Temple Cited in Patient Suicide

By Walter F. Roche Jr.

Citing a discrepancy between hospital records and video surveilance tapes, state Health Department investigators have concluded that Temple University Hospital workers failed to properly monitor a suicidal patient allowing him to hang himself.
A report on the Sept. 7 suicide at the hospital's Episcopal Campus concludes that while hospital employees were supposed to check on the patient face-to-face every 15 minutes, video tapes showed no one went into the patient's room a single time during a critical more than one hour period.
Nonetheless hospital records stated that the 15 minute checks were dutifully performed.
"Documentation in the medical record showed that 15 minute checks were completed and documented by the mental health technician," the report states.
"The video tape review showed there was a long period of one hour and eight minutes when Patient One was not visualized by a staff member which was in contradiction to the required 15 minute visual checks to be conducted by the staff per hospital policy," according to the report.
"The facility failed to ensure patient monitoring was performed as required," the report states, adding that a registered nurse was ultimately responsible but failed to ensure that the 15 minute checks were actually being performed.
The investigation showed that the unnamed patient tore up a sheet and attached it to a shower curtain rod and then hung himself.
The hospital also was cited for failing to remove ligature risks (the curtain rods) from an area where suicidal patients were being treated. The report does state that the curtain rods in the unit were immediately removed while surveyors were conducting their review.
Further review of video tapes showed there were 17 missed 15 minute checks in the behavioral unit in a two day period including the day of the suicide.
"This placed 21 patients at risk for harm, serious injury or death," the surveyors concluded.
The hospital failed to file an acceptable plan of correction and did not repond to requests for comment.
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