HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure patients who were assessed as high risk for self-harm and/or suicide were supervised in the emergency room department for 2 (#s 2, 3) patients. Findings include:

The facility suicide attempts incidents from January of 2015 to March of 2018 were reviewed.

During an interview on 3/30/18 at 10:30 a.m., Staff member C stated in the last 2-3 weeks if a patient is high risk level 2, staff supervise the patient 1:1 in the emergency department. She stated prior to this, patients who were high risk level 2 were monitored with a nursing assessment every 2 hours, and a walk through visual check every 1 hour.

1. Review of the medical record for patient #2 showed he was brought in to the emergency room on 9/9/17, by a Billings Police Officer, and screened at an emergent level 2. Patient #2 was admitted at 6:06 a.m. for threats to choke himself. He remained in the emergency department until 5:36 p.m. the next day.

Review of the incident report showed patient #2 had been in the emergency department over 24 hours and at 5:00 p.m., was noted as crying, throwing his bed sheets, and thrashing around. Staff member E documented patient #2 had been calm all day but started crying and becoming more agitated around 5:00 p.m. Staff member E documented that as she was walking out of a room and charting, she and the security officer noticed patient #2's arms were in the air with the sheet. Staff member E documented when she and the security officer entered patient #2's room he was strangling himself with the bed sheet. She documented they were able to get the sheet out of his hands. She noted the doctor assessed the patient and his airway was patent. She documented he was transferred to a room in the psychiatric unit an hour later. In the Safety Net report staff member C documented she discussed the event with staff member E. Staff member C documented the ongoing concern of secure psych patients being held for extended amounts of time. She documented on the report that patients and staff are at risk for harm when they are in the emergency department for long periods of time. She documented in the past, the immediate fix was to require a security 1:1 standby, but this had not been effective as security often did not have enough staff for that to happen. She noted, "ongoing discussion with leadership (psych, ED, security, etc.) is required."

Review of the medical record for the two-hour RN assessments showed patient #2 did not receive an assessment from 6:29 a.m. to 9:13 a.m. and 9:13 a.m. to 12:31 p.m. on 9/10/17. The medical record showed staff did not complete the one-hour check at 10:00 a.m. and 11:00 a.m., and 1:00 p.m. on 9/10/17.

2. Review of the medical record for patient #3 showed he was brought to the emergency room via ambulance on 5/12/17. The medical record showed patient #3 reported he shot up methamphetamine in an attempt to kill himself and was homicidal if he was discharged. Patient #3 was triaged at 11:38 p.m. and screened as an emergent level 2. Because patient #2 had been a possible medical emergency due to an overdose he was placed in a room on the A Pod.

Review of an emergency room patient care assessment at 2:00 a.m., showed patient #3 was in A Pod when he turned on his call light after tying the string around his neck. Another notation showed at this time, "security standby outside of room." At 2:30 a.m. there was a note that showed, "assumed care of pt. moved to B5 from A7."

Review of the security officer observations form dated 5/13/17 showed patient #3 was move to B5 as he tried to choke himself with his pants string. The time entries for the security observations were approximately fifteen minutes apart from 12:50 a.m. to 5:40 a.m.

Review of an incident report for patient #3 showed at 2:20 a.m., he turned on his call light and when the nurse entered the room, he was found with a pant string tied around his neck. The report showed a Billings Police Officer cut the string, the M.D. was notified and security standby was initiated. The incident report follow-up showed the safety search policy was reviewed with the RN on duty, and RN stated she would make sure in the future that all psych patients were in scrubs, not a hospital gown.

Review of the two-hour RN assessment showed patient #3 did not receive an assessment from 7:21 a.m. to 10:24 a.m.

During an interview on 3/29/18 at 9:25 a.m., stated that currently, the process for reporting and trending incidents would include the safety net entries being reviewed by the manager, the psychiatrist, and the director of psychiatric services. He stated those individuals would categorize the incident, complete a debriefing with the emergency department staff, and document the planned interventions and monitoring. Staff member B stated in the past, the department did not log or trend suicide attempts. He stated currently, the suicide attempts would be included on the quality score card and would be trended monthly and reported to the Senior Executive team quarterly. He stated this had been put into place in the last few weeks. He stated in the past, the department did not trend incidents but looked at them individually.

During an interview on 3/29/18 at 10:06 a.m., staff member C stated the new patient monitoring system is a better system. She stated the department now had a 360 degree view of the patient. She stated in the old process, the staff's ability to monitor relied too much on security because there were not enough staff to allow for 1:1 supervision for high risk patients. She stated the emergency department could now request for staff to come from other areas of the hospital if there was a need for assistance with the 1:1 supervision.

During an interview on 3/29/18 at 11:50 a.m., staff member G stated if harm were indicated, the incident would be screened and move past the manager, and to upper management for patient safety for incidents that require a root cause analysis and interventions. Staff member G stated currently, the managers are to follow the protocols and document a solution within 14 days if there was no harm to the patient.

During an observation on 3/27/18 from 12:30 p.m. to 1:30 p.m., the emergency room environment from the entrance to the rooms used for patients at risk for self-harm or suicide were observed. The emergency room entrance was clearly marked with proper signage and led to the registration desk. Adjacent to the registration desk was a security desk with video surveillance of the emergency room B Pod. A security staff member was at the desk. At the registration desk was the registration clerk and a nurse. Staff member H stated if a patient that is at risk for suicide or self-harm comes to the desk, that patient is immediately taken to triage to the nurse. Staff member I was the triage nurse at the desk. She stated she screened patients using a SAD screen to determine their risk for self-harm. She stated she supervises the patient until they can be placed in a room in the B Pod. Staff member I stated after the patient is placed in an exam room, they are given a safety search to ensure they did not have anything on their person that they could harm themselves with. (The B Pod is a series of rooms across from the nurse's station and include rooms B1-B5 and B10.) The rooms are empty with the exception of a chair and gurney. The security staff were monitoring the rooms via video surveillance. Staff at the nurse's station also had video surveillance of the B Pod rooms.

During an interview on 3/30/18 at 11:30 a.m., staff member J, a security officer, stated not everything shows up on the camera. He stated there are a lot of rooms to monitor and they cannot all be seen at once. He stated the new process for 1:1 monitoring of patients is a better process as there are a lot of concerns to be looking for.

During an observation on 3/28/18 at 8:01 a.m., pediatric psych patient #7 was observed in a B Pod room with her foster parent and 1:1 staff supervision. A gurney covered with a sheet was the only item in the room. Staff member D stated if the patient was high risk and exhibiting agitation a mattress was placed on the floor instead of using a gurney. Staff member D stated the security staff was a great show of force if there was an elopement risk or potential for violent behavior. She stated there was a concern for adequate staffing for the security staff members, and that over the weekend there were only two staff members scheduled, when typically, there are four. She stated the video surveillance is helpful.

During an observation on 3/29/18 at 8:15 a.m., the B Pod bathroom was inspected. The bathroom had been remodeled recently and had a latch on the door that could be opened by pushing in and pulling out. The toilet did not have exposed plumbing. The toilet paper dispenser had a non-ligature design. The sink was outside of the bathroom and did not have exposed plumbing and had a non-ligature design. The mirror was not made of glass but a safety material that did not break. The towel and soap dispensers were break away from the wall.