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A. Based on policy review, clinical record review and staff interview, it was determined that for 1 of 10 clinical records reviewed (Pt. #1), the Hospital failed to identify suicidal triggers documented for Pt #1 and implement effective actions; failed to ensure a debriefing occurred with Pt #1 after a tumultuous family therapy session; and failed to ensure the root cause analysis included actions to prevent reoccurrence of suicide. Subsequently, Pt #1 committed suicide by hanging. As a result, it was determined that the Condition of Patient Rights was not in compliance.

An Immediate Jeopardy (IJ) and serious threat to patients' safety and wellbeing was created from the cumulative effects of this systematic practice.

Findings include:

1. An Immediate Jeopardy (IJ) was identified on 3/28/12 at 3:45 PM and the Hospital's Director of Inpatient Services and Chief Nursing Officer were notified at 4:05 PM. The IJ identified was the Hospital's failure to identify Pt #1's recent suicidal triggers documented in the following sources: the transferring Hospital's Suicide Risk Assessment, the Hospital's Comprehensive Level of Care Assessment, Psychosocial Assessment, and Interdisciplinary Treatment Plan . The Hospital also failed to ensure an assessment/debriefing was conducted with Pt #1 after a tumultuous family therapy session. Subsequently, Pt #1 committed suicide by hanging. In addition, the Hospital failed to ensure the root cause analysis included specific findings leading to immediate implementation of effective actions to prevent reoccurrence of suicide.

2. On 3/7/12 at 5:54 PM, Pt #1, a 17 year old male, was brought by ambulance and police to the Emergency Department of the transferring Hospital after an altercation with his father. He was seen by a Licensed Clinical Social Worker (LCSW) for a Psychosocial Evaluation and Suicide Risk Assessment at the transferring Hospital. This assessment included, "Pt is a 17 year old male brought to the ED because of a recent increase in suicidal feelings, depression, and anger ...Last Wednesday, Pt was thinking about suicide. He told his mother afterwards that he was going to sit in the garage with the car on and play his guitar until he passed out. Pt asked his mother to get his pillow out of the car and he threw the car keys into the room his parents were in. This was Pt's 2nd time doing this. Mom doesn't know if he really turned the car on or not."

Pt #1 was transferred from the ED of the transferring Hospital and admitted to the Adolescent Psychiatric Unit of the receiving Hospital on 3/8/12 at approximately 4:00 AM with diagnoses of Depressive Disorder Nonspecific and Marijuana Dependence. Another assessment, "Comprehensive Level of Care Assessment" for Pt #1 dated 3/8/12 at 1:37 AM was completed by a LCSW (E #2), and counter-signed by the admitting child psychiatrist (E #1) on 3/9/12, and included, " ...Suicidal/Homicidal - Present: Suicidal Y (yes); Ideation Y; Plan Y ...History: Suicidal Y; Ideation Y; Plan Y ...Details: Patient stated that he has been suicidal for the last two days and was thinking of staying in the garage with the car running until he passed out and died. Patient was suicidal in 1/12 when his girlfriend broke up with him and was hospitalized at that time ... " Admission orders were obtained on 3/8/12 at 4:00 AM from the psychiatrist on call (E #15) and included, " ...Safety Precautions for: Assault ... "

Subsequently, a "Psychosocial Assessment" completed by E #3 (Clinical Therapist) dated 3/8/12 at 3:16 PM included, "Problems Identified during Assessment ...1.1 Threat to others; 1.2 SI (suicidal ideation) ..."

The "Treatment Plan" for Pt #1 dated 3/8/12 documented by E #3 and signed by the Interdisciplinary team (including E #1-Psychiatrist) on 3/9/12 included, "Presenting Problems - Primary 1.1 Homicidal Ideation/Intent (Harm towards others); Secondary 1.2 Suicidal Ideation/Intent (harm towards self) ..."

Suicide Precautions were never ordered for Pt #1. Staff failed to identify the need to place Pt #1 on suicide precautions. Pt #1 committed suicide by hanging, on the Adolescent Psychiatric Unit on 3/9/12, and was found at approximately 4:55 PM. Refer to Tag A 144(A).

3. Pt #1's clinical record included documentation that a family therapy session was conducted on 3/9/12 (untimed) with Pt #1 during which Pt #1 became very agitated. A "Family Therapy BIRP (Behavior Intervention Response Plan)" note by E #6 (CT - Clinical Therapist) dated 3/9/12 included, " ...After safely escorting the parents into another room the CT called a Silent Code (Yellow) to assist the pt with self- soothing. Pt was verbally redirected to the Quiet Room without incident .." However, there was no documentation that a follow up assessment and analysis was conducted with the patient to see if the patient was at risk for behavioral changes, in order to adequately monitor the patient's condition. Refer to Tag A 144 (B).

4. This event was declared a Sentinel Event, an RCA (Root Cause Analysis) was performed on 3/15/12. A Quality Committee Meeting was held on 3/21/12, and a Medical Executive Committee Meeting was conducted on 3/23/12. The Hospital failed to specifically and completely identify possible contributing factors in the RCA, and failed to implement immediate actions to help prevent reoccurrence of suicide. Refer to Tag A 144 (C).

A. Based on review of Hospital policies, clinical records, and staff interview, it was determined that for 1 of 10 (Pt #1) clinical records reviewed of a patient with recent suicidal ideation and a plan for suicide, the Hospital failed to ensure suicidal precautions were implemented for Pt. #1 to protect the patient from committing suicide. This could potentially affect all inpatients (current census 92).

Findings include:

1. On 3/26/12 at approximately 11:00 AM, the Hospital policy entitled, "Gen_025 Patient Rights and Responsibilities (revised 9/8/11)", was reviewed and required, "10. Personal Safety: Patients have the right to expect reasonable safety."

2. The Hospital policy entitled, "LOH- CLIN 078 Safety Precautions" (revised 7/21/11), was reviewed on 3/26/12 at approximately 11:00 AM and included, "...Suicidal Precautions ("S") - Used when patient has a history of suicidal attempts/gestures and/or has a specific suicidal plan or when the patient is exhibiting intense feelings which may result in harm to self: Document suicidal risk status in the progress notes..."

3. The transferring Hospital's clinical record for Pt #1 was reviewed on 3/26/12 at approximately 10:00 AM. Pt #1, a 17 year old male, was brought by ambulance and police to the Emergency Department (ED)after an altercation with his father. He was seen by a Licensed Clinical Social Worker (LCSW) for a Psychosocial Evaluation and Suicide Risk Assessment. This assessment included, "Pt is a 17 year old male brought to the ED because of a recent increase in suicidal feelings, depression, and anger ...Last Wednesday, Pt was thinking about suicide. He told his mother afterwards that he was going to sit in the garage with the car on and play his guitar until he passed out. Pt asked his mother to get his pillow out of the car and he threw the car keys into the room his parents were in. This was Pt's 2nd time doing this. Mom doesn't know if he really turned the car on or not."

4. The Hospital's clinical record for Pt #1 was reviewed on 3/26/23 at approximately 10:15 AM. Pt #1 was transferred from the ED of the transferring Hospital and admitted to the Adolescent Psychiatric Unit of the Hospital on 3/8/12 at approximately 4:00 AM with diagnoses of Depressive Disorder Nonspecific and Marijuana Dependence. A
"Comprehensive Level of Care Assessment" for Pt #1 dated 3/8/12 at 1:37 AM was completed by a LCSW (E #2), and counter-signed by the admitting child psychiatrist (E #1)on 3/9/12, and included, " ...Suicidal/Homicidal - Present: Suicidal Y (yes); Ideation Y; Plan Y ...History: Suicidal Y; Ideation Y; Plan Y ...Details: Patient stated that he has been suicidal for the last two days and was thinking of staying in the garage with the car running until he passed out and died. Patient was suicidal in 1/12 when his girlfriend broke up with him and was hospitalized at that time ... " Admission orders were obtained on 3/8/12 at 4:00 AM from the psychiatrist on call (E #15) and included, " ...Safety Precautions for: Assault ..."

Subsequently, a "Psychosocial Assessment" completed by E #3 (Clinical Therapist) dated 3/8/12 at 3:16 PM included, "Problems Identified during Assessment ...1.1 Threat to others; 1.2 SI (suicidal ideation) ..."

The "Treatment Plan" for Pt #1 dated 3/8/12 documented by E #3 and signed by the Interdisciplinary team (including E #1-Psychiatrist) on 3/9/12 included, "Presenting Problems - Primary 1.1 Homicidal Ideation/Intent (Harm towards others); Secondary 1.2 Suicidal Ideation/Intent (harm towards self) ..."

Staff failed to identify the need to place Pt #1 on suicidal precautions. Pt #1 committed suicide by hanging on the Adolescent Psychiatric Unit on 3/9/12, and was found at approximately 4:55 PM.

5. The above findings were confirmed in an interview with E #17 (Director of Inpatient Services) on 3/27/12 at approximately 10:30 AM.

6. An interview was conducted with E #1 on 3/27/12 at approximately 10:46 AM. E #1 stated, " The reason Pt #1 was not put on Suicidal Precautions was that he denied any thoughts of suicide, intent or plan. He said he was only there because he threatened his father. He did tell me that he had been suicidal a few days ago, but not now.

7. In another interview with the Medical Director (E #9) on 3/28/12 at approximately 10:00 AM, E #9 stated that he had reviewed Pt #1 ' s clinical record and was aware of the Sentinel Event on 3/9/12. "We are thinking that after a patient has been in the quiet room, there should be a transition plan and they need more frequent monitoring. We are going to look at that. "


B. Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 1 of 10 (Pt #1) clinical records reviewed, the Hospital failed to ensure the patient was reassessed and monitored for safety after an episode of severe agitation.

Findings include:

1. The Hospital policy entitled, "LOH-CLIN 047 Nursing Assessment of Patients" (revised 6/16/11) was reviewed on 3/26/12 at approximately 11:00 AM and required, "...Reassessment is completed at regular intervals and/or as a result of a change in condition or response to an intervention..."

2. The clinical record for Pt #1 was reviewed on 3/26/12 at approximately 10:00 AM. Pt #1 was a 17 year old male transferred from the transferring Hospital's Emergency Department and admitted to theAdolescent Psychiatric Unit of the Hospital on 3/8/12 at approximately 4:00 AM, with diagnoses of Depressive Disorder Nonspecific and Marijuana Dependence. Pt #1's clinical record included documentation that a family therapy session was conducted on 3/9/12 with Pt #1, during which Pt #1 became very agitated. The "Family Therapy BIRP (Behavior Intervention Response Plan)" note by E #6 (CT - Clinical Therapist) dated 3/9/12 included, " ...After safely escorting the parents into another room the CT called a Silent Code (Yellow) to assist the pt with self- soothing. Pt was verbally redirected to the Quiet Room without incident ... " The clinical record lacked documentation that included Pt #1 was reassessed and monitored for safety, to include a debriefing with Pt #1 following the family session which led to a change in Pt #1's condition.

3. An interview was conducted with E #6 (CT-Clinical Therapist) on 3/26/12 at approximately 2:45 PM. E #6 stated " I met with his parents to obtain collateral information and parents ' expectations. Then, I brought Pt #1 in and facilitated the session...As the session progressed, Pt #1 became more irritable and conflicted with his father...Pt #1 was agitated at that time and I called a Code Yellow. Pt #1 was verbally redirected to the Quiet Room."

4. An interview was conducted with E #7 (RN) on 3/26/12 at approximately 3:05 PM. E #7 stated " ... Pt #1 was ending his family session and he was agitated that he was not going home... Within an hour, Pt #1 was found. When the surveyor asked if patient rounds were conducted differently based on the patients ordered safety precautions, E #7 stated " Rounds are just basically where the patient is at and what actions they are doing i.e. lying down, sleeping. "

5. The above findings were confirmed in an interview with E #17 (Director of Inpatient Services) on 3/27/12 at approximately 10:30 AM.


C. Based on review of Hospital policy, clinical record, Root Cause Analysis (RCA), and staff interview, it was determined that for 1 of 1 (Pt #1) Sentinel Events, involving death of a patient by suicide, the Hospital failed to identify specific contributing factors in the RCA and immediately implement an effective plan of correction to protect the patients from committing suicide. This could potentially affect all of the Hospital's inpatients (current census 92).

Findings include:

1. The Hospital policy entitled, "CLIN 143 Sentinel Events" (revised 7/14/11) was reviewed on 3/26/12 at approximately 12:00 PM and required, "...Suicide of any patient receiving care, treatment and services in a staffed around the clock setting ...If the event is determined to be a Sentinel Event or an event requiring investigation, Risk Management convenes a team to perform a root cause analysis on behalf of the Medical Staff Quality Committee ..."

2. The clinical record for Pt #1 was reviewed on 3/26/12 at approximately 10:15 AM. Pt #1 was transferred from the ED of the transferring Hospital and admitted to the Adolescent Psychiatric Unit of the Hospital on 3/8/12 at approximately 4:00 AM, with diagnoses of Depressive Disorder Nonspecific and Marijuana Dependence. The clinical record included documentation of Pt #1's history of Suicidal Ideation with a plan for suicide, and Pt #1 was placed on Assault Precautions per the on call psychiatrist's (E #15) admission orders. Pt #1 remained on Assault precautions, which included checks every 15 minutes, through 3/9/12. Pt #1 was found hanging from his bathroom door on 3/9/12 at approximately 4:55 PM and the patient died.

3. Pt #1's death by suicide was determined to be a Sentinel Event by the Hospital, and a Root Cause Analysis (RCA) was performed on 3/15/12. This document was reviewed on 3/26/12 at approximately 12:15 PM and lacked detail of specific contributing factors as well as documentation of immediately implemented actions to prevent reoccurrence.

4. An interview was conducted with E #18 (Director, Quality and Risk, Chief Nursing Officer) on 3/26/12 at approximately 12:30 PM. E #18 stated that in response to the findings in the RCA, they are planning to meet with a consulting company that specializes in patient safety in mid-April; and reviewing information for staff education on suicide assessment that will be occurring in April and will be mandatory for all staff.

5. The above findings were confirmed in an interview with E #9 (Medical Director) on 3/28/12 at approximately 10:15 AM.

A. Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 1 of 10 (Pt #1) clinical records reviewed, the Hospital failed to ensure the ordered precautions for Pt #1 were evaluated based on the patient's recent history of suicidal ideation and a plan for suicide. This could potentially affect all of the Hospital's inpatients (current census 92).

Findings include:

1. The Hospital policy entitled, "LOH- CLIN 078 Safety Precautions" (revised 7/21/11), was reviewed on 3/26/12 at approximately 11:00 AM and included, "...Suicidal Precautions ("S") - Used when patient has a history of suicidal attempts/gestures and/or has a specific suicidal plan or when the patient is exhibiting intense feelings which may result in harm to self."

2. The transferring Hospital's clinical record for Pt #1 was reviewed on 3/26/12 at approximately 10:00 AM. Pt #1, a 17 year old male, was brought by ambulance and police to the Emergency Department after an altercation with his father. He was seen by a Licensed Clinical Social Worker (LCSW) at the transferring Hospital for a Psychosocial Evaluation and Suicide Risk Assessment. This assessment included, "Pt is a 17 year old male brought to the ED because of a recent increase in suicidal feelings, depression, and anger ...Last Wednesday, Pt was thinking about suicide. He told his mother afterwards that he was going to sit in the garage with the car on and play his guitar until he passed out. Pt asked his mother to get his pillow out of the car and he threw the car keys into the room his parents were in. This was Pt's 2nd time doing this. Mom doesn't know if he really turned the car on or not."

3. The Hospital's clinical record for Pt #1 was reviewed on 3/26/12 at approximately 10:15 AM. Pt #1 was transferred from the ED of the transferring Hospital and admitted to the Adolescent Psychiatric Unit of the Hospital on 3/8/12 at approximately 4:00 AM, with diagnoses of Depressive Disorder Nonspecific and Marijuana Dependence. Another assessment, "Comprehensive Level of Care Assessment" for Pt #1 dated 3/8/12 at 1:37 AM was completed by a LCSW (E #2), and counter-signed by the admitting child psychiatrist (E #1)on 3/9/12, and included, " ...Suicidal/Homicidal - Present: Suicidal Y (yes); Ideation Y; Plan Y ...History: Suicidal Y; Ideation Y; Plan Y ...Details: Patient stated that he has been suicidal for the last two days and was thinking of staying in the garage with the car running until he passed out and died. Patient was suicidal in 1/12 when his girlfriend broke up with him and was hospitalized at that time ... " Admission orders were obtained on 3/8/12 at 4:00 AM from the psychiatrist on call (E #15) and included, " ...Safety Precautions for: Assault ..."

Subsequently, a "Psychosocial Assessment" completed by E #3 (Clinical Therapist) dated 3/8/12 at 3:16 PM included, " Problems Identified during Assessment ...1.1 Threat to others; 1.2 SI (suicidal ideation) ... "

The "Treatment Plan " for Pt #1 dated 3/8/12 documented by E #3 and signed by the Interdisciplinary team (including E #1-Psychiatrist) on 3/9/12 included, "Presenting Problems - Primary 1.1 Homicidal Ideation/Intent (Harm towards others); Secondary 1.2 Suicidal Ideation/Intent (harm towards self) ..." The staff failed to evaluate and determine the need for suicide precautions. Pt #1 committed suicide by hanging.

4. An interview was conducted with E #17 (Director of Inpatient Services) on 3/26/12 at approximately 1:00 PM. E #17 stated that staff, including RN's, BHAs, and Clinical Therapists can initiate Suicide Precautions if suicidal ideation is verbalized by patient or behavior indicates. They can then call the physician for the order.

5. The above findings were confirmed in an interview with E #17 on 3/27/12 at approximately 10:30 AM.


B. Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 1 of 10 (Pt #1) clinical records reviewed, the Hospital failed to ensure that the patient was reassessed for medication effectiveness after administration of a PRN (as needed) medication.

Findings include:

1. Hospital policy entitled, "LOH-CLIN 042 Medication Administration" (revised 2/16/12) lacked any requirement for reassessment for medication effectiveness after administration of all PRN medications.

2. The clinical record for Pt #1 was reviewed on 3/26/12 at approximately 10:00 AM. Pt #1 was a 17 year old male transferred from Hospital A's Emergency Department and admitted to the Hospital B's Adolescent Psychiatric Unit on 3/8/12 at approximately 4:00 AM with diagnoses of Depressive Disorder Nonspecific and Marijuana Dependence. The clinical record included a telephone order dated 3/9/12 at 4:00 PM signed by E #1 (child psychiatrist) that required, " Ativan 1 mg (milligram) PO (by mouth) every 6 hours PRN (as needed) for anxiety/agitation. The Medication Administration Record (MAR) included documentation of Ativan 1 mg PO was given at 4:05 PM on 3/9/12 by E #7 (nurse). The nurse's notes lacked documentation of Pt #1's response to the PRN medication administration.

3. E #17 (Director of Inpatient Services) stated during an interview on 3/27/12 at approximately 9:00 AM, "I think that only if the medication is for pain, that we require documentation of effectiveness."

4. The above findings were confirmed in an interview with E #17 on 3/27/12 at approximately 10:30 AM.