Unsupervised suicide risk patient at Palm Shores engages in self-harm with scissors

Palm Shores Behavioral Health Center was cited by the Florida Agency for Health Care Administration (AHCA) for deficiencies related to operating standards. AHCA found that a client had committed self-injury with a pair of scissors obtained from an unlocked and unsupervised cabinet, resulting in necessary medical attention. Following the incident, the facility failed to complete a comprehensive investigation and did not educate staff members to prevent future occurrences until 15 days later.

A review of Client #1s clinical chart revealed a “New Admission Significant information form” that had a checked box for “suicide risk” and “elopement risk,” along with “close obs (observation) until Doctor discontinues.” The same document also had “Suicide attempts – serious one in April (took own medications)” listed in the Significant History portion. Through interviews with staff and video footage from 9/14/14,  AHCA found that the client retrieved a pair of scissors from an unlocked cabinet in the day room and engaged in self-harm behavior (that required 6 stitches) when a staff member left the unit. AHCA wrote in its report:

“(client) notified staff (C) about her agitation, self-harm temptations, and suicidal feelings. Staff member (C) left the unit after receiving the information. Staff member did not communicate to the (client) what his plan was or what he was doing…(Client) opened the craft cabinet that was unlocked at the time. (Client) retrieved the pencil box from inside the cabinet, and inside the box the (client) found a pair of safety scissors. (Client) placed the scissors under her blanket…using the scissors to self-harm under the blanket.”

AHCA noted on 9/29/14, 15 days after the self-harming event took place, the following items:
1.) “The facility had not comprehensively educated the approximately 60 direct care staff members in regards to ensuring the day room cabinets were to be locked at all times unless in use with direct staff observation…”
2.) “The facility had not comprehensively followed up with the allegation stated by Client #1, that she had verbalized her self-harm intentions; the facility had no documentation of providing any education to the facility Mental Health technicians regarding keeping a client safe when they verbalize self-harming intentions or agitation; nor did they have documentation of education for maintaining ‘close observation’ for a client.”

AHCA also cited Palm Shores Behavioral Health Center for failing “to ensure that it adequately supervised 1 (#1) of 3 sampled clients as evidenced by Client #1 being able to obtain a pair of scissors from an unlocked cabinet and proceed to self-harm by cutting her arm.”

In the plan of correction, the facility noted that the Director of Risk Management “received a refresher training to ensure his knowledge that investigation, determination of actions to be taken, and follow through to ensure actions taken must occur timely.” Also, the facility noted that “Mental Health Technicians have received refresher training.”