HospitalInspections.org

Based on staff interview, medical record review, and review of facility documents, it was determined the facility failed to ensure patients at risk for self-harm are kept safe.

Findings include:

1. The facility failed to ensure a process was in place to assess patients at risk for self-harm for the presence of weapons or anything that can be used to harm themselves or others. (Refer to Tag 0144)

2. The facility failed to follow their policy ensuring that continuous visual observation was maintained for a patient at risk for self-harm. (Refer to Tag 0144)

3. The facility failed to follow their policy ensuring that documentation of patients on one-to-one observation was recorded and maintained in the patient's medical record. (Refer to Tag 0144)

Based on review of facility policies and procedures, staff interview and medical record review, it was determined the facility failed to: 1. Assess patients for the presence of weapons. 2. Provide continuous visual observation for patients at risk for suicide. 3. Ensure staff implemented the policy and procedure titled, "Safety Precautions and Observation Guidelines for Risk of: Elopement or Harm to Self or Others," for 4 patients (Patient (P)1, P8, P9 and P11) at risk for self harm/suicide risk precautions.


Findings include:

Reference: Facility Policy titled, "Safety Precautions and Observation Guidelines for Risk of: Elopement or Harm to Self or Others (effective 2/2021)," stated, " ...Procedure: ...2. Information is obtained either directly from the patient's verbal or nonverbal behaviors, or collateral sources that the patient wishes to die or to harm him/ herself or others. ...6. An Environmental Safety Checklist will be completed in the EMR [electronic medical record] immediately, at every observer change, every room change, and every RN [Registered Nurse] shift change, for items that may be potentially hazardous for removal by the RN with a witness. An environmental assessment should be completed during RN hourly rounding. The safety checklist is to be completed with the RN and the 1:1 observer. ...8. One to one is continuous visual observation, including their hands when indicated, with the ability to immediately intervene when necessary by a patient observer at all times. The patient observer must provide continuous visual observation with the ability to immediately intervene when necessary at all times, including during bathroom use, at a minimum with the bathroom door ajar... 11. Documentation of patient's behaviors will be recorded every 15 minutes by the team member assigned as the patient observer on the HMH Patient Observation Sheet ..."

Facility Policy titled, "Suicide Risk Screening, Assessment and Prevention Process (effective 1/2022)," stated, " ...A. Operational Definitions: Patient Safety Screener 3 (PSS3) Patient Secondary Screener (ED Safe Secondary Screener: ESS6): Validated tools used to screen adult patients for suicide, determine the need for further mental health evaluation, age 18 years old and above. ...Comprehensive suicide risk assessment: Evidenced based process used when a patient screens positive for suicide risk to further determine appropriate, safe care. The assessment directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors. ...1:1 Observation: Uninterrupted patient observation with continuous visual observation with the ability to immediately intervene when necessary until such time as the physician discontinues the need for constant 1:1 observation. ...C. Key Points: ... At any point in the screening process, a RN may initiate site specific Suicide/Safety Precautions. HMH Safety Precautions and Observation Guidelines ...D. Procedure: 1. Emergency Department ... If patient scores as HIGH RISK- Patient will be placed on 1:1 sitter for safety -Environment is secured -Secondary screener or brief suicide safety assessment is completed to determine need for a full mental health evaluation. A. ADULT (greater than or equal to 18 years old) All patients 18 years old and greater after arrival to emergency department will be screened for suicide using the Patient Safety Screener 3. 1. If the patient answers YES to #2, Suicidal ideation in the past two weeks OR #3, Suicidal attempts in the past six months on the PSS3 ...IMMEDIATELY INSTITUTE Safety Precautions and Observation Guidelines, using the Patient & Environmental Safety Checklist for the room safety process: HMH Safety Precautions and Observation Guidelines and initiate the patient safety secondary screener (ESS 6) ..."

Facility Policy titled, "Network Weapons Check Policy (effective 9/2022)," stated, " ...POLICY: Weapons are PROHIBITED on all property owned or operated by Hackensack Meridian Health. ... PROCEDURES: 1. If a patient or visitor volunteers that he/she is in possession of a weapon or is found to be in possession of a weapon, the Security department shall be notified and a Security supervisor shall respond to the area and advise the possessor of policy prohibiting weapons. The weapon should not be taken from the Patient or visitor by any staff member. Security will take the weapon into possession and will notify local law enforcement. ..."

1. Patient (P)1, presented to the facility on 3/30/23 at 2:33 AM accompanied by law enforcement, who stated P1 expressed Suicidal Ideations. Review of the PSS3 (Patient Safety Screener) in the ED Timeline, indicated that P1 screened negative for suicide, however the patient was placed on 1:1 constant observation. P1 was taken from the triage area into Trauma Room #5 to change into paper scrubs, as per facility policy. The Emergency Department (ED) Notes in the ED Timeline in the medical record, dated 3/30/23 at 2:49 AM, stated, " ...Patient was getting changed with security team and pct [patient care technician] at bedside. Patient was in the bathroom getting changed with door open and patient pulled out a gun and shot [him/herself] in the head ...".

On 4/3/23 at 12:11 PM during interview with S6, the Director of Security, he/she explained that when it's determined a patient is at risk for self-harm, security is dispatched to assist with the patient and the inventory of the patient's belongings. S6 explained that the ED staff will assign a 1:1 observer for the patient and the security officer will escort the patient into Trauma Room #5, so the patient can change into a hospital provided green paper scrubs and have their belongings inventoried. S6 indicated that the process of inventorying the patients' belongings includes going through the belongings to check for anything that can be used as a weapon. S6 emphasized that the security officer will do a visual inspection of the patient but that the officers do not pat down patients as it is not the facility's policy.

On 4/3/23 at 1:28 PM during interview with S12, an ED Registered Nurse (RN), he/she explained that all patients who present to the ED are assessed for self-harm using the PSS3 (Patient Safety Screener). The PSS3 is a series of 3 questions that are asked to assess the patient for risk of self-harm. S12 explained that if the patient's PSS3 screening is positive for self-harm, the patient is further screened using the ESS-6 (ED-Safe Secondary Screener). The ESS-6 is a 6 question screening tool that further assesses patients at risk for self-harm for a suicide plan or intent to act on the plan. S12 explained that during the ESS-6 screening he/she would ask the patient if they had anything on them that they could use to harm themselves or others.

On 4/3/23, review of P1's ED timeline stated " ...3/30/23 02:36 PATIENT SAFETY SCREENER (PSS3) ...Suicide Screening Status: NEGATIVE SCREEN ...." P1 also had a ESS-6 screening done in which he/she answered "NO" when asked about a suicide plan or intent. P1 was still placed on 1:1 observation and asked to change into the hospital issued green paper scrubs.

On 4/20/23 at 10:40 AM, during a telephone interview with S20, the RN who triaged P1, he/she explained the patient was not questioned regarding weapons due to the fact that the law enforcement that accompanied P1 verbalized that law enforcement had removed a weapon from P1.

On 4/24/23 at 5:15 PM during interview with administrative staff, S1, S2 and S26, they explained that if a patient comes in and screens negative for self-harm, the patient can still be placed on 1:1 observation based on the staff's clinical judgement. S26 explained that the triage nurses in the ED use the PSS3 and ESS6 screening tools but also consider the patient's behavior, demeanor, any outside information that may be obtained during the triage assessment, and information that may be provided by anyone who presents with the patient.

The ED Triage Notes Addendum from 3/30/23 at 2:37 AM stated, "Patient arrived at the emergency room for suicidal ideation. Per __ [law enforcement] who is with patient states [he/she] has expressed suicidal ideation however patient denies HI/SI [Homicidal Ideation/Suicidal Ideation]. Patient reports '[he/she] is going through some rough times.' Per __ [law enforecement] of [name of township] who is with patient reports [his/her] weapon was taken away by the __ [law enforcement]. ..."

P1 presented to the facility accompanied by law enforcement, who expressed that P1 had suicidal ideations. P1 screened negative for self-harm using both the PSS3 and ESS-6 screenings. The facility failed to ensure that a process is in place to assess patients who screen negative for self-harm but are still perceived to be at risk for self-harm for the presence of weapons or anything that can be used to harm themselves or others.

An Immediate Jeopardy (IJ) under the requirement of 482.13 Patient Rights was identified on 4/24/23 at 5:13 PM.

The facility failed to ensure all patients at risk for self-harm are assessed for weapons.

The Manager, Director and VP of Regulatory Affairs were informed of the IJ and were provided with the IJ template on 4/24/23 at 6:53 PM. A removal plan was requested at that time.

A removal plan was received and on 5/1/23, surveyors verified implementation of the removal plan. The facility implemented changes to its electronic medical record to include questions regarding the possession of anything that can harm the patient or others (including weapons). The facility policy was revised to include that security would be present when patients are questioned, for any patients determined at risk for self harm. On 5/1/23 interviews were conducted with triage nurses, patient care technicians (PCTs), and security officers, who stated they were educated of the changes made in the policy and process.

It was determined the facility fully implemented their removal plan for the IJ and the IJ was removed on 5/1/23 at 11:11 AM.

2. The Security Report from 3/30/23 at 8:03 AM stated, " ...Narrative text: ...PCT [name of PCT] along with Security Officer [name of security officer] escorted [name of patient] to Trauma 5 so the patient can get changed into green hospital issued scrubs. [Name of patient] entered the bathroom located inside Trauma 5 while captain [name] was standing in the doorway of the bathroom. Officer [name] was standing by inside Trauma 5 while PCT [name] was right outside of Trauma 5. At approximately 2:50 AM, [name of patient] shot [him/herself] in [his/her] head with a firearm, that [he/she] had on [his/her] person in an unknown location. ..."

On 4/20/23 at 10:31 AM during a telephone interview with S8, the security officer, explained that at the time of the incident, P1 was inside the bathroom with the door open and the law enforcement officer was standing in the doorway of the bathroom. S8 explained that the PCT stepped outside of the room and that he/she was standing inside the room, on the left side, and was unable to visualize the patient from where he/she was standing.

The facility failed to follow their policy ensuring continuous visual observation is maintained for a patient at risk for suicide.

3. On 4/3/23, a review of the ED (Emergency Department) Timeline in P8's medical record revealed that P8 arrived at the ED on 3/2/23 at 9:27 AM with a chief complaint of Suicidal Ideation. A physician order for "One to One Monitoring- 1:1 Observation Risk of Harm to Self" was placed at 9:50 AM. The ED Notes from 10:12 AM stated, " ...1:1 sitter at bedside. Report given to sitter. No belongings at bedside. Pt [patient] currently in green hospital clothing per policy. Safety maintained. Environmental safety check complete. ..." On 4/3/23 at 2:30 PM, S5, the ED Director of Nursing, was asked to provide the 1:1 Patient Observation Sheets for P8, and the observation sheets could not be located. The medical record lacked evidence that the 1:1 Patient Observation Sheets were completed.

On 4/3/23, a review of the ED Timeline in P9's medical record revealed that P9 arrived to the ED on 3/12/23 at 1:31 AM with a chief complaint of Psychiatric Evaluation. A physician order for "One to One Monitoring - 1:1 Observation Risk of Harm to Self" was placed at 1:37 AM. The ED Triage Notes from 1:38 AM, stated "Pt [patient] transferred from [name of facility] for psych [psychiatric] evaluation. States "I've been down for a little bit and my therapist recommended I go to the nearest ER [emergency room]". ..." The Environmental Safety Checklist was documented at 1:40 AM. On 4/3/23 at 2:30 PM, S5 was asked to provide the 1:1 Patient Observation Sheets for P9, and the observation sheets could not be located. The medical record lacked evidence that the 1:1 Patient Observation Sheets were completed.

On 4/3/23, a review of the ED Timeline in P11's medical record revealed that P11 arrived to the ED on 3/31/23 at 1:04 PM with a chief complaint of Suicidal Ideation. The ED Triage Notes from 1:30 PM state, "Received patient to area E. 1:1 sitter at bedside. Patient observation tool provided. Safety sweep completed. Pending MD [medical doctor] eval [evaluation]." The medical record lacked documentation that an Environmental Safety Checklist was completed for P11.

On 4/3/23 at 2:35 PM, during an interview with S5, the ED Director of Nursing, he/she indicated the 1:1 patient observation sheet is filled out on paper and when the patient is discharged, the paper portion of the chart is sent to medical records to be scanned into the EMR. S5 explained that in late February 2023, the facility self identified that the 1:1 patient observation sheets were being misplaced in transit to medical records. S5 indicated the facility is implementing a new process where the 1:1 observation sheets will be scanned into the medical record by the ED staff , however, this new process had not been fully implemented as of the date of this survey.