Teenage patient attempted suicide while on "special care"

The Center for Medicare and Medicaid Services (CMS) determined Cumberland Hall violated the Patient Rights and Nursing Services conditions of CMS participation, and “placed patients at risk for injury, harm, impairment or death.” Immediate Jeopardy was identified to exist at the facility, and was abated prior to the departure of CMS surveyors.

CMS substantiated allegations that a patient on the adolescent unit was able to attempt suicide using the drawstring of a pair of shorts when left alone and unsupervised. CMS found that the patient, who was admitted for a suicide attempt, “was placed on special care, and … was required to remain in his/her room during free time following an outburst in the cafeteria.”

The patient stated, “I had plenty of time to think about everything since I was alone in my room on special care. I have been upset and stressed about all the pain I have caused my family. The string I used was hidden in my gym shorts that could not be seen because it was sewn in the fabric.”

The patient was being monitored by a Mental Health Technician (MHT) who had to monitor a total of 18 patients and missed a 7:00 pm check “[d]ue to the activity on the unit.” Upon returning, the MHT found the patient lying on the bathroom floor unresponsive, with the string tied above the head and wrapped around the throat. Immediate jeopardy was identified and determined to exist, and was abated prior to the surveyors’ departure.

CMS noted that, “On 05/07/14, the facility discontinued the practice of special care where a patient was given a ‘time out’ due to unacceptable behavior and was alone in their room for a specified length of time.”