An inpatient suicide or serious attempt is devastating for the family and for the staff who cared for the patient. When it becomes a legal matter, the review asks three main questions. Was the risk assessed? Did the plan match the risk? And did the observation level and the environment keep the patient safe?
Nurses are with psychiatric patients around the clock. They do the observation rounds, search belongings, notice changes in mood and pass information along at every shift change. That is why the nursing record is often the center of these cases.
Why a Psychiatric Nurse Expert
Psychiatric nursing has its own routines: observation levels, room and belongings searches, safety plans and constant reassessment. A psychiatric nurse expert such as Doreen Riordan, RN, whose expertise is psychiatric mental health and geriatric nursing, can explain how a unit is expected to run and how to read observation sheets and safety checks the way the staff who wrote them did.
The Rules in the Background
Several real standards frame the review:
- Safe setting. Under the Medicare hospital rules, patients have the right to receive care in a safe setting. CMS guidance on ligature risk and assessment in hospitals (QSO-23-19-Hospitals) says hospitals can show compliance through appropriate patient assessments, adequate staffing and monitoring, and reducing environmental risks.
- Psychiatric hospital records. 42 CFR 482.61 sets special medical record rules for psychiatric hospitals, including a psychiatric evaluation within 60 hours of admission and an individual comprehensive treatment plan.
- Joint Commission. Its suicide prevention requirements (R3 Report Issue 18, NPSG.15.01.01) include an environmental risk assessment, screening with a validated tool, an evidence-based risk assessment for those who screen positive, documenting the risk level and plan, and written policies on staff training, reassessment and monitoring of high-risk patients. Joint Commission now presents this topic as National Performance Goal #8.
1. Risk Screening and Assessment
The expert starts with the admission screening. Was a validated tool used, and was it used as written? If the patient screened positive, was a full assessment done, asking directly about thoughts, plan, intent, past behavior, risk factors and protective factors?
Then the expert follows the risk over time. Was the patient reassessed after a change, such as bad news, a hard family visit, a medication change, a request to leave or a planned pass? A risk level charted once on admission and never revisited is a common finding.
2. Observation Levels: Q15 Checks vs 1:1
Observation is ordered, and hospital policy defines each level. Common examples are checks at set intervals, often every 15 minutes (Q15), and continuous one-to-one observation by an assigned staff member.
The expert asks:
- Did the ordered level match the documented risk?
- Who could change the level, and was every change ordered and explained?
- Were checks done as charted? Rounding sheets with identical times, or entries filled in ahead, are a red flag. Video, door logs and staffing records can confirm or contradict them.
- Was a 1:1 truly continuous, including during breaks, bathroom use and shift change, and was the observer trained for the role?
Even perfect Q15 checks leave minutes between rounds, which is why the match between risk and observation level matters so much.
3. Environmental and Ligature Safety
The expert reviews the unit's environmental risk assessment and what the hospital did about the risks it found. Was the patient in a room that suited their risk? Were belongings and items from visitors searched under policy? Were known hazards fixed, or tracked with a plan?
The Joint Commission notes that unlocked inpatient units and non-inpatient settings do not need to be ligature resistant, but are expected to identify high-risk patients and protect them, for example with continuous monitoring in a safe location. So the setting shapes the question.
4. Communication and Handoffs
Risk information has to travel. The expert checks shift reports, treatment team notes and whether concerns from family or other patients were passed on and acted on.
Records to Request
For a complete review, request:
- Admission assessment, suicide screening tools and the psychiatric evaluation
- The treatment plan and every update
- All observation orders and every observation or rounding sheet
- Nursing notes, the medication record and PRN use
- The unit environmental risk assessment, mitigation plan and maintenance logs
- Search and contraband logs
- Staffing grids and assignments for the shifts involved
- Video and door or badge access logs, requested early
- Policies on observation, searches and ligature risk in effect at the time
A fair review also looks for what went right. Sometimes the chart shows careful, well-matched care for a patient whose death could not reasonably have been prevented, and a qualified expert says so.
Learn more about Doreen Riordan on LinkedIn.
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