HospitalInspections.org

Based on interview, record review, and review of facility video surveillance footage, the facility failed to mitigate environmental safety risks when facility staff placed a suicidal patient next to an unlocked exit door without 1:1 observation; and failed to follow their policy for suicidal patients who present to the ED for 1 (#2) of 1 sampled patients. This deficiency had the potential for the patient to escape the facility and follow through with his plan to commit suicide. Findings include:

Review of patient #2's EMR (Electronic Medical Record), dated 3/6/24 at 1:43 a.m., showed patient #2 presented to the ED and reported he was suicidal. Patient #2 told the triage nurse he was going to drink himself to the point of death, or he was going to overdose on drugs. The triage nurse assigned the patient an ESI (Emergency Severity Index) score of 2 (Emergency: could be life threatening). Patient #2 was escorted into the Emergency Department at 1:51 a.m. Patient #2 was placed on 1:1 observation at 1:56:18 a.m., although review of facility video surveillance footage showed there was no 1:1 provided until 2:35:51 a.m. Review of patient #2 ' s physician note showed the patient stated he had a gun hidden in the bushes in town and he was going to shoot himself with it. Patient #2 ' s blood alcohol level was documented as 340 mg/dl.

Observation of a facility surveillance video titled, "ED North Nurses Station East," dated 3/6/24, showed:

1:51:03- Patient #2 entered the ED hallway with staff member M. The ambulance bay doors were observed at the end of the hall (these doors did not lock and exited the building to the outside. The doors were operated by a push button located on the wall).

1:51:36- Patient #2 was placed in a chair in the hallway approximately five feet from the ED ambulance bay doors. The patient was left unsupervised.

1::53:17- 1:55:16- Patient #2 was unsupervised.

1:55:35-2:04:14 Patient #2 was unsupervised.

2:04:40-2:18:53- Patient #2 was unsupervised.

2:18:53-2:21:59- Staff member K, the emergency department physician, was observed talking to patient #2 in the hallway. Staff member K was not observed with the patient for the remainder of the patient ' s stay in the Emergency Department.

2:21:59- 2:27:59- Patient #2 was unsupervised. The doors to the ambulance bay opened and closed when an ambulance brought another patient into the ED.

2:33:00- A security staff member escorted patient #2 to ED room #6.

2:35:51- A 1:1 provider arrived outside ED room #6 and remained outside the room until patient #2 was taken to his inpatient hospital room.

4:02:00- Patient #2 was observed being wheeled out of ED room #6 by the transporter. The 1:1 staff member followed.

Patient #2 was left alone next to the ambulance exit doors for a total of 29 minutes without a dedicated 1:1 staff member. The time stamp on the surveillance video coincided with the time stamp in the EMR for patient #2 ' s entrance to the ED and for the time patient #2 was transported out of the ED.

Review of a facility document titled, "High Risk Patient Room Checklist", not dated or timed, showed ED room #6 had unsafe contents removed from the room. The document had a patient label affixed to the lower right corner showing patient #2's name and the label was dated 3/6/24.

Review of a facility document titled, "15 Minute Patient Safety Check", dated 3/6/24 at 2:00 a.m., showed a patient label for patient #2 in the lower right corner. This was a handwritten document that had been scanned into the EMR. The document showed ED room #6 was cleared at 2:00 a.m., despite video surveillance footage showing security arrived at 2:25:39 a.m. to clear the room. The document showed documentation of the patient being in bed, calm and cooperative, with his hands visible every 15 minutes starting at 2:00 a.m.; however, video surveillance footage showed the patient was sitting in a chair in the hallway and was not in the room until 2:33:00 a.m. The 1:1 staff member was not outside the room until 2:35:51 a.m.

During an interview on 3/13/24 at 5:21 p.m., staff member D (ED physician) stated it would not be safe to place a patient who stated they were suicidal, next to an exit door, without 1 to 1 supervision. Staff member D stated she would expect a suicidal patient who presented to the ED to be taken out of their personal clothing, placed in a hospital gown, and have their personal property removed from their possession until the ED physician was able to assess the patient.

During an interview on 3/15/24 at 8:04 a.m., staff member L (Facility Security staff member) stated, "From the second a patient says they are suicidal, we need to treat them like an E-hold (emergency hold.) We need to try to stop them from leaving to keep them safe. The ED can always call us to stand by with a patient if they need someone right away. We stand by as the 1:1 until a 1:1 provider can arrive. That usually happens if they have to put the patient in the hallway because there are no rooms available. We usually do the room clear to make sure any hazardous items are removed from a room." Staff member L stated, "It would not be safe to leave a fully dressed suicidal patient next to an exit door without a dedicated person watching them."

During a telephone interview on 3/18/24 at 9:47 a.m., staff member K (ED physician) said he remembered examining patient #2 on 3/6/24. Staff member K said he knew patient #2 very well. Staff member K stated he did not know who made the decision to put patient #2 by the ambulance bay doors, but he thought the staff might have put the patient there because they see that patient frequently and they do not always believe him. Staff member K said he decided to refer patient #2 to the hospitalist and admit him to the hospital because the patient did not usually report wanting to kill himself. Staff member K stated he was also concerned because patient #2 had a history of being abusive to staff, verbalizing profanities, and using obscene hand gestures, but this time the patient was not doing those things and seemed more subdued. Staff member K said it would not be safe to put a fully clothed suicidal patient next to an exit door. Staff member K said his expectation for a suicidal patient would be to put the patient on 1 to 1 observation right away and if possible, place the patient in a patient room right after triage. Staff member K stated when patients report they are suicidal, staff should take the patient seriously, no matter what their previous interaction with staff had been. Staff member K stated that did not occur on this occasion and, "That probably wasn't a good thing."

During a telephone interview on 3/20/24 at 10:23 a.m., staff member M (ED RN) stated she remembered patient #2 from the 3/6/24 visit when he reported he was suicidal. Staff member M said she filled in the Columbia suicide Severity Rating Scale questions for the patient because he would not answer her. When given a scenario from the surveyor using patient #2 ' s stated chief complaint, the answers she gave for the Columbia Suicide Severity Rating Scale differed in question #1, "Have you wished you were dead or wished you could go to sleep and not wake up?" She documented "No" in patient #2's chart but stated the question should have been answered "yes." For question Number 3, "Have you been thinking about how you might do this?" she documented, "No" in patient #2's chart but stated the answer should have been "yes" as the patient had given a plan in triage. For question #4, "Have you had these thoughts and had some intention of acting on them?" she documented "No" in patient #2's chart but stated the patient would not answer her at the time. For question #5, "Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?" she documented "No" despite the patient giving a plan in triage. Staff member M stated patient #2 did not answer her but she documented "No" in the EMR. Staff member M stated she did not believe patient #2 was suicidal. Staff member M stated placing patient #2 next to the ambulance bay doors, "Might not have been the best place for him." She stated if it had been any other patient complaining of suicidal ideation, she most likely would not have placed the patient in that chair next to the exit without a 1 to 1 staff member assigned to the patient.

Review of a facility policy titled, "Identification and Care of Patients at Risk for Suicide", dated 2/14/24, showed:

"7. 1:1 Sitter/Safety
a. Patients with suicidal ideations must be placed under demonstrably reliable monitoring (1:1 continuous monitoring by trained associates who can provide immediate intervention when called for)."

Review of a facility document titled, "Emergency Department Suicide Risk Process- SVH- Supporting Document", dated 10/2021, showed:

"Patient arrives in the ED, Active/Stated Suicide, Escort back to the ED (Must have 1:1 sitter with patient at all times until pt. is placed in ED w/staff, Implement Suicide Precautions: Place patient in room visible to nurse's station (if no open rooms, pt to sit on gurney or chair in ED hallway) with 1:1 sitter. Contact Department of Public Safety (DPS) for assistance, RN/Tech assist patient into a gown and DPS to remove all patient belongings, Examine room carefully and remove anything (that can be removed) that may potentially cause harm (including but not limited to : sharp items, belts, glass, electrical cords, metal eating utensils), RN completes assessment as pertinent to chief complaint, ED physician completes assessment, Note: ED physician to determine need to continue or discontinue 1:1 sitter, initiate Emergency Hold process, and Behavioral Health consult...The patient is not free to leave the Emergency Department until evaluated by a physician..."

Based on interview, record review, and review of facility video surveillance footage, the facility failed to maintain an accurate medical record for 1 (#2) of 3 sampled patients. This deficiency has the potential to affect all patients who receive care in the ED.

Findings include:

Review of patient #2's ED Provider Note, dated 3/6/24 at 5:05 a.m., showed patient #2 presented to the Emergency Department for suicidal ideations. Staff member K documented, " ... Physical Exam ... Cardiovascular: ... No Murmurs, No rubs, No gallops. Thorax and Lungs: Normal breath sounds ... No wheezing ... Abdomen: Soft, nontender, nondistended ..."

Observation of facility video surveillance footage titled, "ED North Nurses Station East", dated 3/6/24, showed:

-1:51:03- Patient #2 entered the ED hallway with staff member M.

-1:51:36- Patient #2 was placed in a chair in the ED hallway.

-2:18:53-2:21:59- Staff member K (ED physician) was observed talking to patient #2. Staff member K's stethoscope remained around his shoulders, and he did not physically touch patient #2. Staff member K was not seen with the patient for the remainder of the patient ' s stay in the Emergency Department.

-2:33:00- Security escorted patient #2 into a room (ED room #6).

-4:02:00- Patient #2 was observed being wheeled out of ED room #6 by the patient transporter. Staff member K was not observed entering ED room #6 at any time.

During a telephone interview on 3/18/24 at 9:47 a.m., staff member K stated he was a physician at the facility and assigned to work in the ED on 3/6/24. Staff member K stated he recalled seeing patient #2 on 3/6/24. Staff member K said he occasionally used a documentation template when he documented his physical assessments for patients. Staff member K stated the template included a review of systems showing everything being within normal limits. Staff member K stated he should delete the items he doesn ' t complete. Staff member K stated if a patient presented to the emergency department for a laceration of the finger, it would not be necessary to listen to the patient ' s lung sounds, and he would delete those portions on the premade template. Staff member K said it was entirely possible he documented heart sounds, lung sounds and an abdominal assessment he did not perform for patient #2. He said he would not typically listen to lungs, heart, and assess a patient's abdomen for a patient who presents for suicidal ideation, unless the patient had specific complaints. Staff member K stated he found another patient chart a week prior where he realized he had documented a full assessment on a patient, although the assessment was not performed. Staff member K stated he knew it was not best practice to utilize the premade template, and he was trying to decrease his use of it. Staff member K stated it could be dangerous to document a patient assessment that was not performed.