Cottage Fined $100,000 for Failing to Stop Suicide

California’s Department of Public Health fined Cottage Health $100,000 for failing to prevent a 93-year-old patient from killing himself in Cottage’s psychiatric emergency room in 2015. The fine was announced in a press release mailed out December 28. Cottage was one of ten hospitals statewide named in the release; its fine was the highest of the ten.

According to Public Health documents, the patient — a 93-year-old minister with a long history of manic depression — was presented to the Cottage Emergency Room for suicidal thoughts and depression on August 7, 2015. At that time, the patient spoke openly about engineering a deliberate fall so he could sustain fatal head injuries. Initial screening documents indicated the patient was rated 13 as a suicide risk; eight is considered high.

During his stay at Cottage, the patient was shuttled between the regular emergency room to a special emergency room facility designed for those experiencing psychiatric crisis. There was talk of booking him into the hospital’s voluntary psychiatric wing — known as 5 East — but the facility was not equipped to manage such a fall risk. The patient’s suicidal thoughts continued unabated. He expressed “wanting someone from the hospital to help him exterminate himself in a way that won’t compromise their professional license or care.”

The threat risk was sufficiently high that a security guard was assigned to watch the patient. Even after clinicians determined the patient posed an imminent threat to himself, no space could be found. At that point, he “gave a very personal good bye to his son,” and asked that he be given some time to himself. The patient stood on the floor beside his bed, crossed his arms in front of his body, and hurled himself backwards onto the floor without extending his arms to break the fall. The injuries sustained eventually took his life.

At the time of the “fall,” the second security guard assigned to the patient was watching from 30 feet away on a video monitor. He, it turned out, had never been appraised of the patient’s specific plans to kill himself this way. The previous security guard had been. According to the Department of Public Health Assessment, Cottage did not have specific protocols in place to make sure such communication gaps — involving high risk suicide patients — took place.

Cottage has since submitted a plan of correction with Public Health, which has been deemed satisfactory. In submitting this it, Cottage stated the plan should not be read to constitute any admission of wrongdoing or deficiency.