CLASS AA CITATION -- PATIENT CARE 72523(a) Patient Care Policies and Procedures
Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.
On March 21, 2008 at 1:15 p.m., an anonymous complaint/entity reported incident was investigated regarding a Patient who hung herself.
Based on observation, interview and record review the facility's nursing staff failed to:
1. Continuously monitor a Patient who was placed on increased supervision (15-minute monitoring) because of previous attempts to elope from the facility. The Patient's location was unknown for approximately 50 minutes. The Patient was eventually found on a patio, that was locked and off limits to Patients, with a rope around her neck and hanging from a tree and pronounced dead at 10:50 p.m. on March 19, 2008.
A review of Patient A's Admission Records indicated she was a 39-year-old female, who was admitted, to the facility (a locked facility with a special treatment program (STP), approved by the Department of Mental Health to provide treatment to chronically mentally ill adults age 18 to 65. The program is certified as an Institution for Mental
Disease (IMD). The patients progress through four program levels. The program provides five days of therapeutic groups and seven days of activity groups. The facility also provides several progressive groups such as a process group called crisis management group, and impulse control), from a psychiatric hospital, on January 28, 2008, with diagnoses including psychosis (a psychiatric disorder such as schizophrenia or mania that is marked by delusions, hallucinations, incoherence, and distorted perceptions of reality) and schizophrenia (a severe psychiatric disorder with symptoms of emotional instability, detachment from reality, and withdrawal into the self).
The Patient's psychiatrist describes her history of present illness, in a report dated January 30, 2008, as anxious, paranoid, with delusional thinking and auditory hallucinations. Her thought process was linear (fixed) and impoverished (disorganized and fragmented), and her insight and judgment were impaired.
A Psychosocial Assessment, dated February 1, 2008, indicated Patient A had a past history of suicidal thoughts and wanting to be dead. The number of times the Patient had these thoughts or made the statement was not indicated.
A Psychological Evaluation, dated February 5, 2008, indicated Patient A was not currently suicidal but stated she did not have any reason to live.
According to the Minimum Data Set (MDS) Assessment (a standardized comprehensive assessment of the Patient's problems and conditions), dated February 6, 2008, Patient A's cognitive skills for daily decision-making were moderately impaired. Her speech was clear and she was able to make her needs known and was understood by others. The Patient was assessed as making verbal expression of distress, i.e., nothing matters; would rather be dead; what's the use; regrets having lived so long; let me die. These expressions were exhibited up to five days a week. She was seen with sad, pained worried facial expressions and had behaviors that included repetitive physical movements, such as, pacing, hand wringing, restlessness, fidgeting and picking. She was withdrawn from activities of interest and had reduced social interactions. The Patient was resistant to care, which was not easily altered and expressed sadness, anger and/or empty feelings over lost roles/status. She suffered from delusions and because of her disease process (psychosis/schizophrenia) her cognition; mood and/or behavior patterns were unstable.
Interdisciplinary Progress Notes, dated March 14, 2008, indicated Patient A attempted to AWOL (absent without leave) x 2 at noon. The two attempts were approximately two hours apart. The Patient was placed on 15-minute checks for AWOL risk.
A Care Plan, dated March 15, 2008, indicated Patient A was at risk for being AWOL as evidenced by the Patient starting/attempting to leave the facility on March 14, 2008, following/attempting to follow staff out of the doors. A goal/objective had been developed for the Patient not to AWOL while on pass or to leave the facility without permission. Approaches used to ensure the Patient's goal was met included:
1. Program staff to present the Patient with a behavior contract to agree not to AWOL from the facility and to inform the staff if she was having thoughts/impulses to AWOL.
2. If at any time the treatment team decided the Patient was displaying behavior that was at risk for AWOL, the Patient would be placed on increased supervision to ensure safety until the treatment team decided the Patient was no longer at risk.
A facility policy indicated, under Increased Supervision, a Patient who is on increase supervision would have a staff person assigned to do a visual check on the Patient every fifteen minutes.
Interdisciplinary Progress Notes, dated March 19, 2008 at 9:15 am., indicated Patient A had increased agitation and anxiety, she was crying, pleading and calling her ex husband numerous times. The program counselor (PC) and director of nursing (DO attempted to calm the Patient down but the crying and agitation continued.
On the same day at 5:00 p.m., according to Interdisciplinary Progress Notes, Patient attended a special treatment program (SIP) group. She talked about feeling lonely overwhelmed by feelings of isolation and loneliness.
According to Interdisciplinary Progress Notes, dated March 19, 2008 at 10:50 p.m., Patient A was found on the back patio standing next to a tree, when called, the Patient did not respond. Closer examination of the Patient revealed she had a rope tied aroi her neck and was without a pulse. Emergency services were called and they pronounced the Patient dead on the scene.
On March 21, 2008 at 1:15 p.m., during an interview, the Administrator stated he was called at home and told Patient A had hung herself. He stated the Patient had attempted elopement from the facility a few days ago, (March 14, 2008) and she was being monitored every 15-minutes.
On March 21, 2008 at 1:30 p.m., Patient A's room (1OA) was observed by the Evaluator and the Administrator. The room had a large window next to bed B which allowed immediate access to a 'walking patio", the walking patio was locked and did not provide access to the patio area where the Patient was found hanging. The "smoking patio" was then observed and it was noted to have one large tree. The Administrator stated there were three trees but since the incident two of them had been cut down and they were in the process of cutting down the other one. There were approximately 4 benches that were being bolted to the cement floor of the patio. The Administrator stated the Patient used a plastic chair to stand on and those chairs were removed from the patio area after smoking hours. A wire fence enclosed the area above the smoking patio.
On March 21, 2008 at 2:00 p.m., during an interview, the Administrator stated they do not knowingly admit any Patient with suicidal thoughts, hallucinations, or thoughts tha lead them to harm themselves. If the Patients decompensate after they are admitted the facility they are stabilized and transferred out. If they are actually acting out the PET team or the police will pick them up. He stated Patients have laundry hampers in their room and Patient A took the cord out of her laundry hamper and tied it around her neck.
On April 3, 2008 at 3:00 p.m., during an interview, CNA 3 stated her assignment for monitoring the building and Patients began at 10:00 p.m., and ended at 10:45 p.m. Sh stated she saw Patient A between 9:45 p.m. and 10:00 p.m., when she brought a toile box to another co-worker. She stated she made a mistake on the monitoring sheet when she documented the Patient was sleeping between 10:00 p.m., and 10:45 p.m., she was thinking of another Patient and documenting the other Patient's location on Patient A's monitoring sheet, she did not actually see Patient A. She stated she was i the Annex between 10:20 p.m., and 10:25 p.m. and she had fallen behind during rounds because there was an incident between two Patients on the Annex. After she left the Annex she began rounds on Station I, she went to two separate Patient rooms and neither one of the patients were in their rooms. She then went through room 19 or 20 see if the patients were on the smoking patio. She stated she saw Patient A standing by a tree and told her you know I have been looking for you, Patient A did not respond She heard a noise to her left and looked over and saw the other Patient she was looking for and told her to go back inside, the Patient complied and went through one of the Patient rooms that surrounded the patio area to get back in the building. She then looked to see if Patient A had gone back into the building but when she saw she had not, she walked toward the Patient telling her she had to go back inside, but still received no response from her. When she got closer she looked up and saw a rope around the Patient's neck, she then walked quickly back into the building and screamed for help, she stated that was around 10:45 p.m., and the last time she saw the Patient was between 9:45 p.m., and 10:00 p.m.
A review of an Alert Record, dated March 19, 2008, at 10:00 pm., 10:15 p.m., 10:30 p.m., and 10:45 p.m., indicated Patient Awas in her room sleeping, which did not correlate with the interview of CNA 3, on April 3, 2008, at 3:00 p.m.
On April 3, 2008 at 3:13 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Certified Nursing Assistant 3 (CNA 3) came screaming hysterically to the nursing station saying Patient A hung herself. LVN 1 stated she ran through room 19 to get to the patio. When she reached the Patient her hands were cold there was no pulse or signs of life. She had staff stay with the Patient while she ran out to call for emergency services (911). She did not cut the Patient down because she had never experienced anyone who had hung himself or herself and she did not know what to do. The fire department was in route but instructed her to sweep the Patient's mouth and begin cardiopulmonary resuscitation (CPR). The staff assisted in cutting the Patient down but before she could begin CPR the fire department arrived and took over.
On April 3, 2008 at 4:00 p.m., during an interview, LVN 2 stated she gave Patient A her medications around 8:20 p.m.. She saw the Patient walking around the hallway but does not remember the time. She stated the Patient later asked for a towel so she could take a shower. Approximately 30 minutes to 1 hour later she saw the Patient walking down the hallway from her room toward the shower and back again. LVN 2 stated she was coming out of the restroom, at approximately 10:50 p.m., when she saw CNA 3 on the floor screaming loudly. When they figured out what CNA 3 was saying they all ran outside and saw the Patient. She appeared to be leaning against a tree but when they got closer they saw her feet were slightly elevated off the ground.
On April 29, 2008 at 2:10 p.m., during an interview, CNA 4 stated Patient A came to the nursing station around 9:25 p.m. and asked for a towel so she could take a shower, she came back around 9:35 p.m. to 9:40 p.m., to give back the shower supplies. At 9:45 p.m., she saw the Patient in her room sleeping with the back of her head against the headboard, around 9:50 p.m.; she passed the monitoring assignment/sheet to CNA 3.
A facility policy, regarding Patient Supervision and Monitoring, dated July 2002, indicated the team will provide increased levels of supervision to ensure optimal Patient safety and outcome. When a staff person observes that a Patient presents significant risk the staff member is responsible for ensuring the immediate safety of the individual. Supervision checks must not be dropped in an emergency. The check sheets must be transferred to another staff person. If other staff is not available in an emergency, i staff must call for assistance immediately and use good judgment in reacting to the situation
On March 19, 2008, at 10:50 p.m., Patient A was found on a locked restricted patio area with a rope around her neck hanging from a tree. The Patient had been placed on increased supervision (15-minute monitoring). At the time the Patient was found hanging from a tree, her whereabouts were unknown for approximately 50 minutes.
Therefore, the facility failed to:
1. Continuously monitor a Patient who was placed on increased supervision (15-minute monitoring) because of previous attempts to elope from the facility. The whereabouts of the Patient was unknown for approximately 50 minutes. The Patient was eventually found on a patio, that was locked and off limits to Patients, with a rope around her neck hanging from a tree.
This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and was direct proximate cause of death of the patient.