Thursday, May 27, 2010 | 2 a.m.
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The 59-year-old man, seeking help at MountainView Hospital, said he was depressed and having suicidal thoughts. He volunteered to be transferred to a mental hospital, but after waiting at least 10 hours, he hanged himself with his belt, investigators found.
The patient arrived at MountainView’s emergency room at 11:20 a.m. May 19 and met with an intake coordinator for a mental hospital who was at MountainView to process the transfer. The patient said he had not taken his medications for weeks and was easily overwhelmed, frustrated and worried about his finances and the state of the nation, the investigation report said. He reported mild paranoia and delusional thoughts, and said that in addition to seeing signs of Armageddon in the world around him, he’d had flashbacks to Vietnam. He told the intake coordinator that he tried to commit suicide three years ago, but “the rope broke,” the report said.
What happened next, according to the investigation, was the step-by-step mismanagement of the man’s care:
• A MountainView social worker and case manager failed to read the intake coordinator’s report.
• A doctor failed to complete discharge paperwork, delaying the man’s voluntary transfer to a psychiatric facility.
• The man somehow changed into his street clothes, in violation of hospital policy — and obtained his belt.
• A technician who was supposed to monitor the man via a camera in his room failed to check on him when he lingered in the bathroom.
Twelve hours after telling the intake coordinator of his suicidal thoughts, the man was being lowered from a shower rod with his belt around his neck. Hospital staff tried to revive him before pronouncing him dead the next morning.
Richard Whitley, administrator of the Nevada State Health Division, said the death was the unfortunate outcome of a combination of errors.
“In isolation (the errors) maybe would not have led to this tragedy,” Whitley said. “But in total, in looking at it, you can see how the dots connected to have this outcome.”
The case was investigated by the Health Division’s health care quality and compliance bureau, which licenses hospitals and investigates complaints. The 38-page report, made public Wednesday, documents interviews with key people who knew about the man’s care.
MountainView officials said they take patient safety seriously and are investigating the matter. They said they offer their sympathies to the patient’s family and could not comment further because of privacy laws.
The Health Division will assess a penalty for the violations found during the investigation. It also notified the Joint Commission, which accredits hospitals, and the Centers for Medicare & Medicaid Services, the government’s insurance payer, which also conducts investigations into complaints. The two agencies could investigate the case.
The man’s hospital roommate told investigators that the patient had been depressed about a divorce and losing his job as a heavy-equipment operator. After being admitted to MountainView, the man’s mood improved. He had completed his assessment with the psychiatric hospital’s intake coordinator and was just waiting for his discharge from MountainView.
He was “feeling as if things were starting to look up for him due to the help he was going to have dealing with his depression, and he was looking forward to his transfer to a mental health facility,” the roommate told investigators.
The patient became increasingly agitated, anxious and depressed when the transfer was delayed by so many hours, the roommate said.
The transfer never came.
A case manager noted at 1:18 p.m. that a physician was called to do the discharge summary. Another note at 5:58 p.m. indicated that the doctor still had not arrived to do the paperwork.
The intake coordinator, who had assessed the suicide risk, said the social worker was to follow up with the physician and arrange transportation to the psychiatric hospital, the investigation found. The intake coordinator said that because of the suicide risk she “assumed the facility would watch the patient closely,” the report said.
But neither the social worker nor the case manager read the intake assessment.
The doctor said he had not been notified that a psychiatric assessment had been completed. He said that if anyone had told him the patient had suicidal ideas combined with a past attempt, he would have placed the patient on suicide precautions. He expected the intake coordinator, social worker or case manager to notify him of the assessment.
MountainView’s medical records document no evidence that a self-harm risk assessment was completed by the emergency room staff, a failure in policy and procedure, according to the hospital’s director of emergency services. But his nursing care plan included suicide risk.
The man was transferred to a camera-equipped room for 24-hour observation, but was not placed on suicide watch. A monitor was assigned to continuously observe 10 rooms containing 12 patients, but the view was obscured when the man went into the bathroom.
The chief nursing officer told investigators that the hospital has no policy for how much time can elapse after a patient goes into the bathroom without being checked. The nursing officer said nurses should be notified within three minutes of at-risk or suicide-watch patients entering the bathroom. A camera technician told investigators he’s been at the hospital four years and has never been given a policy on the matter. And MountainView’s vice president of quality and risk management could not locate any written policy for the monitoring of patients on camera beds, the investigation said.
The man’s belongings were taken from him, including his clothes, and he was supposed to be transferred in a hospital gown to the psychiatric hospital, the report said. His clothes were brought to the fourth floor at 4:30 p.m. in preparation for his discharge, and somehow he obtained them and put them on.
The nurse assigned to care for the man on the overnight shift said the patient was in street clothes when he arrived at 7 p.m. At 8 p.m., the patient asked about the delay and the nurse noted that the doctor still needed to complete the paperwork. The nurse did not call the doctor to ask about the delay.
At 11 p.m., the nurse and charge nurse decided to cancel the transfer and the patient was informed. Ten minutes later a nursing assistant found the patient hanging by his neck in the bathroom.