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Based on policy review, observation, medical record review, document review, and interview, the facility failed to ensure that care is provided in a safe setting. Specifically, there is no policy for the observation and monitoring of behavioral health (BH) patients in the medical emergency department (ED). Established policies are not being followed for vital sign assessment.

Refer to Tag 1104.

Based on policy review, observations, medical record review, document review, and interviews, the facility failed to establish and implement policies to ensure the ongoing assessment of care provided in the Emergency Department (ED) related to the following:
1. The facility does not have a policy for the observation/monitoring of behavioral health (BH) patients in the medical emergency department (ED) for six of nine patients (Patient #2, #3, #5, #6, #7, and #8). ED staff do not follow the established policy for vital sign assessment for seven of nine patients (Patient #2, #3, #5, #6, #7, #8, and 15).
2. The facility does not have a policy for maintenance of refrigerator temperatures in the ED.
3. The facility does not have a process or policy to ensure expired supplies are not utilized in the ED.

Findings #1:

Review of policy "Behavioral Health Assessment Procedure for Patients who Present to the Emergency Department for Services," dated January2019, indicates all patients seeking or in need of BH services will be triaged by ED nursing staff and sent to the appropriate treatment area based on the patient's priority needs. The triage nurse will escort the BH patient to the psychiatric ED. BH patients will change into hospital garb. Clothing and valuables will be checked for contraband and secured. The BH ED nurse will conduct an assessment upon arrival and every shift. Reassessments will be conducted every four hours. This policy does not address monitoring and assessment of a BH patient if housed in the medical ED.

Review of policy "The Adult and Child/Adolescent Observation/Rounds in the Psychiatric Emergency Room," last revised April2016, indicates all patients will be observed every 15 minutes in the Psychiatric Emergency Room by direct observation and/or via camera. Direct person observation is conducted every 30 minutes. A patient on 1:1 observation (direct visual) means the patient will be continuously visually observed by a staff member, who will remain within arm's length of the patient at all times. Staff will document on the Observation Record. [This policy is specific to the BH area of the ED.]

Review of policy "Patient Monitoring/Rounds for Level of Observation," last revised January 2019, indicates upon admission, all BH patients will be placed on a Level III (observation documentation every 15 minutes) or Level IV-1:1 (1:1 continuous monitoring who are determined to be an immediate danger to themselves or others and/or behavior requires increased observation/directions for safety) to observe and assess the potential for self-destructive, aggressive, or other dangerous behavior. When a patient is placed on 1:1 observation, the patient will be continuously observed by a staff member who is within arm's length at all times. The physician is required to evaluate the patient daily and either renew or change the level by written order. Observation by a Registered Nurse (RN) will be conducted at least hourly. [This policy is specific to BH inpatient units.]

Review of policy "Assessment of the Emergency Department Patient," last reviewed January2022, indicates every patient will be assessed by a RN. All patients presenting to the ED will be triaged and categorized as a Level 1- Critical; Level 2- Emergent; Level 3- Semi-urgent; Level 4- Urgent; or Level 5- Non-urgent. Initial vital signs for Level 2 is every hour or per Attending order, 30 minutes prior to transport to an inpatient unit, and one hour prior to discharge. RN assessments will be completed/documented a minimum of every six hours and change in condition.

Observations on 09/21/23 from 10:13 AM until 12:00 PM revealed two behavioral health patients sitting in reclining chairs, located in the ED hallway in front of rooms #1, #2, #3, and #4. There were two staff members sitting next to the two hallway patients.

Interview on 09/21/23 at 11:35 AM with Staff (H), ED Manager, revealed that the two patients in the hallway were BH overflow patients being held in the medical ED due to overcrowding in the BH section of the ED. Staff (BB), PCA II Sitter stated to the Staff (H), ED Manager they were monitoring the hallway patient sitting next to them (Patient #2) and the patients in Rooms #3 and #4 (Patient #5 and Patient #7) and staff (AA), PCA II Sitter, was monitoring the other hallway patient (Patient #8) and the patients in rooms #1 and#2 (Patient #3 and Patient #6).

Interview on 09/21/23 at 01:00 PM with Staff (H), ED Manager, confirmed Patient #2 was with a 1:1 Sitter, Staff (BB),who was also responsible for watching two other BH patients and Staff (AA), PCA II Sitter was watching the other three BH patients. Staff (H), ED Manager confirmed that they do not have a policy for monitoring BH patients in the medical ED but use the BH policies. Additionally, staff are to document 1:1 observations on paper every 30 minutes in the BH ED and ED medical staff document sitter monitoring in an EMR note.

Medical record review on 09/22/23 revealed Patient #2 arrived on 09/20/23 at 01:09 PM on a 9.39 status (9.39 mental health status-substantial risk for harm by threats of suicide and is a danger to self or others) for a diagnosis of suicidal ideation. No order for 1:1 status or level of observation was found. However, there were "sitter" notes dated 09/20/23 at 02:00 PM and on 09/21/23 at 07:04 PM. No other observation notes were found in the medical record. On 09/21/23 at 07:00 AM, the ED MD documents Patient #2 is awaiting evaluation from the Psychiatrist. Patient #2 was triaged as a Level 2 acuity. Vital signs were documented on 09/20/23 at 01:11 PM, 05:25 PM, 11:51 PM, and on 09/21/23 at 4:00 AM and 07:18 AM. Patient #2 was discharged on 09/21/23 at 04:58 PM. Vital signs were not obtained hourly and/or prior to discharge per policy.

Medical record review on 09/22/23 revealed Patient #3 arrived on 09/21/23 at 07:41 AM on a 9.41 status requesting a psychiatric evaluation. No order for 1:1 status or level of observation was found. However, on 09/21/23 at 06:12 PM, a nursing assessment indicates "Safety needs managed per Basic Protocol, 1:1 nursing." No observation notes were found in the medical record. Patient #3 was triaged as a Level 2 acuity. Vital signs were documented on 09/21/23 at 07:49 AM, 11:45 AM, and 01:37 PM. Patient #3 was discharged on 09/21/23 at 04:16 PM. Vital signs were not obtained hourly and/or prior to discharge per policy.

Medical record review on 09/22/23 revealed Patient #5 arrived on 09/21/23 at 03:22 AM with a diagnosis of chronic bipolar affective disorder and acute alcohol intoxication with alcoholism. No order for 1:1 status or level of observation was found. However, on 09/21/23 at 04:02 AM, a nursing assessment indicates "Safety needs managed per Basic Protocol, 1:1 Nursing." One "sitter' note is documented on 09/21/23 at 07:04 AM. No other observation notes were found in the medical record. On 09/21/23 at 01:45 PM, Patient #5 was admitted to the behavioral inpatient unit for major depression with thoughts of Suicide. Patient #5 was triaged as a Level 2 acuity. Vital Signs were documented on 09/21/23 at 03:22 AM, 07:23 AM, and 11:39 AM. Vital signs were not obtained hourly and/or prior to Patient #5 transferring to the inpatient BH unit per policy.

Medical record review on 09/22/23 revealed Patient #6 arrived on 09/21/23 at 06:22 AM with a diagnosis of agitation requiring sedation protocol and a general psychiatric evaluation for drug intoxication, and depression with suicidal ideation. No order for 1:1 status or level of observation was found. However, on 09/21/23 at 06:28 AM, a nursing assessment indicates "Safety needs managed per Basic Protocol, 1:1 nursing." One "sitter" note was documented on 09/21/23 at 07:04 AM. No other observation notes were found in the medical record. On 09/21/23 at 07:00 AM, the ED MD documents Patient #6 is awaiting evaluation from the Psychiatrist. Patient #6 was triaged as a Level 2 acuity. Vital Signs were documented on 09/21/23 at 06:25 AM, 07:28 AM, 11:36 AM, and 08:29 PM and on 09/22/23 at 12:09 AM, and at 04:01 AM. Vital signs were not obtained hourly per policy.

Medical record review on 09/22/23 revealed Patient #7 arrived on 09/21/23 at 04:38 AM with a diagnosis of acute drug and alcohol intoxication and general psychiatric exam on a 9.41 status (law enforcement request for psychiatric evaluation) for threatening suicide possible drug use and acting manic. Patient #7 is awaiting evaluation from the Psychiatrist. No order for 1:1 status or level of observation was found. However, on 9/21/23 at 5:30 AM, a nursing assessment indicates "Safety needs managed per Basic Protocol, 1:1 nursing." On 09/21/23 at 09:27 PM, Patient #7 was an involuntary admitted (9.39 mental health status-substantial risk for harm by threats of suicide and is a danger to self or others) and transferred to room 386. At 09:40 PM, the provider orders inpatient Level 3 observation for Patient #1. Patient #7 was triaged as a Level 2 acuity. Vital Signs were documented on 09/21/23 at 04:57 AM, 11:41 AM, at 04:27 PM, at 08:30 PM, and at 09:30 PM. Vital signs were not obtained hourly and/or prior to Patient #7 transferring to the inpatient BH unit per policy.

Medical record review on 09/22/23 revealed Patient #8 arrived on 09/21/23 at 01:22 AM with a diagnosis of acute alcohol intoxication, chronic depression, and depression with suicidal ideation. No order for 1:1 status was found, however, on 09/21/23 at 04:00 AM, a nursing assessment indicates "Safety needs managed per Basic Protocol, 1:1 nursing." One "sitter" note was documented at 07:04 AM. No other observation notes were found in the medical record. At 07:00 AM, the ED MD documents Patient #8 is awaiting evaluation from the Psychiatrist. At 02:52 PM, Patient #8 was an involuntary admitted under 9.39 status. Patient #8 was triaged as a Level 2 acuity. Vital Signs were documented on 09/21/23 at 01:23 AM, 07:20 AM, and at 11:37 AM. Vital signs were not obtained hourly and/or prior to Patient #7 transferring to the inpatient BH unit per policy.

Medical record review on 09/22/23 revealed Patient #15 arrived on 07/31/23 at 09:49 AM for night terrors of self-harm, requiring psychiatric evaluation. Patient #15 was triaged as a Level 2 acuity. Vital signs were documented on 07/31/23 at 09:52 AM, at 10:00 AM, 12:00 PM, 06:00 PM, and at 08:09 PM. Patient #15 was discharged to home on 07/31/23 at 07:59 PM. Vital signs were not obtained hourly per policy.

Interview on 09/22/23 at 08:27 AM with Staff (Q), ED Charge Nurse revealed when a BH patient presents to the medical ED, they are triaged and sent to the BH ED to be evaluated by the Psychiatrist. If a patient is suicidal, they are sent directly to the BH ED. If there are BH patients being held in the medical ED, they are usually placed in Zone 1 (rooms #1-#4). BH patients are always triaged as a Level 2 (acuity). All BH patients are placed on 1:1 status. According to the Office of Mental Health, there is a 2:1 observer/BH patient ratio for observations.

Interview on 09/22/23 at 08:35 AM with Staff (R), ED Medical Director confirmed that there is no formal policy for 1:1 observation in the medical ED. It is left to the clinician to decide if a patient needs a 1:1 observation. Only true suicidal/homicidal patients receive 1:1, all others are direct observations. It is verbally communicated between staff what level of observation is needed. There is no order entered into the medical record. The aides are expected to document 1:1 observations. They try to maximize the resources they have but do not have staff to provide 1:1 for all BH patients. If the BH ED is full, the overflow BH ED patients are held in the medical ED and direct observation is provided. If there is a 2nd BH overflow patient, then a 2:1 observation is maintained. If there is a 3rd BH overflow patient, they will pull another staff to assist in watching the patients.

Interview on 09/22/23 at 03:36 PM, with Staff (H), RN Director of ED Services, verified the above findings.

Findings #2:

Observation on 09/21/23 at 11:30 AM of the ED refrigerator located across from Room #4 revealed a "Daily Refrigerator/Freezer Temperature Log." Review of the log revealed instructions for staff to check and document refrigerator temperatures daily. Temperatures were not documented from 09/01/23 to 09/03/23, 09/06/23 to 09/10/23, 09/13/23 to 09/15/23, and 09/17/23 to 09/20/23. Documented temperatures ranged between 2-8 degrees Celsius. Inside of the refrigerator were seven SARS-CoV-2 specimen collection kit devices.

Review on 09/21/23 of the manufacturer insert "Hologic® Direct Load Tube Collection Kit- AW-18114-001 Rev. 001," last revised March 2021, indicates that kits are required to be stored at room temperature (15-30 degrees Celsius).

Interview on 09/21/2023 at 01:45 PM with Staff (H), RN Director of ED Services, verified the findings and indicated that there is no policy for refrigerator monitoring.

Findings #3:

Observation on 09/21/23 at 11:00 AM in the ED medication storage room revealed 7 of 18 Hi-Flo 3-Way Stopcock w/Swivel Male Luer Lock devices (mainly used to provide higher flow rates of viscous fluids and rapid infusion of fluids) expired on 08/27/23.

Interview on 09/21/23 at 01:45 PM with Staff (H), RN Director of ED Services verified these findings and indicated that the facility does not have a policy for ensuring expired supplies are not available for use.