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Based on clinical record reviews, interviews with staff, and review of Hospital documentation, the Hospital failed to ensure that Patient #1 remained safe during hospitalization, failed to ensure that staff were able to access the hospital's emergency response system, and failed to ensure that emergency supplies were readily available. The findings include:

Patient #1 was admitted on 10/29/10 with a diagnosis of bipolar disorder, following a failed attempt to hang his/her self at home. Although a clinical assessment dated 10/29/10 identified that Patient #1 was depressed and had suicidal ideations with a plan to hang his/her self, treatment/care plans failed to include the patient's stated suicidal plan to hang him/her self and lacked interventions specific to Patient #1's safety needs. On 10/31/10 at approximately 6:10 PM, Patient #1 was found hanging from a closet hinge in his/her room by a rope fashioned from strips of a bed sheet. Staff were unable to access the hospital's emergency response system and did not have emergency supplies readily available. The patient was eventually cut down, resuscitated, intubated and in critical condition following the hanging. On 11/4/10, Patient #1 was extubated (per family wishes) and expired at 12:19 PM.

Please refer to A144.

Based on clinical record reviews, interviews with staff, and review of Hospital documentation, staff failed to ensure that Patient #1's care plan identified the patient's plan for suicide (overdose, hanging, etc) and failed to include patient specific interventions to ensure that the patient remained safe during hospitalization. The findings include:

Patient #1 was admitted on 10/29/10 with a diagnosis of bipolar disorder, following a failed attempt to hang his/her self at home. Although a clinical assessment dated 10/29/10 identified that Patient #1 was depressed and had suicidal ideations with a plan to hang his/her self, treatment/care plans failed to include the patient's stated suicidal plan to hang him/her self and lacked interventions specific to Patient #1's safety needs. On 10/31/10 at approximately 6:10 PM, Patient #1 was found hanging from a closet hinge in his/her room by a rope fashioned from strips of a bed sheet. Patient #1 was resuscitated, intubated and in critical condition following the hanging. On 11/4/10, Patient #1 was extubated (per family wishes) and expired at 12:19 PM.

Subsequent to surveyor inquiry, all patients on the adult psychiatric unit on 11/3/10 had a suicidal risk assessment completed. Treatment plans were updated to identify each patient's plan for suicide (overdose, hanging, etc), and interventions specific to the patient's safety needs were identified.


Please refer to A396.

Based on clinical record reviews, interviews with staff, and review of Hospital documentation, the Hospital failed to ensure that Patient #1 remained safe during hospitalization, failed to ensure that staff were able to access the hospital's emergency response system, and failed to ensure that emergency supplies were readily available. The findings include:

Patient #1 was admitted on 10/29/10 with a diagnosis of bipolar disorder, following a failed attempt to hang his/her self at home. A clinical assessment dated 10/29/10 identified that Patient #1 was depressed, had suicidal ideations with a plan to hang his/her self, and admitted to drinking a large amount of alcohol prior to admission. Review of the initial treatment plan dated 10/29/10 identified the patient with behavioral/personality problems and identified that the patient would remain safe on the unit, however, there were no interventions identified to ensure that the patient remained safe. Nursing care plans dated 10/29/10, 10/30/10, and 10/31/10 identified the patient had an alteration in coping and thought process, had audio, visual, and command hallucinations, was anxious, and had suicidal ideations. The patient was also identified as a risk of self-harm due to delusions, substance abuse, hallucinations, suicidal ideations, suicide gesture/attempt, and poor insight and judgment.

Review of Patient #1's clinical record dated 10/31/10 and interviews with staff identified that at approximately 6:10 PM, Patient #1 was found hanging from a closet hinge in his/her room by a rope fashioned from strips of a bed sheet. Staff were unable to access the hospital's emergency response system and did not have scissors readily available. The patient was eventually cut down, the rope was removed revealing deep ecchymotic areas on the neck, CPR initiated, and the cardiac response team arrived approximately 7 minutes later. The patient was eventually cut down, resuscitated, intubated and in critical condition following the hanging. On 11/4/10, Patient #1 was extubated (per family wishes) and expired at 12:19 PM.

Interview with RN #1 on 11/9/10 at 11 AM identified that he/she was assigned to care for Patient #1 on 10/31/10. From 5:45 PM to shortly after 6PM, Patient #1 was medicated for pain associated with a cough. At that time, the patient identified that he/she was not experiencing auditory hallucinations or thoughts of hurting him/her self, and was instructed to find staff if anything changed. Within a few minutes, Patient #1 was found hanging on the closet hinge in his/her bedroom. While the patient was being careD for by other staff, RN #1 identified that he/she attempted to dial the hospital's emergency code telephone number from the nurse's station, which did not work. RN #1 identified that he/she requested that RN #2 call the code from another phone, which also did not work. RN #1 then ran to the front desk and asked another staff member to call the code (third attempt).

Interview with RN #2 on 11/9/10 at 12:45 PM identified that he/she made a second attempt to dial the hospital's emergency code telephone number from another phone, which also did not work.

Interview with RN #3 on 11/9/10 at 1:50 PM identified that he/she ran to find scissors to cut the rope that the patient was hanging from, found a small pair of pinking-type sheers (with a blade approximately 3/4 inches long), and used this to make several cuts into the rope before it cut through.

Interview with RN #4 on 11/9/10 at 10 AM identified that he/she ran to find another pair of scissors, found bandage scissors, but the patient was already cut down when he/she returned with them. RN #4 identified that he/she then ran to get emergency supplies, making three trips to bring an ambu-bag for respirations, the emergency cart, and then the defibrillator.

Interview with the Director of Patient Care Services on 11/9/10 at 1:20 PM identified that he/she was not aware that the psychiatric unit did not have a pair of emergency scissors available to cut a rope, and the hospital was unable to identify why the emergency code system did not work on the psychiatric unit on 10/31/10. In addition, the Director of Patient Care Services identified that the hospital did not have a mechanism in place to ensure that staff on the psychiatric unit were knowledgable about the emergency code system and/or processes.

Based on clinical record reviews, interviews with staff, and review of Hospital documentation, staff failed to ensure that Patient #1's care plan identified the patients plan for suicide (overdose, hanging, etc) and failed to include patient specific interventions to ensure that the patient remained safe during hospitalization. In addition, for 7 of 20 patients (Patient #3, 4, 8, 15, 16, 19, and 21) admitted with suicidal attempts/ideations, the treatment plans failed to identify the patient's plan for suicide (overdose, hanging, etc) and failed to identify interventions specific to the patient's safety needs. The findings include:

a. Patient #1 was admitted on 10/29/10 with a diagnosis of bipolar disorder, following a failed attempt to hang his/her self at home. A clinical assessment dated 10/29/10 identified that Patient #1 was depressed and had suicidal ideations with a plan to hang his/her self. The patient was admitted to the psychiatry unit and placed on every 15-minute checks. Review of the initial treatment plan dated 10/29/10 identified the patient with behavioral/personality problems and identified that the patient would remain safe on the unit, however, there were no interventions identified to ensure that the patient remained safe. Nursing care plans dated 10/29/10, 10/30/10, and 10/31/10 identified the patient had an alteration in coping and thought process, had audio, visual, and command hallucinations, was anxious, and had suicidal ideations. The patient was also identified as a risk of self-harm due to delusions, substance abuse, hallucinations, suicidal ideations, suicide gesture/attempt, and poor insight and judgment. Interventions included to assess, evaluate, and monitor risk behavior every 8 hours, safety checks every 15-minutes, implement suicide precautions, and remove objects with self-harm potential. The care plans failed to include the patient's stated suicidal plan to hang him/her self, and lacked interventions specific to what types of objects and/or environmental hazards had the potential for self-harm. In addition, staff failed to follow the hospital policy for suicide precautions, which included initiating a constant observation, as identified in the care plans.

Review of nursing notes dated 10/31/10 identified that at 5:50 PM, Patient #1 denied having suicidal thoughts and was encouraged to come to staff if suicidal thoughts or hallucinations increase. At approximately 6:10 PM, Patient #1 was found hanging from a closet hinge in his/her room by a rope fashioned from strips of a bed sheet. Patient #1 was lowered to the floor, the rope was removed, deep ecchymotic areas were noted on the neck, a code was called, the cardiac response team arrived approximately 7 minutes later, and the patient was taken to the emergency department. Further review of Patient #1's clinical record identified that the patient was intubated and in critical condition following the hanging. On 11/4/10, Patient #1 was extubated (per family wishes) and expired at 12:19 PM.

Patient #1's treatment plan was reviewed with the Director of Patient Care Services on 11/9/10 at 1:20 PM. Although Patient #1's treatment interventions identified to initiate suicide precautions, the hospital policy for suicide precautions was not followed (ie: placing the patient on constant observation). In addition, the plan failed to identify specific safety interventions related to Patient #1's stated suicidal plan to hang him/her self.

Interview with the Director of Quality on 11/9/10 at 1:20 PM identified that although the hospital had a policy specific to monitoring patients with a potential for alcohol withdrawal, this policy was not used on the psychiatric unit.

b. Patient #3 was admitted to the hospital on 10/17/10 for treatment of self-inflicted stab wounds to the abdomen and arm that required surgical intervention. Patient #3 was identified as having experienced the death of a significant other within the past week, had a persistent wish to die, and identified that he/she had recently attempted suicide by consuming an overdose of prescription medications. Following medical treatment, the patient was admitted to the psychiatric unit with diagnoses of mood disorder and opiate dependence. Review of Patient #3's treatment plan dated 10/24/10 and nursing care plan dated 11/3/10 identified the patient's suicidal ideations and identified to assess the patient every 8 hours and conduct routine safety checks (every 1 hour). However, the plans failed to identify the patient's mode for suicide (overdose and stabbing), and failed to identify environmental safety hazards and interventions specific to Patient #3's suicidality (i.e. mouth checks/sharp object surveillance).

c. Patient #4 was admitted on 11/1/10 following an attempted suicide by consuming an overdose of prescription medications that required medical intervention. Review of Patient #4's treatment plan dated 11/2/10 and nursing care plan dated 11/2/10 identified the patient's suicidal ideations and gesture and identified to assess the patient every 8 hours and conduct 15-minutes safety checks. However, the plans failed to identify the patient's mode for suicide (overdose), and failed to identify environmental safety hazards and interventions specific to Patient #3's suicidality (i.e. mouth checks).

d. Patient #8 was admitted on 10/30/10 with suicidal ideations that included statement of a wish to kill his/her self, and visiting train tracks. A clinician's assessment dated 10/30/10 identified that the patient's suicidal ideation and risk for violence could not be assessed at that time. Review of Patient #8's treatment plan dated 10/30/10 and nursing care plan dated 11/3/10 identified the patient's suicidal ideations and gesture and identified to assess the patient every 8 hours and conduct 15-minutes safety checks. However, the plans failed to identify the patient's mode for suicide.

e. Patient #15 was admitted on 10/23/10 with suicidal ideations and a refusal to contract for safety. The patient had a history of multiple suicide attempts by hanging, cutting, and overdose. Review of Patient #15's treatment plan dated 10/23/10 and nursing care plan dated 11/3/10 identified the patient's suicidal ideations and gestures, and identified the need to assess the patient every 8 hours and conduct constant observations. However, the plans failed to identify the patient's mode for suicide (overdose/hanging/cutting) and failed to identify environmental safety hazards and interventions specific to Patient #15's suicidality (i.e. mouth checks/sharp object surveillance/hanging hazards).

f. Patient #16 was admitted on 10/26/10 with suicidal ideations that included statement of a wish to kill his/her self with a gun, said goodbye to family members, and wished to lie down and die in a cemetery. Review of Patient #16's treatment plan dated 10/27/10 and nursing care plan dated 11/3/10 identified the patient's suicidal ideations and identified the need to assess the patient every 8 hours and conduct 15-minutes safety checks. However, the plans failed to identify the patient's mode for suicide.

g. Patient #19 was admitted on 11/1/10 following an attempted suicide by walking in front of a car and had a history of an overdose attempt. Patient #19's treatment plan dated 11/2/10 failed to identify the patient's suicidal ideations. Review of the nursing care plan dated 11/3/10 identified the patient's suicidal gesture and identified to assess the patient every 8 hours and conduct 15-minutes safety checks. However, the plans failed to identify the patient's mode for suicide (history of overdose), and failed to identify environmental safety hazards and interventions specific to Patient #19's suicidality (i.e. mouth checks).

h. Patient #21 was admitted on 10/26/10 with passive suicidal ideations and a history of suicide attempts by overdose. Patient #21's treatment plan dated 11/3/10 failed to identify the patient's passive suicidal ideations. Review of the nursing care plan dated 11/3/10 identified the patient's passive suicidal ideations and identified to assess the patient every 8 hours and conduct 15-minutes safety checks. However, the plans failed to identify the patient's mode for suicide and failed to identify environmental safety hazards and interventions specific to Patient #19's suicidality (i.e. mouth checks).