HospitalInspections.org

Based on observation, interview, record review, policy review, and video footage review, the facility staff failed to ensure a safe environment when facility staff failed to:
- Follow their internal suicide precautions (SP, interventions put into place to prevent self-harm or death) policy, in the Emergency Department (ED), by not providing constant line-of-sight observation (continuous visual contact with the patient) on two current patients (#51 and #59) of two current patients observed on suicidal precautions. (A-0144)
- Ensure that suicide ligature/looping (to tie or bind, typically used to self harm) and suffocation hazards were unavailable, in the ED, for two current patients (#51 and #59) of two current patients observed on suicidal precautions. (A-0144)
-Follow their internal suicide precautions policy by removal of the patient's personal belongings for one discharged patient (#58) of one discharged patient reviewed on suicidal precautions in the ED. (A-0144)
The facility census was 405.

These failed practices had the potential to place all suicidal ED patients at risk of self-injury or death, and resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights.

Based on observation, interview, record review, policy review, and video surveillance review, the facility staff failed to ensure a safe environment when facility staff failed to:
- Follow their internal suicide (thoughts of killing self) precautions policy in the Emergency Department (ED), by not providing constant line-of-sight observation (continuous visual contact of patient) on two current patients (#51 and #59) of two current patients observed on suicide precautions.
- Ensure that suicide ligature/looping (to tie or bind, typically used to self harm) and suffocation hazards were inaccessible in the ED, for two current patients (#51 and #59) of two current patients observed on suicide precautions.
-Follow their internal suicide precautions policy by removal of the patient's personal belongings for one discharged patient (#58) of one discharged patient reviewed on suicidal precautions in the ED.
These failed practices had the potential to place all suicidal ED patients at risk of self-injury or death. The facility census was 405.

Findings included:

1. Review of the facility's policy titled, "Emergency Department - Adult and Pediatric Behavioral Health," dated 05/09/18, showed that when a presenting patient is determined to be at risk to harm self or others, elopement (to run away and to not come back to the point of origination) precautions will be initiated during this evaluation period to determine the necessity for further intervention. These precautions are used to keep the patient safe, based on the patient's chief complaint and can include but are not limited to:
- The use of red colored scrubs to denote elopement risk;
- The removal of the patient's belongings from the room;
- Staff caring for the patient will perform a room survey to ensure items not required to provide patient care are removed from the room (bedside tables, monitor cords, items on the counters); and
- Patients under elopement precautions will be monitored.

Review of the facility's undated document titled, "Care Guidelines for 96 Hour Holds (court ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) and Potential Holds Suicidal/ Homicidal (thoughts to harm another person) /Psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature) Patients Emergency Department Care," showed that if the ED patient answered "yes" to suicidal/homicidal or was acutely psychotic, then initiate elopement precautions. Elopement Precaution patients are change into red paper scrubs/gown, belongings are removed from the room, security/sitter are to observe the patient, keep the curtain and door open for patient observation and use the room checklist to ensure environmental safety.

Review of the facility's Electronic Health Record (EHR) Room Precautions checklist, showed directives for staff to do the following:
- Constant staff supervision - in view of staff at all times;
- Bedside cart removed;
- Bed/transport IV poles removed;
- Plastic trash bags removed;
- Room and door curtains open;
- Remove Intravenous (IV, in the vein) tubing and supplies;
- Remove sharps box (a hard plastic container used to safely dispose of needles and other sharp medical instruments)/ all sharp objects;
- Minimize any phone cords or oxygen tubing;
- Monitor cords at a minimum;
- Patient's clothing in a secure location; and
- Patient clothed in paper pajamas.

Review of the facility's policy titled, "Patient Care - Suicide Precautions - Clinical Guideline," dated 07/15/16, showed directives for staff to validate if a patient observer was assigned, the observer was sitting where the patient can be clearly viewed. Provide continuous observation as needed. Remind observers that it is unacceptable to leave unless relieved by staff.

Review of Patient #59's ED medical record, dated 04/29/19, showed that she was a 32 year old female that presented to the ED with a chief complaint of suicidal ideation. She was brought to the ED in police custody and placed on a 96 hour hold (court ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) after she stated to police that she "wanted to die." She had a past medical history of anxiety excessive fear or worry) and depression (extreme sadness that doesn't go away). She stopped taking medication for depression because she thought her condition had improved. The patient care documentation showed elopement precautions were initiated at 3:02 PM, patient belongings removed, Missouri University Psychiatric Center (MUPC) notified of 96 hour hold and security outside of room.

2. Observation on 04/29/19 at 3:07 PM, in the ED west hallway, showed Staff E, Security Officer, stood by the nurse's station outside of Patient #59's room (room 25). In patient #59's room were the following risk items (could be used to cause self-harm) that were not medically necessary:
- A plastic trash bag liner with extra plastic liners in the trash can (suffocation hazard);
- Two cords (ligature hazard); and
- A sharps container (receptacle used to place items such as needles in for disposal) on the wall (installed only in locations where the containers can be continually monitored by staff).

During an interview on 4/29/19 at 3:15 PM, Staff E, stated that they did not document patient activity while they watched patients in the ED, and that he was just there to make sure the patient did not leave.

During an interview on 04/29/19 at 3:10 PM, Staff F, ED Manager, stated that since security staff watched the behavioral health patients, there was no need to remove cords and plastic trash liners from the patient rooms.

Observation on 04/29/19 at 4:15 PM, in the ED west hallway, showed Patient #59 in room 25 by herself with the curtain closed. Staff E, Security Officer assigned to watch Patient #59, stood by the nurse's station with his back turned away from room 25.

During an interview on 04/29/19 at 4:20 PM, Staff E, stated that he did not have to watch the patient at all times. He was there to provide assistance in case the patient tried to leave since she was a 96 hour hold and on elopement precautions.

During an interview on 04/29/19 at 4:25 PM, Staff II, Registered Nurse (RN), stated she was the nurse assigned to care for Patient #59. Patient #59 was on suicide precautions. She was required to check on her patients every hour and she tried to check on behavioral health patients about every 30 minutes. She did not document 15 minute safety checks on suicidal or homicidal patients.

During an interview on 04/29/19 at 4:30 PM, Staff F, ED Manager, stated that he expected nursing staff, when taking care of behavioral health patients that were suicidal or homicidal, to have the patients wear red scrubs, keep the curtains open and have security watch the patient.

Review of a Digital Versatile Disc (DVD) titled, "UH ER 2019.04.29," dated 04/29/19, which contained recorded video surveillance of the west hallway area from 3:06 PM through 7:19 PM, showed the following:
- 3:06 PM through 3:11 PM, Patient #59's room (room 25) with a closed curtain and no staff within line of sight of the patient.
- 3:46 PM through 3:48 PM, Staff II, RN, exited Patient #59's room. Staff E, Security Officer, with his back to Patient #59's room, walked to the edge of the camera's view, and no other staff were within line of sight of Patient #59. Staff E left the hallway and entered the nurse's station, where Staff E appeared to be talking to other staff and looking at a female staff member's exposed leg. No other staff were within line of sight of the patient.
- 4:08 PM through 4:12 PM, Staff II exited Patient #59's room. Staff E, who was near the nurse's station, looked away from Patient #59's room. Staff E appeared to be looking at his cell phone. No other staff were within line of sight of the patient.
- 5:42 PM through 5:52 PM, a staff member exited Patient #59's room. Staff E was near the nurse's station, looking away from Patient #59's room. Staff E appeared to be looking at his cell phone. No other staff were within line of sight of the patient.
- 6:40 PM through 6:42 PM, Staff II exited Patient #59's room. Staff E was near the nurse's station, looking away from Patient #59's room. Staff E appeared to be looking at his cell phone. No other staff were within line of sight of the patient.
- 6:59 PM through 7:19 PM, a staff member exited Patient #59's room. Staff E was near the nurse's station, looking away from Patient #59's room. Staff E appeared to be looking at his cell phone. No other staff were within line of sight of the patient. Staff E walked in the nurse's station, sat down and appeared to be looking into the cabinet drawers. No other staff were within line of sight of the patient. Staff E while sitting at the nurse's station, again, appeared to be looking at his cell phone. No other staff were within line of sight of the patient.

During an interview on 04/30/19 at 9:30 AM, Staff JJ, ED RN, stated the following:
- He had worked in the ED at this facility for eight months.
- Suicidal or homicidal patient belongings were placed in a bag and kept at the nurse's station.
- Security watched suicidal or homicidal patients so they did not elope.
- Security watched up to four patients at once.
- He did not document 15 minute safety checks and neither did security.
- He checked on behavioral health patients at least every hour.
- He left monitor cords, IV pole and plastic trash bags in the room of a suicidal patient because security watched the patient.

During an interview on 04/30/19 at 2:00 PM, Staff OOOO, ED RN, stated the following:
- She had worked in the Emergency Department at this facility for five years.
- She never documented 15 minute safety checks on a suicidal patient.
- Nursing staff rounded hourly on their assigned patients or more often if needed.
- Behavioral health patients were placed in red scrubs and security was called to watch them.

Review of Patient #51's ED medical record, dated 05/01/19, showed that he was a 34 year old male that presented to the ED with a chief complaint of psychiatric problems, depression (extreme sadness that doesn't go away), in which he took 30 pills in a suicide attempt (attempt to kill self). The patient had symptoms of depression, was anxious (excessive fear or worry) and with agitation (a state of feeling irritated or restless). The patient's mood and affect was anxious, abnormal/ psychotic, (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature) thoughts of suicide, and a flight of ideas (jumping from one topic to the next). The ED initial assessment form showed that the patient reported suicidal ideations (thoughts of causing one's own death) with a plan. The patient care documentation showed elopement precautions with interventions of placing the patient in paper scrubs, patient belongings removed, and security at bedside.

Observation on 05/01/19 at 11:10 AM, in ED west hallway, showed Patient #51's room (room 26) with the curtain closed, with no staff within line of sight of the patient. In patient #51's room were the following at risk items that were not medically necessary:
- Plastic trash bag liner with extra plastic liners in the trash can (suffocation hazard);
- One used intravenous tubing (ligature hazard), with spike adapter (puncturing, weapon hazard) in the trash can;
- One IV pole (looping hazard); and
- Two cords (ligature hazard).

Review of a DVD titled, "UH ER 2019.05.01," dated 05/01/19, of video footage of the west hallway area from 7:35 AM through 11:15 AM, showed the following:
- 7:37 AM through 7:40 AM, Staff NNN, RN, exited Patient #51's room, closed the curtain, with no other staff in line of sight of the patient. Staff OOO, Security Officer, appeared to look away from Patient #51's room.
- 8:07 AM through 8:09 AM, Staff OOO with his back to Patient #51's room and no other staff were within line of sight of the patient.
- 8:42 AM through 8:47 AM, Staff OOO appeared to look away from Patient #51's room, talking with another staff member, looking toward his cell phone in his hand. No other staff were within line of sight of the patient.
- 9:06 AM through 9:08 AM, Staff OOO appeared to look away from Patient #51's room, looking toward his cell phone in his hand. No other staff were within line of sight of the patient.
- 10:01 AM through 10:07 AM, Staff OOO appeared to talk to another staff member, cell phone in hand, not in line of sight of Patient #51. No other were staff within line of sight of the patient.
- 10:08 AM through 10:19 AM, Staff OOO with his back turned toward Patient #51's room, at the end of the hallway, looking out the window. Another staff member appeared to talk to Staff OOO, looking at his cell phone. No other staff were within line of sight of the patient.
- 10:21 AM through 10:27 AM, Staff OOO left the hallway of Patient #51's room. No other staff were within line of sight of the patient.
- 10:43 AM through 10:48 AM, Staff OOO left the hallway of Patient #51's room, and entered the nurses' station. No other staff were within line of sight of the patient.
- 10:58 AM through 11:01 AM, Patient #51's curtain closed and no staff were within line of sight of the patient.
- 11:14 AM through 11:15 AM, Staff OOO left the hallway of Patient #51's room, and entered the nurses' station. No other staff within line of sight of the patient.

During an interview on 05/01/19 at 2:00 PM, Patient # 51 stated that he had come to the ED because he tried to "kill himself." When he was in the ED room #26, there were times he was alone in the room and could not see any staff.

During an interview on 05/01/19 at 11:12 AM, Staff OOO, Security Officer, stated that:
- He was responsible to observe patients in the ED for elopement precautions only.
- He was assigned to rooms 25, 26 (Patient #51's room) and 28 (which was down another hallway).
- Security was not responsible to provide line of sight for SI patients.
- Clinical staff were responsible for the safety of the SI patients, security was only to support the clinical staff in the event the patient attempted to leave the ED.
- There were times when he was not in line of sight of Patient #51.

During an interview on 05/01/19 at 11:14 AM, Staff PPP, Patient Care Technician (PCT), stated that:
- He was assigned to Patient #51.
- He did not know that the patient had attempted suicide.
- He had not received training on the removal of ligature hazards from a patient room, for a patient that was suicidal.

During an interview on 05/01/19 at 11:15 AM, Staff NNN, RN, stated that:
- He was assigned to Patient #51.
- Patient #51 presented to the ED because he attempted suicide by overdosing on unknown medications.
- Security was responsible for the safety of the patients while in the ED.
- Staff NNN acknowledged the plastic bags, cords, and the used IV tubing, and stated that the hazards should have been removed from the room.
- Security did not document any safety checks on the SI patients.
- The nurses were responsible for 15 minute checks.
- He had not had a chance to document any reassessments (safety checks) on Patient #51 (review of the medical record showed no patient care assessments documented by Staff NNN from 7:30 AM through 10:00 AM).

Review of the facility provided reassessments on Patient #51, showed Staff NNN documented late entries for the 15 minute safety checks on 05/01/19 for the times of:
- 7:30 AM, actual documented time 11:07 AM;
- 7:50 AM, actual documented time 11:08 AM;
- 8:05 AM, actual documented time 11:08 AM;
- 8:20 AM, actual documented time 11:09 AM;
- 8:35 AM, actual documented time 11:10 AM;
- 8:50 AM, actual documented time 11:10 AM;
- 9:05 AM, actual documented time 11:10 AM;
- 9:20 AM, actual documented time 11:11 AM;
- 9:35 AM, actual documented time 11:11 AM;
- 9:50 AM, actual documented time 11:12 AM;
- 10:05 AM, actual documented time 11:12 AM;
- 10:20 AM, actual documented time 11:13 AM; and
- 11:00 AM, actual documented time 12:30 PM.
The reassessment of a suicidal patient not performed in real time had the potential for self-harm by the patient.

During an interview on 05/01/19 at 11:25 AM, Staff F, ED Manager, acknowledged the plastic bags, cords in Patient #51's room, and that Staff NNN was assigned to more than one patient. Staff F stated that the clinical staff were responsible for the safety of the patients.

During an interview on 05/01/19 at 10:03 AM, Staff LLL, Security Director, stated that:
- Security officers were not to provide line of sight observations for SI patients.
- Security was only to provide support to the clinical staff in the event that the patient attempted to leave the ED.
- Security officers had not received training to provide safety checks, have the ability to document safety checks, and/or the training to remove ligature hazards patient rooms that were at risk of self-harm.
- The safety responsibility of at risk of self-harm patients was the clinical staff, not security.

Review of discharged Patient #58's ED medical record, dated 04/02/19, showed that she was a 60 year old female that presented to the ED with a chief complaint of depression and SI. The patient had a past medical history that included SI, psychosis with hallucinations (seeing or hearing things which are not there), depression, anxiety, bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.) The ED initial assessment form showed that the patient reported SI with a plan to overdose with pills. The patient care documentation showed elopement precautions with a plan to transfer her to MUPC for psychiatric evaluation and treatment. Nursing documentation showed the patient became agitated after being informed of a positive result for methamphetamine. She then changed out of her hospital scrubs and into her personal clothes, which were left in her room. This resulted in her being placed in four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) by security to get her back into hospital scrubs so that she could be transferred to MUPC. The patient was discharged on 04/02/19 after being seen by psychiatry.

During an interview on 05/01/19 at 3:20 PM, Staff JJJJ, Physician Assistant (PA), stated that Patient #58's clothes were left in her room and the patient got upset with him and changed back into her street clothes.

During an interview on 05/01/19 at 3:50 PM, Staff IIII, Security Officer, stated that:
- Security's main goal was to keep the patient from leaving the hospital until the doctor released them.
- He watched other patients and did not always have his eyes on patient #58.
- He was unsure how Patient #58 got her street clothes.
- He did not see Patient #58 change back into her street clothes because her curtain was closed.
- Suicidal patients did not typically get to keep their belongings.

During an interview on 05/01/19 at 4:48 PM, Staff MMMM, RN, stated that:
- Suicidal patients must be changed into red paper scrubs and security notified.
- Patient's belongings (clothing) were taken out of the room.
- The nurses did not perform 15 minute checks on SI patients when security watched the patients.
- There was no reason for SI patients to have their clothes if security was with them.

During an interview on 05/01/19 at 4:25 PM, Staff A, Security Supervisor, stated that:
- Security's purpose was to be in the ED to stop patients from eloping, not to provide one-on-one or suicidal precautions.
- If patients were suicidal or restricted from leaving, their personal belongings would be placed in a bag and kept at the nurse's station.
- If Patient #58 was not allowed to leave, then she should not have had her clothes in her room.

During an interview on 05/02/19 at 10:12 AM, Staff G, Chief Nursing Officer (CNO), stated that:
- The expectation in the ED with a suicidal patient would be that the nurse would assess the room first, and remove unnecessary items.
- Initially, nurses should perform an assessment of the risk in the room.
- If the curtain was closed in a SI patient's room, someone should be right there with the patient.










41474




39562