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The patient had trouble breathing after the incident. Hospital Employee #13 denied
awareness of Patient #8's suicidal intention prior to the incident.
Hospital Policy BHC V.5 titled Self harm/Suicide Prevention, dated 07/2013,
reflected that staff members were to review suicide prevention education sheets.
The hospital provided Suicide Awareness pamphlet, undated, noted that suicide
warning signs included talking about suicide or death, or "ending it all."
2) A two-drawer cabinet filled with multiple compact discs (CDs), digital video
discs (DVDs), and video tapes breakable into sharp edges was observed accessible
to a female patient who was by herself in the dayroom in the hospital's PCU
(Progressive Care Unit) on 10/08/14 at 14:50. Staff members were behind the
nurses' station.
Hospital Personnel #2 acknowledged on 10/08/14, at 14:50, that CDs and DVDs
could be used for self-harm and would be removed.
On 10/09/14, at 16:55, the same two drawers were observed again with CDs, DVDs,
and video tapes. Hospital Personnel #2 witnessed the items at that time and stated
she had delegated the task of removing the items the day before and it did not get
done.
On 10/09/14, at 15:30, Hospital Personnel #5 was asked whether she was worried
about patient safety and stated, "Yes, because staff stays behind the nurses'
station."