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Based on review of hospital documents and interview, it was determined that the hospital failed to use data collected to identify opportunities for improvement for 1 of 1 Behavioral Health Unit patient incident involving a medication overdose (Pt # 2).

Findings include:

Cross Reference Tag (A0395) for information regarding Pt #2.

An Event Report regarding the patient's overdose was completed on 10/22/10. The Patient Safety Program Coordinator followed up by notifying Clinical Management (CM) for review and further follow-up. The remote data entry was given an initial severity score of High. A focused event review was held on 11/23/10.

Review of documents provided by the hospital revealed:

The Behavioral Health Unit leadership considered the search of the patient to be very thorough. Therefore, staff determined that the patient did not bring in the medication herself. The visitor who saw the patient on 10/21/10, did not sign the visitor log and no one could determine whether staff provided verbal instruction to the visitor regarding prohibited items. The focused event review identified required actions for improvement which focused on the conduct of patient searches; visitation policy; training of mental health technicians regarding information/instructions provided to visitors; supervision of visits; communication between mental health technicians and nurses regarding patient background which may relate to visitors; storage of visitors' items; and consideration of body cavity searches for specific patients.

The Behavioral Health Unit Director and the Patient Safety Program Coordinator confirmed, during interview conducted on 12/9/10, that the focused event review did not include discussion of the Behavioral Health Unit staff's assessment of the patient's suicide risk; consideration of clinical indications for re-implementing the patient's suicide precautions; or the patient's care plan.

Based on review of Medical Staff Bylaws, hospital document, physician credential files, and interview, it was determined that the medical staff failed to enforce the bylaws to carry out its responsibilities for 4 of 4 Emergency Department physicians who were granted reappointment in October and November, 2010 (Physicians #7, #8, #10, & #11).

Findings include:

Review of the Flagstaff Medical Center Northern Arizona Healthcare Medical Staff Bylaws revealed:
"...Part D: Clinical Privileges...Section 1: General...Each individual who has been given an appointment to the medical staff of the hospital shall be entitled to exercise only those clinical privileges recommended by the Executive Committee and specifically granted by the Board...Article VIII Actions Affecting Medical Staff Appointees...Part A: Procedure for Reappointment...Section 1: Application...Each current appointee who wishes to be reappointed to the medical staff shall be responsible for completing the reappointment application form approved by the Board. The reappointment application shall be submitted to the FMC president or his designee at least four months prior to the expiration of the physician's then current appointment...Section 4: Department Procedure...(a) No later than three months prior to the end of the current appointment period, the FMC President (or designee) shall send to the Credentials Committee the list of those appointees desiring reappointment...The Executive Committee shall then in turn transmit to the chairman of each department a current list of all appointees who have clinical privileges in that department, together with the clinical privileges each then holds, accompanied by copies of their applications...."

Review of the Exclusive Professional Services and Medical Director Agreement between Flagstaff Medical Center and Flagstaff Emergency Physicians revealed: "...Each physician shall maintain active medical staff privileges at FMC and shall be subject to the Medical Staff Bylaws of FMC...."

Physician #7 is an ED physician. His/her Clinical Privileges were effective from 10/9/08 through 9/30/10. S/he signed the application for reappointment on 9/2/10. His/her reappointment was effective 10/7/10. S/he did work on 10/01/10, when Clinical Privileges were expired. S/he did not comply with the requirement to submit the application for reappointment 4 months prior to expiration of current privileges.

Physician #8 is an ED physician. His/her Clinical Privileges were effective from 10/9/08 through 9/30/10. S/he signed the application for reappointment on 8/18/10. His/her reappointment was effective 10/7/10. S/he worked on 10/1/10, 10/2/10, 10/3/10, & 10/4/10 when his/her Clinical Privileges were expired. S/he did not comply with the requirement to submit the application for reappointment 4 months prior to expiration of current privileges.

Physician #10 is an ED physician. His/her Clinical Privileges were effective from 11/13/08 through 10/31/10. S/he signed the application for reappointment on 9/10/10. His/her reappointment was effective 11/4/10. This physician did not work while his/her privileges were expired. However, s/he did not comply with the requirement to submit the application for reappointment 4 months prior to expiration of current privileges.

Physician #11 is an ED physician. His/her Clinical Privileges were effective from 11/13/08 through 10/31/10. S/he signed the application for reappointment on 10/5/10. His/her reappointment was effective 11/4/10. S/he worked 11/1/10 and 11/2/10 when his/her Clinical Privileges were expired. S/he did not comply with the requirement to submit the application for reappointment 4 months prior to expiration of current privileges.

Employee # 7, Director of Quality Management and Medical Staff Services, confirmed during interview on 12/8/10, that physicians #7, #8, #10, & #11 did not submit application for reappointment to the Medical Staff as required by the Medical Staff Bylaws and that the process and time frames as required in the Medical Staff Bylaws were not followed. In addition, Employee #7 stated that the Medical Staff Office sends the applications out to the physicians 3 months before the expiration of the physicians' Clinical Privileges and reminds the physicians to return the application to the Medical Staff office before the Credentials Committee meeting. (This practice is also not according to the Bylaws.) Employee #7 stated that the Bylaws need to be changed.

Employee #7 confirmed during interview on 12/9/10, that three of the four ED physicians who were granted reappointment worked when their Clinical Privileges were expired.

Based on review of medical record, hospital policy/procedure, and interview, it was determined that the registered nurse failed to supervise and evaluate the nursing care for 1 of 1 patient hospitalized on the Behavioral Health Unit with suicidal ideation (Pt. #2) as evidenced by:

1. failure to re-implement suicide precautions when a patient expressed suicidal ideation and command hallucinations to harm herself and/or failure to document assessment of patient's suicide risk and interventions in response to patient's expression of suicidal ideation which would provide clinical rationale for not re-implementing suicide precautions other than verbal contracting;

2. failure to supervise implementation of department guidelines of practice for patient visitors regarding prohibited items; and

3. failure to initiate a care plan regarding patient's suicidal ideation.

Findings include:

Patient #2 was seen in the hospital Emergency Department (ED) on 10/20/10 at 1243. An RN documented: "...Chief Complaint...SI (Suicidal Ideation). here for self inflicted lac (laceration) to left fa (forearm) last week. having continuous thoughts of harming herself. states her plan is to take 'a bunch of meds because she just got them all refilled. tomamax (sic) is very lethal in high doses; would take that'...hearing voices 'its not worth living and nobody cares'. command hallucinations to 'take the pills.'...."

An RN documented, at 1249: "...Suicide Risk Assessment...Constant suicidal thoughts...Detailed plan with actual or potential access to method...High lethality of plan...past attempts/High lethality/Family Hx (history)...Support Systems...Few/One friend, co-worker, relative available...Arrange for Patient Safety Attendant/Security Officer, Inform care team members of patient's status...."

The ED physician saw the patient at 1330 and documented: "...She was then seen yesterday for a wound recheck...She reports that she was not suicidal yesterday; however today she has had increased thoughts of wanting to harm herself. She reports that her plan is to take a bunch of her medications and she just got them refilled and she has not taken any medications today...She would like to be admitted, that she is feeling unsafe at home. She reports that she is hearing voices. Reports that it is not worth living and that nobody cares. She reports that she is having command hallucinations to take her pills...EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING: The patient was seen by myself in the emergency department. behavioral health came and saw the patient...She was refusing Guidance Center admission but would like Behavioral Health admission. The patient will be admitted to the Behavioral Health...."

An RN documented, at 1700, in a Behavioral Health Consult: "...pt states she cut herself on her left forearm with a 'scalpel from a dissection kit'. She stated that if she were to return home that she would overdose on her medications. She reports having negative auditory hallucinations. also reports a relationship with partner of 17yrs coming to an end and that she is having emense (sic) difficulties ending the relationship. Reports that her partner is verbally abusive and will not let her end the relationship...Hx of disassociation, auditory hallucinations and ptsd (Post Traumatic Stress Disorder), and has had previous suicide attempts...Pt is severely depressed, tearful, blunted affect. Pt states she is having increased suicidal ideations...Reports she had a safety plan to come to the hospital if SI increased and she was unsafe...She requested to come to FMC BH (Flagstaff Medical Center Behavioral Health) and was adamant that she not go to TGC (The Guidance Center)...."

The patient was admitted to the Behavioral Health Unit at 1800.

1. An RN documented a telephone order from a physician at 1730: "...Admit: Behavioral Health Unit...Transfer requested to next available attending provider per protocol...Dr. (_______) in AM...."

An RN documented a telephone order from a physician at 2000: "...Precautions: Suicide Precautions...Level I...."

The medical record contained a pre-printed Order Set titled Suicide Precautions Orders for Behavioral Health Unit. An RN placed a mark next to "Level 1 Suicide Precautions (Standard)" and signed the order form as a telephone order from a physician at 2000.

Level 1 Suicide Precautions contained the following specific orders:
"...1. Single room (when possible). 2. Room must be made safe, no...potential items of self harm...4. 15 minute checks. 5. Bathroom must be checked for safety before patient use. 6. Bathroom use only with staff supervision (door ajar; staff outside door). 7. Showers only under...staff supervision (staff in room)...10. Room door remains open at all times. 11. Visitation only under staff supervision. 12. Daily status review...."

The patient's attending psychiatrist dictated a Psychiatric Evaluation on 10/21/10, at 1758. Review of this evaluation revealed: "...HISTORY OF PRESENT ILLNESS: What led to her suicide attempt, last week when she cut her left arm, was her difficulty with her significant other...Eight days ago...the patient made the decision to cut herself as a suicide attempt. She describes her cut as very deep such that, 'I can see my muscles. It is kind of cool.'...She states that she chose to come here because, 'I hate the PAC (Psychiatric Acute Care) Unit at the Guidance Center...Nothing is resolved.' ...states that she will hear voices at night, which apparently is long-term, 'Talking about things that have happened.' ...PAST PSYCHIATRIC HISTORY:...previous hospitalizations too numerous to count. She states that she was hospitalized at Aspen Hill when she was 13 and states that she was sexually assaulted by a nurse during that hospitalization and states that he has since gone to prison for this. She states that she has no difficulty being in this program, which is the successor to Aspen Hill...has made about six 'serious' suicide attempts in her life...MENTAL STATUS EXAMINATION:...She reports that she is experiencing continued suicidal ideation but does contract for safety here on the unit and contracts that she will let staff know if she becomes a risk of harm to herself...reports hearing voices, primarily when she is trying to go to sleep...PLAN:...The patient is admitted on voluntary basis. Suicide precautions which were initiated at the time of admission are discontinued...."

The attending psychiatrist wrote an order on 10/21/10, at 6:40 PM: "D/C (Discontinue) SP1 (Suicide Precautions Level 1)...."

The Behavioral Health Unit Director provided a document titled Rounds for Patient Observation which serves as Departmental Guidelines of Practice for staff observation of patients who are not on Suicide Precautions: "...To insure that patients are appropriately supervised and participating in the therapeutic milieu...Procedure...1. Staff are assigned each shift to perform patient rounds and document each patient's location every 15 minutes...."

Review of nursing documentation during the patient's hospitalization on the Behavioral Health Unit revealed:

Flow Sheet documentation in category "Behavioral Health:"

10/20/10 at 1811: "...Mood...Anxious, Depressed...Affect...Normal, Constricted, Blunted...Current Suicidal Comments...plan to overdose on home medications...Suicidal Safety Contract...Verbal Contract...."

10/21/10 at 0800: "...Auditory hallucinations...command hallucinations...Mood...Anxious, Depressed...Affect...Blunted...Patient Profile SI...Yes...Current Suicidal Comments...voices telling her to harm self...Suicidal Safety Contract...Verbal Contract...."

10/21/10 at 1904: "...Auditory hallucinations...intermittent voices telling her to harm self...Mood...Depressed...Affect...Blunted...Patient Profile SI...Denies...Suicidal Safety Contract...Verbal Contract...."

10/22/10 at 0951: "...Auditory hallucinations...pt states she hears a voice telling her to harm self at times...but is able to not listen to it...Mood...Anxious, Depressed...Affect...Blunted...Patient Profile SI...Yes...Current Suicidal Comments...pt states she hears a voice telling her to harm self at this time...Suicidal Safety Contract...Verbal Contract...."

Nursing Documentation of Shift Summary/Update revealed:

10/20/10 at 2155: "...mood anxious & depressed/affect blunted/denies SI in this setting/contracts for safety on unit...admits to auditory hallucinations-voices telling her to harm self...."

10/21/10 at 1557: "...Pt reports voices that are command telling her to kill herself. She is able to contract for safety here and attempts to distract self through withdrawal to room and sleep...."

10/21/10 at 1908: "...walking in hall/mood depressed/affect remains blunted/minimal conversation...hears intermittent voices telling her to harm self/cooperative & agreeable to interview by nursing student...."

10/22/10 at 0957: "...pt states she hears a voice that tells her to hurt herself in various ways but she says she would not act on these voices and feels able to contract for safety, will continue to monitor...."

Addendum at 1306: "...pt at 1215 noted by mht (mental health technician) to be complaining of being very tired, I went out and checked the pt and her vs (vital signs) at that time were: 135/78 hr (heart rate) of 120 bpm (beats per minute), sat (oxygen saturation) mid 80's on room air, pt placed on 02 (oxygen) by nc (nasal cannula) at 2L (liters per minute) at about 1225, pt was talking to me and having trouble keeping her eyes open...she disclosed to Dr. (_____) that she overdosed this am on about 13 tabs of oxycodone (5/325) by pt account, rapid response was called at about 1230, they responded to the unit, iv (intravenous) was started and labs drawn and sent to the lab, I called ED to let them know pt was coming and what had happened, pt is off the unit with rapid response going to the ED...."

The medical record contained a Discharge Summary completed by the patient's attending psychiatrist which revealed: "...The patient was discharged to the Emergency Department after Rapid Response was contacted after the patient was noted to be excessively sedated with O2 saturations on room air dropping into the mid-80's. The patient disclosed that she had taken an overdose of about 13 to 15 oxycodone which she had hidden in her pocket. When the patient was medically cleared, she agreed to be admitted to the Guidance Center Inpatient Psychiatric Unit. The patient is an active patient of the Guidance Center and sees Dr. (_______)...She stated that her intention was to die by this overdose in our unit and was very disappointed and upset, even angry, that she had not accomplished this goal...I discussed the matter with nursing staff as well as the unit director and intake supervisor. There was agreement that we would recommend that the patient, when medically stabilized, be referred to the Guidance Center Inpatient Unit where she receives ongoing psychiatric care and has for many years. The patient made it very clear that she had the full intention to end her life on this unit...."

Review of the Departmental Guidelines of Practice titled Suicide Precautions revealed: "...Purpose...To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients...1. Suicide precautions will be ordered by the physician, but nursing personnel will implement suicide precautions while awaiting the order...2. Orders for suicide precautions must include the degree of staff supervision and restriction from potentially harmful objects or activities using levels described below and must be based on a clinical assessment and a physician's order...3. Suicide precautions are ordered for a maximum of 24 hours and reassessed each 24-hour period for renewal. the physician may discontinue them at any time, but nursing must re-implement as clinically indicated...."

The remainder of the Suicide Precautions document included the specific provisions of Level 1, Level 2, and Level 3 Precautions.

The patient was initially placed on Level 1 Precautions as described above. Those precautions were discontinued per physician order on 10/21/10 at 1840, and not re-implemented.

On 12/7/10, the Behavioral Health Unit Charge Nurse confirmed that the nursing assessments recorded in the patient's medical record contained documentation that the patient was experiencing auditory hallucinations, of a command nature, to harm herself. S/he also confirmed that nurses frequently documented that the patient contracted for safety. In addition, s/he confirmed that the facility has no procedure or clinical guidelines to define what contracting means or whether it is used to determine the patient's suicide risk and/or need for re-implementing suicide precautions. The Charge Nurse also confirmed that there are no consistent guidelines that the nurses utilize as clinical indication for re-implementing suicide precautions or for suicide risk assessment. S/he stated that inservice education has focused primarily on knowledge of the particular levels of suicide precautions; not clinical indications for each level.

The Director of Behavioral Health also confirmed, on 12/7/10, that the Unit has no clinical guidelines or procedure for the use of contracting either as an assessment tool or an intervention for a patient's suicide risk.

2. Review of Departmental Guidelines of Practice titled BHS Search for Contraband revealed: "...Visitors and Contractors...All visitors/contractors will sign the visitor log book prior to being escorted onto the BH Inpatient Unit. At this time the staff escort will have a brief discussion with visitor(s) of this nature: '...You may not bring any prohibited items on the unit as per the list in the lobby. Do you have any questions about prohibited items?'...."

Review of Unit document titled FMC Behavioral Health Services Visitor Expectations revealed: "...I understand that the safety of all patients, BHS staff and visitors on the inpatient unit is of the highest importance. I agree that I will not bring any prohibited items onto the unit and that I will immediately tell BHS staff if I learn that there are any prohibited items on the unit...."

This document included a list of prohibited items which included medications and numerous other potentially hazardous items.

The Director of the Behavioral Health Unit described, during interview conducted on 12/7/10, that she and other leadership staff had investigated the incident since the day that the patient ingested the overdose. S/he identified that the patient received a visitor during the evening of 10/21/10. The visitor was the patient's domestic partner, from whom she was attempting to separate. The staff described the visitor as wearing a "pocketed, hooded sweatshirt" and wearing a "water bottle." The Unit Director identified that the staff member receiving the visitor for the patient did not ask the visitor to relinquish any prohibited items prior to the visit, as required by Unit procedure. In addition, the staff member did not have the visitor complete the form titled FMC Behavioral Health Services Visitor Expectations, as required by Unit procedure. The visit occurred in a public area, but was not monitored by staff.

3. The medical record contained a Nursing Plan of Care. The problem identified was "Coping." Neither the Outcomes nor Interventions included content related to the patient's suicidal ideation/command hallucinations or suicide risk assessment.

Review of Departmental Guidelines of Practice titled Treatment Planning- Role of Multidisciplinary Team revealed: "...Nurse...Initiates the Treatment Plan within 8 hours of admission to include a plan for all medically indicated problems...Functions as the liaison between MDT (Multidisciplinary Team) and the psychiatrist as needed in communicating information relative to ongoing treatment planning and provision of care.

The Director of the Behavioral Health Unit confirmed, during interview conducted on 12/9/10, that the patient's Care Plan did not address suicide risk.