HospitalInspections.org

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

1. Based on observation, clinical record review, hospital policy and staff interviews for 1 of 5 sampled residents reviewed for suicidal ideation (Patient #2), the facility failed to ensure the patient was accurately assessed for safety risk factors and/or failed to implement appropriate safety precautions and/or failed to reassess the patient according to hospital policy and/or failed to educate staff on a newly implemented patient safety assessment prior to being assigned to care for a patient with suicidal ideation.

2. Based on observations during a tour of the ED, the facility failed to ensure a safe environment for patients at risk for suicidal ideation.

Please refer to A-144
Cross reference A-701

Based on observation, clinical record review, hospital policy and staff interviews for 6 of 9 sampled residents reviewed for suicidal ideation (Patients #2, 10, 11, 12, 13, and 14), the hospital failed to ensure the patient was accurately assessed for safety risk factors and/or failed to implement appropriate safety precautions and/or failed to reassess the patient according to hospital policy and/or failed to educate staff on a newly implemented patient safety assessment prior to being assigned to care for a patient with suicidal ideation and/or failed to ensure that staff conducted hourly checks in accordance with policy. The findings include:

Review of hospital documentation identified that the hospital implemented an immediate action plan on 5/31/19 in response to an accrediting agency's concerns regarding the assessment and monitoring of patients at risk for suicide.

1. Patient #2 was admitted on 6/1/19 at 5:38PM.

Review of the admission PEER (Police Emergency Examination Request) dated 6/1/19 identified the patient was found holding an axe and stated numerous times that he/she wanted to die. The report further noted that the patient asked police to shoot him/her and during the ride to the hospital and the patient was banging his/her head against the window.

Review of the hospital admission assessment (Triage) dated 6/1/19 at 5:38PM identified the patient was there for a crisis evaluation. The assessment noted the patient had altered mental status, was intoxicated and the patient's affect was anxious, agitated, angry and loud.

Nurse's notes dated 6/1/19 at 5:50PM identified the patient as anxious, agitated, angry, loud, speaking inappropriately using profanity, and admitted to alcohol consumption. The note identified a bed alarm was placed on the patients bed. Additionally the note identified the patient was attempting to get out of bed and refusing to follow instructions.

Between 5:38 PM and 5:55 PM, the clinical record failed to identify that Patient #2's supervision requirements were assessed or that patient monitoring was conducted.

Nurse' notes dated 6/1/19 at 5:55PM identified that Patient #2's bed alarm was alarming. The patient was observed attempting to get out of bed and standing on the bed, and the nurse instructed patient to sit down. The note further identified the patient's assigned nurse (RN #1) left the room and the patient immediately got out of bed and was banging his/her head multiple times against the window in patient's room. Security and a Physician's Assistant (PA) came to the bedside and Patient #1 was placed in restraints at 6:00 PM. At 6:05 PM the patient received Benadryl 50 mg Intramuscularly (IM), Ativan 2 mg IM and Haldol 5 mg IM.

Interview with RN #3 on 6/4/19 at 2:44 PM stated that she was assisting with patient care and was in Patient #2's room when the patient jumped off the bed and began banging his/her head against the window. RN #3 stated that the PA came into the room with security and the patient was placed in 4 point locking restraints. RN #3 stated the patient left the unit while in 4 point restraints to have a CT scan of the head. RN #3 further stated that she stayed with the patient until she left at 6:30PM and was not sure what happened after that.

Review of the Behavioral Restraint documentation dated 6/1/19 at 6:00PM identified the patient was a danger to self, aggressive and posturing with concern for physical harm and a danger to others. The patient was placed in 4 (four) point locking restraints. Review of the every fifteen minute restraint assessments noted the patient was assessed every fifteen minutes from 6:00 PM through 6:30 PM. At 6:30 PM the patient was identified as a danger to self, aggressive, posturing, attempting to get out of bed, inability to respond and continued in 4-point restraints. The patient was not assessed again until 7:00 PM and was noted to be sleeping. Documentation failed to identify that Patient #2 was monitored inbetween the 15 minute checks when the patient continued with behaviors of danger to self, aggressive, posturing, attempting to get out of bed and inability to respond.

Interview with the Director of In-Patient Behavioral Health and RN #2 on 6/2/19 at 1:50 PM identified that on 5/31/19 the hospital implemented a new Columbia Suicide Severity Rating Scale (C-SSRS) to assess a patient's suicidal risk and implement appropriate safety monitoring. RN #2 stated that RN #1 did not use the new assessment for Patient #2 on 6/1/19 and should have.

Review of the hospital policy for the C-SSRS assessment implemented on 5/31/19 identified an initial assessment would be completed on all patients twelve years or older in the ED, at the point of the patient's entry and on arrival to unit for all bedded patients. The policy identified for all patients identified as moderate or high risk the C-SSRS would be completed every 8 hours. The assessment identified for patients in the ED, the C-SSRS assessment would be completed at the time of triage and with a change in condition. The policy further identified if a patient was assessed as a moderate risk, safety checks would be performed at a minimum of every fifteen minutes and documented on the Safety observation checklist. If the patient was assessed as a high risk the patient would be placed on continuous monitoring and complete a C-SSRS frequent screener every shift.

Review of Patient #2's suicide risk assessment dated 6/1/19 at 6:00PM identified that staff utilized the hospital's prior suicide risk assessment and not the newly implemented C-SSRS assessment. This risk assessment identified the patient as having considered suicide in the past, depended on alcohol and drugs for stress relief, had reported feelings of sadness, irritability and some hopelessness. The assessment identified the patient's mood as defensive, agitated, combative and threatening. The assessment placed the patient at medium risk (for self-harm) with interventions to have all belongings removed, checked by security and the patient was placed on hourly checks.

Review of the previous suicidal risk assessment and previous policy on 6/4/19 with the ED Clinical Nurse Manager on 6/4/19 at 10:00AM identified that Patient #2 was not assessed using the new C-SSRS assessment which would have identified Patient #2 at a high risk of immediate suicide and should have been placed on continuous observation and not hourly checks.

Between 7:15 PM and 11:38 PM, the clinical record failed to identify that Patient #2's supervision requirements were appropriately assessed in accordance with the new C-SSRS policy resulting in the patient not being continuously monitored for his/her safety.

Review of the clinical record identified that RN #3 initiated a C-SSRS assessment on 6/1/19 at 10:10PM. However, only 2 of the 6 questions were answered on the assessment. The assessment identified that the patient wished he/she was dead or wished he/she could go to sleep and never wake up and had thoughts of killing self. The assessment failed to answer how you might kill yourself, have you had these thoughts and had some intention of acting on them, have you started to work out details of how to kill self and have you ever done anything, started to or prepared to do anything to end your life.

Interview with the ED Clinical Manager on 6/4/19 at 11:00 AM identified that the staff's failure to complete the risk assessment resulted in the inability to determine the patient's level of risk and inability to determine the appropriate safety measures that the patient required.

Interview and review of Patient #2's clinical record with RN #3 on 6/2/19 at 2:15 PM identified that according to a nurse's note dated 6/1/19 at 11:38 PM a sitter was put in place for the patient. Review of the safety check sheets dated 6/1/19 at 11:00PM noted the patient was on one to one supervision.

Interview with RN #1 on 6/2/19 at 4:15PM stated that she did not receive education on the new C-SSRS assessment or policy prior to the start of her shift on 6/1/19. It was not until later in the shift that she was made aware of the new assessment and policy but had yet to receive the education. RN #1 stated she started to initiate the C-SSRS assessment by asking the patient the questions but the patient would not answer. RN #1 stated that she recalls another nurse telling her the patient needed to be on continuous observation with staff, but she was "so busy" and had a lot going on so she didn't do it.

Interview and review of the facility's Education for the C-SSRS on 6/2/19 at 1:50 PM with RN #2 and the Director of In-Patient Behavioral Health identified of the 19 staff that had worked in the ED from 4PM on 5/31/19 through 6/2/19 at 1:50PM seven (7) staff had not received the education regarding the hospitals new Suicide assessment policy. Further review noted that RN # 1, who cared for Patient # 2, had not yet received any education on the new Suicide assessment policy. The Director stated that they are educating staff when they work and have time to review it.

Interview with the CNO and VP of Patient Quality and Safety on 6/2/19 at 3:10PM stated that the suicide risk assessment was changed on 5/31/19 to include that all patients will be assessed upon admission during triage to identify appropriate interventions according to their risk level. The CNO further stated that staff are to be educated anytime during their shift.

Interview and review of Patient #2's clinical record with RN #2 on 6/2/19 at 2:20PM identified no documentation of patient safety checks were completed on 6/1/19 from the time of admission at 5:38PM until 11:00PM and that the C-SSRS was not completed. RN #2 stated that RN #1 completed the old risk assessment and placed the patient on hourly checks. RN # 2 further stated that when she came in on 6/2/19 she reassessed the patient for suicidal ideation and the patient answered no to all the questions. RN #2 notified the MD who removed the one to one.

The facility failed to ensure that all staff were educated on the use of the newly implemented Suicidal risk assessment (C-SSRS), failed to ensure safety of a patient who was high risk for suicide, and lacked documentation of patient monitoring.

An Action plan was requested on 6/5/19 at 2:30PM and included a policy revision to clarify the C-SSRS assessment and policy, education to all staff prior to working and auditing to ensure the C-SSRS is completed accurately and that appropriate interventions are implemented.

2. Patient #11 was admitted to the Emergency Department (ED) on 10/29/18 at 6:32AM after an intentional overdose of Ativan and had a history of alcohol abuse. A Suicide Risk Assessment was conducted at 6:40am identified that the patient was at medium risk and observation of patient with hourly checks began. Although the Suicide Risk Assessment identified the patient was a medium risk, the patient should have been assessed as a high risk due to history of alcohol addiction or dependence. High Risk interventions included in part, continuous observation provided by video surveillance or staff is documented as 15 minute checks.

The medical record did not to include documentation of 15-minute checks. A psychiatric assessment was completed while in the ED and identified that the patient had suicide ideation, intent, and plan. Diagnoses included depressive major disorder, substance related and addictive disorders alcohol use disorder moderate to severe. The patient was transferred to another hospital for an inpatient admission.

Review of the Suicide Risk Assessment and Precautions policy directed to initiate Suicide Risk Assessments Guidelines, if assessed to be a suicidal risk, the appropriate level of observation will be initiated based upon the suicide risk guidelines. High Risk interventions included in part, continuous observation provided by video surveillance or staff is documented as 15 minute checks. A psychiatric assessment was completed while in the ED and identified that the patient had suicide ideation, intent, and plan.

Review of the medical record identified that an hourly check was not completed at 1:30pm. Interview with the ED Director on 6/3/19 at 11:30am identified that the check was not documented as per hospital policy. The Emergency Department Suicide Risk Assessment Guidelines identified medium risk of suicide included interventions for staff to document hourly checks. Additionally, the Suicide Risk Assessment inaccurately identified at 6:06pm that the patient had no history of suicide attempts.

3. Patient #10 was admitted to the Emergency Department (ED) on 6/3/19 at 9:01am for a complaint of anxiety. Observation of the patient on 6/3/19 at approximately 12pm identified the patient sleeping on a stretcher in a room across from the nursing station. The patient's room had ligature risks present (a call bell with cord was attached to the stretcher, oxygen manometer on wall at the head of the stretcher, side rails on stretcher, suction canister with tubing, and monitor cords). A suicide risk assessment was conducted by the triage nurse at 9:34am which identified that patient as a medium risk level with interventions that included that the patient was undressed and belongings removed, the patient was wanded, and the patient's location was secured for safety and observation with 15 minute checks. However, a Columbia suicide severity rating scale was completed at 9:33am which identified that the patient was at low risk for suicide and safety interventions included to place the patient in a ligature safe room in close proximity to nurses station, remove and secure belongings, wand for metal, and a behavioral health referral at discharge.

Interview with the ED Director on 6/3/19 at 12pm identified that the triage nurse used the old assessment form and completed the new form that was initiated at the hospital recently and the nurse should have only used the new form. A psychiatry evaluation was conducted and identified that the patient denied any suicide ideation's and did not appear to be at acute risk of harm. Review of the Suicide risk Assessment/Columbia Suicide Severity Rating Scale identified that patients identified as low risk in the ED required a behavioral health referral at discharge. The policy further identified that an initial assessment would be completed on all patients twelve years or older in the ED, at the point of the patient's entry and on arrival to unit for all bedded patients.

4. Patient #12 arrived in triage by ambulance personnel on 5/6/19 at 9:22am for bizarre behavior with diagnoses that included exacerbation of schizophrenia. Review of the medical record with the ED Director on 6/3/19 failed to identify that a suicide risk assessment was conducted in accordance with facility policy which identified that behavioral patients required a suicide risk assessment.

5. Patient #13 arrived in triage on 3/18/19 at 12:52pm for worsening hallucination and aggression over the last few days. The patient had a history of suicide attempt by overdose in 2012. Review of the medical record with the ED Director on 6/3/19 failed to identify that a suicide risk assessment was conducted in accordance with facility policy which identified that behavioral patients required a suicide risk assessment.

6. Patient #14 arrived in triage on 2/8/19 at 11:04am after being found dazed and confused with a history of depression. Review of the medical record with the ED Director on 6/3/19 failed to identify that a suicide risk assessment was conducted in accordance with facility policy which identified that behavioral patients required a suicide risk assessment.

7. Based on observations during a tour of the ED unit, the facility failed to ensure a safe environment for patients at risk for suicidal ideation. The findings include:

Observations during a tour of the ED unit on 6/2/19 at 2:40PM identified the room designated for high SI risk patients noted the following ligature points, the stretcher bed had side rails on it, the call bell cord was long and attached to the stretcher, a free standing chair and a regular door handle. Observations on 6/3/19 at 9:30AM identified the stretcher bed with 2 side rails in the up position, the call bell cord was long, a chair was noted in the room and the door handle was not ligature resistant and had a lock on it.

Interview of 6/2/19 at 2:55PM with RN #2 stated that patients who are at risk for self-harm are placed in room #11. RN # 2 stated that they place high risk patients there because there are less items in the room the patient could harm themselves with. RN # 2 further stated that if they have more than one high risk patient and are in the other rooms on the unit they are to be placed on continuous observation.

Based on review of medical records, review of facility policy and interview, for 2 of 3 patients who were restrained (Patient #13, #14), the hospital failed to utilize restraints only when less restrictive measures were ineffective to protect the patient, and staff. The findings include:

1. Patient #13 was admitted to the hospital on 3/18/19 for audiovisual hallucinations and aggression. Review of the Behavioral Restraint records dated 3/18/19 at 4:15pm identified that the patient was placed in 4 point locking restraints after attempting to get out of bed, talking to self and was confused. Attempted interventions included verbal diversional activity, comfort measures and close monitoring, fifteen minutes. Documentation identified that the patient continued to attempt to get out of bed until 9pm, was quiet and lying down at 9:15pm (in 4 point restraints for 5 hours) and was then placed in 2 point locking restraints from 9:30pm to 9:45pm. Restraints were discontinued at 10pm. Documentation failed to reflect that the patient's behaviors of attempting to get out of bed necessitated the use of restraints.

2. Patient #14 was admitted to the Emergency Department (ED) on 2/8/19 at 11:04am with anxiety. Nurse's notes timed at 1:30pm identified that the patient followed another patient out into the waiting room in an attempt to leave. There was a bed alarm in place and security responded and brought the patient back into the ED and the patient was placed in 4 point restraints. Review of the Behavioral Restraint records dated 2/8/19 at 1:30pm identified that the patient was placed in 4 point locking restraints after attempting to get out of bed. The patient remained in 4 point locking restraints until 2:45pm (1 hour, 15 minutes) then was placed in 2 point locking restraints from 3pm until 8pm (5 hours). Although behaviors were documented as quiet from 3:45pm to 4:30pm and 5pm to 7:45pm, the 2 point locking restraints remained.

Review of the Restraint policy of violent or self-destructive behavior directed that alternatives to restraints must be considered and determined to be ineffective in protecting the patient, staff member or others from harm prior to employing the use of restraints. Restraints for violent or self-destructive behaviors are limited to emergencies in which there is imminent risk of an individual physically harming self or others and when nonphysical interventions would not be effective. The least restrictive method of restraint at the time of application (4 point) should be used, and must be changed as soon as a less restrictive method of assuring the patient's or others' safety as soon as possible (2 point).

Based on a review of hospital documentation and staff interviews, the facility failed to implement performance improvement program related to patient safety. The findings include:

Review of the facility's 2018 and 2019 QAPIC (Quality Assurance Performance Improvement Committee) identified the hospital adopted the accreditation's body's patient safety goals including to identify patients at risk for suicide through risk assessment and identification of signs and symptoms indicating risk for suicide. The safety goals further included addressing the patient's immediate safety needs, assessing the environment and eliminate access to potential hazards and to monitor the patients' medical conditions that might increase impulsivity.

Interview with the VP of Quality and Patient Safety on 6/4/19 at 2PM stated that the hospital has adopted patient safety goals from the accrediting agencies and they are posted on the units of the hospital. The VP stated that although they have implemented the C-SSRS for suicide risk (5/31/19) after an accreditation survey, there are no current projects related to the agencies recommendations in the QAPI program.


Review of the hospitals 2019 Quality Assurance and Performance Improvement Plan identified the QAPI plan is developed in conjunction with and is intended to complement the Patient Safety, Patient Experience, Environment of care and Risk Management Plans.

Based on a review of hospital documentation, policy and staff interview, the hospital failed to set clear expectations and ensure staff education related to suicidal assessments was completed prior to staff working. The findings include:

Review of hospital documentation with RN #2 on 6/2/19 at 2PM identified the policy for Suicidal risk assessment was updated as of 5/31/19 to include the C-SSRS (Columbia Suicidal Severity Risk Assessment). The documentation identified from 5/31/19 at 4PM through 6/2/19 at 2pm 19 staff had worked in the ED and seven (7) staff had not received the education on the C-SSRS.

Interview with the Director of inpatient behavioral health at 2:20PM stated that when the new policy was implemented the staff that were on and available received the education at that time. The Director stated he is having people receive the education when they are working and have time to do it. The Director further stated that he was not given direction to educate the staff prior to them working on the floor.

Interview with the CNO on 6/2/19 at 3:10PM stated that they revised the policy regarding high risk for suicide on 5/31/19 to include a new assessment tool (C-SSRS) for staff to use. The CNO stated that the policy identifies any patient identified as high risk for suicide will be placed on constant observation, implementing a checklist, and not leaving high risk patients unattended. The CNO stated that staff were being educated anytime during their shifts.

Based on review of the medical record, review of facility policy and interview for 2 of 3 patients (Patients #15 and #16) who received blood transfusions, the hospital failed to ensure documentation of vital signs upon completion of the transfusion in accordance with facility policy. The findings include:

1. Patient #15 received packed red blood cells on 1/14/19. The unit was hung at 12:18pm and was completed at 5pm. The unit transfusion card lacked documentation that vital signs including temperature, blood pressure, respirations, and blood pressure were obtained upon completion of the transfusion.

2. Patient #16 received packed red blood cells on 4/13/19. The unit was hung at 4:22pm and was completed at 6:50pm. The unit transfusion card lacked documentation that vital signs including temperature, blood pressure, respirations, and blood pressure were obtained upon completion of the transfusion.

Interview with the Risk Manager on 6/4/19 at 2pm identified that the medical records documentation was incomplete. Review of the Transfusion Therapy policy identified that vital signs are done on initiation of blood product, then in 15 minutes after starting blood product, then again in 2 hours, and upon completion.

The Condition of Participation for Physical Environment has not been met.

Based on observations during a tour of the ED unit, the facility failed to ensure a safe environment for patients at risk for suicidal ideation.

Refer to A-701
Cross Reference A-144

Based on observations during a tour of the Emergency Department (ED) unit and interview, the facility failed to ensure a safe environment for patients at risk for suicidal ideation (SI). The findings include:

Based on observations during a tour of the ED unit on 6/2/19 at 2:40PM identified Room #11, the room designated for high SI risk patients, was noted with the following ligature points; the stretcher bed had side rails on it; the call bell cord was long and attached to the stretcher; a free standing chair and a regular door handle that was not ligature resistant.

An observation on 6/3/19 at 9:30AM identified the stretcher bed with 2 side rails in the up position, the call bell cord was long, a chair was noted in the room and the door handle was not ligature resistant and had a lock on it.

Interview of 6/2/19 at 2:55PM with RN #2 stated that patients who are at risk for self-harm are placed in room #11. RN #2 stated that they place high risk patients there because there are less items in the room the patient could harm themselves with. RN #2 further stated that if they have more than one high risk patient and are in the other rooms on the unit they are to be placed on continuous observation.