Patient Committed Suicide by Hanging While Unobserved for One Hour

The State of Georgia’s Healthcare Facility Regulation Division cited SummitRidge Center for a nursing service violation after a patient committed suicide by hanging him/herself with a bed sheet. The patient was under an order to be visually observed every 15 minutes, but when he/she should have been attending a group session, video evidence showed the patient entering his/her bedroom and closing the door at 9:48 a.m. The patient was not observed again by staff until 10:54 a.m. when he/she was found unresponsive and hanging from a bathroom door. The patient was pronounced dead by a Medical Examiner at approximately 12:44 p.m. In its plan of correction, the facility agreed to re-train staff on observation procedures and to replace its bathroom doors with vinyl breakaway curtains.