Dempsey Hospital Slammed For Patient Suicide | Health department fines hospital, cites numerous patient safety, supervision violations
For the second time in less than two years, John Dempsey Hospital in Farmington has been slapped with a fine and cited for a number of health code violations by the state Department of Public Health. The most recent citation stems from its failure to properly monitor a psychiatric patient who hung himself in a hospital bathroom.
In the DPH consent agreement, the Dempsey Hospital nursing staff failed to identify the type and frequency of supervision the patient — diagnosed with paranoid schizophrenia and suffering from visual and auditory hallucinations — required and therefore did not ensure patient safety.
As a result of the May 2007 suicide, the hospital, part of the University of Connecticut Health Center, has been slapped with an $8,000 fine and a slew of required actions to bring hospital operations back up to code. In addition to being cited for patient supervision violations, the DPH found the hospital to be in violation of other safety and medication monitoring problems.
Costly Reforms
Although an $8,000 fine has been levied against the hospital, more costs will come with the implementation of DPH reforms. The department is requiring revisions to hospital policies and procedures related to medication administration, assessment of patient problems and safety risks and patient treatment plans.
The hospital is also required to “employ sufficient personnel to monitor and meet the physical safety and psychiatric needs of the patient population” as well as appoint someone within the facility to make sure all requirements are carried out in the designated time.
In a previous consent decree dated September 2006, Dempsey Hospital was fined $22,000 for a number of health code violations. Among the incidents cited by DPH investigators, the hospital failed to consult the attending physician in a timely manner regarding a patient who arrived to the emergency room at night with severe stomach pain and whose condition continued to worsen until she died.
In response to the current report, Dempsey Hospital officials said they are working on the problems. “We took immediate action based on DPH recommendations at the time of the event, and we continue to work closely with them to monitor and maintain compliance,” said James Thornton, director of Dempsey Hospital, in a written statement.
Safety Violations
One of the biggest issues to be resolved by the hospital is that of “patient assessments to determine safety risks, including but not limited to suicidality, homicidility and elopement,” according to the DPH consent agreement, which Thornton signed on Feb. 21.
According to the decree, the patient who committed suicide resided at the hospital for about three months. In that time, his level of supervision fluctuated from “constant observation” to “constantly monitored on the evening shift only” to “monitoring every 15 minutes,” the report indicated.
But for each change, the hospital staff “failed to document the rationale” behind it. “Record review with the nurse manager failed to identify that nurses consistently assessed the patient’s risk for suicide, homicide and/or elopement every shift in an attempt to meet the goal of safety,” the report stated.
On May 27, 15-minute monitoring was discontinued. Three days later, the patient died after hanging himself from the shower rod.
In the psychiatric ward, patient rooms are supposed to be designed without any hazards, specifically anything that could be used to commit suicide. The patient’s shower did have a “break-away” shower curtain rod, which is “supposed to fall down when pressure was exerted,” the report said.
However, the DPH found that “the hospital failed to ensure that the physical environment was safe for the patient.” The DPH also cited the hospital for failing to make any changes to the shower rods following the patient’s suicide to correct safety issues.
In addition, the DPH discovered the hospital maintenance department had jury-rigged the break-away shower rod with PVC pipe rather than purchasing one from a manufacturer. Although the center of the rod could not bear weight, the end of the rod proved secure enough to hold the weight of the patient.
Safety issues weren’t restricted to the psychiatric ward. Another patient was admitted to John Dempsey Hospital after she suffered a fall at an independent living facility. Physician’s orders indicated the patient should be evaluated by a physical therapist to determine how much walking she could do on her own. But because that request wasn’t indicated to be urgent, the physical therapist “would not evaluate her until the next day, Monday,” the report stated.
Until then, the patient was put on bed rest, and staff helped her when she needed to walk. But she was helping herself to the “commode” on the side of her bed—something that was not yet sanctioned by the physical therapist. At 4:45 a.m. the day she was to be evaluated, the patient climbed out of bed and started walking on her own. She fell and hit the ground, suffering several serious brain injuries. The patient died later that same day.
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