Lancaster Behavioral Cited in Suicide Attempt

By Walter F. Roche Jr.

A patient at a Pennsylvania behavioral hospital who was supposed to be on constant one-on-one watch was able to strangulate himself when a worker allowed him to pull a screen across the entrance to a bathroom.
According to a recently released report from the state Health Department, the incident occurred on March 31 at the 126-bed Lancaster Behavioral Health Hospital.
The facility "failed to consistently ensure that all patients received care in a safe setting," the report states.
The patient, who had been admitted on March 23, had been to the facility previously due to continued attempts to harm himself and others.
The patient was supposed to remain under constant observation with a caregiver no farther than an arms-length away.
According to the report the patient "indicated to the caregiver the need to go to the bathroom" and the caregiver allowed the patient to pull a curtain across the bathroom doorway for "privacy."
The caregiver became concerned, however, when there was no noise or sound of movement from the bathroom. When the curtain was pulled back the patient was found on the floor not breathing and with two socks around the neck.
A code was called, the report states.
A hospital spokesman said the patient survived and was taken to a local emergency room. The state report, however, does not indicate whether resuscitation efforts were successful.
"The caregiver should have maintained direct observation," the report states, adding that he should not have been allowed to pull back the curtain.
"The caregiver should have maintained constant observation and not permitted the curtain to be pulled back thus blocking the ability to continuously visualize the patient," according to the state survey report.
In addition to failing to properly monitor the patient the facility was cited for failure to have a working walkkie talkie system. The caregiver involved in the March 30 incident did not have a walkie talkie apparently because the units were unreliable.
The hospital, which is a partnership between Universal Health Services, Lancaster General Health and Penn Health, filed a plan of correction in which they agreed to conduct education and retraining sessions for staffers. The facility also promised to purchase a new communication system.
The report dated April 10 was the second in less than a month in which the hospital was cited for deficiencies.
In a March report surveyors concluded the facility failed to properly investigate an incident in which a patient was given the wrong version of an anti-psychotic drug. The hospital opened in 2018.
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