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Based on observation, interview and record review, the Condition of Participation for Patient Rights was not met as evidenced by the hospital's failure to provide sufficient observation and interventions to ensure each patient's rights were protected.

Refer to:

A-144: Failure to ensure that patients receive care in a safe setting.

Based on observation, interview and record review Emergency Department (ED) staff failed to effectively assess for the use of nasal cannula tubing for the delivery of oxygen used by a psychiatric patient with suicidal ideation; and failed to assign qualified staff to provide consistent direct observation of the patient resulting in the patient attempting self-harm by strangulation. (Patient #2) Findings include:

On 4/16/19 at 21:13 Patient #2 was brought to the ED via ambulance after ingesting an overdose of prescribed medications to include unknown amounts of Atenolol and Cardizem (both used to treat high blood pressure and cardiac symptoms); and Klonopin (sedative also used to treat seizures, anxiety and panic disorder). Per Emergency Documentation the triage assessment states upon arrival Patient #2 was "....somnolent, arousable only to painful stimuli..." however able to maintain his/her airway. Because of the drugs ingested, Patient #2 was placed on a cardiac monitor to observe changes in heart rate and blood pressure. On 4/17/19 at 01:59 while sleeping, Patient #2's oxygen saturation and heart rate had decreased and the patient was provided oxygen via a nasal cannula at 2 liters. Due to an attempted suicide the patient was placed on 1:1 observations and when medically cleared the patient would be evaluated for a psychiatric admission. At approximately 10:55 AM on 4/17/19 Patient #2 was found to have tied and knotted the oxygen tubing around his/her neck, requiring it to be cut by staff. A red line was noted around the patient's neck, but oxygen level was at 98 % (normal /100%) and heart rate was stable.

Per interview on 6/26/19 at 10:10 AM, the day charge nurse confirmed on the morning of 4/17/19 s/he had requested a replacement of the present psychiatric technician who was assigned to provide 1:1 observation for Patient #2. "I wanted someone more present....better suited for the situation..." The charge nurse further stated the staff member assigned to this responsibility was "...standing across from the patient's room...", not sitting at the entrance to Patient #2's room as required. Per hospital policy Levels of Observation last reviewed on 2/24/17 which states " 2. One to One a. Continuous observation is ordered when a patient is at risk of harm to self or others. When this level of observation is indicated, the following will occur: 2. Staff responsibilities.... Maintain constant view of the patient....avoid placing barriers between staff and patient...Will not become engaged in active conversation with other patients or staff while assigned to the one-to-one. The patient on one-to-one needs will be the complete focus of the staff member doing one-to-one."

At approximately 09:00 on 4/17/19 a replacement was found to provide constant observations for Patient #2. At approximately 10:00 a case manager for the mental health agency who provides Patient #2 community services arrives to visit with Patient #2. The visiting case manager left Patient #2's room at approximately 10:30 around the same time a third staff member was relieving the second staff member. Per telephone interview on 6/26/19 at 9:00 AM, the third observer identified to be a Psychiatric Tech I confirmed s/he sat outside the door way of room #11 where Patient #2 was resting. It was further confirmed after visiting with Patient #2 the case manager engaged this employee and the previous observer in a distracting conversation at approximately 10:30 about charging Patient #2's cell phone. The Psychiatric Tech I further stated s/he had not observed any oxygen tubing including the nasal cannula in the patient's nose or connected to the oxygen outlet within Patient # 2's room. Also during the "hand-off" with the previous staff member s/he was not alerted to any special safety precautions when monitoring Patient #2, to include the use of oxygen tubing and cardiac monitor lines/cable for a patient who was recently actively suicidal. S/he also added they are not assigned to perform clinical responsibilities, it is not within the job description for Psych Tech I. Per interview on 6/25/19 at 10:00 AM, the ED Director also confirmed Level I Psychiatric Technicians perform essential functions associated with behavioral safety but are not responsible for performing vital signs and would not provide hands on medical care such as the application of oxygen or taking a patient's blood pressure.

The charge nurse did confirm when s/he entered Patient #2's room at 10:55 to prepare the patient for transfer to the East Wing by disconnecting Patient #2 from the cardiac monitor and oxygen, s/he observed the oxygen was still flowing and tubing was connected to the wall outlet. Upon further examination the charge nurse discovered hidden under the patient's hospital gown the nasal cannula oxygen tubing wrapped tightly around the patient's neck. Patient #2 did not respond to the nurse's greeting. The charge nurse called for help and the oxygen tubing was cut and removed. Patient #2 was assessed and examined for any possible injury sustained from the attempted strangulation. It was determined Patient #2 did not sustain injury and was hemodynamically stable with the exception of red marks embedded in the patient's neck.

Per hospital policy Suicide Risk Screening and Precautions last revised 6/1/2017 states: " Implementing Precautions: Emergency Department g. The risks presented by the physical environment shall be carefully assessed by nursing staff for all patients for whom suicide precautions have been initiated. 1. The level of patient observation should take into account the degree to which identifiable environmental risks have been addressed. 2. Efforts should be made to reduce the risk of patient self-harm through modification of the physical environment and/or the provision of adequate staff supervision." However, although Patient #2 was placed in a "safe room" within the ED, the additional caution for ligature risks were not acknowledged or addressed by nursing with supervised staff who were providing 1:1 observations. In addition, the form Suicide Precautions Environmental Risk Assessment was not completed by nursing for Patient #2 which allows staff to review and update environmental risks (to include medical equipment) and acknowledged by all staff taking responsibility for observations. The ED Director acknowledged on 6/25/19 at 10:10 AM staff had failed to follow hospital policy related to assuring the safety of the environment for Patient #2. Despite the significant suicide attempt made by Patient #2 prior to ED arrival, the patient's room had not been assessed for ligature risks to include both oxygen tubing and cardiac monitor cables/wires. The intent to ensure patient safety to include close monitoring and awareness of potential risks of self-harm by utilizing medical equipment did not occur during the provision of care for Patient #2.

Based on staff interview and record review, the hospital failed to fully develop and implement preventative actions to address deficient practice and opportunities for improvement, identified as a result of a significant adverse event associated with the care and services provided to a patient in the Emergency Department. Findings include:

On 4/22/19 a Root Cause Analysis (RCA) was conducted by members of the Quality and Safety Department; Emergency Services, Nursing and other staff directly associated with an incident that had occurred on 4/17/19 when a patient attempted self-harm by strangulation using oxygen nasal cannula tubing while on continuous 1:1 observation in the ED. It was not until this significant event had occurred when it was recognized psychiatric technicians assigned to provide 1:1 continuous observation were not being informed by nursing regarding individual patient safety concerns; the apparent difficulties ensuring staff appreciated the intent of hospital policies associated with the responsibilities when providing 1:1 continuous observation; and the failure of staff to consistently conduct suicide precautions environmental safety risk assessments.

Subsequent to the RCA, an Action Plan was developed. However, although communication was sent via email to all ED Nursing and Psychiatric Technicians specifying responsibilities associated with the need for environmental screening, a formal validation process beyond assuring emails were read was not evident. Changes were made to the 1:1 psych technician observation flow sheet, trials of forms are still in progress and although the initial test period was reported to be completed by 5/19/19, a final determination and potentially more revision continued as of 6/27/19.

It was further recognized the case manager for Patient #2 who is employed by Rutland Mental Health in the Community Rehabilitation and Treatment Program (CRT) visitation was upsetting to Patient #2, associating this case manager's visit and later actions and response by Patient #2. The communication to CRT staff was to be conducted by the hospital Senior Director of Social Work. When asked for evidence of communication with Rutland Mental Health only an email was noted to exist without any formal process to ensure CRT case managers would acknowledge to ED nursing staff and/or physician their intent to visit with a patient. A brief consultation with ED staff by the case manager, would help facilitate a safe and appropriate encounter with a patient. In addition, reporting off to ED staff after completion of the visit would also be an effective approach when maintaining a behavioral safety plan.

The RCA had also identified a need to revise the Suicide Precautions Environmental Risk Assessment (form 4130 A), however no date for completion has been identified and form revision has not been completed as of 6/27/19. The RCA and the plans to correct have not been fully implemented with specific expectations for dates of completion and a monitoring/auditing process to analyze the changes and actions are effective in assuring sustainability of patient safety in the ED.

Based on staff interview and record review, nursing staff in the Emergency Department failed to follow policy and procedures to ensure staff were appropriately prepared to provide 1:1 observations of a suicidal patient and failed to complete an environmental risk assessment to include potential ligature risks for 1 applicable patient. (Patient #2). There was also a failure of both ED physicians and nurses to remain compliant with completion of required documentation during the utilization of restraints and emergency involuntary medication as directed per ED policy and procedures.

1. Per hospital policy Suicide Risk Screening and Precautions last revised 6/1/2017 states: " Implementing Precautions: Emergency Department g. The risks presented by the physical environment shall be carefully assessed by nursing staff for all patients for whom suicide precautions have been initiated. 1. The level of patient observation should take into account the degree to which identifiable environmental risks have been addressed. 2. Efforts should be made to reduce the risk of patient self-harm through modification of the physical environment and/or the provision of adequate staff supervision." However, On 4/16/19 at 21:13 Patient #2 was brought to the ED via ambulance after ingesting an overdose of prescribed medications to include unknown amounts of Atenolol and Cardizem (both used to treat high blood pressure and cardiac symptoms); and Klonopin (sedative also used to treat seizures, anxiety and panic disorder). Per Emergency Documentation the triage assessment states upon arrival Patient #2 was "....somnolent, arousable only to painful stimuli..." but able to maintain his/her airway. Because of the drugs ingested, Patient #2 was placed on a cardiac monitor to observe changes in heart rate and blood pressure. On 4/17/19 at 01:59 while sleeping, Patient #2's oxygen saturation and heart rate had decreased and the patient was provided oxygen via a nasal cannula at 2 liters. Due to an attempted suicide the patient was placed on 1:1 observations and when medically cleared the patient would be evaluated for a psychiatric admission. At approximately 10:55 AM on 4/17/19 Patient #2 was found to have tied and knotted the oxygen nasal cannula tubing around his/her neck, requiring it to be cut by staff. A red line was noted around the patient's neck, but oxygen level was at 98 % (normal /100%) and heart rate was stable.

The physical environment for Patient #2 was not assessed as per ED policy. The Suicide Precautions Environmental Risk Assessment was not completed by nursing for Patient #2 which allows staff to review and update environmental risks (to include medical equipment) which must be reviewed and acknowledged by all staff taking responsibility for observations. The ED Director acknowledged on 6/25/19 at 10:10 AM staff had failed to follow hospital policy related to assuring the safety of the environment for Patient #2. Despite the significant suicide attempt made by Patient #2 prior to ED arrival, the patient's room had not been assessed for ligature risks to include both oxygen tubing and cardiac monitor cables/wires. As a result of this failure staff assigned to conduct 1:1 observations were not appraised by nurses of additional safety concerns. In addition, staff assigned to Patient #2 failed to provide continuous observations as directed in hospital policy Levels of Observation last reviewed on 2/24/17. The policy states: " 2. One to One a. Continuous observation is ordered when a patient is at risk of harm to self or others. When this level of observation is indicated, the following will occur: 2. Staff responsibilities.... Maintain constant view of the patient....avoid placing barriers between staff and patient...Will not become engaged in active conversation with other patients or staff while assigned to the one-to-one. The patient on one-to-one needs will be the complete focus of the staff member doing one-to-one." Per interview on 6/26/19 at 10:10 the day charge nurse in the ED confirmed a staff member who was providing 1:1 during the early hours of 4/17/19 from 7:15 to 9:00 was distracted at times and not sustaining observations in close proximity of the patient. In addition, during the "handoff" between staff assigned to observe the patient at approximately 10:30 were engaged in conversation with a case manager who had visited Patient #2. Patient #2 reported later to staff, the visit by the case manager had been significantly upsetting to her/him resulting in the emotional distress. Conversation and concerns between Patient #2 and the case manager were not noted by the 1:1 observers, nor were they able to identify a period in time when the patient was able to perform the attempted strangulation using the oxygen nasal annular tubing.

There was a failure of both nursing staff and ED physicians to complete necessary documentation during the application of restraints and emergency medications for 2 of 10 applicable patients (Patients # 3, 8):

1. Patient #3 was brought to the ED on 3/28/19 at 17:05 by police after being arrested and later expressing suicidal and homicidal ideation. Patient #3 became agitated and threatening and did not respond to multiple attempts by staff to de-escalate. Due to ongoing combative and threatening behavior 4 point restraints were ordered and applied at 18:25. The Patient Evaluation form must be completed within 1 hour of initiation of emergency procedures and completed by the ED physician or a specially trained RN. The date/time of the evaluation was not documented by the physician who conducted the 1 hour face to face. In addition, emergency involuntary medications Geodon 20 mg and Benadryl 25 mg
were administered intramuscularly to Patient #3. The nurse failed to document the time of administration of the medications on the Emergency Involuntary Procedures form.
2. Patient #8 was brought to the ED by police on 5/17/19 at 17:20. Patient #8 was described as belligerent, combative and threatening. Shortly after arrival involuntary emergency medications were administered to include Haldol 4 mg and Ativan 2 mg intramuscularly and 4 point restraints then applied at 17:25 and were discontinued at 19:05 The 1 hour face to face was not conducted until 19:30, 2 hours after the application of restraints. In addition, on the Nursing Restraint Flow Sheet nursing staff failed to describe the patient's actual behavior while in restraints. During the 15 minute monitoring from 18:25 to 18:55 a nurse documents " Non-compliant with disc.criteria" within the column on the form intended for staff to describe the actual behavior demonstrated by Patient #8 to justify the continued use of 4 point restraints. Per hospital policy Restraints and Seclusion: Behavioral last revised on 1/12/18 states: "6. Documentation for the use of Behavioral Restraint and/or Seclusion shall include: b. a description of the patient's behavior...." Per interview with the Quality Manager on 6/27/19 at 2:30 confirmed staff documentation was not meeting the intent of the hospital policy.