HospitalInspections.org

Based on staff interview, clinical record review, and review of facility documents, it was determined the facility staff failed to ensure the rights of each patient were protected and promoted, and that care was delivered safely in regards to:


1. Implementation of the facility's suicide precaution policy.

2. Failure of staff to remove patient belongings and contraband from patients on suicide precautions.

3. Failure of staff to ensure proper restraint monitoring.

Based on record review and interview, it was determined that facility staff failed to ensure that nine (9) of fourteen (14) patients who experienced behavioral health emergencies and required one on one (1:1) sitters during their care, were provided 1:1 sitters per hospital policy, and in a manner to protect their safety. (Patients # 3, 6, 7, 8, 9, 12, 16, 17, and 18).

Findings included:

Patient #3 arrived in the facility's hospital emergency department (ED) voluntarily, accompanied by police for suicidal ideations. Patient #3 was initially detained with an emergency custody order (an ECO is a legal order by the court which authorizes law enforcement agencies to take a person into custody for a mental health evaluation by a qualified mental health professional (QMHP)), but became voluntary by willing to accept treatment after being brought to the ED, so police did not stay with the patient after the ECO ended.

During an interview of 12/10/19 at 10:40 a.m., Registered Nurse (RN) #6 told the surveyor that all psychiatric (psych) patients are considered "level 2", because they require a higher level of attention, but not all psych patients get an order for 1:1 sitters. RN #6 stated "Because [this patient] came in with cutting behavior, that would make [patient] 1:1. I don't see a 1:1 order in the history". RN #6 told the surveyor that 15 minute checks did not start as soon as they should have. Every 15 minute checks started being documented at 8:00 a.m., a sitter was called to stay with the patient at 8:49 a.m., within line of site. A note at 3:00 a.m. evidenced that the police officer was not present, RN #6 said "I don't know when the officer left".

Patient #6 arrived in the ED voluntarily, accompanied by parents, with complaints of suicidal ideation (SI), with a plan, and a history of SI and self-harm. The initial triage suicide assessment of Patient #6 evidenced documentation that the patient was at risk for suicide. "Safe environment" was documented by the ED RN on 11/8/19 at 12:54 p.m.
Nursing notes by ED RN at 12:48 p.m. on 11/8/19 documented that Patient #6's parents were at the bedside.
The record evidenced a behavioral health assessment summary of clinical presentation which recommended inpatient treatment due to SI with plan, and intent, that patient was a safety risk, and that Patient #6 was medically cleared for admission to an adolescent psych unit.

Patient #7 presented to the ED with an ECO, accompanied by police, with diagnosis of depression.
There was no order for a 1:1 sitter; however, there was documentation on 11/15/19 of a sitter by the bedside. RN #6 was unable to tell the surveyor if a sitter was in place prior to police leaving the bedside, based on documentation in the record. Patient #7 was discharged to the care of parents, with a signed safety plan contract.

Patient #8 presented to the ED with an ECO, accompanied by police, with diagnosis of threatened overdose. Evaluation by a QMHP recommended inpatient psych treatment, 1:1 safety attendant, ED behavioral health room, and environmental safety check. Documentation in the record evidenced that Patient #8 attempted to leave the ED, and was escorted back into the room by police and security. Patient #8 became combative and an intramuscular (IM) injection of Geodon (Geodon IM works quickly to reduce tension and anxiety, and is intended for short-term control of severe occurrences of agitation in schizophrenia). Patient #8 was medically cleared and transferred to a psych hospital. Patient #8 did not have an order for 1:1 sitter, and the record lacked documentation that a sitter was present.

Patient #9 presented to the ED as a walk-in to have medical clearance for inpatient psych admission. Patient #9 was sent from school by CSB counselor, with diagnosis of SI and hallucinations. Patient #9 was accompanied to the ED by their grandmother, as a voluntary admission. CSB "Risk assessment details" evidenced documentation that Patient #9 had been "hospitalized twice within the past 60 days, and has endorsed both auditory command hallucinations and visual hallucinations of a demon. [Patient] believes that [patient] could become possessed at any time and kill [self] or someone in [patient's] family". CSB supplemental information evidenced documentation that if the patient or guardian changed their minds about voluntary admission, "TDO criteria can be met and client would be a TDO". (Temporary Detention Order (TDO) is a legal document which requires individuals to receive immediate hospitalization for further evaluation and stabilization on an involuntary basis).

The nursing triage note evidenced documentation that Patient #9 was at risk of suicide, and that an environmental safety check was performed. There were no orders for suicide precautions or 1:1 sitter noted in the medical record. RN #6 was interviewed on 12/10/19 between 1:40 p.m. and 2:00 p.m., and confirmed to the surveyor that they didn't see an order for suicide precautions or for level of observation (1:1 sitter, line of site, direct observation, etc) in the order history. RN #6 also stated "I know for peds [pediatrics] they have to have somebody with them, but I can't find where it's documented that somebody is with [patient]". RN #6 told the surveyor that the record lacked evidence that every 15 minute checks were performed, as well as documentation that the grandmother was with the patient, and that they would "like to see that note". Patient #9 was medically cleared and transferred to a psych hospital, after a bed was secured.

Patient #12 presented to the ED via EMS due to overdose(OD)/attempted suicide. The medical record review revealed a physician order for 1:1 sitter written at 7:29 p.m. on 11/26/19. Documentation of 1:1 sitter did not begin until 11/26/19 at 10:00 p.m. RN #6 was navigating the medical record with the surveyor, and stated "an OD would have gone in room 1, 2, or 3, so we could watch them". Patient #9 was transferred to the intensive care unit (ICU) at 12:30 a.m. on 11/26/19.

Patient #16 presented to the ED as a walk-in, accompanied by their guardian, with diagnosis of bizarre behavior and SI. The ED clinician documented that Patient #16 was delusional and paranoid. The triage nursing assessment evidenced documentation that Patient #16 was at risk for suicide. Suicide precautions and secured patient belongings were documented on 10/28/19 at 11:58 a.m. Safe environment, bed 12, with guardian was documented. At 11:00 a.m. on 12/11/19, RN #6 was navigating record with the surveyor, and said "[Patient] is on 1:1 and [patient] is with parent". At 5:09 p.m. on 10/28/19 a RN documented that they stayed with Patient #16 after the parent requested to leave the room to get fresh air. A behavioral health evaluation was performed, Patient #16 was medically cleared, and the patient was transferred to an inpatient psych facility for treatment.

The surveyor interviewed RN #6 on 12/11/19 at 11:02 a.m. and inquired about the facility's suicide precaution policy which states that family members may be utilized for observation of suicidal patients, "as determined by the attending physician and nursing staff on a cases {sic} by case basis only after careful assessment of these individual {sic}. The physician must document approval in the medical record for the use of a family//significant other in observation procedures...". RN #6 told the surveyor that they did not see physician approval for the use of family for observation procedures, and was unable to locate documentation of an assessment of family members for purposes of providing observation to the patient.

Patient #17 presented to the ED, accompanied by their therapist, with SI. Patient #17 was initially a voluntary admission, and did not have an ECO. 1:1 sitter was initiated at 12:50 p.m. on 12/6/19 by nursing after the patient was triaged; there was no physician order for 1:1 sitter, and documentation by the sitter stopped at 3:00 p.m..
The record evidenced that on 12/6/19 at 3:47 p.m., Patient #17 walked out of the ED and said they could not be forced to stay. The CSB was contacted, and an ECO was issued. Nursing note at 4:24 p.m. documented that law enforcement was putting Patient #17 on a paperless ECO. At 12:40 p.m. on 12/11/19 RN #6 told the surveyor that "The doctor writing an order for 1:1 sitter seems to be the inconsistent part, that seems to be our great opportunity to improve. It's one of the first things we talked about in huddle this morning, closing the loop with initiating 1:1".

Patient #18 presented to the ED due to complaints of a three (3) month history of abdominal pain and nausea and vomiting. A computed tomography (CT) scan was ordered in the ED, and the results were concerning for metastatic cancer. Patient #18 was admitted to the progressive care unit (PCU) at 7:27 p.m. A history and physical (H&P) documented 11/19/19 at 9:33 p.m. by a doctor of osteopathic medicine, first year resident (DO R1), evidenced that Patient #18 expressed suicidal ideations during the intake interview. Suicide precautions and a 1:1 sitter were ordered. The surveyor was given an undated document stamped with Patient #18's name, and included the patient's hospital number, date of birth, admission date, and was titled "Suicide Precautions Observation Record". For type of precautions Standard (q15), line of sight, and 1:1 were all checked. The document evidenced the comment "suicide precautions initiated", and a time of 10:30 p.m., almost one (1) hour after suicide precautions were ordered by the clinician.

At the top of the document in the "key", the document included an environmental checklist which documented that: All linens counted; All patient belongings secured (clothing, jewelry, shoes); Patient is in paper scrubs/gown without ties and footies; Patient had been wanded for any metal/sharps in their possession (on arrival and any time suspicion is aroused); Visitors have had their belongings secured and did not given any items to patient prior to authorization; Bathroom door (if applicable) is locked to prevent unknown patient access; Plastic liners removed from trash cans; All cords not needed for ongoing patient care are removed; All sharps containers are removed; All glove boxes/gloves are removed; All supplies in the room that are sharps/plastics/ligature prone removed or secured; Dietary notified to provide paper plates, plastic utensils, and no knives; Electric beds disabled/unplugged; Nurse call cord secured".

Admission Health History was entered by RN #22 on 11/19/19 at 9:57 p.m. documented valuables were "kept by patient", and that a medication reconciliation was done. A nursing note documented by RN #22 on 11/20/19 at 2:30 a.m. evidenced that Patient #18 told the nurse that there was a knife in the pocket of their jeans, in a bag, in the room. RN #22 documented that "Security came back for a second time and researched [patient's] belonging {sic} incase {sic} [patient] had other itmes {sic}. Security did take the knife, belt, lighter, screws, charger, keychain and trash bags. Along with other medications that the pt did not disclose during the med rec. Medications were placed in a a bag and will be given to pharmacy".

At 4:00 a.m. on 11/20/19 RN #22 documented in a nursing note the physician was notified that Patient #18 was upset with the 1:1 sitter because items noted above had been taken from the patient and secured. The doctor attempted to explain why the items were removed from the room, and Patient #18 became more upset, self-removed the intravenous (IV) line, telemetry box, and got on the elevator, accompanied by hospital security and the nursing supervisor. The local police department was notified, and the physician called to obtain a TDO. Patient #18 went to the hospital lobby where the local police handcuffed and detained the patient until the TDO was obtained.
Patient #18 was taken back to the PCU and placed in four (4) point restraints.

Staff Member (SM)#15, a security guard, was interviewed on 12/12/19 at 9:50 a.m. to discuss security's role in checking for contraband for patients on suicide risk. SM #15 told the surveyor that security is called when patients in the ED are placed on suicide precautions. The surveyor was told that usually security "wands" patients with a hand-held metal detector, removes any bags, checks pockets of any clothing, and removes any contraband like knives or other weapons, which are placed in a lock box. Narcotics are sent to the local police department. SM #15 told the surveyor that nursing staff generally remove clothes after security has done their safety check, and that the nursing staff would ensure that clothes, shoes, belts, and other personal belongings are placed in a locker. When the surveyor inquired about inpatients on suicide precautions, SM #15 said "Sometimes if it is ordered from the floor, we aren't even notified, most of the time. We only get notified if suicide precautions are started in the ED".

SM #15 returned to the conference room after looking through reports, and told the surveyor that security was called to the floor and searched Patient #18, and provided the surveyor with the following information documented by the security guard on duty 11/20/19:

On 11/20/19 at 2:15 a.m. security "received a call from PCU. There was no information given, just a call for my presence in Room 227. Upon arrival, I was informed that the patient [patient hospital #] had a knife in [their] belongings. I searched [patient's] belongings. I removed a mass quantity of medication which was given to the Nurse. I took into my custody, the knife, a belt, lighter, phone charger cord, roll of blue plastic bags, a package of screws, and keys on a retractable chain. I bagged and tagged them and placed them in the security office. Nothing further to report".

At 4:00 a.m. on 11/20/19 the security guard documented that they were called to PCU for Patient #18, who was on suicide precautions and attempting to leave the hospital against medical advice (AMA). Security wrote that after the patient was brought back to the unit to the room by local police officers and the nurse leader, the patient was restrained, and confiscated items mentioned above were returned to the patient's family member.

The facility's policy entitled "Suicide Precautions" effective, last revised 11/2018, with expiration of 11/2021, was reviewed, and revealed the following information, in part:

"Suicide precautions will be initiated when a physician's order has been written on any patient who has made a suicide attempt or is expressing suicidal ideation. Suicide Precautions may be initiated by the charge nurse, manager or clinical coordinator in a crisis situation, until collaboration with the attending physician can occur. The goal is to provide protection for the patient in the least restrictive environment that allows for the necessary level of observation and/or physiologic monitoring. Interventions range from regular and periodic observation to 1:1 contact observation.
Observation will be provided by nursing staff (RN, LPN, NA). Use of family members and/or significant others as observers is determined by the attending physician and nursing staff on a cases {sic} by case basis only after careful assessment of these individual {sic}. The physician must document approval in the medical record for the use of a family//significant other in observation procedures. If the patient is a minor, it is preferred that a family member stay at all times unless observed family dynamics contribute to patient's distress.

The level of precautions needed may be ordered by the attending physician or the nursing staff. Should the nursing staff initiate any level of observation, rationale for this decision is recorded in the medical record and the patient's physician notified as soon as possible. If the physician concurs, an order must be written. Orders for "suicide precaution" must specify what level of observation is intended. Level of observation can be reduced only by physician order...If the patient is determined to be of suicide risk, the results of this screening will be clearly communicated to the treatment team immediately. a. A "YES" answer to any of the suicide risk screening questions will identify patients at risk for suicide. Any patient that responds YES will be placed on suicide precautions and the RN will assign patient observation monitoring immediately and a licensed independent practitioner (LIP) order will be generated in order to gain further suicide risk assessment by a QUALIFIED MENTAL HEALTH PROFESSIOANL {sic} (QMHP) or assigned LIP and determine ongoing safety observation and monitoring level. Safe environment and patient safety guidelines will be implemented...6. Patients, who no longer meet guidelines for heightened protective measures or precautions upon reassessment, will be evaluated for a decrease in protective measures or precautions by a physician who will provide appropriate orders...".

The policy's guidelines for monitoring and observation of patients for "Standard Observation" included to monitor and observe a minimum of every 15 minutes and/or place a trusted family member, friend, or significant other with the patient. Per the policy, "Standard Observation" may be used for patients who have not had a suicide attempt within the previous year, have not displayed self injurious behaviors in the preceding eight (8) to twelve (12) hours, is having SI, with no plan for self-harm.

The policy defined "Line of Sight Observation" as "continuous visual observations", to be used for extremely confused patients at risk of unintended self-harm, medically unstable patients, and patients after a suicide attempt, patients with SI, patients at risk of having assaultive behavior, but who do not meet 1:1 guidelines. Patients on line of sight observation, per the policy, are not to be out of the visual contact of a staff member at any time.

The policy defined 1:1 monitoring and observation as "the patient is NEVER to be out of arms reach of the assigned and dedicated staff member", and used for patients who have attempted suicide within 48 hours, displayed self-injurious behaviors within 8-12 hours, current SI with plan, having command hallucinations to harm self, feelings of hopelessness, have experienced traumatic loss, event or disruption within 24 hours.

On 12/12/19 between 9:30 a.m. and 10:30 a.m. the surveyor discussed serious concerns related to implementation of the facility's suicide precaution policy with Staff Members # 4, 6, 13, 15, and 16. The discussion included, but was not limited to, the facility staff's failure to remove contraband, which included among other items, a knife, belt, plastic trash bags, cell phone cord, and "mass quantities" of unknown medications, from Patient #18, who was on suicide precautions.

Based on record review and interview, it was determined facility staff failed to ensure that restraint monitoring was conducted for one (1) of two (2) patients (Patient #8).

Findings included:

Patient #8 presented to the facility's emergency department (ED) with suicidal ideations (SI) and in police custody under an emergency custody order. (an ECO is a legal order by the court which authorizes law enforcement agencies to take a person into custody for a mental health evaluation by a qualified mental health professional (QMHP)).
A nursing note documented on 11/15/19 at 4:58 p.m. Patient #8 attempted to leave the ED, and when escorted back to the room by police and hospital security, became "combative". An intramuscular (IM) injection of Geodon was documented as administered for "patient and staff safety". (Geodon IM works quickly to reduce tension and anxiety, and is intended for short-term control of severe occurrences of agitation in schizophrenia).
Geodon was not listed as a medication that Patient #8 took on a routine basis, and the record lacked documentation of restraint monitoring for Patient #8 after administration of Geodon for the purposes of controlling the patient's behavior.

The facility's policy for Patient Restraint and Seclusion revised 2/2018 was reviewed, and evidenced in part that patients in restraint would be monitored by a Registered Nurse (RN) at least every two (2) hours, and a trained staff member would monitor restrained patients three (3) times an hour for safety and to confirm maintenance of patient rights and dignity. The policy stated that a drug would be considered a restraint when used "as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition".

Concerns related to the lack of monitoring when Patient #8 received IM Geodon for the purposes of controlling behavior was discussed with RN #6 on 12/10/19 at approximately 1:00 p.m.