The Ridge Behavioral Health System was cited by the Centers for Medicare and Medicaid Services (CMS) for condition level deficiencies in the areas of patient rights and nursing services. CMS also determined that Immediate Jeopardy existed at the facility.
Acting on a complaint, CMS found:
Patient #1 was admitted to the facility on a voluntary basis after he/she expressed suicidal ideations (SI) and homicidal ideations (HI). Patient #1 reported to family these ideations and also the intent to elope from the facility which in turn were communicated to the nursing staff of the facility. The failure of the facility to provide a safe environment and inadequate nursing supervision resulted in Patient #1 eloping from the facility with subsequent self-injury with a box cutter resulting in multiple lacerations to his/her neck, bilateral wrists, and left thigh.
This patient had been admitted to a locked unit with diagnoses of psychosis, suicidal ideation, and homicidal ideation. The physician ordered routine visual monitoring of the patient every 15 minutes. Following a family visit the day after admission, family members reported to staff that the patient said he/she was going to elope from the facility and commit suicide. The family also provided a written summary of the patient’s “recent behavior, such as auditory hallucinations to hurt self and others and that he/she had developed plans to do so.” An hour after the family visit, “Patient #1’s cousin called nursing staff on the unit to report Patient #1 had called to say he/she was going to elope from the facility and kill self.”
As a result, “nursing staff decided to move Patient #1 to the ‘safe room’ by the Nurses Station. … [H]owever, when going to do this, Patient #1 was asleep, and it was decided to let him/her sleep until morning.” The patient was not placed on 1:1 observation or elopement precautions such as unit restriction.
In the morning, the patient was observed in the Day Room at 8:15 AM. By 8:30 AM, staff noticed that a plank on the wooden fence surrounding a courtyard had been broken and the patient could not be located. According to a police report, the patient was transferred to an Emergency Department at 9:00 AM with multiple self-inflicted lacerations to neck, wrists, and left thigh which required surgery to repair.
In an interview, the Chief Nursing Officer “revealed the evening of 4/22/14 was a busy evening on Unit 2.” The Charge RN for the unit that evening “stated the House Supervisor told her she had done everything she could do for Patient #1, and he/she should be safe until morning.”
Immediate Jeopardy was determined to be abated after the facility agreed to limit patient access to the courtyard area and to keep patients restricted to their units for the first 24 hours after admission.