HospitalInspections.org

Based on document review, video review, and interview, it was determined that the hospital failed to comply with the Condition for Coverage 42 CFR 482.13, Patient Rights.

Findings include:

1. The Hospital failed to ensure that staff failed to monitor a patient at risk for suicide as required. (A-144).

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt.#4) clinical records reviewed for suicide risk assessment, reassessments and interventions, the hospital failed to ensure that staff monitored a patient at risk for suicide as required.

Findings include:

1. The hospital's policy titled, "Assessment and Managing Suicide Risk (revised 08/2024)" was reviewed. the policy required, "... Reassessment of Risk: 1. Reassessment of suicidality will occur every 12-hour-shift for any patient on increased observation (i.e. 1:1) or who exhibits a sudden or significant change in mental status. This is documented using the Columbia Reassessment form... 3. Patients who continue, or begin to present at high-risk for suicidality are to continue on, or be evaluated for, heightened observations or precautions, as outline below.... Heightened Observations: All acute patients will be monitored at least every 15 minutes. Patients who are assessed to be at higher risk for suicidality than the rest of the patient population will be placed on suicide precautions and may be placed on a one to one (1:1) observation status as outlined in the Level of Observation policy.... 9. Patients on suicide precautions or heightened observation levels for suicidality self-destructive behaviors may have the following restrictions: ... 1:1 - Toileting and Showering - Staff must be continuously present with patient..."


2. The clinical record for Pt. #4 was reviewed on 11/19/24. Pt #4 was admitted on 9/7/24 with a diagnosis of "1. Bipolar disorder, current episode depressed, severe without psychosis. 2. Posttraumatic stress disorder. 3. Attention deficit hyperactivity disorder and anxiety disorder, by history." Pt #4 was placed on 1:1 observation on 10/17/24 with an "Indication" of "Major depressive disorder. On 11/13 and 11/14 all suicide risk assessment questions were answered no which indicated no risk. On 11/15/24 a "Daily Nurse Progress Note" indicated for both 7:00 am to 7:00 PM shift and 7:00 PM to 7:00 AM (16th) yes to all suicide risk assessment questions. The clinical record lacked documentation that the provider was notified of the change in risk assessment. The "Psychiatric Progress Note" by the telepsychiatry (MD #1) conducted on 11/16/24 (E #2 reported all evaluations are conducted at 9:30 am every day for Pt #4). The progress note indicated, "... Subjective: ... Patient with limited engagement Reported that 'I'm still here, no one cares, they can't find me a place to go.' ... Continue with one-to-one with high precaution with patient feeling abandoned. Monitoring at all times including while in the bathroom to ensure safety..." A "Patient Progress Note" by E #9 on 11/16/24 at 8:52 PM indicated, "At approximately, 20:52 (8:52 PM) Pt asked the 1:1 staff to go to the bathroom where Pt tied a string on (Pt #4) neck and was on the floor, staff immediately intervened and Pt began having one of (Pt #4's) psychogenic seizures and wasn't responding to staff. Staff moved Pt out of (Pt #4's) room bathroom and took vitals, which were slightly high but o2 (oxygen) was normal. Once Pt began responding to staff, staff told pt (Pt #4) would have to go into a safety suit due to suicidal behaviors...." An order for was placed on 11/16 at 11:00 PM for One-to-one with "no privacy to be observed." The Psychiatric Progress Note dated 11/17/24 indicated, "... Last evening, it was reported to clinician that patient did find part of (Pt #4's) clothing, went to the bathroom and tried to strangle self, 1:1 staff intervened promptly. Bathroom supervision continued...."

3. An interview was conducted with E #9 on 11/19/24 at 2:00 PM. E #9 stated, "(Pt #4) was on a one to one. (Pt #4) had been on them for about a month and it had been based on self harming behaviors. The staff had took off the bathroom curtain (acts as a door to the bathroom) when (Pt #4) became a one to one for better visual purpose. (Pt #4) walked into (Pt #4's) room with the one to one (E #10). From what (E #10) told me after the incident, (Pt #4) had asked to go to the bathroom. At that time we have to be within arms reach of her, so like outside the bathroom door/curtain. We had to visually watch (Pt #4) go to the bathroom at the time. From my understanding the staff member would have been on the outside of the doorway against the wall. The staff was asking (Pt #4) periodically how (Pt #4) was doing and then (Pt #4) stopped answering. The staff member went in to check and (Pt #4) was sitting on the floor in between the toilet and the shower. (E #10) had yelled from the doorway to get me. When I came in (Pt #4) had a thin string, like a thread, around (pt #4's) neck that (Pt #4) might've peeled off (Pt #4's) shirt. (Pt #4) was in scrubs at that time. Once I saw the thread around (Pt #4's) neck, I removed it and then I had the other staff go grab the vital cart and alert the nurse. We moved (Pt #4) out of the bathroom to a more safe area and ended up calling the code 99 (medical emergency) just to have other nurses come check (Pt #4) out make sure (Pt #4) was doing.

4. An interview was conducted with E #10 on 11/19/24 at 3:00 PM. E #10 stated, "Because of her behavior, (Pt #4) had expressed suicidal ideation, (Pt #4) was on one-to-one. I was (Pt #4's) one to one that night. (Pt #4) said that (Pt #4) needed to use the bathroom. I was in the doorway but I turned my back so I wasn't staring at (Pt #4) while on the toilet. I didn't hear (Pt #4) urinating or anything and (Pt #4) didn't answer when I called (Pt #4's) name so, I turned around and (Pt #4) was sitting on the floor between the shower and the toilet. (Pt #4) was just sitting there with her eyes closed and I did not see the string. so I called for the Lead MHT[E#10] and the nurse to come in. I stayed with (Pt #4). The Lead MHT[E#10] came in and we pulled (Pt #4) out of the bathroom. (Pt #4) started coughing and saying (Pt #4) couldn't breathe. We took her vitals her blood pressure was up but the rest including (Pt #4's)oxygen was 96 or 98, it was normal."

5. An interview was conducted with the /E #2 on 11/20/24 at approximately 10:48 AM. E #2 reviewed Pt #4's record and verbally agreed, Pt #4 was on suicide precautions with 1:1 and the staff were not monitoring the patient while going the bathroom as required. E #2 stated, "(Pt #4's) plan of care was updated to increase the monitoring. (Pt #4) remains on the one-to-one close observation with the direct visualization while using the restroom. We have not been able to complete the investigation into the event as it was just over the weekend. Each suicide precaution is an order based off of the provider's impression. Not all interventions are the same. The higher the risk, more interventions/monitoring is put in place. There have been no other incidents."