HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on clinical record review, hospital documentation review, policy review, and staff interviews for 1 of 3 sampled patients reviewed for ingestion of foreign bodies (Patient #10), the hospital failed to ensure the patient was cared for in a safe environment, was monitored per hospital policy, and that safety measures were effective to prevent ingestion of objects that requied several endoscopic removal procedures, which resulted in Immediate Jeopardy.

In addition, the hospital failed to ensure that a patient's level of sedation was assessed in accordance with physician orders (Patient #46), failed to ensure that the contents of a sharp's disposal box (used needles/syringes and medication) were not accessible to patients, and failed to conduct a thorough investigation when physical abuse was reported.


Please see A144 and A145

Based on clinical record review, hospital documentation review, policy review, and staff interviews for 1 of 3 sampled patients reviewed for ingestion of foreign bodies (Patient #10), the hospital failed to ensure the patient was cared for in a safe environment, was monitored per hospital policy, and that safety measures were effective to prevent ingestion of objects that required several endoscopic removal procedures, which resulted in Immediate Jeopardy.

In addition, the hospital failed to ensure that a patient's level of sedation was assessed in accordance with physician orders (Patient #46) and failed to ensure that the contents of a sharp's disposal box (used needles/syringes and medication) were not accessible to patients.



The findings include:

1. Patient #10's diagnoses included Schizoaffective disorder, Bipolar and PICA (eating disorder). Patient #10 presented to the Emergency Department (ED) on 7/12/22 with abdominal pain after swallowing 2 batteries in the community. Nurse's notes dated 7/12/22 at 7:15 PM noted patient presented to ED on a Police Hold (PEER) for evaluation of pain after swallowing 2 batteries and the patient stated they feel depressed and suicidal. Physician orders dated 7/12/22 at 7:22 PM directed one-to-one observation for safety to self. Review of the ED provider note dated 7/12/22 at 9:06 PM noted the patient had a history of PICA. On 7/13/22 at 9:02 AM the patient underwent an upper GI Endoscopy for removal of 2 batteries in the stomach and proximal jejunum. Review of the clinical record noted the patient was admitted to the psychiatric inpatient unit. Review of the psychiatry notes dated 7/13/22 at 7:02 PM noted in weighing the patient's presenting symptoms and behaviors as well as the patient's risk and protective factors, the patient was at high risk for suicide in the emergency psychiatric setting due to the patient being depressed, extremely impulsive and had poor coping skills and required one-to-one supervision for suicide.

Review of Patient #10's clinical record and interview with the Nurse Manager of the ED, the Nurse Manager of the psychiatric unit and the Assistant Nurse Manager of the psychiatric unit on 9/7/22 at 10:00 AM noted the following:

a. Physician orders dated 7/12/22 at 7:22 PM directed that Patient #10 be maintained on a one-to-one (supervision) for safety to self. Review of the Psychiatry progress notes dated 7/15/22 at 4:27 PM noted the patient reported stomach pain and stated that the night after the endoscopy on 7/13/22 while in the ED, his/her clothes were returned, the patient found batteries in the pocket and swallowed them. The patient was transported to the ED for an evaluation and treatment. ED Nurse's notes dated 7/15/22 at 5:32 PM noted the patient reported swallowing 2 batteries yesterday, was complaining of abdominal pain, a sitter was at the bedside, and a safety check was completed. Nurse's notes dated 7/15/22 at 4:00 AM noted received report from PACU, unable to retrieve batteries during procedure. Review of the procedure report dated 7/16/22 at 2:57 AM noted no foreign body was observed in the stomach or duodenum. The report noted the Endoscope was not available for further evaluation of the small bowel for retrieval. The report further noted to resume previously tolerated diet, return to ED with close monitoring and to follow up with psychiatry for prevention of additional ingestions of foreign body. Patient #10 was then transferred back to the psychiatric unit. Interview with Observation Associate #1 on 9/9/22 at 10:00 AM stated that she was providing the one-to-one with the patient on 7/13/22 and she did not see the patient swallow anything. The Observation Associate further stated that they did not do an environmental safety checklist at the time of this incident, but now have implemented it and it includes a risk assessment and environmental risks for a patient at risk for self-harm. Interview with the ED Nurse Manager on 9/7/22 at 11:50 AM stated no investigation was completed to identify how the patient was able to get a battery and ingest it while on a one-to-one.

The hospital failed to ensure safety precautions were effective while P #10 was on a one-to-one observation while in the ED and the psychiatric unit.

b. ED Nurse's notes dated 7/16/22 at 6:38 PM noted that Patient #10 admitted to his/her one-to-one sitter that while in the bathroom, he/she took the metal piece out of the face mask and swallowed it. Review of the upper GI endoscopic report dated 7/16/22 at 11:34 PM noted the patient underwent an Endoscopy and an 8-centimeter (cm) mask wire was removed from the duodenal bulb extending to the first portion of the duodenum. The report recommendation was to ensure very close supervision to prevent foreign body ingestion and do not give masks with metal components in it. Patient #10 was then transferred back to the psychiatric unit. Interview with RN #7 on 9/8/22 at 1:45 PM stated that he informed the one-to-one sitter that the patient was on a one-to-one, was high risk for ingestion, and had to be watched at all times. RN #7 stated that he spoke to the sitter and the sitter told him that he did not go into the bathroom with the patient but stood at the door and saw the patient place their hands over their mouth and face. RN #7 further stated that he wasn't sure that the hospital policy for level of observation and a one-to-one meant that the staff had to be within arm's length of the patient. Interview with Observation Associate #2 on 9/9/22 at 10:20 AM stated that he brought the patient to the bathroom and remained at the door while the patient used the bathroom but does not recall telling the RN that the patient placed their hands over their face and mouth. Observation Associate #2 stated that he was aware that he must watch the patient at all times, but that he was not sure he needed to be within arm's length of the patient. Interview and review of the clinical record with the ED Nurse Manager on 9/7/22 at 11:35 AM identified that although the patient was on a one-to-one while in the ED, there was no documentation to indicate where the patient was located, any behaviors, or the patient's activity. The ED Nurse Manager stated that when a patient comes to the ED from the community a safety check is completed to ensure the patient has nothing to harm self or others. The ED Nurse Manager stated that when a patient is transferred from the psychiatric unit it is at the nurse's discretion to do a safety check. Additionally, the Nurse Manger stated that in August 2022, the ED environmental safety checklist and risk assessment for non-behavioral areas was implemented for patients who are at risk for self-harm. The ED Nurse Manager stated no investigation was completed to identify how the patient was able to get a wire out of a surgical mask and ingest it while on a one-to-one.

The hospital failed to ensure safety precautions were effective while P# 10 was on a one-to-one observation while in the ED and the psychiatric unit.


Between 7/16/22 and 8/22/22, Patient #10 remained hospitalized and swallowed objects 10 more times requiring endoscopic removal. The hospital failed to ensure that safety precautions were effective while the patient was in the ED and the psychiatric unit, failed to document monitoring observations to include location, activity, and behaviors, and failed to conduct investigations to determine how the patient was able to repeatedly ingest objects while hospitalized.


c. ED Nurse's notes dated 7/17/22at 3:08 PM noted Patient #10 disclosed that last night at change of shift he/she found a paper clip on the floor and when the PCA was sleeping, and the patient ingested the paperclip. An endoscopic report dated 7/17/22 at 8:46 PM noted a paperclip surrounded by food was found in the gastric body and was removed. ED Nurse's notes dated 7/18/22 at 12:00 PM noted per hospitalist, batteries were still visible on X-ray (from 7/13/22), will order medication to expedite bowel movement, and once batteries have been excreted the patient will return to the psychiatric unit. Interview and review of the clinical record with the ED Nurse Manager on 9/7/22 at 11:35 AM identified although the patient was on a one-to-one while in the ED, there was no documentation of monitoring observations to include location, activity, and behaviors, and there was no post-ingestion investigation.

d. Physician orders dated 7/22/22 at 11:36 AM directed Patient #10 to be on standard observation (observation of patient twice in one half hour). Nurse's notes dated 7/25/22 at 9:28 PM noted Patient #10 reported swallowing a wire from the surgical mask and 2 colored pencils and underwent an endoscopy on 7/26/22 at 2:00 AM for removal of 2 pencil halves and 2 mask wires. Interview with the Nurse Manager of the in-patient psychiatric unit on 9/7/22 at 11:30 AM stated that wires were removed from patient masks (unit wide) as an intervention around 7/25/22 and it was reported in staff huddles, but no formal education was provided to all staff. The Nurse Manager stated that she could not recall if staff checked patient rooms and garbage bins on the unit for masks with wires in them.

e. Nurse's notes dated 7/27/22 at 6:13 PM identified the patient reported that they ingested a wire from a surgical mask around 5:00 PM. ED Nurse's notes dated 7/27/22 at 7:47 PM noted patient complained of pain that worsened with palpation. The note further identified a sitter was at the patient's bedside in the ED. Review of the Endoscopy report dated 7/28/22 at 9:00 AM noted 2 metal mask wires were removed from the patient's third portion of the duodenum, with a recommendation to provide close observation to prevent further ingestions.

f. Nurse's notes dated 7/29/22 at 9:02 PM noted that Patient #10 reported that while in the ED on 7/27/22 and 7/28/22, the patient went to the bathroom unsupervised and took 2 metal pieces out of a surgical mask that was in the garbage. The patient reported abdominal pain and blood in stool and was transferred to the ED. Review of the Endoscopic report dated 7/30/22 at 2:08 AM noted 2 metal mask nose pieces were found in the gastric fundus and removed. And recommended to monitor the patient closely and keep patient away from metal objects and masks.

g. Physician progress notes dated 7/30/22 at 7:46 PM noted that the patient reported that around 5:30 PM he/she saw their roommate's masks with wires in them, impulsively took them and went into the bathroom and swallowed them. The note further identified that the patient complained of epigastric pain, and was transferred with a one-to-one sitter to the ED for evaluation. An Endoscopy report dated 7/30/22 at 11:26 PM noted a linear metallic white object from surgical mask was found in the stomach and was removed, and a linear metallic white object from a surgical mask was found in the second part of the duodenum and was removed. The recommendations from the endoscopy team noted the patient should be closely observed, one-to-one to prevent further foreign body ingestions, and remove all potential ingestible foreign bodies from room including masks.

Interview with the Psychiatric Nurse Manager and the ED Nurse Manager on 9/7/22 at 11:00 AM noted the GI physicians requested a meeting around the end of July to discuss a plan of care for Patient #10. Each department including psychiatry, ED, GI, and anesthesia met and developed a care plan to help reduce foreign body ingestions and standardized care across all care sites. Each department educated staff on the plan of care including that the patient would be on a one-to-one sitter, the environment would be modified to eliminate/remove foreign objects, reduce ingestible objects on the units, if transport is required, transport the patient only in a hospital gown, a one-to-one sitter will accompany the patient, provide verbal warning of swallowing behaviors to transport team, and to search the patient upon return to unit.

h. Physician progress notes dated 7/31/22 at 6:53 PM noted Patient #10 reported they just ingested another metal wire from a mask that the patient found in the trash can. The patient was transferred to the ED for evaluation and removal of the foreign object. An Endoscopy report dated 7/31/22 noted a linear metallic white object from a mask was found in the stomach and removed.

i. A significant event note dated 8/13/22 at 6:32 PM noted Patient #10 had an overwhelming urge to swallow something and found a new patient who "didn't know the rules", took the remote from the new patient, removed the battery, went to the bathroom, and swallowed it. The note identified that the patient reported they swallowed a AA battery. The MD was made aware, and the patient was transferred to the ED for evaluation and returned with a plan to return to the ED the next day for further treatment. Nurse's notes dated 8/14/22 at 9:13 PM noted patient was irritable upon assessment and refused medications and blood sugar checks. The patient was sent to radiology for an X-ray which identified that the AA battery the patient swallowed the day before was now in the patient's bowel, and the patient returned to the psychiatric unit.

j. Physician orders dated 8/13/22 at 8:36 PM directed Patient #10 to be on a one-to-one. Nurse's notes dated 8/14/22 at 9:13 PM noted the patient asked to speak to this writer and reported while in the shower that day, the patient took a toothbrush broke it and swallowed half of the toothbrush. The note further identified the remaining broken piece of the toothbrush was found in the bathroom shower. The MD was notified, and the patient was transferred to the ED for an evaluation. Review of the Endoscopy report dated 8/15/22 identified that the toothbrush was removed from the patient.

k. Physician orders dated 8/1/22 at 1:12 PM directed Patient #10 to be on a one-to-one. Physician progress notes dated 8/21/22 at 5:22 PM noted while the patient was outside, he/she found a face mask on the ground and brought it back to the unit. The note identified the patient later removed the wiring from the face mask and ingested it while alone in a room. The patient was transferred to the ED for imaging and GI consult. Review of the Endoscopy report dated 8/22/22 at 7:44 AM noted a mask wire was found in the gastric body and removed. Additionally, the report identified multiple diffuse erosions without bleeding were found in the duodenum bulb.

l. Physician orders dated 8/22/22 at 4:47 AM directed Patient #10 to be on a one-to-one observation for safety to self. Physician progress note dated 8/31/22 at 1:43 PM noted the patient ingested a small pencil that another patient left and gave the eraser to staff as evidence. Nurse's notes dated 8/31/22 at 1:55 PM noted the patient reported taking a "golf pencil" from the nursing station, then went into the bathroom and ingested it. The patient was transferred to a medical floor and underwent an endoscopic procedure on 9/1/22 at 3:53 PM for removal of a foreign body.

Interview with the Psychiatric Nurse Manager on 9/7/22 at 2:15 PM stated that staff are to be within arm's length of the patient and continually monitoring while they are on a one-to-one. The Nurse Manager stated that she did not do an investigation on how they patient was able to ingest foreign objects while the patient was on a one-to-one on 8/4/22, 8/13/22, 8/14/22 and 8/21/22.

Interview with Psychiatric MD #1 on 9/8/22 at 11:30 AM stated that Patient #10 had a history of ingestion, PTSD, and schizoaffective disorder. MD #1 stated that Patient #10 had an extremely complicated history and he worked with the patient regularly and the patient would identify he/she was motivated to return home and was very convincing that the ingestion was out of his/her system, so he ordered the patient to be on standard observation. MD #1 stated that they met as an interdisciplinary team in late July 2022 or early August 2022 to develop a behavior plan for the patient that included attending group, at times having courtyard privileges, and having hard candy or ice chips when the patient presents with cravings for swallowing foreign objects. MD #1 stated that in retrospect it was not a good rationale to have the patient on standard observations. MD #1 stated that since the August 4, 2022, incident of ingestion, the patient has been on a one-to-one observation and continued to have incidents of ingesting foreign objects.

Review of the hospital policy for Patient level of observations identified when a patient is on a one-to-one, the patient is continually monitored by staff, and remains within an "arm's length" of staff unless increased distance for aggression, agitation or infection prevention/control is indicated.

Immediate Jeopardy was identified on 9/8/22 at 2:00 PM for failure to maintain a safe environment and monitor the patient to prevent the swallowing of inanimate objects.

The hospital implemented an immediate corrective action plan which identified the following: The suicide risk screening, assessment and precaution policy, and the Patient Level of Observation (Psychiatry and non- Psychiatry) were reviewed by the organization. Nursing staff on the inpatient Psychiatric unit and the Emergency Department will be re-educated on patient observation consistent to the above policies. Hand off communication between patient observers for this patient will only occur in the patient's room. Hand off communication and review of the environment at change of shift and each transfer will be documented. The patient's care plan will be reviewed and updated on an ongoing basis and after any significant event. The patient's care plan will be audited after any significant event. Random audits will be conducted. On 9/9/22, the action plan was verified as implemented and Immediate Jeopardy was removed at 2:00 PM.


2. Patient #46's diagnoses included respiratory failure. Review of a physician's order dated 8/27/22 directed to administer Precedex 0.2 mcg/kg/hr titrate to goal Richmond Agitation Sedation Score (RASS) -1 to 0 drowsy, by 0.1 mcg/kg/hr no more frequently than every 30 minutes. The order directed minimum frequency of titration goal parameter assessment every 4 hours and/or pre/post dose changes.

Review of the patient's clinical record dated 8/ 28/22 for the period of 2:00 AM to 7:00 AM identified that the patient's hourly RASS was assessed and measured (-1). Review of the record for the period of 8:00 AM to 6:00 PM failed to identity that the patient's level of sedation was assessed.

The record failed to identify documentation of the patient's RASS until 8/28/22 at 6:00 PM.

Interview with Clinical Manager #3 on 8/28/22 at 10:15 AM identified that the nurse was expected to document the patient's RASS score at least every four hours as ordered. The Clinical Manager was unable to provide documentation of the patient's RASS score for the aforementioned period and RN was unavailable for interview during the onsite survey.


3. Tour of the emergency room, trauma bay 2, with emergency room unit manager #2, vice president of administration, and safety coordinator on 8/29/22 at 9:50 A.M. identified a large floor model style sharps container with an opening of approximately 6 inches by 10 inches with 3 acetaminophen tablets in open wrappers.

Interview with the unit floor manager#2 on 8/29/22 at 9:52 A.M. identified that a patient or a visitor would be able to place a hand into the sharps container and remove an item.

Tour of the emergency room walk-in triage station on 8/29/22 at 11:00 A.M. with emergency room unit manager #2, Safety coordinator, and vice president of administration identified a large floor model sharps container with an opening that measured 4 x 10-inch opening with two needle attached syringes.

Interview with the vice president of administration on 8/29/22 at 11:05 A.M. identified that the sharps container, located in the emergency room's walk-in triage area, was open approximately 4 x 10-inch opening and is large enough for a person to put a hand in and pull something out.

A review of the hospital's policy directed all non-hazardous pharmaceutical waste must be segregated from other waste at all YNHHS facilities and stored in plastic lined non-hazardous pharmaceutical waste containers.




14216

Based on clinical record reviews, review of hospital documentation and interviews for one of three sampled patients (Patient #2) who were reviewed for alleged mistreatment from staff, the hospital failed to conduct a thorough investigation when physical abuse was reported. The findings include:

Patient #2 was admitted to the pediatric behavioral unit on 8/4/2022 for suicidal ideation and behavioral dysregulation. Diagnoses included ADHD, disruptive mood disorder, anxiety and a medical diagnosis of autoimmune encephalopathy.

Nurse's progress notes dated 8/7/2022 on the 7:30 AM to 3:30 PM shift identified Patient #2 was tearful throughout the shift and reported that during the night he/she was hit on the chest and a red bruise was present. The Registered nurse conducted a physical assessment of the Patient and no red bruise was present.

A Physician's Progress Note dated 8/7/2022 at 2:15 PM identified the Patient continues to be anxious and tearful on the unit. Yesterday the Patient reported he/she overheard an adult threaten a child at 6:00 AM and also seeing dots. On 8/7/2022 the Patient reported being hit on the chest and then someone walking out of the room. The Physician questioned if the Patient was experiencing hypnopompic hallucinations.

A Social Service Note (SW#1) dated 8/8/2022 identified that Person #2 believed that Patient #2 was experiencing trauma on the unit and requested discharge. The Physician was notified and assessed the Patient to ensure a safe discharge. Patient #2 left the hospital on 8/8/2022 at 4:00 PM with referrals to a community therapist.

Interview and review of the clinical record on with SW#1 and the Assistant Manager of the unit identified that although the Patient's report was discussed in the unit's morning meeting, an official investigation was not initiated.

Interview and review of the clinical record on 8/24/2022 at 2:30 PM with the Registered Nurse who conducted the physical assessment of the Patient identified that although she discussed the incident during the morning meeting, she failed to interview the staff who were on duty at the time the incident occurred.

Interview and review of the clinical record on 8/25/2022 with the Physician who met with the Patient on 8/7/2022 identified because the Patient reported the incidents in the morning, and they could have been hypnopompic hallucinations, although there is no diagnostic test to confirm that.

The hospital failed to conduct a thorough investigation to rule out an incident of patient abuse when an alleged physical abuse was reported.

The Hospital Policy directs staff to conduct a thorough investigation when an alleged abuse is reported.

The Condition of Participation for Nursing Services has not been met.

Based on clinical record review, hospital documentation, policy review and staff interviews for 1 of 3 sampled patients reviewed for ingestion of foreign objects (Patient #10), Nursing staff failed to provide the necessary supervision and a safe environment in accordance with hospital policy for a patient with a history of PICA resulting in the ingested objects on twelve (12) occasions.

In addition, the hospital failed to assess a patient's level of sedation in accordance with physician orders (Patient #46).


Please see A395



A survey that concluded on 11/29/21 identified Condition level noncompliance related to nurse staffing levels and the failure to supervise and monitor patients and the hospital submitted a plan of correction in part, to address patient supervision. Despite the hospital alleging compliance by 1/26/22, the Hospital failed to sustain compliance with the Condition of Participation for Nursing Services as evidenced by the same issues being noted for Patient #10 in the current survey of 9/9/22.

Based on clinical record review, hospital documentation, policy review and staff interviews for 1 of 3 sampled patients reviewed for ingestion of foreign objects (Patient #10), Nursing staff failed to provide the necessary supervision and a safe environment in accordance with hospital policy for a patient with a history of PICA resulting in the ingested objects on twelve (12) occasions.

In addition, the hospital failed to assess a patient's level of sedation in accordance with physician orders (Patient #46). The findings include:

1. Patient #10's diagnoses included Schizoaffective disorder, Bipolar and PICA (eating disorder). Patient #10 presented to the Emergency Department (ED) on 7/12/22 with abdominal pain after swallowing 2 batteries in the community. Nurse's notes dated 7/12/22 at 7:15 PM noted patient presented to ED on a Police Hold (PEER) for evaluation of pain after swallowing 2 batteries and the patient stated they feel depressed and suicidal. Physician orders dated 7/12/22 at 7:22 PM directed one-to-one observation for safety to self. Review of the ED provider note dated 7/12/22 at 9:06 PM noted the patient had a history of PICA. On 7/13/22 at 9:02 AM the patient underwent an upper GI Endoscopy for removal of 2 batteries in the stomach and proximal jejunum. Review of the clinical record noted the patient was admitted to the psychiatric inpatient unit. Review of the psychiatry notes dated 7/13/22 at 7:02 PM noted in weighing the patient's presenting symptoms and behaviors as well as the patient's risk and protective factors, the patient was at high risk for suicide in the emergency psychiatric setting due to the patient being depressed, extremely impulsive and had poor coping skills and required one-to-one supervision for suicide.

Review of Patient #10's clinical record and interview with the Nurse Manager of the ED, the Nurse Manager of the psychiatric unit and the Assistant Nurse Manager of the psychiatric unit on 9/7/22 at 10:00 AM noted that while hospitalized on the behavioral health unit and while being treated in the ED between 7/16/22 and 8/22/22, Patient #10 swallowed objects eleven (11) more times requiring medical intervention including endoscopic removal.

The nursing staff failed to ensure that safety precautions were effective while the patient was in the ED and the psychiatric unit, failed to document monitoring observations to include location, activity, and behaviors, and failed to conduct investigations to determine how the patient was able to repeatedly ingest objects while hospitalized.

Interview with the Psychiatric Nurse Manager and the ED Nurse Manager on 9/7/22 at 11:00 AM noted the GI physicians requested a meeting around the end of July to discuss a plan of care for Patient #10. Each department including psychiatry, ED, GI, and anesthesia met and developed a care plan to help reduce foreign body ingestions and standardized care across all care sites. Each department educated staff on the plan of care including that the patient would be on a one-to-one sitter, the environment would be modified to eliminate/remove foreign objects, reduce ingestible objects on the units, if transport is required, transport the patient only in a hospital gown, a one-to-one sitter will accompany the patient, provide verbal warning of swallowing behaviors to transport team, and to search the patient upon return to unit.



2. Patient #46's diagnoses included respiratory failure. Review of a physician's order dated 8/27/22 directed to administer Precedex 0.2 mcg/kg/hr titrate to goal Richmond Agitation Sedation Score (RASS) -1 to 0 drowsy, by 0.1 mcg/kg/hr no more frequently than every 30 minutes. The order directed minimum frequency of titration goal parameter assessment every 4 hours and/or pre/post dose changes.

Review of the patient's clinical record dated 8/ 28/22 for the period of 2:00 AM to 7:00 AM identified that the patient's hourly RASS was assessed and measured (-1). Review of the record for the period of 8:00 AM to 6:00 PM failed to identity that the patient's level of sedation was assessed. The record failed to identify documentation of the patient's RASS until 8/28/22 at 6:00 PM.

Interview with Clinical Manager #3 on 8/28/22 at 10:15 AM identified that the nurse was expected to document the patient's RASS score at least every four hours as ordered. Clinical Manager #3 was unable to provide documentation of the patient's RASS score for the aforementioned period and RN was unavailable for interview during the onsite survey.


25210

Based on clinical record reviews, review of policies and procedures, observation and interviews with staff, the hospital failed to ensure adequate numbers of personnel to meet the needs of patients for 1 of 31 patients reviewed for Emergency Services failed to assess a patient timely for self-harm (Patient #10). The findings include:

a. Patient #10 was admitted to the ED on 8/13/22 at 7:42 PM after ingestion of a battery. Review of the clinical record with RN #4 on 8/30/22 at 11:35 AM identified the patient was not assessed for suicide ideation until 9:39 PM (a total of 1 hour and 57 minutes after admission). RN #4 stated that although the patient arrived at the ED with a sitter, the patient was to be assessed for suicide ideation at time of admission.

Interview with (RN #4) on 8/30/22 at 11:30 AM stated that when patients come into the ED, they are to have a rapid triage completed including, chief complaint of why the patient is there, allergies, travel screen, and a language/ needing of interpreter, a full set of vital signs including weight, a complete fall risk screening and patient ESI level. RN #4 further stated that each patient is to have a full triage completed by the bedside nurse which includes medical history, sepsis screening, actual weight, suicide screening, home medications and dosages, fall screening and abuse screening.

Review of the hospital policy for Standards of Practice in the Emergency Department identified the triage RN will complete a rapid triage on each patient which includes completing the following sections in the EPIC triage screen: language/ interpreter, travel screen when appropriate, chief complaint, allergies/ contraindications- apply red allergy band, a full set of vital signs including temperature, pulse, respiratory rate, blood pressure, oxygen saturation along with delivery method, weight and pain score, a complete fall risk screening and ESI (acuity) level. The policy further identified under assessments that a patient has a full triage completed including, allergies, pre-arrival information, sepsis screening, medical history, actual weight, suicide screening, home medication and dosages if available, police hold/emergency detention on all patients, if applicable, use of interpreter services if applicable, fall screening and abuse screening.

Nurse staffing was reviewed in current time and staff to patient ratios fluctuated between 1:4 and 1:6, and medical screening evaluations were present in current records.