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Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure nursing staff supervised the care of one (1) of three (3) sampled patients (Patient #1). Review of facility documentation and interviews with staff indicated Patient #1 made "suicidal statements" and obtained a pair of "scissors" from a bedside table during the initial triage nursing assessment, when he/she arrived to the facility Emergency Department (ED) on 01/10/2021. However, staff failed to complete the required Suicide Nursing Assessment related to his/her exhibited behaviors/statements and failed to provide Patient #1 with a sitter, as outlined in the facility policy. Interview and record review revealed the patient continued to exhibit suicidal ideations for the next two days while the patient while the patient remained in the ED, awaiting transfer to another facility. However, there was no evidence the facility implemented their suicide screening policy as required. On 01/12/2021, Patient #1 obtained a pair of scissors from the ED nurses ' station and stabbed a staff nurse in the left side of the face. The staff nurse was then transported to a trauma center, on 01/12/2021 to be evaluated by a plastic surgeon due to his injuries.

The findings include:

Review of a facility policy titled "Suicide Screening/Assessment" dated March 2019, revealed all patients admitted to the ED would be screened for risk of suicide. The policy stated if patients were determined to be at risk of suicide the patient would be more thoroughly assessed and staff would implement appropriate suicide precaution interventions as necessary. According to the policy, if patients were determined to be at low risk, then the patient must be put in direct line of sight of staff. The policy also stated if staff were unable to put the patient in direct line of sight of staff, then the patient would be assigned a sitter. The policy further stated if the patient was determined to be a moderate or high risk, a sitter would be assigned to the patient.

Review of Patient #1's medical record revealed he/she arrived to the facility ED on 01/10/2021 at approximately 6:21 PM. Further review of the medical record indicated Patient #1 ' s chief complaint was Anxiety, his/her mental status was altered and the patient was confused, anxious and combative.

Interview with Registered Nurse (RN) #1 on 01/22/2021 at 11:45 AM revealed she admitted Patient #1 to the facility ED on 01/10/2021. The RN stated the patient informed her that "God wanted to take" him/her "out" and stated, "Just let me die." The RN also stated Patient #1 "grabbed" a pair of scissors from a bedside table in the ED triage area and the patient also "grabbed an oxygen concentrator out of the wall," while the initial nursing assessment was being conducted. She stated she was able to retrieve the scissors and the concentrator from the patient without the patient or anyone else being harmed. According to RN #1, she was aware that staff was required to complete a Suicide Risk Assessment for patients that presented to the ED with suicidal ideations. However, she stated she did not conduct the required assessment for Patient #1 because she did not think he was a suicide risk, even though the patient had informed her that he/she "wanted to die." The RN stated she would have implemented a 1:1 sitter with Patient #1 during after initial assessment; however, she stated the facility had no extra staff to provide adequate supervision and stated, "We did all we could with what we had."

Review nurse ' s notes for Patient #1 revealed on 01/10/2021 at 7:30 PM the patient stripped off all his/her clothes and tried to walk out of the facility ED. According to the medical record, Patient #1 was also anxious and would not "sit or lay on the ER bed." Patient #1 ' s nurses notes also indicated on 01/10/2021 at 8:40 PM that the patient stated, "If I had some pills I would take them, or if I had a gun I would blow my brains out."

Interview with RN #2 on 01/22/2021 at 1:00 PM revealed he had cared for Patient #1 and completed the nursing documentation on 01/10/2021 at 7:30 PM and 8:40 PM. RN #2 stated Patient #1 "came out of the trauma room naked" and the patient told the RN that he/she "wanted to die" a couple of times. However, the RN stated he did not complete the required Suicide Risk Assessment because he thought someone else had completed the assessment of Patient #1. RN #2 stated staff were required to supervise and provide patients with a safe environment and also stated Patient #1 "was unpredictable" and should have had a 1:1 sitter while he/she was at the facility. However, the RN stated there was not enough staff to provide patients with sitters at times. RN #2 stated there was a security guard on duty during the night shift, whom he utilized to monitor Patient #1 during the night shift on 01/10/2021.

Further review of Patient #1 ' s medical record revealed on 01/10/2021 at 11:00 PM staff initiated attempts to transfer Patient #1 to another facility for psychiatric treatment, without success.

Review of Patient #1 ' s nurses notes on 01/11/2021 at 9:01 AM revealed Patient #1 had wrapped a sheet around his/her neck, which the patient had "tied with tape." Nursing documentation on 01/11/2021 at 9:20 AM also indicated Patient #1 was "belligerent" and stated to staff, "Just gut me and get it over with."

Interview with RN #3 on 01/22/2021 at 9:40 AM revealed she cared for and completed the 01/11/2021 documentation for Patient #1 at 9:01 AM and 9:20 AM. The RN stated the previous nurse reported at the beginning of her shift on 01/11/2021 that the patient had been brought to the facility ED due to self-harm ideations. RN #3 stated the patient had tried to "choke" him/herself by wrapping a sheet around his/her neck. The RN stated she did not complete the required Suicidal Risk assessment for the patient because she also thought one had already been completed. She also stated attempts to find a facility that would accept the patient were conducted during her shift; however, those attempts were unsuccessful. RN #3 stated she supervised the patient "as best as she could" during her shift. She stated the facility should have provided the patient with a 1:1 sitter; however, due to inadequate staffing in the ED, a sitter was not provided to Patient #1 as required.

Review of Patient #1 ' s medical record revealed on 01/12/2021 continued attempts were made to find placement for Patient #1 at another facility for psychiatric treatment; however, attempts were unsuccessful.

Further review of Patient 1 ' s record revealed he/she was "sitting in" the nurse ' s station with facility staff on 01/12/2021 at 10:55 AM.

Interview with the ED Director on 01/21/2021 at 1:30 PM revealed she supervised Patient #1 "at times" during the day shift on 01/12/2021. The Director stated Patient #1 had presented with and continued to exhibit suicidal ideations and visual/auditory hallucinations during his/her stay in the facility ED. She also stated attempts had been made to find the patient placement at another facility; however, the attempts were unsuccessful. According to the Director, she left the facility at approximately 5:30 PM on 01/12/2021, and left Patient #1 at the nurses ' station with staff.

Interview with RN #4 on 01/22/2021 at 12:10 PM revealed she worked day shift (7AM-7PM) in the ED on 01/12/2021. She stated Patient #1 left the ER, went to the front entrance door "and tried to get out" (unable to recall what time) on 1/12/2021, and ED staff assisted the patient back to the ED. RN #4 also stated Patient #1 should have been provided with a sitter, to ensure he/she was adequately supervised; however, she stated, "We didn ' t have the resources to provide a 1:1," due to inadequate staffing in the ED. The RN stated that at approximately 6:30 PM on 01/12/2021, Patient #1 was sitting beside her at the nurses ' station. She stated as she turned away from Patient #1, to complete computer documentation, Patient #1 patted her on her right shoulder, picked up a pair of scissors that were in a cup at the nurses ' station, then stood up and "forcefully stabbed" RN #5 in the left side of the face. The RN stated she then instructed Patient #1 to drop the scissors, and the patient complied. According to the RN, a 1:1 sitter was then provided, until law enforcement arrived to monitor the Patient. According to Patient #1 ' s medical record, staff provided 1:1 supervision until the patient was transferred to another facility on 01/13/2021.

Interview with RN #5 on 01/22/2021 at 2:00 PM revealed he had arrived to work on 01/12/2021 and entered the nurses ' station to call report on another patient that was being admitted to the facility. The RN stated Patient #1 was sitting with staff at the nurses ' station and when RN #5 picked up the phone to call report, Patient #1 "totally blindsided me." The RN stated initially, he thought the patient had hit him, until he saw blood and realized he had been stabbed. RN #5 stated he was transferred to a larger medical facility after the incident occurred to be evaluated by a plastic surgeon, and was now recovering at home.

Interview with the Chief Nursing Officer (CNO) on 01/22/2021 at 3:45 PM revealed staff should have conducted a Suicide Assessment for Patient #1 when he/she arrived at the facility with suicidal ideations on 01/10/2021. She also stated the patient should have been provided with a 1:1 sitter in attempts to ensure nursing staff adequately supervised the patient ' s care, while awaiting bed placement at another facility.