A patient admitted to CHA Cambridge Hospital after a suicide attempt nearly succeeded again inside the hospital in 2020, managing to cut himself or herself repeatedly while under one-on-one observation and care by nurses and doctors, according to a state inspection. When a state Department of Public Health inspector returned four months later, the surveyor found that the hospital still had not carried out all the improvements it promised, putting two more patients at risk.
The first patient was not in a psychiatric unit, but had been admitted to a general ward for medical treatment after the initial suicide attempt in January 2020. The other two patients whose treatment was flagged in the follow-up inspection were also in a medical unit. The findings shone a light on problems in protecting suicidal patients in that setting. One nurse told the state inspector that nurses needed more training in caring for such patients. A 2014 study of 45 suicide attempts and five completions at Veterans Affairs hospitals over a dozen years said there was little research on caring for suicidal patients in non-psychiatric units or data on suicide and suicide attempts.
It recommended more training for workers, “standardized communication about suicide risk and clear management protocols for suicidal patients.” The Joint Commission on Accreditation of Healthcare Organizations, the major industry accreditor, recommends the most stringent precautions in psychiatric wards and hospitals, saying those units must be “ligature resistant” to prevent patients’ hanging themselves. Medical-surgical areas and intensive care units don’t have to meet that standard but “should minimize risks in the environment for patients identified at risk for suicide,” the commission said.
“At CHA we are committed to learning from every adverse event, which includes analyzing the systems and behaviors that led to the injury, communicating transparently across the organization and taking action to prevent future injury,” CHA spokesman David Cecere said in response to the initial inspection report. Cecere said the Alliance had established “several new practices to keep hospitalized patients safe,” including better assessments for patients who could harm themselves and better training for one-on-one observers; “creation of an easy-to-order ‘bundle’ of safety precautions for patients at risk for self-harm”; and procedures for “debriefing adverse events within 24 hours of occurrence” and for “communicating across the institution about adverse events.”
Cambridge Health Alliance was cited for serious lapses after the first inspection in February last year, putting the Alliance at risk of losing its ability to participate in Medicare and accept Medicare patients unless it corrected the violations within a certain time. It received an extension partly because of the pandemic when inspectors returned and still found violations, Cecere said.
“The action plan period included the months of the initial surge of the Covid pandemic, during which Cambridge Health Alliance was focused on addressing an unprecedented public health crisis,” he said in response to the follow-up inspection. “When [the state health department] came back to assess our performance on the action plan in June 2020, our adherence to the action plan was less than 100 percent. In part given the extenuating circumstances of the pandemic, [regulators] offered us an extended timeline to hardwire our action plan.” In August, an inspection found CHA in full compliance with Medicare requirements.
Plan of correction
The Alliance’s “plan of correction” submitted after the first inspection promised that the psychiatry unit would acknowledge an “urgent request” to see a suicidal medical-surgical patient facing “imminent risk” within 30 minutes and a psychiatrist would see that patient “by the close of business on the day of request.” It had taken more than 40 hours for a psychiatrist to see the patient who almost killed himself or herself inside the hospital and cut himself or herself repeatedly before and after. The new policy was to be effective March 1, 2020, and meetings with psychiatry residents and leaders were to be held March 26. Consultations were to be audited for at least four months starting May 1, the plan said.
Nevertheless, a psychiatrist was summoned to see a suicidal patient in a medical-surgical unit on May 29, 2020, at 8:59 p.m. and didn’t arrive until 9:42 p.m. the next evening, the follow-up inspection found. For another suicidal patient, the admitting doctor didn’t order the bundle of safety precautions when the patient was admitted on June 2, 2020. It had been created on March 17, 2020, and all staff were supposed to complete training on the new precautions by May 25, 2020, the plan of correction said.
The doctor had still not been trained on June 2, 2020, the hospital’s director of risk management and safety told the state inspector.
The story of Patient No. 1
A state health department inspector first visited the hospital, one of two operated by the Alliance, on Feb. 5-7 last year to look into the incident involving the first suicidal patient, identified in the report as Patient No. 1. The inspection report doesn’t disclose what prompted the visit. Such investigations usually result from a complaint, although in this case CHA itself reported the events, Cecere said Saturday. Routine inspections of the Alliance, like most other Massachusetts hospitals, usually are carried out by the Joint Commission.
Patient No. 1, whose gender and age wasn’t disclosed, was admitted to Cambridge Hospital from the emergency room on Jan. 11, 2020, around 2 a.m. after overdosing on cough medicine and extra-strength Tylenol. The person “had evidence of prior and current cutting on the right forearm” and was “at high risk of self-harm right now,” according to the admission history and physical, the inspection report said.
The individual had been diagnosed with “depression with multiple suicide attempts,” addiction and another mental health disorder that is associated with patients’ exaggerating their symptoms and also with self-harm. “The admission orders included 1:1 constant observation due to active suicidal thoughts with intent to harm him/herself as well as a psychiatry consult,” the report said.
Later that morning, around 11:20 a.m., there was another request for a psychiatrist to see Patient No. 1, but it was unfulfilled. The next morning, on Jan. 12, the patient “woke up and asked to see a psychiatrist,” then fell back to sleep. The patient woke up again and started cutting his or her forearms with the pull tab of a soda can, the report said. During the person’s three-day stay, the patient repeatedly pulled the metal tabs out of his or her socks and the hospital continued to deliver soda in metal cans to the patient, against policy.
A doctor saw Patient No. 1, then the individual asked to use the telephone at the nurse’s station because his or her cellphone was dead and the hospital removed hospital room phones for safety. The patient made a call, then grabbed a pair of scissors at the desk and started cutting his or her wrist with the blade. The one-to-one observer and a doctor couldn’t get the scissors away.
Hospital security guards arrived, making the patient “more agitated.” Patient No. 1 then tried to leave through a back stairway “and was able to cut his/her wrists deeper,” the report said. The guards managed to recover the scissors and return the patient to his or her room. “After the public safety officers left, the patient took another pull top of a soda can out of his/her sock and started cutting him/herself again,” the report said.
The psychiatrist arrived as workers were summoning the security guards. “The psychiatrist indicated that Patient No. 1 was visibly anxious and distressed. Patient No. 1 told the psychiatrist that he/she had been feeling ‘really suicidal’ and hopeless,” the inspection report said.
The patient’s stay in the unit ended Jan. 14. During the four days, he or she “continued to hide and obtain sharp objects” including a paper clip, a pin, a metal knife from a food tray and “some sort of socket equipment from the hospital room.” Many of the objects were hidden in the patient’s hair and socks, the inspection report said.
The patient also tried “to wrap a bathroom call cord around his/her neck” and hit his or her head against the TV in the hospital room, the report said.
After a second follow-up visit Aug. 12, 2020, stemming from the initial inspection, Medicare found CHA in compliance with all requirements.
Cameras on emergency beds
In another, less serious lapse, a state inspection Feb. 18 this year at CHA Everett Hospital found six beds in the emergency department – at least four for psychiatric patients – that were monitored by cameras without signs telling patients that they could be seen. The findings cited the hospital for violating patients’ privacy.
CHA immediately posted the required signs before the inspector left the building, according to a copy of the Alliance’s plan of correction provided by the state Department of Public Health under state public records law. There was already a surveillance warning sign at the entrance to the hospital, the document said.
The Alliance also checked the Cambridge Hospital emergency room and “other areas of the organization where other monitoring cameras are present and patients would have a reasonable expectation of privacy” to make sure “consistent signage is present,” the plan of correction said.
This post was updated July 23, 2021, with remarks by Cambridge Health Alliance spokesman David Cecere.
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