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Based on interview and record review, the hospital failed to provide care in a safe setting when Emergency Department (ED) staff did not follow policy for close observation of a patient at risk of suicide (Patient 1). As a result, the patient was allowed to use the restroom with the door closed and attempted suicide via suffocation. The patient suffered an anoxic brain injury and subsequently expired.

Findings:

Patient 1 was admitted to the ED on 10/31/23 on an involuntary hold from a therapist's office after stating he had suicidal ideation with thoughts to hang himself, according to a Psychiatry Consult Note, dated 10/31/23. The note further indicated, "Concerning development of suicidal ideation leading to placement of involuntary hold. Although patient denying suicidal ideation this morning, suspect minimization. Requires inpatient psychiatric hospitalization for safety monitoring, symptom stabilization, disposition planning."

On 11/8/23 at 8:58 A.M., the ED Manager (EDM) was interviewed. According to the EDM, Patient 1 was assessed to be at moderate risk of suicide upon triage on 10/31/23 and required a sitter for continuous observation. Around 9:45 A.M on 11/1/23, Clinical Care Partner (CCP) 1 accompanied the patient to the bathroom and allowed the door to be closed. The EDM stated, "That is not our expectation." CCP 1 knocked twice and the patient stated, 'I'm okay.' However, the patient did not answer on the third knock, so CCP 1 opened the door and found Patient 1 sitting on the toilet with paper towels in his mouth. The patient initially had his eyes open but then went unconscious and lost a pulse. Cardiopulmonary Resuscitation (CPR) was initiated, and the patient was taken to the resuscitation room where forceps were needed to pull out paper towels in order to secure an airway.

The EDM stated Patient 1 was then admitted to the ICU. On 11/4/23, an MRI was done to check brain perfusion. The results were "suboptimal and not viable with life" per the EDM. The family made the decision to remove life support and Patient 1 expired on 11/4/23.

The EDM acknowledged that Patient 1's death was preventable. The EDM stated, "We identified there was a breach in observation."

During a tour of the ED on 11/8/23 at 10:46 A.M., a sitter was outside the bathroom observing a patient with the door ajar.

CCP 1 was interviewed on 11/8/23 at 10:55 A.M. CCP 1 stated he worked the CCP float pool. According to CCP 1, at the start of his shift on 11/1/23, he received report from the outgoing sitter that Patient 1 was on a 1:3 observation (one sitter observing three patients). Around 9:40 A.M. the patient requested to use the bathroom. CCP 1 stated, "I said [to Patient 1] I have to be there, but he wanted privacy." CCP 1 stated when Patient 1 did not answer after he knocked, he opened the bathroom door and found the patient on the toilet with "paper towels in his mouth." CCP 1 then called for help and ED staff came to assist.

CCP 1 further stated that a suicidal patient should be within sight at all times when using the bathroom.
The Assistant Nurse Manager for the CCP Float Pool (ANM) was interviewed on 11/9/23 at 10:45 A.M. The ANM stated that Float Pool CCPs receive one-time training on Constant Observer Attendant (COA)/sitter observation upon hire. According to the ANM, Float Pool CCPs do not receive annual training on COA/sitter observation. CCP 1 last received training on sitter observation upon his hire date of 9/20/21, two years prior.

The ED Director (EDD) stated during an interview on 11/9/23 at 11:04 A.M. that ED CCPs have in-person skills training annually which includes COA/sitter observation. According to the EDD, Float Pool CCPs only do COA/sitter training upon hire.

On 11/9/23 at 12:19 P.M., EMT 1 stated during an interview that she was currently assigned as a 1:1 sitter in the ED. EMT 1 stated that when taking a patient to the bathroom, the door needs to be wedged open for visual, keeping sight of the patient at all times.

When interviewed on 11/9/23 at 11:15 A.M., Registered Nurse (RN) 2, the primary ED nurse for Patient 1 on 11/1/23, stated she was in a room next to the bathroom when she responded to the call for help. According to RN 2, nurses were trying pull paper towels out the patient's mouth, but patient was clenching down. Patient 1 was turning blue and lost pulses, so CPR was started. RN 2 stated that when a patient is suicidal with a sitter for 1:3 observation, the patient becomes 1:1 sitter observation for the bathroom and the door should not be closed or locked.

The medical record was reviewed on 11/8/23 and 11/9/23.

The ED Care Timeline indicated Patient 1 arrived to the ED on 10/31/23 at 12:23 P.M. Per the Columbia-Suicide Severity Rating Scale (an assessment tool used to identify and assess individuals at risk for suicide), the patient was assessed as moderate risk upon triage. Interventions implemented included a sitter for 1:3 continuous observation.

On 11/1/23 at 9:50 A.M., RN 2 documented in an ED Note, "Was in another patient's room close to the restroom when this RN heard staff calling for help for the patient in the restroom. This RN stepped out of room 10 and noticed that other ED RNs and MDs were attempting to remove paper towels from the patient's mouth and arouse the patient. Pt [patient] was noted to be cyanotic and with his teeth clenched around paper towels ...No femoral pulses palpated. CPR initiated while pt was wheeled to room 6 for resuscitation."

According to an ED MD Progress Note, dated 11/1/23, "At approximately 9:50 a.m. the patient was reportedly found unresponsive in the bathroom on the toiled and witnessed to has [sic] stuffed multiple wet paper towels into his mouth ...The paper towels were removed and patient immediately brought into the resuscitation room he was found to be pulseless and apneic and CPR started immediately. Patient had ongoing prolonged resuscitation. At the time of intubation he was noted to have multiple wet paper towels that were stuffed deep into the oropharynx that were removed with Magill forceps." Patient was then admitted to ICU.

The Discharge Summary, dated 11/4/23, indicated Patient 1 had "Diffuse anoxic brain injury ...Successful suicide attempt s/p [status post] resuscitation." The Discharge Summary further indicated, "After family meeting on the afternoon of 11/4/23, decision was made by family to discontinue life support and compassionately extubate." The patient expired on 11/4/23.

According to the hospital's policy, Suicide Risk Management, last revised 10/25/22, "Emergency Department: All patients ?7 years will be screened for possible suicide risk using a validated suicide risk screening tool (C-SSRs: Colombia-Suicide Severity Rating Scale) ...Based on results of screening, appropriate interventions are implemented: ...Moderate Risk Interventions (Suicide attempt in the past three months): Immediately initiate 1:3 continuous observation. Do not leave patient unattended at any time until the level of observation is modified by provider order ..."

According to the hospital's Department of Emergency Services policy, Psychiatric Patient Care, last revised 10/2022, "Patients under any level of observation are to be transitioned to 1:1 Direct Continuous observation for all toileting and bathroom use. The restroom door is to remain ajar and direct visualization is to be maintained throughout use of the restroom. Return to level of observation may be resumed upon return to the assigned treatment area."

According to the hospital's policy, Patients' Rights and Responsibilities, last revised 10/26/21, "Patients have the right to ...Receive care in a safe setting ..."