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Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff reviewed patient rights with one patient. This affected Patient #1.

Findings include:

Review of the medical record of Patient #1 revealed the patient presented to the ED on 12/01/23 at 11:00 PM after intentionally taking 800 mg Trazodone (medication used to treat depression), 1 mg Ativan (medication used to treat anxiety), and 8 mg Klonopin (antiepileptic medication with an off-label use of treatment of anxiety) in an attempt to commit suicide. She reported no psychiatric history prior to 09/21, however, stated that she did not want to wake up. An application for emergency admission (pink slip) was completed by an emergency physician. The medical record lacked documentation any staff member reviewed the patient rights or provided a copy of the patient rights to the patient. Nursing notes revealed the patient was most often sleeping in the ED but when awakened, she was cooperative. She remained in the ED until she was admitted to NP5 on 12/02/23 at 7:40 PM.

On admission to NP5, a nurse's note on 12/02/23 at 10:20 PM stated the patient reported feeling very overwhelmed and stressed. She stated that she didn't know if it was all worth it and reported taking an overdose of medication the day before. Although the note stated that she was given a tour of the unit, the medical record lacked documentation a staff member reviewed patient rights with her.

The facility policy titled Patient Rights and Responsibilities, effective 09/01/21, was reviewed on 01/31/24 at 5:45 PM. According to the policy, all employees and staff have an ethical obligation to ensure that the rights of every patient are supported in all interactions and in the provision of health care services. Patient rights will be offered to and reviewed with the patient every time a patient is admitted to the hospital or the Emergency Department.

Staff C was interviewed on 01/31/24 and asked to provide documentation the patient rights were reviewed with the patient. The medical record contained no such documentation.

Based on medical record review, and staff interview, the facility failed to ensure nurses followed a physician order for a sound machine to aid in sleep. This affected Patient #1.

Findings include:

Review of the medical record of Patient #1 revealed the patient presented to the ED on 12/01/23 at 11:00 PM after intentionally taking 800 mg Trazodone (medication used to treat depression), 1 mg Ativan (medication used to treat anxiety), and 8 mg Klonopin (antiepileptic medication with an off-label use of treatment of anxiety) in an attempt to commit suicide. She reported no psychiatric history prior to 09/21, however, stated that she did not want to wake up. An application for emergency admission (pink slip) was completed by an emergency physician. Nursing notes revealed the patient was most often sleeping in the ED but when awakened, she was cooperative. She remained in the ED until she was admitted to NP5 on 12/02/23 at 7:40 PM.

A physician's communication order for nursing care dated 12/04/23 at 11:41 AM stated patient can have a sound machine in room to help with sleep at night. The order remained in effect until the patient was discharged on 12/07/23.

An occupational therapist's (OT) note dated 12/04/23 at 4:03 PM stated an OT discussed with the patient, a psychiatric physician and registered nurse the use of a sound machine to assist patient with sleep. The physician verbally approved the sound machine. The OT demonstrated use of the sound machine and the patient verbalized understanding use of the machine. The sound machine was placed behind the nurse's station for use at night.

The medical record lacked documentation a sound machine was provided to the patient to aid with sleep.

Staff E was interviewed on 01/31/24 at 7:04 PM. Staff E was asked if she provided a sound machine in the patient's room at night to aid in sleep. She stated there was not a sound machine in the patient's room. Staff E was unaware of the order for a sound machine.

Staff C was interviewed on 01/31/24 at 7:30 PM. It was confirmed that the physician's order was not followed as the patient never received a sound machine to aid with sleep.