HospitalInspections.org

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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation 482.13 Patient's Rights, was out of compliance.

A-144 The facility failed to appropriately monitor a suicidal patient, (#10). This failed practice created an opportunity for patient #10 to inflict self-harm and placed all other behavioral health patients being treated in the emergency department at risk for injury and self-harm.
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Based on record review, interview, observation and video review, the facility failed to ensure 1 patient (#10) out of a census of 7 patients, received care in a safe setting. Specifically, the facility failed to monitor a suicidal patient according to policy. This failed practice created an opportunity for patient #10 to inflict self-harm, and placed all other behavioral health patients being treated in the emergency department at risk for injury and self-harm. Findings:

Record review from 11/14/22 and 11/16/22 of the nurses' documentation in the "ED Triage Notes ...," dated 11/6/22 at 7:46 PM revealed "[Patient] arrives with APD [Anchorage Police Department] for auditory hallucinations and suicidal thoughts. [Patient] stated the voices are commanding [him/her] to harm [him/herself] ..."

Review of the Physician's note "EMERGENCY DEPARTMENT ENCOUNTER," dated 11/6/22 at 8:42 PM, revealed the patient had "multiple mental health hospitalizations, who presents with command hallucinations [auditory hallucinations that instruct a patient to act in specific ways] telling [the patient] to harm [him/herself] ..." The final impression documented by the physician included psychosis [loss of contact with reality], history of command hallucinations and suicidal ideation [thinking about suicide].

During an interview and initial tour of the Psychiatric Emergency Department on 11/14/22 at 9:51 AM, Room #1 was occupied and dark. An observation through the window revealed the inability to visualize the patient from the window with the room lights off. Two monitor screens filming the patient rooms and hallways were observed in the nurses' station area. The Mental Health Specialist (MHS) #3 stated a dark room would show a black and white screen on the monitor, where staff could have visualized the Patient. The MHS further stated if staff observed a concern on the monitor, they would have gone into the patient's room to check on the patient.

During an interview on 11/14/22 at 10:07 AM, Licensed Nurse #4 stated the facility utilized a Patient Care Technician (PCT) who was dedicated to observing the monitoring station which included the Patient rooms and hallways. The LN further stated in addition to the dedicated staff, all staff were responsible for observing the monitors.

When asked about the monitoring of the suicidal patient, LN #4 stated if the patient was actively attempting to harm themselves, that patient would have been placed on a 1 staff to 1 patient ratio and be observed continuously. Otherwise, all patients were checked upon every 30 minutes. When asked about documentation of patient safety checks, LN # 4 stated the LN's documented every 2 hours, while the PCTs documented every 30 minutes.

During an interview on 11/14/22 at 10:16 AM, when asked his/her responsibilities for monitoring the suicidal patient, PCT #5 stated a lot of patients admitted into the facility were suicidal. The PCT stated the patient would have been checked every 30 minutes. If something concerning was seen on monitors, staff would have gone into the patient's room.

When asked about watching the patients from the nurses' station monitors, PCT #5 stated there was not enough staff to have a dedicated person watching the monitors. If it was a busy day, it was impossible to have someone consistently watching, so as a team, staff would all watch the monitors. When asked if monitor checks were acceptable as a 30-minute patient check, PCT #5 stated the checks were 50/50 monitor checks or going into the patient's room, such as bringing in a food tray and checking on them.

When asked about staffing in the facility, the PCT stated the facility was short staffed. PCT #5 further stated it was a matter of time for an event like this to occur, because if there were 7 suicidal patients and only 1 PCT and 1 LN, how could the facility expect for something like this event not to happen?

During a follow-up interview on 11/14/22 at 10:30 AM, MHS #3 stated he/she had worked as a PCT during times of short staffing, in addition to his/her other responsibilities. The MHS states there were usually 2 PCTs on duty every shift with 1 PCT responsible for every 30-minute behavioral observations. MHS #5 further stated if the patient appeared asleep from the monitor observation, staff would have entered the patient's room and checked the patient for safety and counted the patient's respiratory rate.

The MHS stated all staff members were responsible for watching the patient monitors, but the LNs and clinicians didn't watch as much because they had more charting to do, but everyone "looked up" at the monitors.

A video review and interview were held on 11/14/22 at 11:45 AM with the Senior Manager of Physical Security (SMPS).

View #1:

A video review of the camera angle outside of Patient #10's room, on the morning of the event, revealed no staff had entered the room or performed a visual check on Patient #1 from 6:00 AM to 8:45 AM. The SMPS stated no staff had entered or were observed doing a visual check on Patient #10 from 6:00 AM to 8:45 AM.

Record review of "Continuous Visual Observation," note dated 11/6/22 at 6:30 AM revealed "Patient Observation: Asleep."

Record review of "Continuous Visual Observation," note dated 11/6/22 at 7:00 AM revealed "Patient Observation: Asleep."

Record review of "ED Quick Note," dated 11/6/22 at 8:00 AM revealed " ...Patient is resting comfortably ...Patient appears to be sleeping. Respirations even and unlabored. Safety: bed in low position, wheels locked, call light in reach, [Identification] band on."

Further review of Patient #10's notes revealed no documented notes from 8:01 AM to 8:40 AM.

View #2:

A video review of the camera angle inside Patient #10's room on 11/6/22 from 7:30 AM to 8:19 AM revealed the Patient to be awake, with brief periods of quiet verses rocking back in forth in bed, sitting up or pacing in the room. The SMPS stated the room was dark and this camera angle is what staff would have seen from the monitors at the nurses' station.

At 8:20 AM, Patient #10 tied a strip of blanket or sheet to the bed rails. The video angle did not reveal how the patient obtained or fashioned the strip of linen.

From 8:21 AM to 8:25 AM, Patient #10 tied the strip of linen around his/her neck. The Patient appeared to use his/her body weight to hang him/herself from the other side of the bed. The Patient was seen to kick a chair in front of the door to possibly prevent staff from entering.

From 8:25 AM to 8:26 AM, Patient #10 was observed to use his/her body weight to test the strength of the linen cord. The SMPS stated the linen cord was noticeable from the camera view but could have been missed by a camera observer glancing at the monitors quickly.

At 8:27 AM, the Patient was observed to sit back up (releasing the pressure from his/her neck). The linen cord was clearly visible across the bed and around the patient's neck.

From 8:27 AM to 8:37 AM, Patient #10 was observed sitting forward, repositioning him/herself, hitting him/herself on the head with his/her hand. The SMPS stated the Patient was trying different positions to achieve a result (hanging).

At 8:38, Patient #10 pulled the bedsheet off the bed, making the view of the linen cord over the bed even more visible to the monitor observer.

From 8:40 AM to 8:46 AM, Patient #10 was observed to position him/herself to achieve pressure on his/her neck. The Patient positioned arms forward and back and moved his/her neck forward to achieve hanging.

At 8:46 AM, staff intervened and entered the room to provide emergency care to the Patient. The patient appeared to be having a seizure during the staff's intervention.

View 3:

A video review of the camera monitor angled inside the nurses' station revealed from 6:00 AM to 8:46 AM, staff were busy with routine tasks. The SMPS stated there was not a designated staff member observed to be monitoring the patient monitors.

Throughout the video observation several staff members were observed to glance at the patient monitors. The SMPS stated at a glance staff may not have visualized the linen strip across the bed area because the cord was next to the bed sheet.

At 8:34 AM and 8:43 AM, when the linen cord was clearly visible across the bed and around the Patient's neck, Mental Health Specialist (MHS) #3 glanced up at the monitors, then continued to work at the desk area.

At 8:46 AM, MHS #3 looked at the monitor and responded to the Patient's room.

A follow up video review and interview were held on 11/16/22 at 11:28 AM with the Senior Manager of Physical Security (SMPS).

A video review of the camera angle inside Patient #10's room on 11/6/22 from 5:50 AM to 6:10 AM revealed the Patient's room was dark and no staff members opened the door or entered the room. The SMPS stated if the room was dark you could not see inside of the room from a hallway window check.

Record review of "Vital Signs," dated 11/6/22 at 6:00 AM revealed the Patient had a respiratory rate of 18.

Record review of "ED Quick Note," dated 11/6/22 at 6:01 AM revealed " ...[Patient] resting quietly in [his/her] bed. No concerns or needs expressed ...call light in reach."

During a joint interview on 11/16/22 at 11:00 AM, when asked about monitoring the patient with suicidal ideation, the Department Chair (DC) for the psychiatry department and the Clinic Manager (CM) for the psychiatric ED stated the patients were monitored by rounding at a minimum of every 30 minutes. When asked about the specifics of the rounding, the CM stated the expectation was a direct visual check of the patient and checking the monitor did not classify as a direct observation of the patient. The CM further stated if the patient was sleeping, staff would have counted the patient's respirations. When asked standard of practice for counting respirations, the DC stated the respiration count was a direct visual assessment for accuracy and the monitors did not classify as a direct observation of the patients.

Linens:

During an interview on 11/14/22 at 10:16 AM, when asked his/her responsibilities in caring for the suicidal patient, PCT #5 stated he/she would have cleaned the patient rooms and set up the rooms for the next patient. When asked about checking the linens for frays and tears when setting up the room, the PCT stated he/she did not perform inspection of the linens. The PCT further stated the linen checks were performed by the laundry department.

During an interview on 11/14/22 at 10:30 AM, when asked if he/she checked the linens for frays or tears, MHS #3 stated sometimes the linens were folded so he/she didn't unfold the linen all the way, but if it was obvious, he/she would have switched the linens out. The MHS stated he/she wasn't aware that staff inspected the linens.

MHS #5 further stated the laundry department was responsible for inspecting the linens and their department should not have received damaged linens from the laundry.

During an interview on 11/14/22 at 3:22 PM, when asked if hospital linens were routinely inspected for frays or tears, the Laundry Manager (LM) stated damaged linens were separated and removed, however linens with frays, especially a small fray, could have been returned to the patient care units. When asked if special procedures were instituted for different hospital units, the LM stated there was nothing special done for different units, but the hospital units could have requested a special order as needed.

Report:

During an interview on 11/14/22 at 10:30 AM, MHS #3 stated Patient #10 seemed intent on committing suicide, as he/she never saw a patient rip a bed sheet like that in the past. The MHS further stated the patient was experiencing command hallucinations to kill him/herself, but this information was not passed along to him/her during the unit report. MHS #5 stated nothing that was stated in unit report made the team think the patient was suicidal.

During an interview on 11/16/22 at 11:00 AM, when asked about a patient's risk of suicide and level of care requirements for higher risk patients, the Department Chair (DC) for the psychiatry department stated the level of care was dictated by the clinician's assessment, and the expectation was for the clinician to verbalize the risk level to the staff to ensure the risk level was reflected in the patient's care.

Review of the Mental Health Specialist note "Psychiatric Emergency Department Suicide/Violence Risk Assessment," dated 11/6/22 at 8:54 PM revealed " ...[Patient] told APD [he/she] has voices in [his/her] head telling [him/her] to hurt [him/herself] and [he/she] doesn't feel safe ..." Further review revealed "The patient's suicide risk in the current environment is stratified as moderate risk ..."

Review of the facility's policy, "Suicide Risk Assessment and Care of the Suicidal Patient," revised 7/2020, revealed monitoring for the Psychiatric Emergency Department, for patients stratified as a moderate risk included "A. Patients shall be observed via Safety Checks at an interval of every 30 minutes throughout their admission. B. Environmental interventions based on patient-specific risks, may include, but are not limited to: 1. Gurney removal 2. Bedside table removal 3. Linen removal 4. Direct observation in bathroom."

During an interview on 11/14/22 at 10:30 AM, when asked what mitigation plans were put in place after the incident to prevent reoccurrence, MHS #3 stated no changes were made, but the facility sent out communication asking the staff to remain vigilant and check upon the patients per protocol.
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