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Based on record review and interview, the hospital failed to protect and promote the right of 1 of 1 suicidal patient (Patient #3) to receive care in a safe environment. Within 24 hours prior to his hospital admission, Patient #3 had made three serious suicide and/or self-harming attempts that included an overdose on methamphetamines and an illicitly marketed central nervous depressant, a self-inflicted head injury that required emergency medical attention, and the attempt to take a police officer's gun. Although hospital staff was aware that the patient was likely to cause serious harm to himself, Patient #3 was left unattended for eleven minutes. At that time, Patient #3 sustained serious self-inflicted trauma to both eyes with removal of his left eye out of the socket. The self-injurious behavior necessitated prolonged intensive medical and/or surgical care and plastic eye surgery consultation.

Refer to A144.

Based on record review and interview, the hospital failed to ensure that a suicidal patient (Patient #3) received care in a safe setting. Within 24 hours prior to his arrival to the patient care unit, Patient #3 had made three serious suicide and/or self-harming attempts. Although hospital staff was aware that the patient suffered from command hallucinations to kill self, had poor insight and judgment, and was likely to cause serious harm to himself, Patient #3 was left unattended by staff for eleven minutes during which he removed his left eye out of the socket and caused serious damage to his right eye.



Finding include:


1) Record review of Patient #3's Integrated Intake Assessment dated 07/05/17, at 1145, reflected the patient's admission per Memorandum of Transfer from a medical hospital. Patient #3 had overdosed on GHB (gammahydroxybutyrate) and methamphetamines in a suicide attempt the day prior to his admission. The patient reported the use of Valium, had increased withdrawal from other people, paranoia, and delusions with the use of methamphetamines. Patient #3 was assessed to be suicidal and taking medications not prescribed for him. Diagnoses included Substance-Induced Psychosis.


Hospital Personnel #7 stated during an interview on 07/27/17, at 1205, that Patient #3 was at high risk for suicide after the patient's initial overdose. Patient #3 had told Hospital Personnel #7 that he wanted to kill himself when he used methamphetamines. Hospital Personnel #7 stated Patient #3's...[family member] had informed her that Patient #3 had been hallucinating and was under one-to-one staff observation prior his arrival to the hospital. Hospital Personnel #7 stated that while awaiting the completion of his hospital admission, Patient #3 hit his head on the encasement window and/or metal window crank, and received a bleeding head wound in need of sutures. The patient was emergently transferred to Medical Hospital B.


Review of Patient #3's Medical Hospital B Emergency Department (ED) documents dated 07/05/17, at 1429, reflected the patient had been admitted with a laceration to his forehead. Patient #3 had a head injury and was noted to be delusional. While under one-to-one staff supervision, Patient #3 "became belligerent and started smashing [his] head against [the] wall...Police notified...[Patient #3] became more aggressive and attempted to pull [the] gun away from Police Officer...given sedation with Ativan and Geodon...calm and sedated at time of evaluation..." An emergency procedure of four sutures to repair the laceration on Patient #3's forehead was dated 07/05/17, at 1536, and the patient returned to the hospital for psychiatric care.


Record review of Patient #3's Preadmission Evaluation dated and signed by Hospital Personnel #13 on 07/05/17, at 1935, reflected, Patient #3 had "command hallucinations to kill self..." Patient #3 was noted to be "dysphoric, anxious...[with] poor insight, judgement...[and] reliability."


Record review of Patient #3's Physician's Certificate of Medical Examination for Mental Illness, dated 07/05/17 at 1954, reflected the patient was "likely to cause serious harm to himself" and suffered "severe and abnormal mental, emotional, or physical distress...deteriorating in his ability to function independently...admitted [with] depression and suicide attempts and auditory hallucinations." The physician noted that Patient #3 presented a "substantial risk of serious harm to self...suicidal with [a] plan..."


Patient #3's Physician Admit Examination Orders dated 07/05/17, at 1953, reflected, the patient's involuntary admission status and ordered fifteen-minute staff observation status for suicide and self-harm precautions. Hospital Personnel #10 noted the order on 07/05/17 at 2045.


Record review of Hospital Personnel #6's Patient Observation Form dated 07/05/17, at 2100, reflected Patient #3 arrived on the hospital's adult unit under routine fifteen-minute staff observation orders. Staff observed the patient "...around 2159, 2208...and 2219...[Patient #3] was in the shower but there was no water running...[Hospital Personnel #6] pulled the shower curtain back...blood on the floor and in the shower...saw [Patient #3] with his eye in his hand hanging from the muscle..."


Patient #3's Behavioral Emergency Intervention Order dated 07/05/17, at 2220, reflected the patient had attempted to "pluck both eyes out...able to damage left eye...running around room pulling at eyeball."


Review of Medical Hospital C Plastic Surgery Consultation document dated 07/06/17, untimed, reflected as Patient #3's chief complaint a self-inflicted stab wound to the left eye which had occurred "at an inpatient psychiatric facility where he was staying...[Patient #3]...stabbed himself in the left eye and possibly the right eye as well...self-inflicted trauma to...[Patient #3's] left eye resulting in significant ocular damage as well as a left medical orbital wall fracture." The plastic surgeon considered future placement of an eye prosthesis.


Review of Medical Center C Surgical Intensive Care Unit Progress Note dated 07/07/17, at 0749, reflected Patient #3 had been admitted on 07/05/17 at 2311 with "self-inflicted eye trauma to both eyes...left eye ball was out of the socket."


Review of Medical Hospital C Discharge Summary dated 07/12/17, at 0955, reflected Patient #3 had attempted to remove his own left eye with "trauma to the right eye as well...intubated for airway protection...a sitter had been remained with...[Patient #3] for the entirety of his hospitalization."


During an interview on 07/27/17, at 1115, Hospital Personnel #2 confirmed Hospital Personnel #7's and Hospital Personnel #10's awareness of Patient #3's attempts to take hold of a police officer's gun at Medical Hospital B.


During a telephone interview on 07/28/17, at 1000, Hospital Personnel #10 acknowledged Patient #3's history of suicidal and self-harming behavior prior to his involuntary admission on 07/05/17. Personnel #10 confirmed the patient was anxious and refused to talk about the incidents earlier that day. Personnel #10 stated there was "no need to place the patient on one-to-one [staff] observation because he was cooperative and never said anything that...[necessitated] a one-to-one observation."



Hospital Level of Observation Policy dated 02/2017 reflected practice guidelines to place a patient on one-to-one observation level in case of active "attempts to harm self or others" and/or "demonstrated unpredictable behavior."


The hospital staff knew that Patient #3 was suicidal with a plan, had demonstrated behavior with the intent to cause serious injury to self on several occasions, but hospital staff failed to take appropriate preventative measures to ensure the safety of Patient #3. Consequently, Patient #3 was able to cause serious injury to self.