Hospital Faulted in Patient Suicide

By Walter F. Roche Jr.

A Philadelphia area behavioral hospital has been cited for multiple violations of state and federal requirements in the death of a patient who died by suicide on Sept. 30.
The unnamed Eagleville Hospital patient was found unresponsive hanging from a doorknob less than 12 hours after staffers noted an acute and alarming change in mental status. That change prompted an order for hourly checks on the individual.
Nonetheless the patient was found unresponsive later in the day. Attempts at resuscitation were unsuccessful and death was declared at 6 p.m.
When state surveyors arrived at the 308-bed Montgomery County facility on Oct. 5, they issued  a declaration of "immediate jeopardy," an action requiring an immediate response from managers of the hospital. Inspectors cited "an unsafe physical environment."
The alarm was sounded because inspectors found patient rooms had not been configured to meet so-called anti-ligature requirements. They cited the presence of duffel bag strings along with door knobs and other protrusions that could be used in a suicide.
The victim had used a doorknob in the successful suicide attempt, the report indicates.
The patient was found "unresponsive and pulseless, sitting on the floor with a band around the neck attached to a doorknob."
Hospital officials responded to the immediate jeopardy declaration with a corrective action plan. That plan included the addition of staffers, increased patient monitoring and additional assessments of patients for suicide risk.
The "immediate jeopardy" was lifted at 9:15 p.m., the report states.
Eagleville officials did not respond to a request for comment on the state report.
The inspectors found additional violations, however, including a hospital policy banning any visitors for detox patients. The state requires that visitors be given access.
Eagleville was also cited for failing to monitor the suicide victim for the effects of a drug administered a little over 12 hours before the suicide was discovered.
The hospital is a non-profit corporation and its most recent tax return listed revenues of $40.5 million and expenses of $36.3 million.
Eagleville is not the first area behavioral facility to be cited in the suicide death of a patient. In 2015
 a patient at the Kirkbride Center drowned himself in a bucket while taking a shower.
The Philadelphia facility was cited for failing to keep the patient under constant observation after a prior suicide attempt only two days earlier. That patient drowned in a rubbish bucket.
Friends Hospital, also in Philadelphia, was cited for similar violations in the suicide death of a patient on Nov. 12 of 2016. That patient was found hanging from a door hinge.
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