In early September, a man who had left Lehigh Valley Hospital-Pocono against medical advance was brought back to the hospital after he tried to kill himself.
Before leaving, the man had told staff members of the East Stroudsburg hospital he was thinking about suicide, and hospital staff took some steps to determine if he was at risk of hurting himself and others. But a subsequent Pennsylvania Department of Health investigation found that an important and required step was missed.
The hospital didn’t complete a suicide risk assessment for this at-risk patient, which according to state investigators violated the patient’s right to receive care in a safe setting under federal regulations and his rights to good quality care and high professional standards that are continually maintained and reviewed under state regulations.
An LVHN spokesperson said the hospital self-reported the incident to the state and took corrective measures that were approved by the health department.
“It is paramount we serve and support all our patients in every step of their healing journey because it’s what they expect and deserve. We value their confidence in us and continuously seek out opportunities to improve,” said the spokesperson in an emailed statement.
LVH-Pocono received a fine as a result of the investigation. A Pennsylvania Department of Health spokesperson said the department cannot comment on specific reports.
What the state report says
On Sept. 5, the patient, referred to as MR1 in the report, fainted while at a rehabilitation facility and was admitted to LVH-Pocono for opioid withdrawal and malignant hypertension, a form of high blood pressure where the pressure increase is sudden and can cause organ damage.
Sometime on Sept. 6, the patient became aggressive and engaged in “abusive outbursts” towards staff, which led him to being restrained, the report said. Documents in the patient’s record from a physician stated the restraints were supposed to be removed prior to the patient eating breakfast; despite this, one restraint was kept on his left arm. The patient didn’t like this, so much so that he told a hospital staff member that it was causing him to think about suicide, according to a nursing document dated 9:32 a.m. Sept. 6.
A physician was informed of the patient’s suicidal ideation, but a suicide risk assessment wasn’t completed.
However, a suicide risk assessment was required under LVH-Pocono’s “Suicide Assessment And Prevention — Patient Care Services” policy. The policy states that “all patients who are being evaluated or treated for behavioral health conditions as a reason for care will be screened for their risk of self-harm” using the Columbia Suicide Severity Rating Screen, which will help determine the right course of precautions to take. If a patient expresses suicidal ideations during or after they are admitted, a suicide risk assessment also must be completed.
The patient’s restraints were removed and he became cooperative with hospital staff but also began requesting that he be discharged. Those requests were declined “because the patient was not medically stable.” The report states a physician was then informed that the patient wanted to leave against medical advice.
The physician had a conversation with the patient, writing afterward in his medical record that he “was not at risk to self or others.”
The patient then was allowed to leave against medical advice: His medical intravenous lines were removed, he signed out and left the floor escorted by security at 10:26 a.m. Sept. 6.
Hours later, the patient attempted suicide. He was returned to the hospital, treated for minor injuries and involuntarily committed.
Other similar incidents
The events described in the report are reminiscent of experiences two other patients had at LVH-Pocono more than two years ago. The hospital was cited each time by the state.
On Dec. 29, 2020, a patient was admitted to LVH-Pocono for mental health reasons. About two weeks later, the man was discharged without staff completing a pre-discharge suicide assessment, crisis prevention plan or discharged safety plan, the state found in an investigation. Hours later, he attempted to take his own life.
In another instance, on Feb. 15, 2021, another patient hospitalized after a suicide attempt was discharged from the hospital, only to attempt suicide again. LVH-Pocono discharged him without completing a suicide risk assessment, crisis prevention plan or discharge safety plan, an investigation found.
At the time the investigation was conducted, staff told a state investigator the patient was “disruptive” to LVH-Pocono’s behavioral health unit’s social environment, “not cooperative with treatment and needed to be discharged quickly.”
Corrective steps
According to a plan of correction submitted by the hospital to the state Department of Health, LVH-Pocono took several corrective measures following the September incident.
Patient care services leadership met and while they determined the hospital’s “Suicide Assessment and Prevention-Patient Care Services” policy didn’t need to be revised, all registered nurses and licensed practicing nurses were required to complete education that emphasized that a Columbia Suicide Severity Rating Screen must be completed for all at-risk patients.
The progressive care unit’s director or manager also was required to review all medical records of patients at risk for suicide to ensure the suicide screens were completed for all of them. These audits were set to go on for at least three months with any “fallouts” to be addressed by the director or manager and corrective actions documented.
Results of these audits were to be reported to the hospital’s critical care nurse administrator and the chief nurse executive council at regular intervals.
