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One of the state’s two private psychiatric hospitals failed to lock a kitchen door after a patient entered the off-limits room in February. Months later, another patient was able to rush into the kitchen through the same unlocked door, grab a knife and kill themself.
The death at Spring Harbor Hospital in Westbrook drew a citation from state regulators for failing to ensure patient safety and security following a review earlier this year. The review spurred the hospital to install locks on its kitchen doors to prevent patients from accessing it. MaineHealth, Spring Harbor’s parent organization, also retained a safety consultant to identify areas for improvement, a spokesperson said.
If left unaddressed and uncorrected, citations can escalate to a hospital losing Medicare and Medicaid funding.
On June 12, an unnamed patient was selecting food in the hospital’s cafeteria area when they suddenly slammed their tray on the floor and ran into the facility’s kitchen — where patients aren’t allowed — through an unlocked door, according to the citation.
The patient grabbed several items before seizing a knife and dying of a self-inflicted wound. Hospital staff and emergency medical technicians tried to resuscitate the patient, but they were pronounced dead at the scene, the report said.
Spring Harbor Hospital is a 60-bed facility in Westbrook that treats adults who experience acute psychiatric illness, such as major depression, schizophrenia and bipolar disorder, according to its website.
The patient’s death prompted an on-site investigation from state inspectors into the hospital’s ability to protect patients. That review found that a patient a few months prior had accessed the kitchen, though that breach didn’t result in the patient’s death. However, the hospital didn’t record the issue or take steps to prevent it from happening again.
In that instance, on Feb. 24, a different unnamed patient was able to run into the hospital’s kitchen from the cafeteria and make it about 10 feet into the room before hospital staff redirected them. Hospital staff, however, never filed an incident report after the breach.
Hospital staff should have used that incident as an opportunity to evaluate the security of the kitchen and surrounding area, but that was never done, according to the state citation.
After the second patient accessed the kitchen and ended their own life, the hospital installed a temporary lockable door in the entrance of the kitchen through which both patients accessed the kitchen, according to the correction plan report. Additionally, the hospital locked other unlocked kitchen doors that opened into the hallway.
MaineHealth retained the safety consultant for Spring Harbor “in light of the fact that our inpatient population, generally, is more acutely ill than in the past,” spokesperson Nadine Grosso said.
“We recognize these steps do not mitigate the tragic nature of this event and its impact on the family and friends of this patient as well as on our care team members,” Grosso said. “The safety of our patients and our care team is, and has always been, of the utmost importance at Spring Harbor Hospital.”