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Mental Ward Suicides Put Tampa General's Medicare At Risk

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TBO.com

Published: August 21, 2008

TAMPA - Conditions at Tampa General Hospital's psychiatric unit "pose an immediate and serious threat to the health and safety of patients," according to a federal agency's investigation of two suicides there in July.

The hospital's Medicare contract with the federal government will be pulled in two weeks unless Tampa General comes up with a plan before then to alleviate a host of problems outlined in a report by the Department of Health and Human Services.

The scathing report was prompted by two suicides two days apart at the hospital. On July 21, a 44-year-old woman hanged herself with a bedsheet. On July 23, a 28-year-old man hanged himself the same way.

The report criticizes Tampa General Hospital on a number of specific and general failings. Among its findings:

•There are discrepancies in the documentation on whether the staff checked on the 28-year-old man every 15 minutes as ordered by the patient's doctor.

•After the first suicide, the staff was told to increase observation of other patients on the psychiatric ward, but there were no additional checks made between the first suicide and the second.

•The hospital did not prescribe a higher level of observation for the woman, even after the psychiatric doctor and nurse had documented she still was having suicidal thoughts and fantasizing about how to kill herself.

•The day after the first suicide, the man asked to be moved to a different room because he was having a problem with his roommate. The hospital transferred the man to the same room where the woman had committed suicide the day before, without first assessing the man's "feelings or thought process" about the move.

•About two weeks after the second suicide, Tampa General presented in-house training on suicide prevention. Only 17 of 137 direct-care staff underwent the training.

•Because of fear of possible lawsuits, the hospital would not give investigators adequate information on any investigation the hospital had performed on the suicides.

•A federal investigator on Aug. 14 saw four psychiatric ward patients in the hospital's dining room and one in the hallway, all of whom were supposed to be under constant observation. All five were under the supervision of one staff member, and a nurse told the investigator the five patients are "kept together in the hallways to sleep and are brought in the dining room for staffing convenience," according to the report.

Today, the hospital released a "letter to the community" from President and Chief Executive Officer Ron Hytoff.

In the letter, Hytoff wrote, "I was saddened, embarrassed and concerned reading the surveyor's observations about our psychiatric unit. I am sincerely committed to taking whatever steps are necessary to prevent this from happening again. We are responding to the findings in an aggressive manner. We are modifying the physical environment, improving observation of our patients, and changing policies and procedures as cited in the surveyor's report. We have already identified independent experts to review our approaches, provide advice on improvements that need to be made as well as oversight for the foreseeable future.

"Every issue raised by the surveyors is being addressed. A plan of corrective actions and documentation will be delivered to CMS in a timely manner so that the plan can be studied and discussed and modified as needed."

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