the next evening, the follow-up inspection found. Nevertheless, a psychiatrist was summoned to see a suicidal patient in a medical-surgical unit on May 29, 2020, at 8:59 p.m. Consultations were to be audited for at least four months starting May 1, the plan said. The new policy was to be effective March 1, 2020, and meetings with psychiatry residents and leaders were to be held March 26. The Alliance’s “plan of correction” submitted after the first inspection promised that the psychiatry unit would acknowledge an “urgent request” to see a suicidal medical-surgical patient facing “imminent risk” within 30 minutes and a psychiatrist would see that patient “by the close of business on the day of request.” It had taken more than 40 hours for a psychiatrist to see the patient who almost killed himself or herself inside the hospital and cut himself or herself repeatedly before and after.
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In part given the extenuating circumstances of the pandemic, offered us an extended timeline to hardwire our action plan.” In August, an inspection found CHA in full compliance with Medicare requirements. “When came back to assess our performance on the action plan in June 2020, our adherence to the action plan was less than 100 percent. “The action plan period included the months of the initial surge of the Covid pandemic, during which Cambridge Health Alliance was focused on addressing an unprecedented public health crisis,” he said in response to the follow-up inspection. It received an extension partly because of the pandemic when inspectors returned and still found violations, Cecere said. Cecere said the Alliance had established “several new practices to keep hospitalized patients safe,” including better assessments for patients who could harm themselves and better training for one-on-one observers “creation of an easy-to-order ‘bundle’ of safety precautions for patients at risk for self-harm” and procedures for “debriefing adverse events within 24 hours of occurrence” and for “communicating across the institution about adverse events.”Ĭambridge Health Alliance was cited for serious lapses after the first inspection in February last year, putting the Alliance at risk of losing its ability to participate in Medicare and accept Medicare patients unless it corrected the violations within a certain time. “At CHA we are committed to learning from every adverse event, which includes analyzing the systems and behaviors that led to the injury, communicating transparently across the organization and taking action to prevent future injury,” CHA spokesman David Cecere said in response to the initial inspection report. Medical-surgical areas and intensive care units don’t have to meet that standard but “should minimize risks in the environment for patients identified at risk for suicide,” the commission said. It recommended more training for workers, “standardized communication about suicide risk and clear management protocols for suicidal patients.” The Joint Commission on Accreditation of Healthcare Organizations, the major industry accreditor, recommends the most stringent precautions in psychiatric wards and hospitals, saying those units must be “ligature resistant” to prevent patients’ hanging themselves. A 2014 study of 45 suicide attempts and five completions at Veterans Affairs hospitals over a dozen years said there was little research on caring for suicidal patients in non-psychiatric units or data on suicide and suicide attempts. One nurse told the state inspector that nurses needed more training in caring for such patients.
The findings shone a light on problems in protecting suicidal patients in that setting.
The other two patients whose treatment was flagged in the follow-up inspection were also in a medical unit. The first patient was not in a psychiatric unit, but had been admitted to a general ward for medical treatment after the initial suicide attempt in January 2020. When a state Department of Public Health inspector returned four months later, the surveyor found that the hospital still had not carried out all the improvements it promised, putting two more patients at risk. (Photo: Marc Levy)Ī patient admitted to CHA Cambridge Hospital after a suicide attempt nearly succeeded again inside the hospital in 2020, managing to cut himself or herself repeatedly while under one-on-one observation and care by nurses and doctors, according to a state inspection. A police cruiser stops by CHA Cambridge Hospital on Friday.
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