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UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW 2450 RIVERSIDE AVENUE MINNEAPOLIS, MN 55454 Sept. 14, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and document review, the hospital failed to promote the safety needs of child patients at risk for suicide, for 1 of 7 child patients reviewed (P1), who was admitted to an inpatient adolescent psychiatric unit with active suicidal ideation and did not receive adequate oversight to prevent a suicide attempt while residing on the inpatient unit. The hospital was found not in compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13.

Refer to deficient practice at A-144/482.13(c)(2). Based on observation, interview, and document review, the hospital failed to ensure that each child patient received care in a safe setting that preserved the patient's welfare, for 1 of 7 child patients reviewed (P1), who attempted suicide during an inpatient stay, after hospital staff abruptly discontinued continuous supervision of P1 without adequate monitoring of P1's safety. A code blue was called after P1 self-asphyxiated in her room; P1 was transferred to the emergency department and then admitted to the pediatric intensive care unit for critical care.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview, and document review, the hospital failed to ensure that each child patient received care in a safe setting that preserved the patient's welfare, for 1 of 7 child patients reviewed (P1), who attempted suicide during an inpatient stay, after hospital staff abruptly discontinued continuous supervision of P1 without adequate monitoring of P1's safety. A code blue was called after P1 self-asphyxiated in her room; P1 was transferred to the emergency department and then admitted to the pediatric intensive care unit for critical care.

Findings include:

P1's Emergency Department (ED) record indicated that P1 was accompanied to the ED by her parents on 08/30/17 at 5:08 p.m. P1 had significant symptoms of self-injurious behavior, including suicidal ideation. P1 had auditory hallucinations telling her to kill herself. P1 was highly agitated, aggressive, and impulsive. P1's history entailed self-injurious behavior as a means of coping with emotional stress. Due to P1's high risk for self-harm, P1 was maintained on continuous observation in the ED for the duration of the 7-hour ED visit; during this time, P1 attempted to self-asphyxiate twice by wrapping clothing around her neck while staff were present. It was determined that P1 needed inpatient hospitalization for "safety and stabilization."

P1's progress notes indicated on 08/31/17 at 12:23 a.m. P1 was admitted to the inpatient adolescent psychiatric unit 7ITC shortly after midnight. Within an hour of arrival on 7ITC, P1 took off her hospital scrub pants and attempted to wrap them around her neck; P1 was aggressive and attempted to kick and bite the care giver who removed the scrub pants. Afterward, P1's supervision was increased to two staff for continuous observation of P1.

P1's physician's orders from 08/31/17 to 09/03/17 indicated that P1 remained on continuous observation of two staff at all times from 08/31/17 to 09/03/17. On 9/03/17, P1's continuous observation was decreased to one staff during unit groups, milieu activities, or sleep, but remained at continuous observation of two staff for all other times. On 09/08/17, P1's observation was decreased to continuous observation by one staff at all times, which was defined as one foot in the door during shower and bathroom use, bedroom door blinds open, and staff in attendance outside the bedroom door.

P1's progress notes from 08/31/17 to 09/08/17 indicated that P1 had routine occurrences of unstable behavior, such as verbal and physical aggression toward staff, self-harm (head-banging, suicide gestures of placing her hands around her throat, and tying clothing articles such as socks around her neck), property destruction (throwing furniture and kicking doors), and an inability to be re-directed. P1 remained on continuous observation after 09/08/17, due to P1's impulsive behavior.

P1's progress notes on 09/11/17 indicated that the interdisciplinary team convened at 9:30 a.m. on 09/11/17 to review P1's status and discuss the plan to discharge P1 to home later that day. P1 was very excited about going home. At 11:30 a.m., P1 tried to contact her parents about her discharge and returning home. P1 became so anxious and agitated when she was unable to reach her parents, she requested prn medication (Thorazine 50 mg, as needed) to calm her, which was given.

The physician's orders on 11:50 a.m. on 09/11/17, indicated that P1's continuous observation was discontinued and P1 was placed on 15-minute observation checks.

P1's progress notes on 09/11/17 at 2:13 p.m. indicated that staff told P1 she was not being discharged and not going home that day. Staff had learned that Child Protective Services (CPS) blocked P1's discharge to home, due to insufficient support to manage P1 within the home setting. P1 became agitated and very anxious about not going home as planned; P1 recognized her anxiety and requested another prn medication (Thorazine 50 mg, as needed), which was given. One hour later at 3:15 p.m., P1 was observed crying in her room and asked to talk to the social worker, who could not be reached. At 3:30 p.m., P1 was observed standing in the hall outside of her room. At 3:45 p.m., P1 was found on the floor in her room with her scrub pants tied tightly around her neck, knotted two times. P1 was blue and unresponsive. Staff called a code blue. Staff untied the scrub pants from around P1's neck and P1 breathed spontaneously. The code team arrived and transferred P1 to the pediatric ED for a trauma evaluation.

P1's ED record, dated 09/11/17 at 3:55 p.m., indicated that P1 arrived in the ED breathing on her own with pink color returning to her skin. P1 underwent a trauma evaluation including a head CT and C-spine imaging, which did not reveal any acute pathology. P1 was transferred to the PICU at 7:30 p.m.

P1's PICU progress notes, dated 09/11/17 at 7:30 p.m., indicated that P1 was hemodynamically stable, breathing comfortably on her own, and had returned to baseline behavior. P1 remained in the PICU overnight for close monitoring of her neurological status. On 09/12/17 at 4:53 p.m., P1 was medically cleared for transfer back to the inpatient adolescent psychiatric unit, 7ITC.

P1's progress notes, dated 09/12/17 at 4:55 p.m., indicated that P1 was readmitted to 7ITC. On unit admission, P1's mood was labile. P1 was teary and asking questions about the duration of hospitalization . P1 was placed on continuous observation.

Psychiatric Associate (PA)-H was interviewed on 09/14/17 at 1:40 p.m. PA-H stated she worked on 7ITC on 09/11/17 from 2:00 p.m. to 10:30 p.m. PA-H was familiar with P1's behavior and had been assigned to P1's care several times when P1 was on observation with either two staff or one staff. PA-H saw P1 several times between 2:00 p.m. and 3:00 p.m. on 09/11/17 when P1 was either in her room or in the hall. That day, P1 was depressed with flat affect. PA-H received shift report from 3:00 p.m. - 3:30 p.m. and was told to keep an eye on P1 because P1's discharge plan had failed and P1's continuous observation was discontinued earlier that day; P1's level of observation was 15-minute safety checks by staff. PA-H conducted the 15-minute check at 3:30 p.m. at which time P1 was standing in the hall, waiting to use the phone. PA-H conducted the 15-minute check at 3:45 p.m. at which time PA-H observed P1 slouched on the floor behind her room door. PA-H entered P1's room and observed that P1 had removed her scrub pants and knotted them around her neck. P1 was unresponsive with bluish skin. PA-H pushed the distress beeper and untied the clothing from around P1's neck. P1 started breathing. The code team came and assumed P1's care.

PA-I was interviewed on 09/14/17 at 1:00 p.m. PA-I stated she worked on 7ITC on 09/11/17 from 3:00 p.m. to 11:30 p.m. PA-I was familiar with P1's behavior and had been assigned to P1's care several times during the past week and a half. On 09/11/17, PA-I received shift report from 3:00 p.m. - 3:30 p.m.; PA-I was told that P1 was unhappy and upset that she wasn't going home as planned and staff should keep a close eye on her because P1's continuous observation had been discontinued; P1's level of observation was 15-minute safety checks by staff. PA-I stated she was surprised that P1's continuous observation was not re-started after P1's discharge plan fell through. PA-I saw P1 at 3:35 p.m., right after shift report. P1 was standing in the doorway to her room, crying. Ten minutes later at 3:45 p.m., PA-I responded to PA-H's distress beeper. When PA-I entered P1's room, P1 was sitting on the floor with no pants on. P1's scrub pants were tied tightly around her neck and P1's face was blue. P1 did not appear to be breathing. PA-H was trying to untie the scrub pants. PA-I assisted PA-H and after they removed the scrub pants, P1 started to breathe on her on. The code team arrived and took P1 to the pediatric ED.

Registered Nurse (RN)-G was interviewed on 09/14/17 at 1:25 p.m. RN-G stated she worked on 7ITC on 09/11/17 from 3:00 p.m. to 11:30 p.m. and was assigned to P1's care. RN-G received shift report from 3:00 p.m. - 3:30 p.m.; RN-G was told that P1 was not discharged earlier in the day as planned but P1 was handling the news "pretty well" about not going home; P1's physician had discontinued the continuous observation around lunchtime and changed P1's level of observation to 15-minute observation checks by staff. Ten minutes after RN-G left shift report, staff summoned RN-G to P1's room via distress beeper. RN-G observed that P1 was sitting on the floor, slumped against the wall behind her room door. P1's eyes were closed, P1's face was blue, and P1 was not breathing. P1 had no scrub pants on and P1's bare legs were cyanotic. P1's scrub pants were knotted around her neck twice and two staff were trying to untie them from her neck. RN-G called a code blue. RN-G assisted the two staff and as soon as P1's scrub pants were removed from her neck, P1 took a spontaneous breath and had a pulse. P1's color started turning from blue to pink but P1 remained unresponsive with her eyes closed. P1 had a one to two-inch swollen ligature mark around the entirety of her neck. The code team arrived and transported P1 to the pediatric ED for a trauma evaluation.

Medical Doctor (MD)/Child Psychiatrist-F was interviewed on 09/14/17 at 11:05 a.m. MD-F stated she was covering another psychiatrist's patients from 09/11/17 through 09/14/17, which included P1. MD-F was aware of P1's history of severe mental illness involving multiple suicide attempts due to ineffective coping skills. MD-F met P1 for the first time on 09/11/17. P1 was pleasant, calm, and had many questions. P1 wanted to go home. MD-F attended P1's team meeting on the morning of 09/11/17 when P1's discharge plan was formalized. After the team meeting, MD-F changed P1's level of supervision from continuous observation to observation checks by staff every 15 minutes, which was consistent with the team's discussion of P1's current behavior and safety needs. In the early afternoon of 09/11/17, P1's parents and CPS expressed concerns about P1's safety in the home setting and as a result, P1's discharge for 09/11/17 was canceled. Around 2:00 p.m., staff told P1 she wasn't going home that day. MD-F stated she should have re-ordered SIO with continuous observation of P1 as soon as P1's discharge plan did not materialize.

There was no evidence that hospital staff re-assessed P1's suicide risk or safety needs after P1's discharge plan failed, including the degree of supervision necessary to keep P1 safe.

The hospital's policy on Suicide Risk Assessment, reviewed December 2016, indicated "Patients will be monitored throughout their hospitalization for risk of self-harm, suicidal behavior, or other behavior which would have implications for safety."

The hospital's policy Level of Observation and Patient Care Alerts, reviewed July 2016, indicated "Status Individual Observation: the most restrictive Level of Observation used with patients that require close physical supervision. Status Individual Observations require a provider order, must be renewed every 24 hours, and must be discontinued by provider order. The RN can initiate Status Individual Observations until a provider order is obtained."