HospitalInspections.org

Based on medical record review, document review and interview, in 1 of 18 medical records reviewed, the facility failed to ensure that a potentially suicidal patient was appropriately monitored (Patient #1).

These failures resulted in patient harm.

Findings include:

Review of medical record for Patient #1 identified a 31-year-old male who presented to the Emergency Department on 8/19/17 with suicidal ideation and was placed on 1:1 observation. The patient's observation status changed when he was in the Psychiatric Emergency Department where he remained until he was admitted to the inpatient psychiatric unit on 8/23/17 at approximately 12:10 AM. At 4:34 PM, the patient was found unresponsive; the patient was pronounced dead following resuscitation attempts.

There was no documented evidence that the facility implemented its policies and procedures to appropriately monitor Patient #1 who repeatedly voiced suicidal ideation.
See Tag A-0144.

Based on medical record review, document review and interview, in 1 of 18 medical records reviewed, the facility failed to ensure that a patient with suicidal ideation was safely monitored (Patient #1).

These failures resulted in patient harm.

Findings include:

Review of medical record for Patient #1 identified a 31-year-old male who presented to the Emergency Department (ED) on 8/19/17 with a chief complaint of a painful right knee. At 12:56 AM, during triage, the patient complained of suicidal ideation and was placed on 1:1 observation.

The ED Physician Assistant (PA) noted at 2:06 AM: " ... Patient stated he had suicidal ideations in the past but now has a clear plan of how he wants to end his life. No homicidal ideations. No drug/alcohol abuse. No visual or auditory hallucination. 1:1 observation will re-evaluate."

An order for 1:1 Observation for 24 hours was documented on 8/19/17 at 2:10 AM.

Psychiatric Consultation at 8:15 AM noted the following: " ... the patient stated he became homeless yesterday as he was told he no longer has residency at Project Renewal residence in the Bronx. The patient reported he is stressed and when he is stressed, he feels suicidal; history of old scars on his forearms from previous attempted suicides. At present patient states, he still feels suicidal and wants help." The physician recommendations included further evaluation in the Psychiatric Emergency Department (PED) upon medical clearance and continuation of 1:1 observation for safety.

On 8/19/17 at 11:12 AM, the patient was medically cleared for transfer to the PED.
The initial nursing assessment in PED on 8/19/17 at 12:26 PM notes, "patient denies any suicidal/ homicidal ideations or plans. Patient denies any auditory, visual, or tactile hallucinations. Monitoring ongoing pending psychiatric re-evaluation in the morning."

While the patient was in the PED, from 8/19 to 8/23/17, there were several assessments conducted by clinical staff that indicated the patient denied suicidal and homicidal ideation; however, there were instances where the patient continued to express hopelessness and unwillingness to live. For example:

On 8/19/17 at 7:24 PM, psychiatrist noted the patient was restless but cooperative, complaining of suicidal ideation and depression. He is not psychotic, not aggressive. Clear sensorium, no delirium, speech clear, thoughts coherent, insight and judgment limited."

On 8/20/17 at 11:43 AM, Social Worker notes, "Patient states he does not know how to function independently. He is unable to cook. Has been asking for residential placement, does not want to be alone. He has no contact with his family that resides in Idaho. He has no one who cares about him or is there to help him. Patient denies any suicidal ideation this minute, admits that he feels like dying more often that he desires to live. Patient is asking for inpatient admission at this time."

In the Voluntary Request For Admission (Office of Mental Health form 913), signed by the patient on 8/23/17, he documented his reason for applying for admission or conversion to voluntary Status are: "I want to kill myself and need help."

The observation record revealed the patient was monitored every 15 minutes (Q 15 minutes) in PED from the time of his admission on 8/19/17 at 12:26 PM to when he was admitted to the psychiatric inpatient unit past midnight on 8/23/17 at 12:10 AM.

The initial C-SSRS (Columbia-Suicide Severity Rating Scale) assessment conducted in the inpatient unit by Staff A, Nurse Practitioner on 8/23/17 at 12:24 PM, shows that the patient answered "Yes" to all six questions in the assessment tool as follows:
1) In the past month, have you wished you were dead or wished you could go to sleep and not wake up? 2) In the past month, have you actually had any thoughts of killing yourself?
3) In the past month, have you had these thoughts?
4) In the last three month, have you had these thoughts and had some intention of acting on them?
5) In the past month, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
6) In the past month, have you ever done anything, started to do anything, or prepared to do anything to end your life?

Staff A, notes, "Patient denies current active ideation and intent, though remains at elevated risk for self-harm given extensive history of self -mutilation and suicide attempts ...Patient denies any intent to harm others, however given history of violence towards others patient is at elevated risk for harm to others ... Plan: Q15 observation ..."

At approximately 4:34 PM on 08/23/17, during Q 15 minute rounds, Staff E, a Behavioral Health Technician found the patient unresponsive, with his head hanging off the bed. There was a wet white string around his neck tied in three knots. The patient was resuscitated and later pronounced dead by the code team at 5:06 PM.


The facility's policy and procedure titled "Heightened Patient Observation: 1:1 and Continuous Observation" notes, "The rationale for 1:1 must be specified in the physician's order and may include the following: ... b) Actively suicidal and/or homicidal (recent attempt and /or suicidal thoughts and / or verbalization with plan and /or intent) ... Only a psychiatrist or NP may reduce the level of observation once it has been ordered ... If the 1:1 or continuous Observation is to be discontinued or changed, an order to decrease the intensity of observation must be written and the plan of care reevaluated."

The order for 1:1 observation of the patient written on 8/19/17 at 2:10 AM in the Medical Emergency Department did not specify the rationale for the order as indicated in the policy. There was no documented evidence that a psychiatrist or a Nurse Practitioner either discontinued the order or decreased the intensity of the observation.

On 08/30/17 at 12:30 PM, during interview with Staff P, Associate Director of Nursing, she stated that all patients in the Psychiatric Emergency Department are monitored Q 15 minutes. She acknowledged that there was no assessment by an NP or Psychiatrist prior to the change of patient's observation status from 1:1 to Q15 minutes.

Review of the facility's Behavioral Health policy and procedure titled: "Patient Monitoring: Close Awareness/Level 3 Monitoring- Q15 minute Check" last revised 0/06/2016 notes, "All admitted patients must be monitored closely by Behavioral Health Nursing staff members. Patients admitted to the inpatient service are maintained on Q 15 minutes monitoring throughout their entire admission."

The initial assessment of the patient conducted by the NP on 8/23/17 at 12:24 PM identified the patient at elevated risk for self-harm and harm to others. The rationale for assigning standard observation (Q 15 monitoring) to a patient with elevated risk for harm was not documented.


On 08/28/17 at 3:30 PM, during interview with Staff A, Nurse Practitioner (NP), he reported that the patients screened positive during his assessment on the in-patient psychiatric unit, but denied current active suicidal ideations, intent or plan. Staff A confirmed his assessment of the patient as being at elevated risk for self-harm and harm to others, but stated that 'Q15' minutes observation was appropriate to monitor the patient's safety.

Review of facility's policy titled "Room Assignment" last revised 06/16/2016 notes, "Room 522 and 523 on the 5th floor and 319 and 320 on the 3rd floor should be used for acutely disturbed patients who are in need of close observation including newly admitted patients who have been assessed as potentially suicidal'.

The patient was not assigned any of the rooms dedicated for close observation of patients who are potentially suicidal.

On tour of inpatient unit, Unit # PIP5 on 08/28/17 at 10:30 AM, it was observed that the patient was roomed at the end of a hallway around an alcove. The patient's room was approximately 75 feet from the nursing station and the doorway to patient's room could not be observed from the nursing station.

In addition, the patient was not observed Q 15 minutes as ordered by the NP on 8/23/17. The patient's observation record for 8/23/17 was blank for 4:15 PM.

Review of video surveillance of the unit, revealed that on 8/23/17, Staff E, Psychiatric Technician rounded on the patient at 3:57 PM, the next round was conducted 37 minutes later at 4:34 PM, at which the patient was found unresponsive.

On 08/28/17 at 11:30 AM, during videotape surveillance viewing, Staff B, Interim Director Inpatient Care confirmed that Q15 minutes checks for the patient were not conducted timely.

On 08/28/17 at 3:30 PM, during interview with staff E she acknowledged that she did not conduct 'Q 15' minutes observation rounds at 4:15 PM, and 4:30 PM on the male side of the unit, where Patient #1 was located.