HospitalInspections.org

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

482.55 Tag A-1100 Emergency Services

Based on observation, review of facility policies and medical records (MR), and staff (EMP) interview, it was determined the facility failed to ensure staff followed approved policy for observation of eight of 19 MRs reviewed (MR1, MR5, MR6, MR10, MR11, MR12, MR13 and MR17) with a mental health diagnosis and failed to ensure suicide precautions were ordered and initiated per facility policy for three of 19 MRs reviewed (MR1, MR6 and MR13).

Cross reference
482.55(a)(3) Tag A-1104 Emergency Services Policies

Based on observation, review of facility policies and medical records (MR), and staff (EMP) interview, it was determined the facility failed to ensure staff followed the approved policy for observation of eight of 19 MRs reviewed (MR1, MR5, MR6, MR10, MR11, MR12, MR13 and MR17) with a mental health diagnosis and failed to ensure suicide precautions were ordered and initiated per facility policy for three of 19 MRs reviewed (MR1, MR6 and MR13).

Findings include:

Review on February 2, 2022, of facility policy "Suicide Assessment & Prevention - Patient Care," last reviewed September 2021, revealed "... IV. Definitions ... Observation: Suicide Precautions -This level of observation is for a patient who expresses or demonstrates suicidal intent or actions requiring a greater level of precaution in order to maintain a safe environment. This level of observation requires the assigned clinical staff member to be in direct, constant visual contact (EBH/secure ED -video camera). Staff members must have constant unobstructed visualization of patient activities including toileting or bathing which enables staff to intervene immediately. Provider order is required and is entered into the electronic medical record. This order does not imply arm's length observation. The [name of suicide risk assessment tool] guides the interventions as outlined in Attachment B and C. Observation: Arm's Length -This level of observation is for a patient who requires constant visualization for safety, enabling staff to intervene quickly. The staff member is to be within arm's reach of the patient at all times and under full visualization during all levels of care, including patient toileting or bathing. An order is entered into the electronic medical record. This level of observation is to be reserved for patients who exhibit self-harm (swallowing objects, having immediate access to objects needed for hospitalization, but may be used to harm self, etc). Observation: Visual -This level of observation applies to a patient who requires constant unobstructed observation that allows the staff member to respond and intervene quickly. BH diagnoses: One staff member per patient. ... VII. Procedure: 1. Each patient who presents to the Emergency Room or any other inpatient acute care unit with a behavioral health complaint, suicide attempt, or who presents with suspicious injury will be screened by staff for suicidal ideation utilizing [name of suicide risk assessment tool] a. Provider enters order for suicide precautions for low, moderate or high [name of suicide risk assessment tool]. ... d. Adult patients identified as a Suicide Risk will have patient safety measures implemented as defined in the risk stratification interventions for ED. i. Adult patients in a defined secure BH room (EBH area) are continuously visualized by staff via video monitoring. Patients will have an order for suicide precautions if low, moderate or high [name of suicide risk assessment tool]. .. .i.v. Adult patients outside a secure BH room in the Emergency Department with a high [name of suicide risk assessment tool] score requires an observation attendant. Provider enters order for visual or arms length attendant. ... Attachment B: Risk Stratification with Interventions (ED Only) Risk Stratification High Suicide Risk Triage ... Notify Supervisor/designee to provide 1 :1 attendant per policy (outside EBH) or per provider order (EBH) Initiate SUICIDE level of observation for duration of stay or until cleared by Psychiatry. ..."

Review of MR1 on February 2, 2022, revealed an attempt for self-harm occurred on January 31, 2022, at approximately 0100, while MR1 was in the emergency department (ED). Following the attempt, MR1's [name of suicide risk assessment tool] score was high. However, there was no documentation in MR1 of an order for suicide precautions or an order for a 1:1 attendant.

Observation on February 2, 2022, at approximately 1400, revealed MR1 was in bay two in the emergency department (ED) "fast track" unit. The staff member assigned to visually monitor MR1 was also assigned to monitor MR8.

Interview with EMP2 on February 2, 2022, at approximately 1415, confirmed MR1's high suicide risk and MR1's location in the "fast track" unit was outside of the emergency behavior health (EBH) unit. EMP2 confirmed MR1's high suicide risk required an order for suicide precautions and a 1:1 attendant per facility policy.

Observation on February 2, 2022, at approximately 1345, revealed MR5 was in room EBH1. MR5 was not visible on the video monitoring screen in the nurses' station.

Interview with EMP2 on February 2, 2022, at approximately 1345, confirmed MR5 was in EBH1 and was not visible on the video monitoring screen in the nurses' station. EMP2 confirmed patients in a EBH room are to be continuously visualized by staff via video monitoring per facility policy.

Review on February 2, 2022, revealed MR6 was at high risk for suicide. There was no documentation in MR6 of a provider order for suicide precautions.

Observation in the EBH unit on February 2, 2022, at approximately 1345, revealed MR6 exiting the bathroom door and returning to room EBH2 unaccompanied by a staff member.

Interview with EMP2 on February 2, 2022, at approximately 1345, confirmed the observation of MR6 used the bathroom facilities unaccompanied by a staff member. EMP2 confirmed facility policy required patients in the EBH unit be accompanied to the bathroom. EMP2 confirmed MR6 was at high risk for suicide, and there was no provider order for suicide precautions in MR6.

Review on February 2, 2022, revealed MR10 was a 302 (involuntary commitment) with no documentation of an order for 1:1 observation.

Observation on February 2, 2022, at approximately 1400, revealed MR10 was in bay four in the emergency department (ED) "fast track" unit. The staff member assigned to visually monitor MR10 was also assigned to monitor MR9.

Interview with EMP2 on February 2, 2022, at approximately 1400, confirmed MR10's location in the "fast track" unit was outside of the EBH unit. EMP2 further confirmed MR10's involuntary commitment status required a 1:1 attendant, and the staff member monitoring MR10 was also monitoring MR9.

Review of MR11 on February 2, 2022, revealed a provider order for visual monitoring for a behavioral health diagnosis.

Observation on February 2, 2022, at approximately 1415, revealed MR11 was in a hallway bed in the main ED treatment area. The staff member assigned to visually monitor MR11 was also assigned to monitor MR12.

Interview with EMP2 on February 2, 2022, at approximately 1415, confirmed an order in MR11 for visual monitoring required a 1:1 attendant. EMP2 further confirmed the staff member monitoring MR11 was also monitoring MR12.

Review of MR12 on February 2, 2022, revealed a provider order for visual monitoring for a behavioral health diagnosis.

Observation on February 2, 2022, at approximately 1415, revealed MR12 was in a hallway bed in the main ED treatment area. The staff member assigned to visually monitor MR12 was also assigned to monitor MR11.

Interview with EMP2 on February 2, 2022, at approximately 1415, confirmed an order in MR12 for visual monitoring required a 1:1 attendant. EMP2 further confirmed the staff member monitoring MR12 was also monitoring MR11.

Review on February 3, 2022, revealed MR13 had been admitted to the ED following an attempt at self-harm and scored high risk for suicide. There were no provider orders in MR13 for suicide precautions and 1:1 observation.

Interview with EMP2 on February 3, 2022, at approximately 1000, confirmed MR13 was at high risk for suicide. EMP2 further confirmed there was no provider orders in MR13 for suicide precautions and 1:1 observation.

Review on February 3, 2022, revealed MR17 scored at a high risk for suicide. There was no provider order for 1:1 observation in MR17

Interview with EMP2 on February 3, 2022, at approximately 1017, confirmed MR17 was at high risk for suicide. EMP2 further confirmed there was no provider order in MR17 for 1:1 observation.