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DENVER HEALTH & HOSPITAL AUTHORITY 777 BANNOCK ST DENVER, CO 80204 Feb. 16, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation 482.13, PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. The facility failed to ensure the safety of patients admitted for suicidal ideation on the psychiatric unit in 1 of 3 records reviewed (Patient #1). The failure resulted in insufficient monitoring of Patient #1 who attempted suicide while in the facility's care.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interviews and document review the facility failed to ensure the safety of 1 of 3 patients admitted for suicidal ideation on the psychiatric unit (Patient #1). The failure allowed Patient #1 to attempt suicide while in the care of the facility.

Findings include:

Policy:

The Identification and Management of the At-Risk Detainable Patient (At-Risk policy) reads in part "all staff are responsible for creating a safe environment for patients. At-Risk criteria includes the patient who presented to the hospital after a suicide attempt or is currently exhibiting suicidal ideation. Patients who are exhibiting suicidal ideation will be provided with a Patient Safety Care Attendant at a 1:1 ratio."

The purpose of the Safety Rounds: Patients and Environment-Inpatient Behavioral Health and Psychiatric Emergency Services policy was to define patient monitoring and supervision processes implemented to improve patient safety and provide a safe environment. "The assessment and management of risks in the environment include ligatures and ligature points, as well as the prevention of access to items by patients which could result in patient or staff harm. All patients on the adult inpatient behavioral health unit will be directly observed every 15 minutes from 7:00 a.m. to 11:00 p.m. and every 30 minutes overnight (11:00 p.m. to 7:00 a.m.). A patient's observation status can be upgraded to 15 minute checks round the clock, line of sight (LOS) or one to one (1:1)".

1. The facility failed to provide a safe environment for an actively suicidal patient and failed to identify the misinterpretation of a physician order as a potential contributing factor to a suicide attempt.

a. Review of Patient #1's medical record showed he was admitted to one of the facility's adult psychiatric units (4 East) on 11/24/17 after a suicide attempt. A History and Physical documented by Physician #15 on 11/24/17 stated Patient #1 was diagnosed with a recurrent and severe major depressive disorder (MDD) and a personality disorder. He documented Patient #1 had wrapped a belt around his neck to hang himself prior to admission. Physician #15 stated it was clear Patient #1 was not able to commit to safety. According to the medical record, Patient #1 remained hospitalized until 1/12/18.

On 12/4/17 at 5:23 p.m., Physician #16 documented a progress note which stated Patient #1 was more distressed that day with suicidal ideation and had disclosed his plan to attempt suicide during the night since safety checks were reduced to every 30 minutes. Physician #16's documented assessment showed Patient #1 had two serious suicide attempts in the last month and needed to be observed closely. Physician #16 stated in the progress note, Patient #1 confirmed he had looked for possible hang points on the unit but had not decided what he would use as a noose.

A nursing note documented by Licensed Practical Nurse (LPN) #17 on 12/4/17 at 4:14 p.m. stated, Patient #1 would be transferred to 4 West because the patient verbalized the desire to hang himself when speaking to Physician #16. The medical record showed Patient #1 was transferred on 12/4/17 at 4:58 p.m. An order was placed at 7:42 p.m. by resident Physician #1 for Observation Round the Clock. The order was acknowledged by LPN #18 at 7:48 p.m. and authorized by attending Physician #16.

Review of the Psychiatric/Special Care Units 15 Minute Check Flow Sheet and Patient #1's electronic medical record revealed staff implemented every 15 minute safety checks for Patient #1 overnight as opposed to observation around the clock.

On 12/5/17 at 6:30 p.m., a significant event note was documented in the medical record by Physician #4 which stated he had been alerted that Patient #1 had attempted to hang himself with his pant leg.

b. The Chief Quality Officer (CQO #14) was interviewed on 2/13/18 at 9:00 a.m. CQO #14 stated he was responsible for quality and safety throughout the facility. According to CQO #14, the quality department provided oversight to ensure a thorough investigation was completed of all significant safety events reported through the facility's Safety Intelligence system, but relied upon the unit managers to conduct their own investigation. There was no mandate that every investigation resulted in a change in process or policy. CQO #14 stated the inpatient psychiatric unit had a Critical Incident Committee which involved resident physicians, attending (supervising) physicians and nursing staff who evaluate the events on their unit. The goal of their review process was to identify any action items which would prevent the recurrence of the same type of event with future patients.

CQO #14 stated, Physician #16 and Physician #1 were no longer with the facility and unavailable to discuss the event surrounding Patient #1.

During a second interview with CQO #14 on 2/16/18 at 7:30 a.m., he stated the Identification and Management of the At-Risk Detainable Patient (At-Risk policy) currently applied to all units in the facility, including the psychiatric units.

c. An interview was conducted with the Director of Service of Behavioral Health (Director #13) on 2/15/18 at 10:27 a.m. Director #13 stated the observation status of a psychiatric patient was based on the presentation of the psychiatric problem and was determined by the supervising physician and resident with input from nursing staff. Typically, a patient who verbalized the intent with a specific plan would be transferred to the acute unit (4 west) and placed on increased staff monitoring, either line of sight or 1:1 observation status. Director #13 stated he was not aware of an Observation Round the Clock order on the inpatient psychiatric unit. He added, on the medical units round the clock generally meant an attendant was sitting in the room with the patient.

d. On 2/15/18 at 11:51 a.m. the Medical Director of Adult Inpatient Psychiatric Units (Director #2) was interviewed. Director #2 indicated that routinely the psychiatric units had three levels of observation which included routine (every 15 minutes during the day and every 30 minutes at night); line of sight (LOS) which required a staff member be able to see the patient at all times; and 1:1 observation with a staff member with the patient at all times.

According to Director #2, the clinical team of Patient #1 met after the event to determine what could have been done to prevent the suicide attempt and how to prevent recurrence of the same type of event. At the time of the meeting, Director #2 stated, she was not aware of a potential misinterpretation of observation status order.

Director #2 confirmed the significant event would be reviewed by the Critical Incident Committee of the psychiatric department in the future to determine what could have been done differently to prevent the suicide attempt and how to prevent its recurrence.

Director #2 stated she had not heard the term "round the clock" but thought it would mean 1:1 or LOS observation. Director #2 confirmed she was familiar with the suicide attempt by Patient #1 but had not reviewed the medical record in some time. She reviewed the progress note written by Physician #16 along with the Observation Round the Clock order and stated, Physician #16 was concerned with the suicidality of Patient #1 and wanted more monitoring of the patient as a precaution. The process for patients who verbalized the intent to attempt suicide was the physician would order an escalation of monitoring, which was line of sight or 1:1 and move the patient to the higher acuity unit for increased staff and camera monitoring. Director #2, stated she interpreted the order as 1:1 or LOS observation status and expected the patient would have been watched at all times.

e. Behavioral Health Technician (BHT) #5 was interviewed on 2/13/18 at 2:40 p.m. BHT #5 confirmed he was on duty when Patient #1 made a suicide attempt in the locked psychiatric unit. According to BHT #5, Patient #1 was located in a camera monitored room on an increased frequency of safety checks overnight, not 1:1 observation status. BHT #5 stated the camera monitor display at the nurse's station was not watched at all times.

f. On 2/12/18 at 12:05 p.m., an interview was conducted with Charge Nurse (CN) #7 during a tour of the psychiatric units. CN #7 stated high risk patients may be placed on 1:1 observation status, which was determined by the nurses. A second interview was conducted with CN #7, on 2/13/18 at 4:48 p.m., When asked about the use of camera monitored rooms, CN #7 confirmed the cameras were not monitored by staff at all times and were used only as an adjunct to monitoring when staff worked at the nurse's station.

This was in contrast to the expectation of psychiatric providers.

g. Physician #11 was interviewed on 2/14/18 at 4:12 p.m. Physician #11 stated he cared for Patient #1 during his admission beginning 11/24/17. He confirmed a 1:1 observation status order required a dedicated staff member be assigned to stay with the patient at all times. When asked the meaning of the order Observation Round the Clock, Physician #11 stated the order was a "little vague". Physician #11 stated the process for patients already admitted to the units who verbalized an intent to attempt suicide received clinical assessment of the patient's willingness to contract for safety, and if the patient could not contract or was too psychotic to manage on the low acuity unit, then the patient would be moved to 4 west with camera monitoring. Physician #11 stated, if he ordered a patient be placed in a monitored room on the high acuity unit, it was his expectation that a staff member would monitor the cameras at all times.

h. An interview was conducted on 2/14/18 at 1:55 p.m. with Licensed Practical Nurse (LPN) #10 who stated she was the nurse assigned to Patient #1 on 12/5/17. LPN #10 stated she recalled receiving report that morning from the night shift, and she had been told Patient #1 had moved from the East unit to the West unit because the patient wanted to kill himself. LPN #10 stated she was told Patient #1 had increased safety check frequency to every 15 minutes through the night, and the normal practice was to check patients every 15 minutes during the day. LPN #10 stated she did not know what the order Observation Round the Clock meant. LPN #10 stated she had continued what the night shift was doing, which was safety checks every 15 minutes.

i. On 2/13/18 at 3:23 p.m., an interview was conducted with the Behavioral Health Nurse Educator (RN #6). According to RN #6, patients on a 1:1 observation status order were monitored by a staff member at arms length from the patient until the order was changed. RN #6 reviewed the physician orders of Patient #1 and stated she interpreted the order Observation Round the Clock to mean Patient #1 was to be on 1:1 observation status. Since the order was entered prior to the suicide attempt, she expected staff would have been in the room with Patient #1 on 12/5/17 at 5:45 p.m. when he was found with a pant leg tied around his neck.

RN #6 specified the order was written by a physician resident who rotated among different hospitals and may have confused acceptable orders from an outside facility. According to RN #6, no new education had been provided to the clinical staff to ensure there was a clear understanding of the meaning of the order Observation Round the Clock since the suicide attempt of Patient #1 on 12/5/17.

j. An incident report was submitted into the facility Safety Intelligence system on 12/5/17 at 6:25 p.m. Review of the suicide attempt by Patient #1 included a review by RN #6 on 12/18/17 at 3:22 p.m. She documented the staff were reminded of the importance to complete 15 minute safety checks accurately and were commended for "Great catch."

k. Director of Quality (Director) #3 was interviewed on 2/13/18 at 12:06 p.m. According to Director #3, the quality department could not look into every suicide attempt on the psychiatric unit because "things happen there all the time." Director #3 confirmed there was no additional investigation documentation into the suicide attempt of Patient #1 from the quality department. This was in contrast to the CQO #14's interview on 2/13/18 at 9:00 a.m. in which he stated, a member of the quality department reviewed all events to ensure a thorough investigation was completed by each units manager.