“It’s a major problem, and it’s been a problem as long as I’ve been in the field,” said James Knoll, a professor of psychiatry at SUNY Upstate Medical University who studies suicide risk and prevention. “There’s no centralized tracking of this … It really is hard to compare systems across the country.”

The Joint Commission study also found that hanging accounted for more than 70 percent of suicides, and one half of them occurred in the bathroom. The most commonly used fixture point for hanging is a door, door handle, or door hinge. Experts have long suggested that hospitals could make great strides in suicide prevention if “ligature points” like door handles are replaced with “ligature resistant” types.

Questions about care

Between January 2011 and the end of last year, CMS inspectors documented 57 violations at Montefiore, the most of any New York hospital, according to data from the agency. (Though Montefiore has several campuses in the Bronx, the government counts them as one hospital.)

Montefiore’s most recent deficiency was a “patient safety” violation in September 2017 for failing to adequately respond to episodes when patients removed their own breathing tubes or catheters.

Based on data obtained directly from CMS, since 2011, Montefiore has been cited for placing patients in “immediate jeopardy” four times. Only two other hospitals in the state have been cited over that timespan for that many “immediate jeopardy” situations: St. John’s Episcopal Hospital at South Shore in Far Rockaway, and Arnot Ogen Medical Center in Elmira.

An “immediate jeopardy” designation is the most severe of warnings from CMS and indicates that a hospital’s noncompliance has or is likely to cause serious injury, harm, impairment, or death to a patient. If a facility does not correct issues that triggered the warning, it could lose Medicare and Medicaid funding within a month. For Montefiore, which relies more heavily on federal dollars than other city hospitals, that could have been be a deadly blow.

Over the past eight years there have been more than 1,000 findings of “immediate jeopardy” affecting nearly 750 hospitals around the country, although only 19 facilities have registered four or more such reports, according to data provided by CMS.

In the year before Bryant’s father died in March, Montefiore’s Bronx campuses had been cited by inspectors for failing to follow internal recommendations for depressed or suicidal patients, which allowed additional suicide attempts and suicides to occur.

In June 2016, for example, a patient reported to her psychiatrist that she had been feeling depressed for about seven months and had felt suicidal for the past three weeks at the hospital. In May, her care team noted that she was “teary eyed and upset” and “did not want her family to know she was HIV positive.” On June 23, 2016, she stated she wanted to die, and refused to take any medicines. Later that day, she was found with a telephone cord wrapped around her neck.

The next day, a nurse discovered that the patient had removed her dialysis catheter. Blood gushed out of her body, and she entered hemorrhagic shock. The patient later died. She was supposed to be watched around the clock.

Several months later, in October 2016, a patient with a history of substance abuse, depression, and suicidal thoughts was admitted to a medical unit. He too was supposed to be continuously watched by a staff member to prevent him from attempting suicide, and was supposed to have his belongings checked for hazardous items. But on October 14, nurses found blood on his left wrist from an attempted suicide using shaving razors he retrieved from his bag, where two other razors were also discovered. The patient did not die.

In response to the October incident, an internal group called the Performance Improvement Committee recommended changing hospital policy to remove dangerous items like razors from patients’ belongings, and advised implementing an electronic training program for all nurses. A different group, the Nursing Peer Review Committee, determined that the cause of the incident was poor instruction given by a senior nurse. According to a government report, a managing nurse had instructed a nurse assistant to leave the patient alone.

In February 2017, the Quality Peer Review group recommended another set of steps for preventing future suicides, which included a manager checking to ensure that suicidal patients were being watched around the clock, and that staff understood the rationale for such observation.

That same month an 11-year-old girl was brought to the emergency room after attempting to commit suicide by overdosing on oxycodone, a powerful narcotic. She was supposed to be constantly watched for suicide, but she was not.

While her care providers weren’t looking, a different 13-year-old girl in the emergency room — who had previously attempted suicide by hanging herself — passed her a box cutter knife. The knife was discovered by the patient’s mother, and there was no evidence of self-harm from it. Neither patient was searched prior to entering the ER, and government inspectors found other instances where suicidal pediatric patients were not continuously watched.

The following month, on March 20, 2017, a patient with a history of schizophrenia was admitted to the ER after overdosing on Tylenol and Seroquel, a strong antipsychotic medicine. A day after, inspectors found him in the emergency department within arm’s reach of a lab cart with needles and other equipment for drawing blood, completely unattended. He did not attempt suicide in the emergency room.

The next day, on March 21, 2017, the 77-year-old Bronx resident committed suicide by hanging himself in his bathroom. There was no indication that the bed alarm that would have alerted nurses to his movements was activated, and Montefiore continued to use the system, even though it knew it could be disabled by patients.

Dizzy, then dead

A week later, Bryant’s father Gilbert Calderon committed suicide.

On March 25, 2017, feeling dizzy and overcome with grief after attending a friend’s funeral, Calderon checked himself into Montefiore’s Bronx emergency room, according to government reports. At the time, his physician documented that Calderon was a “patient with very depressed affect.” The next day, the physician noted that Calderon had “recently been under a lot of stress due to medical issues and personal issues.”

But after his admission, inspectors found there was no evidence Montefiore did a further exploration of his feelings or developed a psychiatric plan of care to address his depressed affect. When interviewed by inspectors, the Director of Psychiatry admitted that not providing Calderon with a psychiatric consultation was a “missed opportunity.” “He presented as someone who was probably likely depressed given what happened at his friend’s funeral,” said the director, “and yes this would have been an appropriate consult to have received.”

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