concerns during shift report. Staff #11 reported not being able to assess Patient #7 related to his/her remaining asleep the majority of the shift. Staff #20 stated, "We kept a close watch on [him/her]. My patient was directly across the hall; my patient was up all night wandering so I kept an eye on [Patient #7's name]." Staff #20 reported Patient #7's behaviors were passed on in report but not documented as passed on. Staff #20 reported the information was not passed on to the physician. Staff #20 stated' "Actually the focus that night after going back to [his/her] history was to ensure there was no access to sharps. [He/she] didn't have a history of hanging, but stabbing [his/herself]. I didn't consider [he/she] would hang [his/herself]."

An interview was conducted on January 16, 2014 at 1:48 p.m., with Staff #2 and Staff #3. Staff #2 reported the facility failed to pull together the clinical picture, failed to remove the eight-foot call cord, and failed to consider returning Patient #7 to a higher level of suicide precautions.

Based on document review and interview the facility's nursing staff failed to furnish care and service to ensure patient safety as evidenced by:

The failure to reassess patients after they have experienced a change in mood, correctly assess the patients' environment and remove items (eight-foot call cord), which could be used to self-inflict harm.

The failure to provide necessary care by updating patients' plans of care/interdisciplinary treatment plans and revising interventions to reflect the patients' current needs.

The failure to perform observations, as prescribed by the physician and to provide the patients with a safe environment.

The failure to coordinate care between services (occupational therapy, pastoral care, social work, with nursing) and notify the physician of concerns.


The facility's failure to protect patients resulted in the death of one patient (Patient #7).

The findings include:

Patient #7 had two admissions to the facility for self-inflicted abdominal stab wounds (October 2013 and December 26, 2013).

A physician deemed Patient #7 safe for access to an eight-foot call cord after the patient denied suicidal ideation (December 26 - 29, 2013). The patient was placed on low level suicide precautions requiring documented observation every fifteen minutes.

Various staff document Patient #7 remained suicidal, had a change in affect/emotion/mood, expressed hopelessness and dismissed supportive recommendations from December 30, 2013 - January 1, 2014. Nursing staff had not updated Patient #7 interdisciplinary treatment plan/plan of care after admission on December 26, 2013. Nursing staff continued to document Patient #7's environment was safe and allowed the patient to retain access to the eight-foot call cord. On January 1, 2014 from 11:45 a.m. to approximately 12:20 p.m., staff failed to maintain observations every fifteen minutes. At approximately 12:20 p.m. on January 1, 2014 Patient #7 was found hanging from an air exchange vent in his/her room. Patient #7 had utilized the eight-foot call cord to hang him/herself.

Based on document review and interviews the facility failed to ensure the registered nurse supervised the care provided by non-licensed staff to maintain every fifteen (15) minute observations for one of seven patients included in the survey sample (Patient #7)

The findings included:

Review of the facility's staffing assignments for the unit that cared for Patient #7 revealed on
January 1, 2014 the unit had a census of seventeen (17) patients and from:

7:00 a.m. to 11:00 a.m. the unit had two Care Partners (CP) with one CP assigned to perform a one to one with a patient leaving the other CP to observe the other 16 patients and document 15 minute observations.

11:00 a.m. to 3:00 p.m. the unit had three Care Partners with two assigned to the floor and one CP performing a one to one with a patient.

Review of Patient #7's electronic medical record (EMR) revealed his/her last fifteen (15) minute check had been documented between "11:30 [a.m.] and 11:44 [a.m.]" on January 1, 2014. Staff failed to document fifteen minute checks from 11:45 [a.m.] through 12:29 [p.m.] in Patient #7's EMR.

Review of nursing documentation revealed Staff #26 entered a nursing note at approximately 12:03 p.m. on January 1, 2014. Staff #26 documented Patient #7, displayed a depressed mood and had been "reclusive to room most of the day with the lights off."

An interview was conducted on January 15, 2014 at 2:31 p.m., with Staff #3 and Staff #29. Staff #3 verified Patient #7's EMR failed to have documentation related to 15 minute checks performed from 11:45 a.m. through 12:29 p.m. on January 1, 2014.

An interview was conducted on January 16, 2014 at 8:30 a.m., with Staff #16. Staff #16 reported that Patient #7 had been "increasingly quite and flat (affect)" on January 1, 2014. Staff #16 stated, "I went to lunch at about noon. The last time I had seen the patient was about twenty (20) minutes before. I told [the name of the other CP working the floor] I was going." Staff #16 stated, "The nurses were at the station; I told them I was going to lunch. The other Care Partner knew, I didn't specifically tell a nurse." Staff #16 reported the unit had two Care Partners on January 1, 2014. When asked how many patients he/she had to monitor; Staff #16 stated, "Five no six (paused) no I had seven that day."

An interview was conducted on January 16, 2014 at 11:40 a.m., Staff #26. Staff #26 reported hearing Staff #16 say he/she was leaving the unit for lunch. Staff #26 reported a patient approached the station to request medication. Staff #26 stated, "I pulled the medication and administered it. I figured I'd do a set of rounds. Maybe, around 12:20 [p.m.] when I entered the room I thought [Patient #7's name] was standing on the other side of the curtain. When I pulled the curtain I saw [he/she] was hanging from the vent. [He/she] had used the long call cord ..." Staff #26 verified staff failed to supervise the monitoring of a patient on fifteen minute checks for safety.

An interview conducted on January 16, 2014 at approximately 2:30 p.m., with Staff #3 revealed the CP assigned to perform the one to one from 7:00 a.m. to 11:00 a.m. performed his/her duties from the hallway. Staff #3 reported the patient requiring the one to one observations had a history of accusing male staff of inappropriate advances. Staff #3 reported to protect staff and the patient a decision was made to observe from the hallway. Staff #3 reported Staff #16, was the CP for Patient #7. Staff #3 reported Staff #16 informed the other CP assigned to the floor regarding leaving for lunch on January 1, 2014 around noon. Staff #3 reported the other CP would be responsible for monitoring the patients and documenting fifteen (15) minute checks. Staff #3 reported Staff #16 informed the nursing staff he/she was leaving the floor for lunch. Staff #3 verified staff failed to ensure Patient #7's fifteen minute checks for safety had been performed.

Based on document review and interview the facility failed to develop an individualized interdisciplinary plan of care and failed to update the plan of care to reflect current needs for one of seven patients included in the survey sample (Patient #7).

The findings included:

Patient #7 was admitted to the medical behavioral unit on December 26, 2013 and successfully committed suicide on January 1, 2014.

Review of Patient #7's electronic medical record on January 15, 2014 did not include a plan of care. A request was made to review Patient #7's plan of care. Staff #3 provided a four-page copy of the paper version of Patient #7's "Interdisciplinary Plan of Care" on January 16, 2014. Staff #3 stated, "[Patient #7's name]'s plan of care was sent to medical records as loose sheets. It was not scanned into the electronic chart."

Review of documentation by Staff #21 on December 31, 2013 revealed the social worker had contacted Patient #7's outside case manager for collateral information. Staff #21 documented the case manager reported Patient #7 had "struggled with hopeless feelings throughout the course of their therapeutic relationship." Staff #21 documented the case manager had reported "... genuine concern the patient is at high risk for attempting additional suicide attempts in the future."

Review of Patient #7's "Interdisciplinary Plan of Care" revealed the following areas were checked on admission (December 26, 2013) under "Problems/Needs" only "Suicidal, Sleep/wake cycle changes and Appetite changes." Social services added "Discharge Planning" on December 27, 2013. Although staff documented in Patient #7's electronic medical record (EMR) that he/she expressed feelings of "hopelessness, helplessness, and depression" the patient's "Interdisciplinary Plan of Care" had not been updated to reflect these needs. Review of Patient #7's designated "Treatment Interventions" only documented "Discharge coordination." Patient #7's "Treatment Interventions" did not address interventions to assist the patient with coping skills, therapeutic outlets, education or safety related to his/her history of serious self-inflicted harm.

An interview was conducted on January 16, 2014 at approximately 3:00 p.m. with Staff #2 and Staff #3. Staff #3 and the surveyor reviewed the "Interdisciplinary Plan of Care" and "Treatment Interventions." Staff #3 reported the documentation on the "Interdisciplinary Plan of Care" and "Treatment Interventions" had not been updated and did not provide an accurate picture of what Patient #7 needed. Staff #3 acknowledged Patient #7's "Interdisciplinary Plan of Care" and "Treatment Interventions" did not reflect an ongoing assessment of the patient's needs or response to interventions.

Based on observations, staff interviews, and medical record review, the facility:

1. Failed to ensure that the intake (air exchange) vent would collapse or break-away upon the stress/weight of fifty pounds and that it would be tamper proof. The failure resulted in the death of Patient #7, who committed suicide by strangulation, using an eight foot call bell cord attached to the air vent. Patient #7 committed suicide approximately between 11:44 a.m. and 12:20 p.m., on January 1, 2014. Patient #7 had been admitted to the facility after a self inflicted stab wound to the abdomen on December 19, 2013.

2. Failed to ensure the eight-foot call bell cord was removed and replaced with a short call cord when Patient #7 began expressing that he/she was hopeless and helpless on December 30, 2013.

3. Failed to ensure that staff continued Patient #7's every fifteen minute visual checks between 11:45 a.m. and 12:29 p.m., on January 1, 2014, while the assigned staff (Staff #16) went on a lunch break.

4. Failed to ensure information was communicate among the Registered nurses, the Physicians, the Residents, and the Occupational Therapist related to Patient #7's expressions of suicidal ideations, which might had resulted in the physician placing the patient on a higher level of suicide precautions. [Increasing from a Level 1: Low risk with every 15 minute checks to a Level 2: Moderate risk a visual one to one with a Care Partner at all times or Level 3: High risk a one to one with a Care Partner within an arm's length at all times.

5. Failed to ensure that the call cords were programmed to the assigned Registered Nurse, who would be alerted when the call cord was removed from its attachment to wall.

6. Failed to ensure a proactive assessment by the staff of the environmental safety for patient rooms to include securing the televisions, the mirrors, air exchange vents and shower curtains in a manner to prevent harm.

Based on review of the physical environment and interview it was determined that the facility failed to ensure a safe physical environment for Patient #7, who completed suicide by hanging him/herself with an eight-foot call bell cord, which caused strangulation resulting in death.

The findings included:

1. Patient #7 was admitted to the hospital on December 19, 2013, with a diagnosis of a self-infected stab wound to the abdomen. Patient #7 was transferred to the Medical Behavioral Unit (MBU) on December 26, 2013. Patient #7 had a prior admission to the MBU in October 2013 for a self-inflicted abdominal stab wound and had been discharged in November 2013 with follow up as an outpatient.

Patient #7' admission required surgery for the December 19, 2013 resulted in exploratory laparotomy (Exploratory laparotomy is the standard of care in various blunt and penetrating trauma situations to which there may be multiple life-threatening injuries), ligation of the right inferior epigastric artery (Tying up the bleeding artery, that lives near the crest of the hip bone), ligation of intra-abdominal bleeders (Tying of the sheet of fat that covers the intestine inside the abdomen. On Patient #7's arrival to the MBU December 26, 2013, he/she requested a long call cord related to his/her abdominal incision pain.

The facility failed to replace Patient #7's eight-foot long call cord with a short call cord after the patient expressed suicidal ideations on December 30, 2013.

An interview with Staff #9 was conducted on January 15, 2014, at 1:40 p.m., by the Surveyor. Staff #9 stated, "I was amazed that the last lever [the center portion] of the ceiling vent held the weight of Patient #7, who weighed about 157 pounds." Staff #8 reported the team met monthly for Environment of Care requirements and management. Staff #8 acknowledged they failed to determine the potential hazards on the MBU.

During an interview on January 15, 2014, at 3:14 p.m., Staff #10 confirmed that work still need to be done to ensure the total safety of all MBU patients.

During an interview conducted on January 16, 2014 at approximately 10:29 a.m. with Staff #2, Staff #3, Staff #4 and Staff #5. Staff #4 stated, "We were told the air vents would break-away with 50 pounds of weight." Staff #3 and Staff #5 could not recall where they had obtained the information related to the vents breaking away with 50 pounds of weight. Staff #3 reported during environmental safety rounds staff had not tested the over head air vents to ensure they would break away with a weight of 50 pounds. Staff #3 reported prior to January 1, 2014, the call cord if removed from the wall, the alarm could be canceled from within the patient's room. Staff #3 reported the call system prior to January 1, 2014 could be programmed to ring to the assigned nurse's phone or default to the nurse's station. Staff #3 stated, "There was an issue with programming the call system to the individual assigned nurse's phone. If the call cord alarm went off at the desk staff would respond if it continued to alarm." Staff #3 reported if Patient #7 canceled the call cord alarm in his/her room staff would not have responded.

An interview was conducted on January 16, 2014 at 11:40 a.m., Staff #26. Staff #26 reported hearing Staff #16 say he/she was leaving the unit for lunch. Staff #26 reported being delayed in starting his/her rounds related to a patient approaching the station and requesting medication. Staff #26 stated, "I pulled the medication and administered it. I figured I'd do a set of rounds. Maybe, around 12:20 [p.m.] when I entered the room I thought [Patient #7's name] was standing on the other side of the curtain. When I pulled the curtain I saw [he/she] was hanging from the vent. [He/she] had used the long call cord ..." Staff #26 reported the staff and facility had failed to ensure Patient #7's safety by not addressing and removing his/her access to the eight-foot long call cord.