HospitalInspections.org

Based on policy review, medical record review, grievance file review, observations, facility investigative findings review/facility timeline review and staff interview, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights and an organized nursing service to ensure the safety of patients.

The findings include:

1. The hospital failed to promote and protect patients' rights by failing to ensure a safe setting for patient care in the Emergency Department, ensure time limited physician orders for restraints, ensure monitoring of patients in behavioral restraint and provide written response to a grievance.

~cross refer to 482.13 Patient Rights' Condition: Tag 0115.

2. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff assessed, supervised and monitored suicidal patients in the emergency department to ensure a safe environment.

~cross refer to 482.23 Nursing Services Condition: Tag 0385.

Based on hospital policy review, facility investigative findings review/facility timeline review, closed medical record review, grievance file review, observations and staff interviews, the hospital failed to promote and protect patients' rights by failing to ensure a safe setting for patient care in the Emergency Department, ensure monitoring of patients in behavioral restraint, ensure time limited physician orders for restraints and provide written response to a grievance.


The findings include:

1. The Emergency Department (ED) nursing staff failed to ensure a safe setting for patient care in the Emergency Department.

~cross refer to 482.13(c)(2) Patient Rights' Standard: Tag A0144

2. The hospital staff failed to ensure a time limited restraint order was obtained for patients that were restrained for behavior managment.

~cross refer to 482.13(e)(8) Patient Rights' Standard: Tag A0171

3. The ED nursing staff failed to monitor a patient in fourpoint restraint (restrained for management of behaviors) per the hospital policy.

~cross refer to 482.13(e)(10) Patient Rights' Standard: Tag A0175

4. The hospital staff failed to provide written notice of the resolution of a grievance.

~cross refer to 482.13(a)(2)(iii) Patient Rights' Standard: Tag A0123

Based on hospital policy and procedure review, grievance file review and staff interview, the hospital staff failed to provide written notice of the resolution of a grievance in 1 of 2 grievances reviewed (#11).

The findings include:

Review of hospital policy and procedure "Patient Grievance Procedure" revised January 2009 revealed a grievance is defined as "A written or verbal complaint (when the verbal complaint about patient is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. ... 5. In the case of a grievance, most situations will be resolved and the patient notified of the resolution by letter from the Patient Relations Representative within (7) seven days. The letter will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, and the date of completion (indicated by the date of the letter to the patient)."

Review of Patient #11's grievance file on 01/18/2012 revealed a grievance was submitted on 12/05/2011 regarding the provision of postoperative care following a surgical procedure on 11/30/2011. Review of the file revealed the patient was discharged on 12/02/2011 and the grievance was filed after discharge. Further review revealed the grievance file was "closed" on 12/07/2011. Review revealed no evidence a written response to the complainant was sent.

Interview on 01/18/2012 at 1810 with a risk management staff member revealed the grievance had been sent to staff at the Bariatric Center for investigation and response. Interview revealed a written response to the grievance was not sent. The staff member stated the hospital staff failed to follow the grievance policy.

Based on policy and procedure review, facility investigative findings review/facility timeline review, closed medical record review, observations and staff interviews, the Emergency Department (ED) nursing staff failed to ensure a safe setting for patient care in the Emergency Department for 1 of 6 suicidal patients reviewed (#1).

The findings include:

Review of Policy Emergency Services "ASSESSMENT/REASSESSMENT IN THE EMERGENCY DEPARTMENT" reviewed and revised 8/2011 and approved August 4, 2011, revealed "Needs are prioritized as follows:...b) Category II Urgent: Cases that are urgent in nature but not life-threatening. Reassessment is performed every hour or as needed...3) Risk of suicide is assessed in the triage process. a) The patient is asked the following: i) Are you having thoughts of hurting yourself or someone else? b) If the answer is yes a behavioral health assessment team referral is initiated. c) The patient is taken immediately to an observation area for patients at risk for suicide. d) The triage nurse alerts the charge nurse for 1:1 assignment of staff...The following precautions are implemented: iv)The room/immediate environment is cleared of all potentially dangerous articles such as glass objects, electrical cords, needle boxes, gloves, cloth restraints. etc...f) The patient is medically screened by the ED physician, who determines the need for behavioral assessment. g) The Behavioral Assessment Counselor performs the psychological component of the Medical Screening Exam (MSE.) h) The Assessment Counselor makes recommendation for treatment based on findings...j) The house-wide policy: Nursing: Care of the suicidal patients will be followed."

Review of policy "Nursing Suicidal Patients, Care of" revised 8/11 and approved August, 2011 revealed "2) The actively suicidal patient is within view of a staff member at all times...5) The patient's room is cleared of all potentially dangerous objects. a) If blinds are present, they are maintained in an open position unless personnel is being provided and there is staff with the patient...c) The needle boxes and gloves are removed...8) The patient, who contracts/agrees to call the nurse if he/she develops feelings of imminent self-harm is no longer kept in sight of staff."

Review of the facility investigative findings revealed an Incident Report documenting an incident occurring on 12/11/1022 at 2253 involving an attempted suicide in the Emergency Department by patient #1. Further review revealed a narrative completed by Security Officer #1. Review of the narrative revealed "On the date and timed recorded, while making a security check in the Emergency Department, I observed name of staff nurse #1 of (Name of hospital) enter room 15 and immediately begin to scream. I entered the room and witnessed a white male hanging from the lighting fixture attached to the ceiling. The bed and the lighting fixture was positioned in a way that allowed his body to be fully hanging in the air. He looked to be unresponsive and blue in the face and I immediately assisted name of staff nurse #1 to help lift and hold the subject up. At this time unknown staff entered the room and cut the cords from around the subjects neck. I assisted in laying the patient into the bed and secured the area while staff worked on the patient". Further review of the findings revealed copies of photographs of Room 15 after the incident. Review of photograph #2 revealed wall mounts and wall attachments (oxygen regulators suctioning canister with tubing, etc) secured to the walls. Review of the findings revealed work order # 121448 dated 12/19/11 at 1044 to "Move mini blinds to outside of the rooms and place locks on all cabinets" for rooms 10, 11, and 15. Review revealed a second work order #121448A to "Move mini blinds to outside of the rooms and place locks on all cabinets" for rooms 10, 11 and 15.

Medical record review of Patient #1 revealed a 43 year old who presented ambulatory to the Emergency Department (ED) on 12/11/11 at 2059 with a chief complaint of suicidal ideation with a plan, homicidal ideation and history of suicide attempts. Record review revealed the patient was triaged at 2105 acuity 2. Record review revealed the triage nurse (Staff nurse #2) notified the Charge Nurse (Staff nurse #3) that the patient had "Confirming Thoughts of Hurting Self and Others..Suicide Precautions Initiated". Further review of triage documentation revealed "Pt (patient) reports suicidal plan to "lay on train tracks or step in front car" Pt able to contract for safety while in the ED". Record review revealed the patient was escorted by a nursing assistant to a room in the ED at 2112. Record review revealed documentation by the NA "Pt (patient) aware to use call bell for needs". Record review revealed the assigned nurse (Staff nurse #1) made contact with the patient between 2119 and 2130. Record review revealed documentation by Staff nurse #1 "pt sts (states) he had an argument with his mother over rent and "my temper got the best of me and I threatened to hurt her and myself...I just want something quick, lay in front of a train or step in front of a car" Pt agreed to contract for safety while in the ED." Documentation by staff nurse #1 revealed "(+) call bell within reach by." Medical record review revealed no further documentation until 2235 by staff nurse #1 "Assessment Team at bedside." Record review revealed the next documentation at 2300 "Nurse (name of Nurse #1) called out for help into room 15. Pt found with call bell cord tied to exam light on ceilings down around Pt's neck. Pt was unconscience (unconscious). Cord was cut...SALINE-LOCK INSERTED - 12/11/2011 2301 20 ga (gauge) right foreman following 1 attempt." Record review revealed at 2306 "Restraints, fourpoint extremity applied as orders by (name of physician) and in accordance with hospital policy. Reason for restraints: pt suicide attempt." Record review revealed on 12/12/11 at 0021 four point extremity reassessment...Neck no neck tenderness. Pt has circumferential ligature mark around neck from attempt suicide by hanging". Record review revealed at 0130 on 12/12/2011 a "late entry" by staff nurse #1 "Late note: upon exiting room 17 I noticed the pt door to room 15 was closed all the way and the call light was flashing above the door. I immediately entered pt room and found pt hanging from ceiling light by call bell cord. I ran to pt and hoisted him into the air and began to scream for help. (Name of security officer #1) from security entered the room and assisted with lifting the patient...Pt was unconscious and face had turned blue. the call light cord was cut from pt neck. Dr. (name of physician) was at bedside and assessment and life saving measures initiated. After the pt was transferred to unit I spoke with (name of Psychiatric team member) from the assessment team and she stated she "had been in pt room and pt requested his clothing because he wanted to leave." She stated she "exited the pt room to speak with (name of the physician's assistant (PA)) taking care of the pt and the door was open upon her exit from the room. (name of Psychiatric team member) stated "It was 5 mins or less that I left the room and I heard you yell for help". Record review failed to reveal the time of the medical screening was intiated and completed. Review of the documentation by the physician revealed the patient was "(+) homicidal ideation's, (+) suicidal ideation's, (+) emotional stress and (+) depression." Further record review revealed on 12/11/2011 at 2231 by (psychiatric team member) "ASSESSMENT TEAM NOTE: A-Team w/pt (with patient) at this time." Record review revealed documentation by (name of Psychiatric team member) at 2251 "...Discussed inpt (inpatient) psych admit w/pt. Pt requested clothes to leave. Advised pt he would not be able to leave. A-Team left to speak w/(name of Physician Assisstant (PA)) and advised of pt wanting to leave. (Name of PA) agreed to speak w/pt about staying for inpt psych admit. Discussed petitioning pt d/t (due to) SI/HI (suicidal ideation and homicidal ideation). A-Team will complete IVC (involuntary commitment)." Record review revealed patient #1 was assessed by staff nurse #1 at 2119 and no further documentation by staff nurse #1 of an assessment.

Observation during tour of the ED on 1/18/2012 at 1115 revealed Room 15 with miniblinds located in the room on the window. Observation revealed no locks on cabinets in room 15. Observation revealed packages of gauze "kerlix". Observation of room 17 revealed blinds on the outside of the window and a staff member by the bedside of the patient.

Interview with ED Director during tour on 1/18/2012 at 1115 revealed there had been a "near miss" with a psychiatric patient in December 2011 involving room #15. The interview revealed the event had been made a sentinel event.

Interview with ED staff RN #4 on 1/18/2012 at 1300 revealed room 17 in the ED was considered a safe/secure room for psychiatric patients to go to. The interview revealed all potential hazards (monitors with cords, cables cords, etc) are removed from the room before the patient goes in. The interview revealed the mini blinds are on the outside of the window and cabinets in the room have locks.

Interview with ED staff RN #5 on 1/18/2012 at 1315 revealed room 17 is considered the room used for patients with a psychiatric diagnosis. The interview revealed room 17 is close to the nursing station. The interview revealed all cords and equipment is removed from the room before the patient goes in. The interview revealed when room 17 is full rooms 15, 10, and 11 are used.

Interview with ED staff RN #6 on 1/18/2012 at 1330 revealed the nurse uses their judgement if the patient needs 1:1 ( 1 staff member to 1 patient) observation. The interview revealed the psychiatric patient is placed in a room close to the nurses' station. The interview revealed "anything that can leave the room" is taken out before the patient goes in. The interview revealed the door and the window are left open to view the patient.

Interview with administrative risk management staff on 1/18/2012 at 1400 revealed there was a sentinel event identified on 12/11/2011 when patient #1, while in the ED, used the call light cord and hung himself from the light fixture in the room.

Interview with ED staff RN #7 on 1/18/2012 at 1640 revealed the policy for psychiatric patient in the ED was to remove anything that could be harmful to the patient from the room. The interview revealed the patient is not left alone. The interview revealed when a psychiatric patient with suicidal ideation's (SI) is identified at triage, the triage nurse calls the charge nurse to let them know a psych patient has been identified. The interview revealed the patient is "never" left alone. The interview revealed the ED nursing Assistant at triage will go with the patient to the assigned ED room. The interview revealed patients with SI and HI (homicidal ideation's) are assigned 1:1 and it may be the patient's family, hospital staff or the police department observing the pt. The interview revealed the 1:1 assigned will be in the doorway of the room. The interview revealed since an event in December 2011 the starting line up (beginning of the shift meeting) it has been reinforced the all SI/HI patients are 1:1. The interview revealed the staff must remove call bell cord, monitors, needle boxes and anything to make the room safe/secure from anything the patient could use to harm themselves.

Interview with ED staff RN #8 on 1/18/2012 at 1840 revealed if a patient has SI the staff must remove all wires, cords call bell cord, needle boxes from the room so it will safe and secure. The interview revealed the miniblinds are left open. The interview revealed a SI patient is 1:1 observation meaning some one must sit with the patient at all times. The interview revealed the 1:1 staff must sit at the door or doorway but must be in a place to ensure the room door a can not be shut. The interview revealed when an SI patient is identified the charge nurse or staff nurse may request 1:1 staff. The interview revealed since the event in December 2011 when a patient hung himself, the staff has been educated that all SI patients are 1:1 constant observation.

Interview with unit coordinator (UC) on 1/18/2011 at 1910 revealed since the event in December 2011 of the hanging patient all SI patients are 1:1 "100%". Before the event the SI patient only needed to be in site of nurses at the station. The interview revealed if the SI patient is 1:1 the staff does not remove everything from the room because not everything may be a threat to the patient. The interview revealed the 1:1 staff are located are inside the room and not in the doorway. The interview revealed the triage nurse will let her know when there is a SI patient. The interview revealed based on the patient she will decide if items are to be removed from a room. The interview revealed if the patient escalates items will then be removed from the room to make it safe. The interview revealed approximately one week after the hanging event there was a meeting in which it was decided that all SI patients would be 1:1 observations. The interview revealed not all SI patients have a 1:1 staff assigned presently. The interview revealed they are not practicing 100% of policy for 1:1 staff assignment.

Interview with Nursing Assistant (NA) #1 on 1/18/2012 at 1920 revealed she was a float pool NA. The interview revealed she had staffed 1:1 observation in the ED. The interview revealed the ED staff had removed from the room any items that were considered harmful for the patient. The interview revealed the cabinet doors were not locked.

Interview with staff ED RN #9 on 1/18/2012 at 1930 revealed she worked as triage and staff RN. The interview revealed everything that can be moved is moved out of the room to safely secure the room. The interview revealed after the event she was told in starting line up (pre shift) the special needs identified for a SI patient such as 1:1 sitter and clearing the room for safe security. The interview revealed if the patient is calm they may not use the 1:1 sitter.

Interview with ED staff RN #1 on 12/19/2012 at 0930 revealed she was still in orientation which would be completed on 1/20/2012. The interview revealed she was assigned the care of patient #1 on 12/11/2011 when the hanging event occurred. The interview revealed on 12/11/2011 she had a preceptor assigned with her. The interview revealed the preceptor went in with her to complete her assessment. The interview revealed the patient contracted for safety during the assessment. The interview revealed contract for safety meant the patient would not harm himself or others while in the ED and he would call if he needed help. The interview revealed she told patient #1 the door would have to stay open. The interview revealed when the patient contracted for safety the room did not have be safely secured. The interview revealed the patient had not been examined by a physician or the psychiatric A-Team when the patient contracted for safety. The interview revealed assessment of the patient was done with routine walking by the room but this was not documented. The interview revealed she charted when the A-Team was at the beside with the patient at 2235. The interview revealed she went into room 17 to assist another staff member. The interview revealed when she came out of the room she saw room 15's door was shut and the call light was blinking above the door. The interview revealed she immediately went into room 15 and found the patient hanging by the call light cord attached to the light fixture. The interview revealed security officer #1 was the first to respond to her call for help. The interview revealed since the event, blinds are outside the windows for rooms 15, 10 and 11. The interview revealed since the event, all SI patients have 1:1 staff observation. The interview revealed the policy on 12/11/2011 was that if the patient contracted for safety the patient did not need 1:1 observation and only needed to be visible and no one needed to be in the room with the patient. The interview revealed before the hanging event items were removed from the room only if the patient was violent. The interview revealed now a SI patient had 1:1 sitters at all times even if the patient contacted for safety. The interview revealed now all items are taken out of the room that may be a potential harm to the patient even if the patient contracts for safety. The interview revealed patient #1 was her first SI patient.

Interview with the ED director on 1/19/2012 at 0950 revealed the staff are to follow the ED policy for assessment/reassessment and then follow the nursing house wide policy for the care of the suicidal patient. The interview revealed after the hanging event it was noted there was confusion with the staff regarding what policy to follow. The interview revealed all staff was educated that all SI patients are assigned 1:1 staff.

Interview with with ED Charge nurse #3 on 1/19/2012 at 1000 revealed on 12/11/2011 during the hanging event, he was assigned as charge nurse for the ED. The interview revealed policy during the December 2011 event was if a SI patient contracted for safety, a note was put on the chart, items were removed from the room for safety and the patient did not need to 1:1 observation.

Interview with ED staff RN #10 on 1/19/2012 at 1040 revealed she was the triage nurse on 12/11/2011 during the shift of the hanging event. The interview revealed the patient was identified as a SI patient and he contracted for safety with her while in triage. The interview revealed contract for safety means if a patient has a plan for suicide the patient "promised he would not harm staff or self while" in the ED. The interview revealed she notified the Charge RN #3 that patient #1 was a SI and HI patient. The interview revealed the assigned ED staff RN will have the patient contract for safety also. The interview revealed when a patient contracts for safety the door to the room and the miniblinds are left open. The interview revealed on an SI patient that contracts for safety or a SI patient that does not, all items that could be harmful are removed from the room except the call bell. The interview revealed there is no difference between a SI patient contracts for safety and a SI patient that does not. The interview revealed there has been no change about the call light since the event. The interview revealed since the hanging event all SI patients with or without contract for safety have 1:1 staff assigned.

Interview with the ED Director on 1/19/2012 at 1140 revealed during the review and discussion regarding the sentinel event it was recognized there was confusion between the ED policy for assessment/reassessment and the in house nursing policy for care of the SI patient. The interview revealed the policies had been revised but were not approved at this time. The interview revealed even with the in house nursing policy for the care of the SI patient, the room is still to be for safely secured. The interview revealed the staff did not follow the policy to safely secure room 15 on 12/11/2011 when patient #1 used the call light cord to hang himself.

Interview with Risk Management administrative staff on 1/18/2012 at 1815 revealed work orders had been sent on 12/19/2012 to change the mini blinds and place locks on the cabinets for rooms in the ED. The interview revealed the staff thought the work orders had been completed by one person and the other person thought someone else had completed the work order. The interview revealed the staff was not aware the work orders had not been completed until the surveyor's observation on 1/18/2012 at 1115. The interview revealed the ED manager sent the work order and was expected to follow up on completion of the order.

Based on policy review, medical record review, and staff interview, the hospital staff failed to ensure a time limited restraint order was obtained for 2 of 3 sampled patients that were restrained for management of behaviors (#10 and #9).

The findings include:

Review of current hospital policy entitled "Safety - Restraint and Seclusion" revised 12/2010 revealed, "...1) Restraint or seclusion for management of violent or self-destructive behavior is implemented (based on RN assessment) when the patient's behavior jeopardizes the immediate physical safety of the patient, staff or others; patient is unwilling or unable to control his/her violent or self-destructive behavior. 2) The following are required when restraint or seclusion is used for management of violent or self-destructive behavior: ...e) Order may only be renewed in accordance with the following limits for up to a total of 24 hours (no standing order or PRN orders): i) 4 hours for adults 18 years of age or older. ..."

1. Closed medical record review on 01/19/2012 for Patient #10 revealed a 50 year-old female that presented to the emergency department (ED) on 01/15/2012 at 1636 with a chief complaint of panic attacks times four today." Triage notes at 1646 recorded "Patient reports talking out of my head, my eyes blinking and jumping and stuff, hurts in my chest and hard for me to breathe." Review of nursing notes at 1726 revealed the patient was "hollering and acting out." Further review revealed the patient received Geodon (medication for behavior) 20 milligrams intramuscular (IM) at 1854. Nursing notes at 1908 revealed the patient continued to "holler and hyperventilate...Patient escalating and screaming....Patient refuses to cooperate and continues same behavior. (Charge Nurse) aware and decides for safety reasons, patient requires restraints and forceful removal from floor onto a stretcher. Patient moved with assist to stretcher and four point leather restraints placed on patient. During entire episode, patient fighting, biting and screaming." Review of a physician's order dated 01/15/2012 at 1908 revealed the restraint order was for "Non-Violent/Non-Destructive Behavior." Further review revealed the rational for the use of restraints was "attempting to get out of bed." Review of the order revealed no documentation of a time limit for the duration of the restraint.

Interview on 01/19/2012 at 1150 with the ED Nurse Manager revealed restraint orders must contain a time limit for the intervention. Interview confirmed there was no documentation of a time limit for the duration of restraints on the 01/15/2012 restraint order.

2. Closed medical record review for Patient #9 revealed a 50 year-old male that presented to the ED on 12/25/2011 at 0005 via police. Review of triage notes at 0008 recorded the police brought the patient to the ED for evaluation. Triage nurse further recorded the patient was combative, agitated and "smells of alcohol." Nursing notes at 0123 documented "Attempted to start an IV (intravenous line) and was unable to get the patient to cooperate. Security called and it required 5 people to restrain the patient so that lab work could be drawn." Review of physician's orders revealed an electronic entry dated 12/25/2011 at 0045 for "Restraint - Behavioral - Adult." Further review of the restraint order revealed no documentation of a time limit for the duration of the physical restraint.

Interview on 01/19/2012 at 1255 with the ED Nurse Manager revealed restraint orders must contain a time limit for the intervention. The staff member stated there should be a restraint order form (handwritten) that is used when a restraint is ordered. The staff member stated there was no evidence the handwritten restraint order was done. Interview confirmed there was no documentation of a time limit for the duration of restraints on the 12/25/2011 restraint order.

Based on policy review, closed medical record review and staff interview the ED nursing staff failed to monitor a patient in fourpoint restraint (restrained for management of behaviors) per the hospital policy in 1 of 3 behavioral patients restrained (#1).

The findings include:

Review of current hospital policy entitled "Safety - Restraint and Seclusion" revised 12/2010 revealed, "...1) Restraint or seclusion for management of violent or self-destructive behavior is implemented (based on RN assessment) when the patient's behavior jeopardizes the immediate physical safety of the patient, staff or others; patient is unwilling or unable to control his/her violent or self-destructive behavior. 2) The following are required when restraint or seclusion is used for management of violent or self-destructive behavior: ...i) Periodic monitoring is conducted with behavior, interventions, and patient care documented every 15 minutes by nursing staff in the Restraint Record/Electronic Medical Record. ..."

Closed medical record review of Patient #1 revealed a 43 year old who presented ambulatory to the Emergency Department (ED) on 12/11/11 at 2059 with a chief complaint of suicidal ideation with a plan, homicidal ideation and history of suicide attempts. Record review revealed the patient was placed in fourpoint restraints on 12/11/2011 at 2306 after a suicide attempt by hanging. Record review revealed no documentation of assessment from 12/11/2011 at 2331 until 12/12/2011 at 0027 (56 minutes).

Interview with administrative ED nursing staff on 1/19/2011 at 1140 revealed documentation of monitoring a patient in restraints for behavior should be completed every 15 minutes. The interview revealed there was no documentation available of monitoring of patient #1 from 12/11/2011 at 2331 until 12/12/2011 at 0027.

Based on review of hospital policy, closed medical record review, observations, facility investigative findings review/facility timeline review and staff interview, the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff assessed, supervised and monitored suicidal patients in the emergency department to ensure a safe environment.

The findings include:

1. The Emergency Department (ED) nursing staff failed to assess and monitor a suicidal patient.

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

Based on policy and procedure review, facility investigative findings review/facility timeline review, closed medical record review, observations and staff interviews, the Emergency Department (ED) nursing staff failed to assess and monitor a suicidal patient in 3 of 6 suicidal patients reviewed (#1, #5 and #3).

The findings include:

Review of Policy Emergency Services "ASSESSMENT/REASSESSMENT IN THE EMERGENCY DEPARTMENT" reviewed and revised 8/2011 and approved August 4, 2011, revealed "Needs are prioritized as follows:...b) Category II Urgent: Cases that are urgent in nature but not life=threatening. Reassessment is performed every hour or as needed...3) Risk of suicide is assessed in the triage process. a) The patient is asked the following: i) Are you having thoughts of hurting yourself or someone else? b) If the answer is yes's a behavioral health assessment team referral is initiated. c) The patient is taken immediately to an observation area for patients at risk for suicide. d) The triage nurse alerts the charge nurse for 1:1 assignment of staff...The following precautions are implemented: iv)The room/immediate environment is cleared of all potentially dangerous articles such as glass objects, electrical cords, needle boxes, gloves, cloth restraints. etc...f) The patient is medically screened by the ED physician, who determines the need for behavioral assessment. g) The behavioral Assessment Counselor performs the psychological component of the Medical Screening exam (MSE.) h) The Assessment Counselor makes recommendation for treatment based on findings...j) The house-wide policy: Nursing : Care of the suicidal patients will be followed."

Review of policy "Nursing Suicidal Patients, Care of" revised 8/11 and approved August, 2011 revealed "2) The actively suicidal patient is within view of a staff member at all times...5) The patient's room is cleared of all potentially dangerous objects. a) If blinds are present, they are maintained in an open position unless personnel is being provided and there is staff with the patient...c) The needle boxes and gloves are removed...8) The patient, who contracts/agrees to call the nurse if he/she develops feelings of imminent self-harm is no longer kept in sight of staff."

Review of the facility investigative findings revealed an Incident Report documenting an incident occurring on `12/11/1022 at 2253 involving an attempted suicide in the Emergency Department by patient #1. Further review revealed a narrative completed by Security Officer #1. Review of the narrative revealed "On the date and timed recorded, while making a security check in the Emergency Department, I observed name of staff nurse #1 of (Name of hospital) enter room 15 and immediately begin to scream. I entered the room and witnessed a white male hanging from the lighting fixture attached to the ceiling. The bed and the lighting fixture was positioned in a way that allowed his body to be fully hanging in the air. He looked to be unresponsive and blue in the face and I immediately assisted to help lift and hold the subject up. At this time unknown staff entered the room and cut the cords from around the subjects neck. I assisted in laying the patient into the bed and secured the area while staff worked on the patient". Further review of the findings revealed copies of photographs of Room 15 after the incident. Review of photograph #2 revealed wall mounts and wall attachments (oxygen regulators suctioning canister with tubing, etc) secured to the walls. Review of the findings revealed work order # 121448 dated 12/19/11 at 1044 to"Move mini blinds to outside of the rooms and place locks on all cabinets" for rooms 10, 11, and 15. Review revealed a second work order #121448A to "Move mini blinds to outside of the rooms and place locks on all cabinets" for rooms 10, 11 and 15.

Closed medical record review of Patient #1 revealed a 43 year old who presented ambulatory to the Emergency Department (ED) on 12/11/11 at 2059 with a chief complaint of suicidal ideation with a plan, homicidal ideation and history of suicide attempts. Record review revealed the patient was triaged at 2105 acuity 2. Record review revealed the triage nurse (Staff nurse #2) notified the Charge Nurse (Staff nurse #3) that the patient had "Confirming Thoughts of Hurting Self and Others..Suicide Precautions Initiated". Further review of triage documentation revealed "Pt (patient) reports suicidal plan to "lay on train tracks or step in front car" Pt able to contract for safety while in the ED". Record review revealed the patient was escorted by a nursing assistant to a room in the ED at 2112. Record review revealed documentation by the NA "Pt (patient) aware to use call bell for needs". Record review revealed the assigned nurse (Staff nurse #1) made contact with the patient between 2119 and 2130. Record review revealed documentation by Staff nurse #1 "pt sts (states) he had an argument with his mother over rent and "my temper got the best of me and I threatened to hurt her and myself...I just want something quick, lay in front of a train or step in front of a car" Pt agreed to contract for safety while in the ED." Documentation by staff nurse #1 revealed "(+) call bell within reach by." Medical record review revealed no further documentation until 2235 staff nurse #1 "Assessment Team at bedside." Record review revealed the next documentation at 2300 "Nurse (name of Nurse #1) called out for help into room 15. Pt found with call bell cord tied to exam light on ceilings down around Pt's neck. Pt was unconscience (unconscious). Cord was cut...SALINE-LOCK INSERTED - 12/11/2011 2301 20 ga (gauge) right foreman following 1 attempt." Record review revealed at 2306 "Restraints, fourpoint extremity applied as orders by (name of physician) and in accordance with hospital policy. Reason for restraints: pt suicide attempt." Record review revealed on 12/12/11 at 0021 four point extremity reassessment...Neck no neck tenderness. Pt has circumferential ligature mark around neck from attempt suicide by hanging".Record review revealed at 0130 on 12/12/2011 a "late entry" by staff nurse #1 "Late note: upon exiting room 17 I noticed the pt door to room 15 was closed all the way and the call light was flashing above the door. I immediately entered pt room and found pt hanging from ceiling light by call bell cord. I ran to pt and hoisted him into the air and began to scream for help. (Name of security officer #1) from security entered the room and assisted with lifting the patient...Pt was unconscious and face had turned blue. the call light cord was cut from pt neck. Dr. (name of physician) was at bedside and assessment and life saving measures initiated. After the pt was transferred to unit I spoke with (name of Psychiatric team member) from the assessment team and she stated she "had been in pt room and pt requested his clothing because he wanted to leave." She stated she "exited the pt room to speak with (name oaf the physician's Assistant) taking care of the pt and the door was open upon her exit from the room. (name of Psychiatric team member) stated "It was 5 mins or less that I left the room and I heard you yell for help". Record review failed to reveal the time of the medical screening was initiated and completed. Review of the documentation by the physician revealed the patient was "(+) homicidal ideation's, (+) suicidal ideation's, (+) emotional stress and (+) depression." Further record review revealed on 12/11/2011 at 2231 by BBB (psychiatric team member) "ASSESSMENT TEAM NOTE: A-Team w/pt (with patient) at this time." Record review revealed documentation by (name of psychiatric team member) at 2251 "...Discussed inpt (inpatient) psych admit w/pt. Pt requested clothes to leave. Advised pt he would not be able to leave. A-Team left to speak w/(name of PA) and advised of pt wanting to leave. (Name of PA) agreed to speak w/pt about staying for inpt psych admit. Discussed petitioning pt d/t (due to) SI/HI (suicidal ideation and homicidal ideation). A-Team will complete IVC (involuntary commitment)." Record review revealed patient #1 was assessed by staff nurse #1 at 2119 and no further documentation by staff nurse #1 of an assessment.

Observation during tour of the ED on 1/18/2012 at 1115 revealed Room 15 with miniblinds located in the room on the window. Observation revealed no locks on cabinets in room 15. Observation revealed packages of gauze "kerlix". Observation of room 17 revealed blinds on the outside of the window and a staff member by the bedside of the patient.

Interview with ED Director during tour on 1/18/2012 at 1115 revealed there had been a "near miss" with a psychiatric patient in December 2011 involving room #15. The interview revealed the event had been made a sentinel event.

Interview with ED staff RN #4 on 1/18/2012 at 1300 revealed room 17 in the ED was considered a safe/secure room for psychiatric patients to go to. The interview revealed all potential hazards (monitors with cords, cables cords, etc) are removed from the room before the patient goes in. The interview revealed the mini blinds are on the outside of the window and cabinets in the room have locks.

Interview with ED staff RN #5 on 1/18/2012 at 1315 revealed room 17 is considered the room used for patients with a psychiatric diagnosis. The interview revealed room 17 is close to the nursing station. The interview revealed all cords and equipment is removed from the room before the patient goes in. The interview revealed when room 17 is full rooms 15, 10, and 11 are used.

Interview with ED staff RN #6 on 1/18/2012 at 1330 revealed the nurse uses their judgement if the patient needs 1:1 ( 1 staff member to 1 patient) observation. The interview revealed the psychiatric patient is placed in a room close to the nurses/ station. The interview revealed "anything that can leave the room" is taken out before the patient goes in. The interview revealed the door and the window are left open to view the patient.

Interview with administrative risk management staff on 1/18/2012 at 1400 revealed there was a sentinel event identified on 12/11/2011 when patient #1 while in the ED used the call light cord and hung himself from the light fixture in the room.

Interview with ED staff RN #7 on 1/18/2012 at 1640 revealed the policy for psychiatric patient in the ED was to remove anything that could be harmful to the patient from the room. The interview revealed the patient is not left alone. The interview revealed when a psychiatric patient with suicidal ideation's (SI) is identified at triage the triage nurse calls the charge nurse to let them know a psych patient has been identified. The interview revealed the patient is "never" left alone. The interview revealed the ED nursing Assistant at triage will go with the patient to the assigned ED room. The interview revealed patients with SI and HI (homicidal ideation's) are assigned 1:1 and it may be the patient's family, hospital staff or the police department observing the patient. The interview revealed the 1:1 assigned will be in the doorway of the room. The interview revealed since an event in December 2011 the starting line up (begriming of the shift meeting) it has been reinforced all SI/HI patients are 1:1. The interview revealed the staff must remove call bell cord, monitors, needle boxes and anything to make the room safe/secure from anything the patient could use to harm themselves.

Interview with ED staff RN #8 on 1/18/2012 at 1840 revealed if a patient has SI the staff must remove all wires, cords call bell cord, needle boxes from the room so it will safe and secure. The interview revealed the miniblinds are left open. The interview revealed a SI patient is 1:1 observation meaning some one must sit with the patient at all times. The interview revealed the 1:1 staff must sit at the door or doorway but must be in a place to ensure the room door a can not be shut. The interview revealed when an SI patient is identified the charge nurse or staff nurse may request 1:1 staff. The interview revealed since the event in December 2011 when a patient hung themselves, the staff has been educated that all SI patients are 1:1 constant observation.

Interview with unit coordinator (UC) on 1/18/2011 at 1910 revealed since the event in December 2011 of the hanging patient all SI patients are suppose to be 1:1 "100%". Before the event the SI patient only needed to be in site of nurses at the station. The interview revealed if the SI patient is 1:1 the staff does not remove everything from the room because not everything may be a threat to the patient. The interview revealed the 1:1 staff are located inside the room and not in the doorway. The interview revealed the triage nurse will let her know when there is a SI patient. The interview revealed based on the patient she will decide if items are to be removed from a room. The interview revealed if the patient escalates items will then be removed from the room to make it safe. The interview revealed approximately one week after the hanging event there was a meeting in which it was decided that all SI patients would be 1:1 observations. The interview revealed not all SI patients have a 1:1 staff assigned presently. The interview revealed they are not practicing 100% of policy for 1:1 staff assignment. The interview revealed there had been discussion in December 2011 of changing the miniblinds from inside the room to the outside of the room. The interview revealed this change had not occurred.

Interview with Nursing Assistant (NA) #1 on 1/18/2012 at 1920 revealed she was a float pool NA. The interview revealed she had staffed 1:1 observation in the ED. The interview revealed she was located in the room by the bedside. The interview revealed the ED staff had removed from the room any items that were considered harmful for the patient. The interview revealed the cabinet doors were not locked.

Interview with ED staff RN #9 on 1/18/2012 at 1930 revealed she worked as triage and staff RN. The interview revealed when a patient was identified as a SI patient she notified the charge nurse of this. The interview revealed everything that can be moved is moved out of the room to safely secure the room. The interview revealed after the event she was told in starting line up (pre shift) the special needs identified for a SI patient such as 1:1 sitter and clearing the room for safe security. The interview revealed if the patient is calm they may not use the 1:1 sitter.

Interview with ED staff RN #1 on 12/19/2012 at 0930 revealed she was still in orientation which would be completed on 1/20/2012. The interview revealed she was assigned the care of patient #1 on 12/11/2011 when the hanging event occurred. The interview revealed on 12/11/2011 she had a preceptor assigned with her. The interview revealed when she went to the room 15 an NA was with patient #1 assisting him with changing clothes to a gown. The interview revealed the preceptor went in with her to complete her assessment. The interview revealed the patient was calm. The interview revealed the patient contracted for safety during the assessment. The interview revealed contract for safety meant the patient would not harm himself or others while in the ED and he would call if he needed help. The interview revealed she told patient #1 the door would have to stay open. The interview revealed when the patient contracted for safety the room did not have be safely secured. The interview revealed the patient had not been examined by a physician or the psychiatric A-Team when the patient contracted for safety. The interview revealed assessment of the patient was done with routine walking by the room but this was not documented. The interview revealed she charted when the A-Team was at the beside with the patient at 2235. The interview revealed she went into room 17 to assist another staff member. The interview revealed when she came out of the room she saw room 15's door was shut and the call light was blinking above the door. The interview revealed she immediacy went into room 15 and found the patient hanging by the call light cord attached to the light fixture. The interview revealed security officer #1 was the first to respond for her calls for help. The interview revealed since the event blinds are outside the windows for rooms 15, 10 and 11. The interview revealed since the event all SI patients have 1:1 staff observation. The interview revealed the policy on 12/11/2011 was that if the patient contracted for safety the patient did not need 1:1 observation and only needed to be visible and no one needed to be in the room with the patient. The interview revealed before the hanging event items were removed from the room only if the patient was violent. The interview revealed now a SI patient had 1:1 sitters at all times even if the patient contacted for safety. The interview revealed now all items are taken out of the room that may be a potential harm to the patient even if the patient contracts for safety. The interview revealed patient #1 was her first SI patient.

Interview with the ED director on 1/19/2012 at 0950 revealed the staff are to follow the ED policy for assessment and then follow the nursing house wide policy for the care of the suicidal patient. The interview revealed after the hanging event it was noted there was confusion with the staff regarding what policy to follow. The interview revealed all staff was educated that all SI patients are assigned 1:1 staff.

Interview with with ED Charge nurse #3 on 1/19/2012 at 1000 revealed on 12/11/2011 during the event with hanging event he was assigned as charge nurse for the ED. The interview revealed he did not remember if anyone notified him that patient #1 was SI patient. The interview revealed policy during the December 2011 event was if a SI patient contracted for safety a note was put on the chart, items were removed from the room for safety and the patient did not need to 1:1 observation.

Interview with ED Triage RN #2 on 1/19/2012 at 1040 revealed she was the triage nurse on 12/11/2011 during the shift of the hanging event. The interview revealed the patient was identified as a SI patient and he contracted for safety with her while in triage. The interview revealed contract for safety means if a patient has a plan for suicide the patient "promised he would not harm staff or self while" in the ED. The interview revealed she notified the Charge RN #3 patient #1 was a SI and HI patient. The interview revealed the assigned ED staff RN will have the patient contract for safety also. The interview revealed when a patient contracts for safety the door to the room and the miniblinds are left open. The interview revealed on an SI patient that contracts for safety or a SI patient that does not, all items that could be harmful are removed from the room except the call bell. The interview revealed there is no difference between a SI patient contracts for safety and a SI patient that does not. The interview revealed there has been no change about the call light since the event. The interview revealed the policy and procedure is being revised. The interview revealed since the hanging event all SI patients with or without contract for safety have 1:1 staff assigned.

Interview with the ED Director on 1/19/2012 at 1140 revealed during the review and discussion regarding the sentinel event it was recognized there was confusion between the ED policy for assessment/reassessment and the in house nursing policy for care of the SI patient. The interview revealed the policies had been revised but was not approved at this time. The interview revealed even with the in house nursing policy for the care of the SI patient, the room is still to be for safely secured. The interview revealed the staff did not follow the policy to safely secure room 15 on 12/11/2011 when patient #1 used the call light cord to hang himself.

Interview with Risk Management administrative staff on 1/18/2012 at 1815 revealed work orders had been sent on 12/19/2012 to change the mini blinds and place locks on the cabinets for rooms in the ED. The interview revealed the staff thought the work orders had been completed by one person and the other person thought someone else had completed the work order. The interview revealed the staff was not aware the work orders had not been completed until the surveyor's observation on 1/18/2012 at 1115. The interview revealed the ED manager sent the work order and was expected to follow up on completion of the order.



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2. Closed medical record review of Patient #5 revealed a 40 year-old male that presented to the ED on 01/08/2012 at 1640 with "Patient states he has been feeling very depressed-confirms SI (suicide ideations)." Review of triage notes at 1650 recorded the patient requests assistance for suicidal ideations and "reports thinking about killing himself; reports wanting to jump in front of a car or off a bridge." Review of physician's notes at 1733 recorded "Patient reports that he is thinking about killing himself by jumping in front of a car or jumping off a bridge. He has a history of suicide attempt in the past by trying to jump off a bridge but the police stopped him. Patient reports that he is seeing things and hearing things that are not there." Review of a behavioral health screening assessment recorded by a mental health counselor at 1743 revealed "Patient states that he is suicidal with a plan to jump from a bridge or in front of a car. Denies HI (homicidal ideations). Patient also admits to AH (auditory hallucinations) and VH (visual hallucinations). Patient cannot contract for safety at this time." Further review revealed no evidence a staff member (sitter 1:1) was assigned to monitor the patient in the ED after identification of suicide ideations with a plan for suicide action. Record review revealed the patient was admitted to the hospital's behavioral unit on 01/09/2012 at 1211.

Interview on 01/19/2012 at 1420 with the ED Charge #2 triage nurse for Patient #5 revealed she was the Charge Nurse on duty when this patient presented to the ED on 01/08/2012. The staff member reviewed the ED record and confirmed there was no evidence of a staff member assigned to monitor the patient after he was identified as having suicide ideations. The staff member stated there was a "heightened awareness" by staff in the ED after an incident in December with a patient that presented with suicide ideations. The nurse stated all patients that present to the ED with identified suicide ideations/plans should have a staff member assigned to monitor the patient at all times. The nurse was unable to explain why there was no staff member assigned to monitor Patient #5 while in the ED. Interview confirmed nursing staff failed to follow the hospital's policy.

Interview with the ED director on 1/19/2012 at 0950 revealed the staff are to follow the ED policy for assessment and then follow the nursing house wide policy for the care of the suicidal patient. The interview revealed after the hanging event it was noted there was confusion with the staff regarding what policy to follow. The interview revealed all staff was educated that all SI patients are assigned 1:1 staff.


2. Closed medical record review of Patient #3 revealed a 45 year-old male that presented to the ED on 12/28/2011 at 2139 via ambulance. Review of nursing notes at 2148 recorded the patient states he "drank too much and just wants to sleep." Review of physician's orders revealed an order for cardiac monitor with pulse oximetry (monitoring devices with cords). Notes at 2153 documented "Patient now saying that he was trying to hurt himself. Stated he wanted 'to die.'..." Notes at 2205 recorded the Charge Nurse was notified that the patient was suicidal. Record review revealed a "Misc (miscellaneous) Nursing Order" documented at 2220 that recorded "Patient can remain in room alone, while being connected to the monitor." Further review of the record revealed the patient discontinued intravenous lines himself at 0000 and again on 12/29/2012 at 0153. Nursing notes on 12/29/2012 at 0109 recorded the Physician's Assistant was notified that the patient was wanting to go home. Review of the record revealed a behavioral screening assessment conducted by a behavioral health counselor at 0119 that recorded "Patient placed on petition (for involuntary commitment) by (physician) at request of (Physician's Assistant) due to patient wanting to leave but reporting SI (suicide ideations)." Review of a physician's note at 0120 revealed "Patient placed on petition by (physician's name) due to wanting to leave but also reporting SI with plan to OD (overdose) on ETOH (alcohol)." Further review revealed the patient was involuntarily admitted to the hospital's behavioral unit on 12/29/2011 at 0458. Further review revealed no evidence a staff member (sitter 1:1) was assigned to monitor the patient in the ED after identification of suicide ideations with a plan for suicide action.

An interview was attempted with the nurse that recorded the order that the patient could remain in the room alone. The nurse was not available for interview.

Interview on 01/19/2012 at 1125 with the ED Nurse Manager revealed all patients that present to the ED with suicide ideations are to have a staff member assigned to monitor the patient while in the ED. The staff member reviewed Patient #3's ED record and was unable to explain why there was a nursing order for this patient to remain in the room alone and no staff member assigned to monitor the patient. The staff member stated that it was possible that the police were with the patient in the ED. The staff member confirmed there was no evidence in the record that police remained with the patient in the ED.

Interview on 01/19/2012 at 1420 with an ED Charge RN #2 revealed there was a "heightened awareness" by staff in the ED after an incident in December with a patient that presented with suicide ideations. The nurse stated all patients that present to the ED with identified suicide ideations/plans should have a staff member assigned to monitor the patient at all times. The staff member stated there are no exceptions. The nurse stated the assigned staff member should be "our staff, nursing assistants" and that police are not substituted as sitters. Interview confirmed nursing staff failed to follow the hospital's policy.

Interview with the ED director on 1/19/2012 at 0950 revealed the staff are to follow the ED policy for assessment and then follow the nursing house wide policy for the care of the suicidal patient. The interview revealed after the hanging event it was noted there was confusion with the staff regarding what policy to follow. The interview revealed all staff was educated that all SI patients are assigned 1:1 staff.

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