HospitalInspections.org

Based on staff interview and record review, the hospital failed to ensure that the Quality Assurance and Performance Improvement (QAPI) program conducted a thorough analysis and implemented preventive actions to mitigate the potential risk identified during the investigative process for an attempted suicide for 1 applicable patient. (Patient #1). Findings include:

Per information received via an anonymous complainant, an investigation by the State Survey Agency into an alleged patient attempted suicide revealed that the potential risk identified during the hospital's investigation of the event was not effectively mitigated by corrective actions taken by the hospital. Review of the QAPI notes of the investigation as of the date of survey (7/9/18), Patient #1 had attempted suicide on 6/11/18 by using multiple unstretchable, non-slideable nylon locking ties, secured together and locked around the neck.
Patient #1 was admitted on 1/01/18 with a history of violent, unpredictable, assaultive behaviors towards others and a history of multiple prior involuntary hospital admissions. In the previous 2 year period, he had denied thoughts of suicide and had no known suicide attempts until the suicide attempt on 6/11/18.

On 6/11/18, the patient was found in their room (the patient had triggered the door sensor alarm) with three attached, locked ties around their neck; the facial area was 'purple'. The nurse at the scene cut the ties and the patient was assessed. There were ligature marks observed around the neck, with some petichiae visible in the facial area. Per review of the Patient Event Form dated 6/11/18, the severity of the event was categorized as a "Category D - Event/error increased the need for treatment/intervention/monitoring and caused temporary patient/resident harm."

The Mental Health Specialist (MHS) who found the patient on 6/11/18 was interviewed by surveyors on 7/9/18 at 4:05 PM. The MHS said s/he had checked on the patient, who was on every 30 minute observation checks, at 2:55 PM. Approximately 15 minutes later, the MHS heard the door sensor alarm go off for this patient's room. Upon entering, s/he saw the patient standing in the middle of the room, the face was very discolored with the ties encircling the patient's neck. The Registered Nurse (RN) arrived and was attempting to cut the ties and the patient was trying to grab the RN's hands. The MHS and coworker held the patient's hands so the RN could cut the ties....Patient #1 stated "I'm OK". The RN and physician present continued to assess the patient.

Per interview on 7/9/18 at 3:30 PM, the RN present on 6/11/18 stated that staff did a thorough search of Patient #1's room after the event. The MHS stated during interview (7/9/18) that staff on duty did not search any other patient rooms at that time. The Chief Nursing Executive (CNE) stated during interview on 7/11/18 at 10:35 AM that s/he responded to the psychiatric emergency crisis on 6/11/18. S/he stated that they instructed to staff to get rid of all of the ties on the unit. S/he confirmed that ties were to be removed from patients utilizing them on the B Unit. (The Quality Administrator had stated earlier that the hospital had used the locking ties as a safer alternative to shoe laces and belts, to secure the clothing items for patients in the hospital). The CNE confirmed that Patient #1's room was searched. When asked if unit searches were completed on all 4 units after the suicide attempt, s/he stated that it is hospital policy to conduct weekly unit searches, which also includes a thorough search of all patient rooms.

Per review of the weekly Unit Search forms used to document the weekly searches, none of the 4 patient units was following the hospital policy to conduct the searches on a weekly basis. The only documented unit/room search completed on B Unit during June, 2018, was on 6/7/18, 4 days prior to the event. After the suicide attempt, the next unit/room search was not completed until 7/5/18, weeks after the event. Based on a review of the other 3 units and review of the searches documented since since March, 2018, none of the units had done the required checks every week per the facility's policy. (Most searches were done 2 x per month).

Per review, the policy titled Restricted Items Search, under "Room Search: A room search is a thorough search of a patient room for potentially dangerous and restricted items. Room searches shall be conducted weekly and whenever there is a suspicion that restricted items are on the unit or in a patient room. Room searches are also conducted as part of unit searches. A Unit Search: A unit search is a thorough search of all patient rooms and all common areas of the unit. Unit searches shall be conducted weekly and whenever there is a suspicion that restricted items are on the unit."

Per interview on 7/9/18, the Nurse Quality Management Administrator for the hospital stated that leadership staff met after the event and initiated an investigation into the facts immediately after the attempted suicide. A RCA (Route Cause Analysis) was initiated and leadership staff were involved at the time of survey. A plan had been put into place that included searching Patient #1's room for possible additional unused locking ties.
Although the leadership team (QAPI members) had identified the type of ties used during the attempted suicide (unstretchable and non-slideable) as a potential risk as a ligature device, there was no organized plan to search all 4 units and patient rooms in the immediate period after the event to assure that the identified risk was removed and the potential danger mitigated.