Apparent suicide leads to tighter Bartlett procedures

State doesn't fault hospital, but notes flaws

Posted: Sunday, August 12, 2001

Bartlett Regional Hospital has changed the way it checks that mentally ill patients are in their rooms. And it bought a computer program to track requests for maintenance work, all in the wake of an apparent suicide in May.

The actions follow a state investigation in June into the circumstances surrounding the death of the woman, who fell or jumped to her death from a roof outside the mental health unit on May 23.

The state report disclosed concerns about staff training and a problem with reporting, tracking and repairing identified safety concerns, said Shelbert Larsen, administrator of health facilities licensing and certification for the state Department of Health and Social Services.

"It wasn't so much that what we cited was in any way a cause" of the incident, Larsen said. "It just happens there were some systemic issues that needed to be resolved, which we saw as a result of the investigation."

"We don't see this as a demeaning or punishing document. We see it as a learning opportunity," Bartlett CEO Bob Valliant said.

"In essence what it's saying is Bartlett didn't do anything that caused this to happen, but it gives us the opportunity to tighten up a bit," he said.

The woman had got onto the roof by prying off a device that was intended to block a window from being opened more than a few inches and cutting a window screen, the report said.

The report said the woman was admitted to the mental health unit May 10 with diagnoses of major depression disorder and multiple self-inflicted wounds to her neck and wrists. She was taken off a higher level of staff observation several days later, the report said, but she was still subject to checks every half hour.

The staff checked every half hour through the night of May 23 to see that the woman was in her room, the report said. But only when the staff tried to wake her at 8:15 a.m. did they realize the form under the blanket was bedding, not a person. The woman habitually slept with the covers over her head, hospital officials said.

The state report said staff members were unsure and inconsistent in how to observe patients who were sleeping or resting.

"They cited us because our nurses weren't consistently trained on how to check and make sure a patient was in bed," Valliant said.

Nurses and certified nursing assistants are now trained that they have to see the patient during the check.

The state report also said nurses previously had reported that window screens in the unit were missing or needed repair, but the screens hadn't been repaired.

Valliant said the screens weren't a deterrent to getting through the window because they could be punched through. But they were a symptom of work orders either not being generated or that were backlogged and not followed up on, he said.

Bartlett now has a computer program that tracks maintenance work orders and flags orders that aren't completed on time, Valliant said.

The real problem with the window security was that no one on the staff realized that the window blocks were only glued to the wall, he said. The blocks have since been bolted to the wall. And the hospital has attached to the outside walls metal grills that cover the window openings.

The hospital wasn't required to report the suicide to the state Department of Health and Social Services, Larsen said. The agency learned about it from a member of the public who had read about it in the newspaper, he said.

But, Larsen said, "We would probably investigate any suicide in a hospital to be sure the facility had been doing whatever they needed to do to protect that patient."

The state investigated on behalf of its facilities licensing function and for the federal Center for Medicare/Medicaid Services. If Bartlett didn't correct the deficiencies noted in the report it could lose its state license to operate or certification to receive Medicare and Medicaid patients.

The hospital signed off on its plan of correction last month and has made the improvements, Bartlett administrators said.


Eric Fry can be reached at

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