HospitalInspections.org

Based on observation, staff interviews, review of one of one medical record (Patient (P) 1), and review of facility documents, it was determined that the facility failed to ensure the rights of each patient is protected.

Findings include:

The facility failed to provide care in a safe setting by mitigating a ligature risk on the Behavioral Health Unit (BHU), after the risk was identified on twelve of twelve patient rooms (#120, #121, #122, #123, #124, #125, #126, #127, #128, #129, #130, and #131). (Cross refer to Tag A 144)

Based on observation, staff interviews, review of one of one medical record (Patient (P) 1), and review of facility documents, it was determined that the facility failed to provide care in a safe setting by mitigating a ligature risk on the Behavioral Health Unit (BHU), after the risk was identified on twelve of twelve patient rooms (#120, #121, #122, #123, #124, #125, #126, #127, #128, #129, #130, and #131).

Findings include:

On 11/28/22 at 9:48 AM, an entrance conference was conducted with Staff #1, the Director of Quality and Staff #2, the Assistant Vice President of Patient Care Services. Staff #1 confirmed that on 11/3/22, a patient on the BHU hung [himself /herself] with a bedsheet from the patient room door.

P1's medical record was requested and reviewed in the presence of Staff #1 and Staff #2, and revealed the following:

On 10/31/22 at 20:16 (8:16 PM), P1 arrived in the Emergency Department (ED) via ambulance, with a chief complaint of overdose (42 Seroquel - a medication used to treat mental/mood conditions). At 20:23 (8:23 PM) - a Suicide Risk Screening was completed, the patient was identified as high-risk for suicide and at 20:30 (8:30 PM), P1's 1:1 (one-to-one) level of observation sheet was initiated.

On 11/1/22 at 2:46 AM, P1 was admitted to the Intensive Care Unit (ICU) after a suicide attempt at home where he/she ingested 42 Seroquel. P1 was found by police who were delivering a restraining order initiated by his/her wife. P1 was monitored with a 1:1 constant observer during his/her stay in the ICU.

On 11/1/22 at 11:23 AM, P1 was seen by the APN (Advanced Practice Nurse) Psychiatry Nurse Practitioner. The "Consult" note states, "Reason for consult: Suicidal ideation [SI] ... Plan: Continue Psychiatric 1:1 observation for Suicidal Ideation. ... Plan for voluntary admission in inpatient psychiatry upon medical clearance. If patient changes decision, please do not discharge, even AMA [Against Medical Advice], as [he/she] must be screened for potential involuntary commitment and re-evaluated by psychiatry. ... Columbia Scale: See BH assessments. Patient is at high risk for self harm at this time. ... HPI [History of Present Illness]: ...[He/She] admits that [his/her] overdose was a suicide attempt and continues to endorse not wanting to live. [He/She] denies active plan or intent while in the hospital and is able to contract for safety. ..."

On 11/2/22 at 17:21 (5:21 PM), P1 was medically cleared and discharged from the ICU.

On 11/2/22 at 17:27 (5:27 PM), P1 was a voluntary admission to the BHU, Room #120. On 11/28/22 at 2:59 PM, during an interview, Staff #20, the psychiatrist, stated, he/she continued the order for the 1:1 level of observation on the BHU for patient safety until he/she was able to evaluate the patient on 11/3/22. A 1:1 level of observation physicians order was placed on 11/2/22 at 1536 (3:36 PM) frequency: Routine until discontinued 11/2/22 1732 (5:32 PM) until specified. 1:1 observation sheet completed.

On 11/2/22 at 18:52 (6:52 PM) the Columbia Suicide Severity Rating Scale (C-SSRS) (since last visit) was completed, and the patient scored high-risk, requiring 1:1 observation until the psychiatric LIP (Licensed Independent Practitioner) evaluates the patient and a change is made to the ordered precaution level, as per facility policy titled "Suicidal Patients on the Behavioral Health Units, Assessment & Care Of" revised 6/2020.

On 11/2/22 at 18:50 (6:50 PM), the Daily Shift Assessment flowsheet "Precautions" section "Level 1:1 (one-to-one)" indicated "yes" the "Suicidal Ideation" section "1. Wish to be Dead (since last shift)" indicated "yes" "Wish to be Dead Description (since last shift)" indicated "passive SI thoughts", "2. Non-Specific Active Suicidal Thoughts (since last shift)" indicated "No", "3. Active Suicidal Ideation with any Methods (Not Plan) Without Intent to Act (since last shift)" indicated "No", "4. Active Suicidal Ideation with Some Intent to Act, Without Specific Plan (since last shift)" indicated "No", "5. Active Suicidal Ideation with Specific Plan and Intent (since last shift)" indicated "No." The "Intensity of Ideation" section "Most Severe Ideation Rating (since last shift)" indicated "1."

On 11/2/22 at 19:39 (7:39 PM), the Daily Shift Assessment flowsheet "Precautions" section "Level 1:1 (one-to-one)" indicated "yes" the "Suicidal Ideation" section "1. Wish to be Dead (since last shift)" indicated "yes" "Wish to be Dead Description (since last shift)" indicated "passive SI thoughts", "2. Non-Specific Active Suicidal Thoughts (since last shift)" indicated "No", "3. Active Suicidal Ideation with any Methods (Not Plan) Without Intent to Act (since last shift)" indicated "No", "4. Active Suicidal Ideation with Some Intent to Act, Without Specific Plan (since last shift)" indicated "No", "5. Active Suicidal Ideation with Specific Plan and Intent (since last shift)" indicated "No." The "Intensity of Ideation" section "Most Severe Ideation Rating (since last shift)" indicated "1."

On 11/3/22 at 11:29 AM, P1 was evaluated by Staff #20. The "Psychiatric Admission Note" states, "...Assessment/Plan: 1. Unspecified Depressive Disorder -continue Seroquel 100 mg (milligrams) nightly - continue Wellbutrin 150 mg daily - patient encouraged to attend group & milieu activities. Chief Complaint: 'I tried to commit suicide.' History of Present Illness: ...[He/She] states previously [he/she] was having transient suicidal ideation. However, [he/she] has contemplated suicide with a plan for 'a few months.' ... the patient became upset and had ingested 42 tablets of Seroquel in a suicide attempt. ... The patient currently endorses an ongoing depressed mood with unhappiness towards being alive and surviving a suicide attempt. Nevertheless, [he/she] denies active homicidal/suicidal ideation plans or intent. ... Past Psychiatric History: ... Suicide Attempts: 2 prior suicide attempts. Methods: through the use of a firearm and suicide by cop (4-5 years ago) ... Mental Status Examination: ... Thought Content: Devoid of homicidal/suicidal ideation with plans or intent. ..."

On 11/3/22 at 13:00 (1:00 PM), the documentation on the 1:1 Level of Observation Sheet ends. There was no indication on the sheet as to why the 1:1 ended. There was no written or electronic order to discontinue the 1:1 level of observation.

On 11/3/22 at 16:51 (4:51 PM), the 1600 (4:00 PM) the Daily Shift Assessment flowsheet "Precautions" section "Level Q 15" indicated "yes", the "Risk Factors" section "Danger to Self" indicated "No danger to self", "Danger to Others" indicated "No danger to others" the "Suicidal Ideation" section "1. Wish to be Dead (since last shift)" indicated "No" "Wish to be Dead Description (since last shift)" indicated "passive SI thoughts", "2. Non-Specific Active Suicidal Thoughts (since last shift)" indicated "No", "3. Active Suicidal Ideation with any Methods (Not Plan) Without Intent to Act (since last shift)" indicated "No", "4. Active Suicidal Ideation with Some Intent to Act, Without Specific Plan (since last shift)" indicated "No", "5. Active Suicidal Ideation with Specific Plan and Intent (since last shift)" indicated "No." The "Intensity of Ideation" section "Most Severe Ideation Rating (since last shift)" indicated "0", the "Behavior" section "1:1 Observer" indicated "Discontinued."

On 11/3/22 at 17:45 (5:45 PM), the 'Behavioral Health Q 15 [every 15 minute] Checklist Patient Observation Rounds' sheet indicated that the patient was observed in his/her room alone.

On 11/28/22, Staff #1 provided this surveyor with a video surveillance timeline of P1's incident on 11/3/22. Staff #1 confirmed that the surveillance video is not watched in real time. The timeline of the video surveillance revealed the following:

At 17:46 (5:46 PM) - Patient walks out of his/her room, past the nurse's station, to the activity room and then back to his/her room arriving at 17:47 (5:47 PM).

At 17:49 (5:49 PM) - The patient peeks out of his/her room into the hallway, followed by going back into his/her room. He/She then places a sheet with a knot and a very small tail over the door between the patient room and the corridor (at 17:50 (5:50 PM).

At 18:04 (6:04 PM) - The RN (Registered Nurse) arrives to the patient room, meets resistance at the door, but is able to access the room where he/she finds the patient anoxic and pulseless with the bedsheet wrapped around his/her neck several times. The RN removed the sheet, initiated chest compressions, a code was called, and the patient was ultimately transported to ICU.

On 11/3/22 at 1810 (6:10 PM) the "Clinical Notes" located in P1's medical record, entered by Staff #15, P1's nurse, states, "Late entry 1803 [6:03 PM]. Went to patient room to ask about belonging, when attempting to open door I met residence [sic], patient did not respond. I push [sic] the door open noticed sheet falling from door jam. Found the patient unresponsive pale in color, visualized with a flat sheet wrapped around patients neck. yelled for help and code blue and initiated CPR [Cardiopulmonary Resuscitation]. Code team responded."

The facility policy addressing observation for suicidal patients was requested. Review of the policy titled, "Observation Levels & Precautionary Measures of BH" lacked written criteria to discontinue a patient from a 1:1 level of observation.

On 11/28/22 at 2:59 PM, during an interview, Staff #20 confirmed that after evaluating the patient on 11/3/22 at 11:29 AM, he/she conferred with the staff on the unit, and although an order was not entered in the computer, there was a verbal discussion with the staff to discontinue the 1:1 level of observation and downgraded the patient to Q 15 minute checks. Staff #15, an RN, indicated that he/she was in another room admitting a patient at that time, and when he/she exited the room, Staff #16, an RN, was sitting at the nurses station and told him/her that the physician discontinued the 1:1 and the patient was now on Q 15 minute checks. Staff #20 stated that there are no written criteria for removing a patient from 1:1 level of observation. It is the clinical decision of the psychiatrist. When asked what he/she bases his/her decision on, Staff #20 stated that he/she followed the patient since admission in collaboration with the APN and that his/her decision to discontinue to patients 1:1 level of observation was based on the fact that the patient verbally contracted for safety, denied active SI (suicidal ideations), and had protective factors. Staff #20 indicated that this decision is reflected in his/her discharge summary.

On 11/3/22 at 18:10 (6:10 PM) the "Inpatient Discharge Summary" note found in P1's medical record, states, " ... Hospital Course: ... while the patient was sad and tearful and expressing a sense of abandonment from [his/her] family, the patient was hopeful to reconcile with [his/her] wife. The patient was future oriented to work with social work to obtain emergency housing and get in contact with [his/her] daughter. (Patient name) [P1] denied any homicidal/suicidal ideation plans or intent. ... At the conclusion of (patient name) [P1's] initial evaluation, writer conferred with nursing staff and a decision was reached to discontinue the patient's one-to-one sitter and was placed on Q 15 min checks as the patient denied all acute psychiatric symptoms on the general medical floor as well as during his initial psychiatric evaluation on the behavioral health unit. Additionally, the patient was noted to have significant suicide risk protective factors such as future oriented thinking, children under the age of 18, and sense of hope. In summary, the patient's suicide risk was assessed to be chronically elevated, but intermediate for [his/her] initial evaluation. While on the unit the patient was observed to be social with [his/her] peers and nursing staff. The patient was seen smiling on occasions. [He/She] was seen attending group and milieu activities. At approximately 5:30 PM on 11/3/22 the patient was observed in the activity room watching television with [his/her] peers. At 5:45 PM on 11/3/22 the patient was observed in [his/her] room by nursing staff on Q 15 min checks. ..."

On 11/3/22 at 7:42 PM, Staff #20 documented in the "Psychiatric Admission Note," "7:42 PM Addendum: 1:1 supervision order was placed for patient by writer at the time of admission. Patient remained on 1:1 status on 11/2/22 until 11/3/22. The patient was evaluated by writer for [his/her] H&P [History & Physical] and found to deny all acute psychiatric symptoms such as homicidal/suicidal ideation with plans or intent, auditory /visual hallucinations, and symptoms of mania. At this time, the patient's 1:1 supervision was discontinued, and the patient was downgraded to Q 15 min checks."

Prior to the patient hanging himself/herself, the medical record lacked documented evidence that the physician discontinued the 1:1 level of observation for the suicidal patient who three days prior attempted suicide and scored high-risk multiple times on the C-SSRS. Upon interview, Staff #20 confirmed that his/her note to discontinue the patients 1:1 level of observation was an addendum that was written after the incident.

On 11/4/22 at 10:50 AM, P1 was transported to another facility within the network, due to the need for continuous EEG (Electroencephalography) monitoring.

The "Summary of the event" provided by Staff #1 indicated that on 11/9/22, the patient was noted to be spontaneously breathing but otherwise unresponsive to all stimuli. [He/She] was on continuous EEG and noted to have a highly attenuated background that was flat with minimal cortical activity and a prognosis was that there would not be a meaningful neurologic recovery. Based on the patient's and family wishes, the Sharing Network was contacted for organ donation. The patient was terminally extubated on 11/9/22 and suffered a hypoxic PEA [Pulseless Electrical Activity] cardiac arrest. As per family wishes, the patient was a DNR (Do Not Resuscitate), ultimately expired and pronounced deceased at 18:48 (6:48 PM).

On 11/29/22 at 10:30 AM, during a tour of the BHU, patient bedroom doors were observed to be full size doors that separate the patient sleeping room from the corridor. These patient room doors (Rooms #120, #121, #122, #123, #124, #125, #126, #127, #128, #129, #130, and #131) create an anchor point when the door is closed allowing a knot to get lodged between the top of the door and the door frame.

On 11/29/22, the Environment of Care (EOC) Risk Assessments for 2021 and 2022 were requested. The Environmental Risk Assessment conducted in February of 2021 by Staff #3, was reviewed in the presence of Staff #1, Staff #2, and Staff #3. The door tops were identified as ligature risks, specifically anchor points. The Environmental Risk Assessment stated, " ...Item: Door Tops, Issue: Can be used as a anchor point, Guidance: By tying a knot in a rope or sheet and lodging it over a closed door, patients can use the door tops as an anchor point. Tops should be monitored or cut to eliminate ligature opportunities. Risk Identification/ Mitigation Plan: [Space is blank]."

The Environmental Risk Assessment conducted in August of 2022 by Staff #3, was reviewed in the presence of Staff #1, Staff #2, and Staff #3. The door tops were again identified as ligature risks. The Environmental Risk Assessment stated, " ...Location: Multiple patient rooms, Identified Risk: Patient room doors is a concern as well bathrooms - high risk areas. Date Corrected: [Space is Blank, no date provided]."

During an interview on 11/29/22 at 10:45 AM, Staff #1 stated, "It was identified in the August Risk Assessment." When the surveyor asked if the risk was mitigated, Staff #1 replied, "No we did not. It's a known risk in the environment."

The facility utilizes a single page "BH Q 15 Environmental Checklist" when conducting Q 15 minute environmental observation rounds. Staff indicate the entire unit was checked by making a single check in a box for the corresponding timeframe. The form lacks evidence that any individual room was checked. Just that "All Items Checked". Environmental Checklist Items are listed at the top and lettered in order from A - H. Ligature risks, more importantly, identified risks including door tops are not listed as an item to be checked.



33557