HospitalInspections.org

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Patient Rights.

Based on observation, interview, and record review, the facility failed to:

- Protect patients' rights to safety in the B pod unit of the emergency department, where patients with psychiatric conditions were roomed, related to a ligature free environment for patients with suicidal and homicidal ideation (see A144);

- Follow existing policies and procedures for emergency department patients, who presented with psychiatric concerns and were evaluated at risk for suicide for 3 (#s 6, 7, and 8) of 8 sampled patients (see A144);

- Develop and implement policies and procedures for the monitoring of safety of vulnerable patients with psychiatric conditions in a bathroom setting, in the B pod unit of the emergency department (see A144);

- Ensure all locum tenens psychiatric physicians were trained in the hospital's seclusion and restraint policies and procedures (see A176).

These deficient practices had the potential for increased risk for harm to self and/or others in the B pod unit of the emergency department and the safety of individuals residing on the youth psychiatric treatment unit.

Based on observation, interview, and record review, the facility failed to protect patients' rights to safety in the B pod unit of the emergency department, where patients with psychiatric conditions were roomed, related to a ligature free environment for patients with suicidal and homicidal ideation; failed to follow existing policies and procedures for emergency department patients, who presented with psychiatric concerns and were evaluated at risk for suicide for 3 (#s 6, 7, and 8) of 8 sampled patients; and failed to develop and implement policies and procedures for the monitoring of safety of vulnerable patients with psychiatric conditions in a bathroom setting, in the B pod unit of the emergency department. These deficient practices had the potential for increased risk for harm to self and/or others in the B pod unit of the emergency department. Findings include:

1. B Pod Unit in the Emergency Department

During an interview on 4/18/23 at 9:24 a.m., staff member D stated youth who entered the emergency department with mental health issues were triaged for suicidal and homicidal ideation and assigned a preferred bed/room on the B pod unit. He stated a triage nurse did the room assignment after a triage level was determined.

During an observation on 4/18/23 at 9:33 a.m., the B pod unit had six single rooms, all occupied by a patient.

During an interview on 4/18/23 at 9:34 a.m., staff member B stated there was not a time limit for occupancy of beds on the B pod unit in the emergency department.

During an observation on 4/18/23 at 9:45 a.m., a patient in one of the rooms had stepped out to use the bathroom. The room had a standard hospital bed in the center of the room with sheets and a pillowcase on the bed. The hospital bed had multiple ligature risk points in several areas. The patient was not being monitored by staff while in the patient's room.

During an observation and interview on 4/19/23 at 9:42 a.m., the two doors, which opened in the middle, leading into the B pod unit were propped open. Both doors had regular hinges, posing a ligature risk. A charting cart, with vital sign equipment and cords attached, was located within 15 feet of the open doors. Any person walking through these doors had access to other rooms in the corridor with multiple ligature risks. Staff member D stated these doors were open at times but did not know the doors were a ligature risk.

During an observation of a B pod unit patient room on 4/19/23 at 9:52 a.m., a standard hospital bed, which had multiple ligature points, sheets, and a pillowcase was positioned in the middle of the room. A wooden chair and standard hospital bedside table were also in the room.

During an interview on 4/19/23 at 9:54 a.m., staff member I stated when a patient was brought to a room on the B pod unit, the standard hospital bed would be checked to make sure an oxygen tank was not attached. She stated if a patient was aggressive, the chair and bedside table would be removed. Staff member I stated the staff did not regularly remove the sheets or pillowcase from the room unless the patient had a history of strangulation. Staff member I could not speak to the protocol if a patient was presenting to the B pod unit of the emergency department, with suicidal or homicidal ideation, for the first time.

During an interview on 4/19/23 at 1:48 p.m., staff member L stated the safety team had not looked at the physical environment in the B pod unit lately for ligature risks. Staff member L stated the safety team would work with the emergency department if they had concerns. Staff member L stated the team did surveillance rounds, but attention had not been called to ligature risks in the emergency department pods.

2. At Risk Suicidal Patients

During an interview on 4/18/23 at 9:25 a.m., staff member D stated patient triage occurred outside of the clinical area of the emergency department. He stated the triage nurse assigned an ESI (Emergency Severity Index), based on their initial assessment, and then the patient was assigned a room. Staff member D stated the B pod unit was a mental health preferred area of the emergency department.

During an interview on 4/18/23 at 9:43 a.m., staff member D stated there had been times when youth patients spent several days on the B pod unit if space was not available for transfer to the youth psychiatric unit.

During an interview on 4/18/23 at 10:15 a.m., staff member J stated the current census on the youth psychiatric unit was capped at nine at this time, due to staffing availability.

During an interview on 4/18/23 at 10:23 a.m., staff member H stated kids with mental health symptoms may stay longer in the emergency department due to the cap on beds in the youth psychiatric unit.

A. Review of patient #7's EHR (Electronic Health Record) showed he was a 10-year-old male, admitted to the emergency department on 2/8/23 at 6:55 p.m. The emergency department triage was completed with an ESI level 2, emergent. Patient #7 presented with chief complaints of "grabbing knives and had threatened his mom's girlfriend with knife. States he body shamed a kid at school today and this affected his day." [sic] The record showed a C-SSRS (Columbia Suicide Severity Rating Scale) was completed with a "high risk" score of 11. Patient #7 was assigned to a room on the B pod unit.

Review of patient #7's Behavioral Health Notes, dated 2/8/23 at 7:30 p.m. showed "Mental Health Risk Screen: Moderate Risk."

Review of patient #7's EHR showed he was seen by a physician on 2/8/23 at 7:07 p.m., a licensed clinical social worker on 2/8/23 at 10:11 p.m., an advanced practice registered nurse on 2/9/23 at 1:15 a.m., and a psychiatric medical doctor on 2/9/23 at 5:50 p.m. Patient #7 was admitted to the PYTU (Psychiatric Youth Treatment Unit) on 2/9/23 at 11:00 p.m. Review of patient #7's EHR showed no physician orders for a 1:1 observation per facility policy.

Patient #7 remained in a room on the B pod unit, in the emergency department, with ligature risks from 2/8/23 at 6:55 p.m. until 2/9/23 at 11:00 p.m., before he was transferred to a unit free of ligature risks.

B. Review of patient #8's EHR showed he was a 10-year-old male, admitted to the emergency department on 2/6/23 at 2:44 p.m. The emergency department triage was completed with an ESI level 2, emergent. Patient #8 presented with chief complaints of "Attempted suicide by jumping off of a climbing web at school. Recently tried to hurt himself several weeks ago also. Admits to wishing he was dead." The record showed a C-SSRS was completed with a "high risk" score of 28. Patient #8 was assigned to a room on the B pod unit. Review of patient #8's EHR showed no physician orders for a 1:1 observation per facility policy.

Patient #8 remained in a room on the B pod unit, in the emergency department, with ligature risks from 2/6/23 at 2:44 p.m. until 2/7/23 at 9:30 a.m., before he was transferred to a unit free of ligature risks.

C. Review of patient #6's EHR showed she was a 13-year-old female, admitted to the emergency department on 2/6/23 at 3:58 p.m. The emergency department triage was completed with an ESI level 2, emergent. Patient #6 presented with chief complaints of "SI [suicidal ideation] w/ [with] plan. Hasn't worked out details of plan however. Has made a recent attempt." The record showed a C-SSRS was completed with a "high risk" score of 14. Patient #6 was assigned to a room on the B pod unit. Review of patient #6's EHR showed no physician orders for a 1:1 observation per facility policy.

Patient #6 remained in a room on the B pod unit in the emergency department, with ligature risks from 2/6/23 at 3:58 p.m. until 2/6/23 at 9:37 p.m., before she was discharged to home, with a safety plan, and a family member.

During an interview on 4/19/23 at 12:51 p.m., staff member E stated patients #s 6, 7, and 8 did not have documented physician orders for 1:1 observation while in the emergency department, February 6th through 9th of 2023.

Review of the facility's policy titled, Suicide Assessment and Precautions, with an effective date of 7/14/21, showed:

- ... "G. Moderate Risk: Level of suicide precautions for patients who are verbalizing suicidal ideation with a definite plan, who have been admitted following a suicide attempt or self-harm while in the hospital. ...
- H. High Risk: Level of suicide precaution for patients who are actively suicidal with a plan, who have had frequent past suicide attempts that have been very serious. These patients will be assessed using C-SSRS tool minimally once per shift and will have one-to-one (1:1) supervison [sic] at all times. ...
- PROCEDURE
- Patient assessment for suicide may occur on an outpatient, emergency, or inpatient basis. ...
- C. Emergency Department (ED): Patients who present with psychiatric concerns are screened for suicide risk upon arrival to the ED.
- 1. Patients determined to be at high risk for suicide related to their score on the suicide screening tool will be placed on one-to-one staffing." ...

3. B Pod Unit Bathroom Monitoring

During an observation and interview on 4/19/23 at 10:00 a.m., the bathroom on the B pod unit was located at one end of the unit. The sink was located outside of the toileting area and was attached to the wall, the pipes were exposed, and did not have a cabinet underneath, The toileting room had a door which could not be locked. Staff member I stated if a patient needed to use the bathroom, the staff would escort them to the room. Staff member I stated the staff would stand outside the door, verbally prompt the patient while in the room, and if the patient did not answer, the staff could open the door. Staff member I could not speak to any specific time frames for verbal prompting for safety, any protocol for verbal response, or when to enter the room for the safety of the patient. Staff member I stated she would listen for toileting (urinating) and when she could hear the patient using the toilet paper.

A written request was made on 4/19/23 at 10:00 a.m. for a facility policy and procedure for bathroom monitoring on the B pod unit of the emergency department.

During an interview on 4/19/23 at 12:56 p.m., staff member E stated the facility did not have a policy/procedure for bathroom monitoring on the B pod unit of the emergency department.

Based on interview and record review, the facility failed to ensure all locum tenens psychiatric physicians were trained in the hospital's seclusion and restraint policies and procedures. This deficient practice had the potential to place patients on the youth psychiatric treatment unit at increased risk for harm. Findings include:

During an interview on 4/18/23 at 11:42 a.m., staff member R stated on 2/9/23 he was called to the psychiatric children's unit to evaluate a patient who was placed in seclusion. Staff member R stated he had monitored seclusions before, but not often. He stated he had been trained on seclusions in general but requested from the nursing staff to see the hospital's seclusion and restraint policy, protocol, and documentation guidance, as different facilities have varied policies. Staff member R stated he was frustrated that the seclusion and restraint policies and procedures were not readily available at the psychiatric unit's nurses station at the time of the seclusion.

During a personnel file review on 4/19/23 beginning at 8:30 a.m., facility human resources personnel were unable to locate seclusion and restraint training for staff member R.

During an interview on 4/19/23 at 11:09 a.m., staff member A stated staff member R had not received training on seclusion and restraint policies and procedures during orientation or any other time.

Review of the facility's policy and procedure titled, Restraint/Seclusion Policy, with an effective date of 9/29/22, showed:

- "Policy Statement:
- A. ...The patient's rights, dignity and well-being will be protected and preserved by the intra-disciplinary team providing care. ...
- [name of facility] intends to assure safe application and removal of restraint/seclusion by competent and trained staff. ..."