Psychiatric Patient Commits Suicide Due to Alleged Failure to Follow Monitoring Protocols

This case involves a middle-aged patient with a long history of depression and anxiety. The patient was divorced, had 2 children, and worked in a high-stress environment for 25 years. He was admitted to the psychiatry inpatient unit for severe depression with suicidal ideation and psychotic features after attempting to commit suicide in his home. A regular suicide check protocol was allegedly implemented; however, 3 days after arriving at the facility, the patient hung himself in his bathroom. It was alleged that the nurse failed to follow the protocol allowing the patient to commit suicide.

Question(s) For Expert Witness

1. Please describe your experience in an administrative role at a facility with a psychiatry unit.

2. To what extent are unit managers responsible for the supervision of the 15-minute-check protocol?

Expert Witness Response E-139883

I have served as a psychiatric mental health nurse for 40 years with a myraid of populations including children, adolescents, young adults, adults and older adults. I have worked as a frontline staff member, educator, utilization review nurse, case manager, intake coordinator, house supervisor, nurse manager, and psychiatric emergency team member. Currently, I work full time as the senior team coordinator for a bachelor's of science in nursing program and teach mental health at the undergraduate and graduate level. I also facilitate clinical groups each semester in a 150 behavioral health setting and teach psychology at the undergraduate level. In addition, I continue to work in the department of nursing (education and professional practice) on special projects including the guidelines of care and practice change alerts. Fifteen-minute checks are just one of many interventions often utilized when a patient expresses suicidal ideation or intent or is assessed to be at risk for suicide. Locked inpatient units generally perform fifteen-minute checks on all patients on the unit. An actively suicidal patient often requires a locked environment, increased nursing ratios due to patient accessed acuity, 1:1 observation, more frequent contact, and use of a suicide observation room for sleep, among other things. The registered nurse assigned to that patient is directly responsible for that patient for the specified shift. If a behavioral health associate, certified nursing assistant, or licensed vocational nurse completes the fifteen-minute check, it is still the primary registered nurse's responsibility to ensure the checks are done in a timely, professional and efficient manner. In my crisis prevention courses, I teach participants to make direct contact with each patient during each fifteen-minute check by noting their location, behavior, attitude, comments.