WATERVILLE — Northern Light Inland Hospital implemented a series of policy changes after investigators determined it placed a suicidal man in “immediate jeopardy” by prematurely sending him home the day before he shot himself and later died from his wounds.

The Waterville hospital revamped procedures that include training for suicide assessments as well as new oversight and reporting requirements after being issued a citation in November by the federal Centers for Medicare & Medicaid Services. The hospital was found to have violated seven federal regulations concerning patient care and oversight of staff.

The findings and the hospital’s response were outlined in a federal report detailing the investigation that was conducted in October.

“These deficiencies have been determined to be of such character as to substantially limit the hospital’s capacity to furnish adequate care and/or as to adversely affect the health and safety of patients,” the report said.

The hospital pledged in a Nov. 22 letter to regulators to implement new policies to avoid a similar situation from occurring and to improve oversight of staff.

Administrators took the citation seriously and conducted an immediate review to determine what happened and how to prevent something similar from happening again, according to Suzanne Spruce, senior vice president and chief marketing and communications officer for Northern Light Health, which is the health system that includes Northern Light Inland Hospital.


“We addressed every aspect identified by CMS and implemented appropriate changes,” Spruce said in a statement. “In this case that included education, training, improved event reporting processes and changes in our electronic health records.”

Another spokesperson for the health system did not respond to a question asking if anyone was reprimanded over the incident, but did indicate that the hospital in January was found to be in compliance with health care regulations.

Jackie Farwell, spokeswoman for the Maine Department of Health and Human Services, said in an email Wednesday the hospital has “corrected the deficiencies and was found back in compliance with regulatory requirements.”

The man who died had arrived at the hospital Aug. 3 talking about suicide and showed bandages on his wrist where he said he cut himself, according to the federal report.

The unidentified patient was not assessed by a physician’s assistant or nurses that morning, in conflict with hospital policies. Instead, he was advised to go to a crisis center or the emergency department, which he declined to do. Hospital staff then made an appointment for the patient to see the physician’s assistant later that day. The assistant determined during the second visit that the patient was doing “really good” after his “mood and agitation” lifted, and a formal suicide assessment was not done.

The hospital’s president, Teresa Vieira, told investigators that the hospital’s policies were not followed, the report said.


The patient shot himself the following day, Aug. 4, and died seven days later.

The patient’s primary care physician expressed “shock” at the lack of documentation and the fact that the patient was allowed to leave the hospital on the morning of Aug. 3, the report said. The patient had visited the hospital’s outpatient clinic three separate times that summer, expressing suicidal thoughts.

The report also details breakdowns in a review of the incident by hospital administrators, saying medical staff was not held accountable to the hospital’s board of trustees. The hospital failed to conduct timely reviews of the case to prevent a similar situation from happening, according to the report.

The primary care physician, who’s also a part of the hospital’s administration, is quoted in the report as saying that the review of the incident did not begin until eight weeks later when it should have been started within two weeks.

The hospital has implemented additional policies dealing with a “serious adverse patient event,” defined as an event that causes permanent harm. Rules now require an analysis of the “root cause” of such an event to be completed within 21 days and interviews to start with 48 to 72 hours.

If the event is determined to be due to an error by a staff member, then that person will undergo a peer review.


The hospital was cited by the Centers for Medicare & Medicaid Services on three other occasions, in 2019, 2017 and 2011, according to an independent database of federal health care violations maintained by the Association of Health Care Journalists.

In May 2019, the hospital failed to have adequate protections for an elderly female patient who was called in by a male sonographer for an unnecessary ultrasound and then was sexually violated by the man, according to a federal report.

In February 2017, the hospital was cited for failing to report an improper transfer of a patient to another health care facility and for improperly posting signs detailing federal regulations. And in July 2011, it was determined the hospital failed to provide “stabilizing treatment” for a person.

The number for the National Suicide Prevention Lifeline is 800-273-8255. You can also contact the National Crisis Text Line by texting HOME to 741741.

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