HospitalInspections.org

Based on record reviews, interview and observation, the hospital failed to ensure patients who have been deemed as being a danger to self and others, received care in a safe setting. This deficient practice was evidenced by 1 of 2 (Patient #4) patients with an OPC/PEC allowed to elope from the ER out of a total of 5 patient records reviewed.

Review of the hospital's policy titled, Suicide Precautions" revealed in part: The hospital uses the Ask Suicide-Screening Questions Tool (ASQ) as a validated Suicide Risk Screening for inpatients from 10 years of age and older. The ASQ Suicide Risk Screening will be performed on each patient during the patient's initial assessment. One-on-One Observation is required for any "yes" to questions 1-4. On-on-One Flowsheet will be utilized for documentation. PECed patients are to be held in the ED or ICU. Do not allow patient to leave unit for any reason without staff escort. If patient becomes resistant or belligerent call Code White or call security for assistance or 911 by phone if needed.

Review of Patient #4's medical record revealed in part: Physician Documentation - Presents to ER via Law Enforcement with complaints of Psychiatric Problem. The patient presents to the emergency department with homicidal ideation, the patient has harmed or wants to harm family.
Nurse's Notes dated 11/22/21 revealed patient arrived emergency department at 4:53 p.m. Presenting Complaint - patient was brought in per policy department under OPC (Order for Protective Custody). Review of OPC revealed the order was signed by coroner 11/22/21 at 11:28 a.m.
Nurse's Notes - 17:46 Patient refusing to stay in room at this time. Left ER multiple times and slammed waiting room door aggressively when screener told him to come back in and kept walking. Local police called. 17:51 Patient states "Well I gotta go. I have medicine I need to take." Advised patient he could not leave. Patient kept walking and walked out of hospital. Local police department notified.

In an interview on 4/6/22 at 12:40 p.m., S1CNO confirmed the policy and stated patients can elope the ER by pushing the handicap access wall buttons which opens the doors on either side of the ER. S1CNO acknowledged the ER is not secure and a patient with an OPC/PEC cannot be held in the ER according to policy.

Observation on 04/06/2022 at 1:14 p.m. revealed the ER exit doors will open after the handicap button is pushed on the wall at both of the exit doorways which would allow patients to elope.

Based on record review and interviews, the hospital failed to ensure all licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. This deficient practice was evidenced by the emergency room nursing staff failing to provide the required Suicide Risk Screening for 3 (Patients #1, #3, #5) of 5 patient's medical records reviewed.

Review of the hospital's policy titled, Suicide Precautions" revealed in part: The hospital uses the Ask Suicide-Screening Questions Tool (ASQ) as a validated Suicide Risk Screening for inpatients from 10 years of age and older. The ASQ Suicide Risk Screening will be performed on each patient during the patient's initial assessment. One-on-One Observation is required for any "yes" to questions 1-4. On-on-One Flowsheet will be utilized for documentation. PECed patients are to be held in the ED or ICU. Do not allow patient to leave unit for any reason without staff escort. If patient becomes resistant or belligerent call Code White or call security for assistance or 911 by phone if needed.

Review of Patient #1's ER medical record dated 03/15/2022 failed to reveal the Ask Suicide-Screening Questions Tool was performed on the initial assessment.

Review of Patient #3's ER medical record dated 02/08/2022 failed to reveal the Ask Suicide-Screening Questions Tool was performed on the initial assessment.

Review of Patient #5's ER medical record dated 04/05/2022 failed to reveal the Ask Suicide-Screening Questions Tool was performed on the initial assessment.

In an interview on 04/06/2022 at 9:15 a.m., S2ED Nurse Manager acknowledged the Ask Suicide-Screening Questions Tool was not performed on the initial assessments per hospital policy.