Philadelphia Psychiatric Hospital Cited in Patient Suicide

By Walter F. Roche Jr.


A West Philadelphia psychiatric facility has been cited in a federal investigation for failing to properly monitor a patient who was able to commit suicide while under inpatient care.
In a seven-page report just issued by the state Health Department, investigators found that despite a recent history of attempted suicide the patient was able to drown himself in a pail of water while taking a shower.
Cited for failure to comply with federal requirements was the 245 bed Kirkbride Center in University City.
According to the report, the unnamed patient was supposed to be under constant monitoring with much of the time being confined to a lobby, where his or her actions could be observed.
Inspectors found from examining hospital records that the care plan was not properly implemented despite the fact that the patient had attempted suicide just two days earlier on Jan. 18.
"There was no documented evidence that appropriate and adequate interventions were developed and implemented to address this patient's risk for suicide," the report states.
The report states that the patient had asked for shampoo to take a shower at 4:30 p.m. on Jan. 20.
At 4:45 p.m. he was found "with head in trash can full of water. Limbs limp."
Attempts at resuscitation were unsuccessful.
The surveyors found that despite an order for the patient to be confined to the lounge area, that order was not implemented.
While state inspectors were at the facility in early February, they found that yet another patient who was supposed to be confined to the lounge area was alone in a bedroom "without staff supervision."
Yet another patient was kept in the lounge area overnight and had to sleep on a chair or couch.
The facility also was cited for having items in a patient's room that could have been used to commit suicide.
Officials of Kirkbride subsequently filed a plan of correction including a new "plain sight"policy under which high risk suicidal patients will be kept under observation in a lounge area during the day but will be allowed to return to their bedrooms at night with a staff member observing the patient from the doorway.
"We are creating colored risk bands for those individuals who are placed on Plain Sight or One to One observation in order to increase staff awareness of those patients on the unit  who are deemed at high risk of self harm," the corrective action plan states.
Victoria Johnson, an attorney for the Kirkbride Center, said that due to federal privacy laws, center officials could not comment on the care provided to any patients.

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