HospitalInspections.org

Based on observation and interview, the hospital failed to ensure patients could access their rooms without asking for permission of a staff person to unlock their door (A0143).

Based on observation and interview, the hospital failed to ensure patients could access their rooms without asking for permission of a staff person to unlock their door for all patients receiving services from the facility. The patient census was 50.

Findings include:

Observation was made on 11/07/18 at 3:30 PM of the patient rooms. Observation on 11/07/18 at 4:05 PM revealed a patient asking the housekeeper to unlock the door to his/her room.

Interview with Staff A at the time of the observation revealed when the patient was in the day room, the patient's room door was closed and locked. When the patient returned to their room they were brought back by staff. Patients could get into their rooms at anytime with staff assistance. Staff A revealed this was a new intervention as of 10/06/18. All of the staff had a key to the patient rooms. When the patient was in their room the doors were not locked and the patient could leave their room.

Based on document review and staff interview, the hospital failed to ensure accurate assessments were completed and appropriate interventions were implemented to prevent suicide in patients with suicidal ideation (A0395).

Based on document review and staff interview, the hospital failed to ensure accurate assessments were completed and appropriate interventions were implemented to prevent suicide in patients with suicidal ideation for 8 of 18 patient records reviewed (Patient #1, #8, #9, #10, #11, #13, #15, and #18). The patient census was 50.

Findings include:

Review of the document used by the facility titled "Columbia Suicide Severity and Rating Scale (CSSRS) Risk Assessment" revealed instructions to check all risk protective factors that apply. The assessment was to be completed in collaboration with the patient, support person, as well as be based upon past known medical/psychiatric history. If the patient endorsed a positive answer to any of the shaded boxes (Actual suicide attempt, Interrupted attempt, Aborted or Self-Interrupted attempt, Other preparatory acts to kill self, suicidal intent without specific plan, or suicidal intent with specific plan), and initiate suicide precautions and notify the physician.

Interview with Staff K on 11/14/18 at 1:50 PM revealed there were no instructions on how to complete the CSSRS.

Review of the facility's policy titled "Assessment Guidelines" effective 05/14/18 revealed the CSSRS will be used to identify suicide risk and will be completed with the nursing assessment. General suicide risk factors include but not limited to alcohol abuse, substance abuse, psychiatric illnesses, presence of suicide plan, previous suicide attempt, recent loss, social isolation and lack of emotional support, sudden change in behavior or attitude, unnecessary risk taking or self destructive behavior, victim of sexual abuse particularity incest, and domestic violence or other assault.

According to the policy suicide precautions were defined as low risk - place on standard 15 minute observation; moderate risk - possible intervention included belonging/room search, line of site observation, move closer to the nursing station, and limit time alone in room; high risk - possible intervention in addition to those listed above included 1:1 observation. All patients admitted to the program following any suicide attempt would be considered high risk, kept on suicide precautions and assessed every 15 minutes. Suicide precautions were to be ordered by the physician; however, nursing staff would implement suicide precautions while awaiting the physician's order. All patients on suicide precautions were to be on close observation and a treatment plan be developed and implemented for all patients identified as a suicide risk. With the exception of patients who were assessed as high risk, there was no criteria to determine when a patient was considered low risk or moderate risk.

Interview with Staff D on 11/15/18 at 10:14 AM revealed the intake department of the hospital received information from the emergency department (ED). The intake department would call the physician for admission if the patient met the criteria. Intake would take an admission packet to the floor where the patient would be admitted. When the patient arrived, the nurse completed a full nursing assessment along with the CSSRS. The nurse then calls the physician with the outcome of the CSSRS. If there needed to be a change in intervention other than 15 minute checks, the physician will give orders.

1. Review of the intake screening for Patient #1 dated 10/03/18 revealed Patient #1 was an involuntary admission. The patient was dropped off to the emergency department (ED) by police. The patient was psychotic, difficult to interview with mumbled pressured speech, poverty of thought, and loose associations. According to documentation Patient #1's children were taken away from her, her mother died in July and her father raped her in July and the patient's family reports Patient #1 has spiraled since then. The suicide risk according to the outside hospital assessment was low. The patient was pink slipped to this hospital.

Per the ED Patient History dated 10/02/18, the patient had admitted to overdoses in the past, but thought of them as cries for attention.

The CSSRS risk assessment dated 10/03/18 for Patient #1 was marked that the patient had not experienced any suicidal or self-injurious behavior in the past three months or any suicidal ideation in the past month. The assessment revealed the patient had not experienced any recent losses or other significant events. The recent Clinical Status documented that the patient had a Major depressive episode. The patient was identified as low suicide risk and low safety assessment.

The inpatient admission orders dated 10/03/18 at 10:24 AM included specific precautions for elopement, falls,and aggression and every 15 minute checks. These orders were received via telephone from the physician.

Review of the psychiatric evaluation completed on 10/04/18 at 8:00 AM revealed the presenting problem was severe psychosis and severe agitation. The patient was confused and delusional during this assessment. She presented with delusions, paranoid behavior, hallucinations, disorganized speech, disorganized behavior, flat affect, and paranoia and had been declining for the past few months. She presented with severe depression and agitation and she was not cooperative with the assessment.

Further review of the psychiatric evaluation revealed the patient had a history of depression and anxiety and was treated in the past at another hospital. The patient's substance abuse history included mainly marijuana. The patient also had a history of alcohol use. The patient was single and had a limited support system. The patient reported no homicidal ideation, but was assessed as having positive suicidal ideation. The symptoms/problems to be treated were psychosis, agitation, and restless behavior.

The CSSRS risk assessment was not updated to reflect the patient had positive suicidal ideation, recent losses or other significant events, previous psychiatric treatments, substance abuse, agitation/severe anxiety, or sexual abuse. The patient remained a low suicide risk.

Staff O was asked in an interview on 11/13/18 at 3:30 PM what was meant by positive suicidal ideation. Staff O revealed the patient was not happy and that she probably made a statement she does not want to live. The standard treatment was 15 minute checks, unless a patient was actively suicidal then one on one or line of site is used as an intervention. The patient would also need a plan and have made a statement that they would kill themselves. Staff O further revealed the CSSRS showed the patient did not present with a suicidal plan.

Review of a nursing progress note dated 10/06/18 by Staff I revealed at 0850 Patient #1 received morning medication and was sitting on the side of her bed during administration; at 0900 Patient #1 was observed sitting on the side of her bed during routine rounding; at 0903 Patient #1 was observed sitting on her bed during head count; at 0910 Staff B was observed yelling for help in the direction of Patient #1's room. Coming upon the room Staff B directed Staff I to Patient #1's bathroom and Patient #1 was observed hanging from the bathroom ventilation griddle from an apparent suicide.

2. Review of the intake screening dated 11/05/18 revealed Patient #9 presented to the emergency department (ED) with history of abuse, anxiety, depression with suicidal ideation and a plan to overdose on medication. Patient #9 admitted an increase in suicidal thoughts for the past two weeks. Patient #9 had recent triggers of having to move from his/her apartment, grades at school are slipping, was not eating or sleeping and has poor motivation. The patient was unable to contract for safety. Patient #9 has a past history of suicide attempts. The suicide risk according to the outside hospital assessment was high.

Review of the medical record for Patient #9 revealed an admission date of 11/05/18. The psychiatric evaluation dated 11/05/18 at 8:15 AM revealed the presenting problem was depression, suicidal ideation, and anxiety. The history of the present illness included past psychiatric history of major depression, generalized anxiety, and bipolar. Patient #9 was self referred to psychiatric emergency services due to depression and suicidal ideation with a plan to overdose on medication and wants to be admitted, because Patient #9 cannot stop thinking about killing him/herself. Patient #9 has had suicidal ideation for two months, history of abusing heroin, and uses marijuana. Patient #9 expressed symptoms of depression, anhedonia (an inability to feel pleasure), low energy, poor sleep, poor concentration, hopelessness, helplessness, and a hypomania (energy level higher than normal, but not as extreme as in mania) episode in the past. The patient has bipolar disorder and a psychiatric admission at age 15 status post suicidal attempt with overdose. Diagnoses included bipolar disorder type 2, depressed, generalized anxiety disorder, opioid use disorder in partial remission. The treatment plan included every 15 minute checks and suicide precautions.

The inpatient admission orders received on 11/05/18 and signed by the physician on 11/06/18 included observation frequency for 15 minute checks and suicide/self harm precautions.

Review of the CSSRS for Patient #9 dated 11/06/18 included that the patient had suicidal intent (without a specific plan). The CSSRS identified Patient #9 as low suicide risk and low for safety assessment.

The assessment was not updated to include that the patient had anxiety or had a method for suicide available. The patient remained a low suicide risk.

3. Review of the intake screening for Patient #8 dated 11/05/18 revealed the patient presented to the emergency department (ED) having suicidal thoughts. The patient did not verbalize a plan but said that he/she has the means to kill him/herself and is unable to contract for safety. The patient was agitated, reported psych medications were stolen 13 days ago and that is why he/she is having issues. Patient #8 was documented as appearing scattered and reactive at times, cooperative but irritable and downplays his/her substance abuse. The psychiatric diagnosis history included depression, anxiety, and Bipolar. The patient has an inpatient admission history for 01/15/18, 01/18/18, 02/18/18 that were all due to suicidal ideation. The patient admits to substance abuse including marijuana, was positive for methamphetamine, ecstasy, and alcohol level of .23. Admission diagnosis was major depressive disorder, recurrent severe without psychotic features. The suicide risk level according to the outside hospital assessment was high.

Review of the CSSRS for Patient #8 dated 11/05/18 at 2:21 PM did not include that the patient was having suicidal thoughts. Recent clinical status did not include Mixed affective episode (e.g. Bipolar) or Major depressive disorder. Patient #8 was identified as a medium suicide risk and medium safety assessment.

The inpatient admission orders were received on 11/05/18 at 2:23 PM and were signed by the physcian on 11/06/18 at 6:00 AM. The orders included suicide/self harm precautions and every 15 minute checks.

The psychiatric evaluation completed by the physician on 11/06/18 at 8:00 AM revealed Patient #8 had severe depression with suicidal ideation. The patient was a direct admit from the hospital where he/she was reportedly having suicidal thoughts. The patient was not able to verbalize a plan, but stated he/she had been meaning to kill himself/herself. The patient was irritable, with racing thought, distractibility and poor impulse control. Past history of depression, anxiety, bipolar disorder and multiple psychiatric admissions in the past. History of suicidal ideation, with no reported history of suicidal attempt and no reported history of violence. Positive for suicidal ideation with no specific plan and positive for paranoia. The diagnoses included bipolar disorder, type 1, mixed without psychotic symptoms, cannabis use disorder, rule out methamphetamine use disorder. The treatment plan included every 15 minute checks with suicide precautions.

The CSSRS was not updated to include the patient was highly impulsive, having suicidal thoughts, experiencing agitation or severe anxiety. The patient remained a medium suicide risk.

4. Review of the intake screening for Patient #10 dated 11/01/18 revealed the patient's case manager called a crisis center due to the patient's unsafe behavior in the community. Patient #10 covered the case managers eyes while he/she was driving and attempted to open the door. Patient #10 was smoking leaves and tried to drink water with cigarette ashes in it and left burners on the stove overnight. The documentation also included paranoid, suicidal ideation, hyperverbal, bizarre, and at times speaking in a different language. Patient reported he/she needed to be back on medication. The psychiatric history included schizoaffective disorder, bipolar disorder, seasonal affective disorder, previous suicide attempts, history of overdose, cut wrist and panic attacks. Patient has a history of alcohol and marijuana use. The admission diagnosis is schizoaffective disorder, bipolar type. The suicide risk according to the outside hospital assessment was not identified on the intake screening.

The CSSRS was dated 11/02/18 at 2:13 AM for Patient #10. Suicidal Ideation in the past month was marked as not applicable. Under Clinical Status, Mixed affective episode (Bipolar) was not marked. Patient #10 was identified as a medium suicide risk and medium risk for safety assessment.

Review of the psychiatric evaluation for Patient #10 dated 11/02/18 at 10:45 AM included the reason for admission was mood psychosis presenting with inappropriate behavior. The patient has a past psychiatric history of schizoaffective disorder-bipolar type. The patient was having suicidal ideation, hyperverbal, speaking in different language. The patient was admitted for safety and stabilization via a hospital psychiatric emergency service. As long as Patient #10 stays on medication he/she does okay and without medications the patient hears voices, is seeing things, and also has mood lability and irritability. The patient denied any suicidal or homicidal ideation and wants to be back on his/her medications. The patient's past medical history includes multiple psychiatric admissions, history of schizoaffective disorder, no suicide attempt reported or history of violence. The treatment plan included every 15 minute checks and suicide precautions.

The CSSRS was not updated to include Suicidal Ideation.

5. Review of the intake screening dated 11/05/18 for Patient #11 revealed this was an involuntary admission. The patient presented to the ED after attempting to kill him/herself by overdosing on 800 milligrams of Meloxicam (nonsteroidal anti-inflammatory medication). The patient stated two of his/her friends recently died from heroin overdoses. The patient reportedly stated that he/she was angry for going to the ED instead of killing himself/herself. The patient wished he/she were dead already. The patient reports having been very depressed, crying with no appetite and loss of interest. The psych diagnosis history included schizophrenia, bipolar, attention deficit hyperactivity disorder (ADHD) and anxiety. The psych inpatient admission history revealed the patient had been last admitted to this facility on 10/14/18 and had multiple prior admissions. Patient #11's substance abuse history included marijuana and methamphetamines with the last day of use as 11/01/18. The patient was positive for marijuana. The suicide risk according to the outside hospital assessment was high.

The inpatient physician orders were received via telephone at 12:36 AM on 11/06/18. The orders included special precautions for aggression and self harm/suicide. The orders also included every 15 minute checks. The physician orders were signed by the physician at 8:00 AM on 11/06/18.

Review of the psychiatric evaluation dated 11/06/18 revealed Patient #11 was admitted on 11/05/18. The patient's reason for admission in his/her own words were depression. The presenting problem was suicidal ideation. The psychiatric evaluation revealed the patient had a past psychiatric history for bipolar disorder. The patient was a direct admit from the hospital and was well known at this facility from a recent admission in October. The patient stated that he/she was not compliant with taking medications and stopped taking the medicine two days prior. A friend of the patient had overdosed on heroin recently and the patient attempted to kill himself/herself by taking Meloxicam and Trileptal (anti seizure medication). The patient stated that two of his/her friends died due to heroin overdose recently. The patient stated he/she is angry, upset, frustrated, and thinking about killing himself/herself and wished that he/she would be dead. The patient states symptoms of depression, anhedonia (an inability to feel pleasure), low energy, poor sleep, poor concentration, hopelessness and helplessness. The patient reportedly had a history of mania. The patient had a past psychiatric history of bipolar disorder with previous multiple psychiatric admissions. The patient also had a history of psychosis, ADHD, and several suicide attempts with a history of violence. Substance abuse history included methamphetamine, snorting, marijuana and the last use was 11/01/18. The mental status exam included suicidal ideation with a plan. Problems to be treated were mood lability and suicidal ideation. The diagnosis was bipolar disorder, type 1,and depressed without psychotic symptoms. The treatment plan included suicide precautions and every 15 minute checks.

The CSSRS dated 11/06/18 at 2:45 PM for Patient #11. Suicidal Ideation was marked as not applicable. Mixed episode (e.g. Bipolar) was not marked. The nurse noted "patient states he/she has suicidal thoughts but no plan at this time. Patient contracts for safety and will inform staff of any change in thoughts." The patient was identified as medium suicide risk and medium safety assessment.

6. Review of the intake screening for Patient #13 dated 11/09/18 revealed the patient was admitted to an acute care hospital for major depressive disorder. The patient had marital issues and requested sleeping pills from the physician because he/she wanted to die. The suicide risk, according to the screening, was moderate. The patient needed psychiatric care according to the assessment, and the patient's date of referral was 11/09/18.

Patient #13's CSSRS was completed on 11/10/18 at 12:40 AM. Suicidal Ideation were marked as not applicable. Recent losses or other significant negative events was left blank. Major depressive disorder and method for suicide available (gun, pills, etc.) was also left blank. The patient was assessed as a low risk for suicide and safety.

A psychiatric evaluation was completed on 11/10/18 at 8:30 AM. The evaluation revealed the reason for admission in his/her own words was "I want to kill myself". The patient endorsed symptoms of depression, including depressed mood, diminished interest in pleasure activity, weight loss, sleep disturbance, psychomotor agitation, fatigue, loss of energy, feelings of worthlessness, lack of concentration, and difficulty in making decisions. He/she reported significant nightmares and flashbacks. The patient had no motivation or desire for life. The patient's past psychiatric history revealed he/she suffered from depression and anxiety and was treated in the past for depression and anxiety. The patient had positive suicidal ideation and the symptoms/Problems to be treated were suicidal ideation, depression and anxiety.

The CSSRS was not updated to include Suicidal Ideation, major depressive disorder, agitation or severe anxiety. The patient remained a low suicide and safety risk.

7. Review of the intake screening for Patient #18, dated 11/12/18, revealed the patient presented to the ED after an aggressive verbal outburst to another person at home followed by a catatonic state. The patient's spouse reported the patient had been manic since Wednesday. The patient had a history of suicide attempts by hanging and shooting. The patient had a psychiatric history of Bipolar disorder, anxiety, depression and suicide attempts. The patient has had two previous inpatient psychiatric admissions. The patient was unable to contract for safety, and was considered a high risk for suicide. The patient needed psychiatric care.

Patient #18's psychiatric evaluation was completed on 11/12/18 at 2:30 PM. The presenting problem was depression and suicidal ideation. The patient had a history of bipolar disorder. The patient presented to the ED with a chief complaint of catatonic bipolar manic exacerbation. The patient's sister was concerned about his/her mental status and reportedly having a mental breakdown. The patient was reportedly having suicidal ideation. The patient stated he/she took medication as prescribed. Per report, the patient had previous suicide attempts by hanging and shooting, and the patient was having the same features as prior to those suicide attempts. The patient expressed symptoms of depression, anhedonia (an inability to feel pleasure), low energy, poor sleep, poor concentration, hopelessness and helplessness. The patient had a history of bipolar disorder, anxiety disorder and previous psychiatric admissions at two different hospitals. The patient had no history of violence. The patient is married and lived with spouse. The patient had suicidal ideation with no specific plan. The symptoms/problems to be treated was depression. The patient's diagnoses included Bipolar disorder, type 1, depressed without psychotic symptoms. The treatment plan included every 15 minute checks and suicide precautions.

Patient #18's CSSRS was completed on 11/13/18 at 1:00 PM. Suicidal and Self-Injurious Behavior was marked as none apply. Suicidal Ideation was marked as not applicable. Previous psychiatric diagnoses and treatment was not marked. Major depressive episode and hopelessness were not marked. The patient was assessed as a low risk for suicide and safety.

8. Patient #15 was referred on 11/11/18. The patient had presented to the ED with suicidal ideation after reportedly taking 15 Tylenol PM's. The patient stated he/she did not do a good job and wanted to shoot himself/herself. The patient owned a gun. The patient became combative in the ED and had to be restrained. The patient tested positive for amphetamines and admitted to using methamphetamines. The patient was hepatitis B and C positive. The suicide risk according to the outside hospital assessment was high.

The CSSRS was completed on 11/11/18 at 8:27 AM. The patient was not marked as having had a recent actual suicide attempt, but was marked as having had one in his/her lifetime. Suicidal Ideation were marked as not applicable. The patient was assessed as having command hallucinations to hurt himself/herself and having homicidal ideation. The patient was not assessed as having any chronic physical pain or other acute medical problems. The patient was assessed as being at high risk for suicide and safety.

Inpatient admission orders were received via telephone on 11/11/18 at 8:35 AM and were signed off by the physician on 11/11/18 at 11:25 AM. Orders were received for 15 minute checks and specific precautions for self harm/suicide.

A psychiatric evaluation was completed on 11/11/18 at 9:00 AM. The patient was admitted on a 72 hour hold with a presenting problem of severe depression and suicidal ideation. The patient was admitted to this facility secondary to a suicide attempt. the patient stated he/she had overdosed on Tylenol PM and was hoping to end his/her life. The patient stated he/she did not do a good job and wanted to shoot himself/herself. The patient owned a gun. The patient became combative in the ED and had to be restrained. The patient tested positive for amphetamines and admitted to using methamphetamines. The patient stated he/she was trying to self medicate and trying to help himself/herself. The patient was hepatitis B and C positive. The patient expressed symptoms of depression, including depressed mood, diminished interest in pleasure activity, weight loss, sleep disturbance, psychomotor agitation, fatigue, loss of energy, feelings of worthlessness, lack of concentration, difficulty in making decisions, excessive anxiety, worry, restlessness, and feeling keyed up. The patient reported poor sleep and appetite. The patient reported multiple psychosocial stressors. The patient also suffered from severe impulsive behavior. The patient stated he/she had a history of mania in the past. The patient's past psychiatric history revealed the patient suffered from bipolar disorder and anxiety that was currently not being treated. The patient had a substance abuse history of crystal meth, but has had no formal treatment. The patient was single and lived by himself/herself. The patient was unemployed and reported multiple psychosocial stressors. The patient had a limited support system. The patient had a positive suicidal ideation with a plan and no hallucinations. Diagnoses included Bipolar I disorder, most recent episode depressed, severe, without psychotic features. The symptoms/problems to be treated included suicidal ideation, agitation, and depression.

The CSSRS was not updated to include suicidal ideation and that the patient had a highly impulsive behavior, or to remove command hallucinations to hurt self . Agitation or severe anxiety was not added nor was chronic physical pain or other acute medical condition. The patient was originally assessed as having a supportive social network or family; however, this was not updated after the psychiatric evaluation.



19966




29731