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On the days of the Complaint Survey based on observations, record reviews, interviews, log reviews, and review of the hospital's policies and procedures, the Governing Body failed to ensure the Emergency Department (ED) provided a safe environment for Suicidal/Homicidal (SI/HI) patients, failed to ensure ED Staff monitored and documented 1:1 care for patients per the hospital's policy, and failed to ensure functioning toileting facilities were available for patient use in the locked Multipurpose area of the ED.

The findings are:

Cross Reference to A 0115: The hospital did not ensure staff adhered to the hospital's policy for assessment and observations for patients presenting to the hospital's emergency department with suicidal and/or homicidal ideation and implementing interventions to promote a safe environment for those patients.

On the days of the Complaint Investigation based on observations, record reviews, interviews, and review of the hospital policies and procedures, the hospital did not ensure staff adhered to the hospital's policy for assessment and observations for patients presenting to the hospital's emergency department with suicidal and/or homicidal ideation and implementing interventions to promote a safe environment for those patients. This affected 12 sampled patients.

The findings are:

Cross Reference to A 0143: The hospital Emergency Department (ED) failed to maintain and ensure personal privacy for one (1) of 1 patient observed in the ED department, (Patient #34) .

Cross Reference to A 0144: The hospital failed to ensure its Emergency Department (ED) staff adhered to the hospital's policies and procedures to ensure the safety of those persons presenting to the hospital's ED with suicidal or homicidal ideation. The hospital ED based the level of care for those persons presenting to the ED with suicidal ideation using the initial scoring of the Columbia -Suicide Severity Rating Scale (C-SSRS Short Version) that was administered by the nurse upon the patient's admission to the ED as a determinant that the patient presented as either high risk or low risk based on the patient's answers. The Emergency Department's locked Multipurpose Unit was observed to house behavioral health patients that included patients with suicidal/homicidal ideation with no functional bathrooms on the unit. The Multipurpose Unit was closed when the survey was initiated on 08/29/2022 but opened again on 08/31/2022 for housing patients, but neither of the two (2) bathrooms on the locked Multipurpose Unit had received the necessary repairs and/or resolution of the plumbing issues in the bathrooms. Both bathrooms were closed for patient use. Suicidal patients were required to exit the locked Multipurpose Unit and access bathrooms with identified potential safety risks located in other areas of the ED. This affected 9 of 14 patients presenting with either suicidal or homicidal ideation, (Patients #21, #24, #3, #2, #33, #19, #9, #23, and #25).

Cross Reference to A 0175: The hospital failed to ensure nursing staff documented every two hour monitoring for 2 of 2 patients in physical restraints, (Patients #17 and #18).

Based on observations and interview, the hospital Emergency Department (ED) failed to maintain and ensure personal privacy for one (1) of 1 patient observed in the ED department, (Patient #34).

The findings include:

Observations on 08/31/22 at 4:30 PM in the ED revealed Patient #34 in a chair by the nurse station in front of patient rooms #13, #14, #15, and #17. A fifteen (15) year old patient and a family member were sitting in the hallway by room #17. Observations revealed two ED staff members pulling up a diaper on Patient #34 in view of ED rooms #13, #14, #15, and #17, and the patient and the family member in the hallway without a privacy curtain, partition, or any type of barrier to obstruct the view of Patient #34 during the event.

In an interview on 09/01/22 at 11:35 AM, Registered Nurse (RN) #4 stated, "The patient came in with Altered Mental Status (AMS). The patient started out in room #16 and she made her way out to the sitter's desk. She was sitting in a chair, and we helped her back and forth to the room to change her. The patient ultimately decided to go AMA (against medical advice)".

During an interview on 09/01/22 at 1:30 PM with ED Director #1, he/she stated, "I don't know if the patient pulled off her brief or if they were trying to put it (brief) back on, but they were doing what they could. I haven't spoken to the nurse about it yet".

Based on observations, record reviews, interviews, log data, and the hospital's policies and procedures, the hospital failed to ensure its Emergency Department (ED) staff adhered to the hospital's policies and procedures to ensure the safety of those persons presenting to the hospital's ED with suicidal or homicidal ideation. The hospital ED based the level of care for those persons presenting to the ED with suicidal ideation using the initial scoring of the Columbia -Suicide Severity Rating Scale (C-SSRS Short Version) that was administered by the nurse upon the patient's admission to the ED as a determinant that the patient presented as either high risk or low risk based on the patient's answers. The Emergency Department's locked Multipurpose Unit was observed to house behavioral health patients that included patients with suicidal/homicidal ideation with no functional bathrooms on the unit. The Multipurpose Unit was closed when the survey was initiated on 08/29/2022 but opened again on 08/31/2022 for housing patients, but neither of the two (2) bathrooms on the locked Multipurpose Unit had received the necessary repairs and/or resolution of the plumbing issues in the bathrooms. Both bathrooms were closed for patient use. Suicidal patients were required to exit the locked Multipurpose Unit and access bathrooms with identified potential safety risks located in other areas of the ED. This affected 9 of 14 patients presenting with either suicidal or homicidal ideation, (Patients #21, #24, #3, #2, #33, #19, #9, #23, and #25).

The findings are:

Observations on 8/29/22 at 11:15 AM during a tour in the ED revealed a locked unit identified as the "Multipurpose Unit" that had 10 patient beds located in 5 rooms and two bathrooms with showers. The ED Director and Nurse Manager reported the locked unit had not been used for the past 2 weeks since 08/16/2022 due to plumbing issues in one of the toilets that affected the plumbing in both toilets. The ED Director reported the locked unit housed both medical patients and behavioral health patient's waiting for admission to the hospital's PPS (Prospective Payment System) psychiatric unit, or waiting on discharge planning, or waiting for the Crisis/Critical Access Team assessment/plan. The ED Director stated the locked multipurpose unit was currently not in use.

The ED Director reported on 08/29/2022 at 11: 20 AM that Behavioral Health patients were placed in green gowns and housed in general ED beds. Observations on 8/29/22 at 11:20 AM revealed three (3) Behavioral Health patients clothed in green gowns in Hall Beds #5, #6, and #7. Observations in the ED (Major Care Back Area) on 8/29/22 at 2:24 PM with the ED Director and Nurse Manager revealed the four (4) restrooms accessible to ED patients housed in the Major Care Back area contained potential safety ligature risks for patients presenting with certain behavioral diagnoses such as suicidal ideation that were housed in this area. Restroom #1 located in the small ED hallway contained a call light cord approximately 18 inches in length, a plastic trash bag, and a hinged toilet seat. Observations on 08/29/2022 from 2:20 to 2:24 PM in the ED's long hallway across from the nurse station revealed Restroom #2 had a plastic trash bag and hinged toilet seat. Restroom #3 had a plastic trash bag and a hinged toilet seat. Restroom #4 located a short distance from Restroom #3 had a call light cord approximately 18 inches in length, a plastic trash bag, a hinged toilet seat, and exposed metal plumbing/pipes. The ED Director verified the observations of potential ligature safety risks in the restrooms and stated that all the ED restrooms along with all the patient rooms/bays/hallways contain the same safety risks as they are all used by the general ED patient population.

During an interview on 8/29/22 at 1:42 PM, Security Officer #1 stated there were 4 different posts for security guards in the ED and she/he was manning one of them. Security Officer #1 reported that one of the purposes for the posts was to ensure behavioral health/psychiatric patients get to the restroom and back to their bed. Security Officer #1 stated she/he stands at the restroom door and knocks on the restroom door about every 3 minutes to check and make sure behavioral health patients are okay. Security Guard #1 reported if she/he gets a response, she/he will continue to monitor the behavioral health patient. If no response, she/he will enter the restroom, and can get in the restroom even if the door is locked. Security Officer #1 stated she/he identifies behavioral health/psychiatric patients by their green gown. Security Officer #1 also stated that security officers are required to make rounds in other areas and may be called to other areas for issues.

During an interview on 8/31/22 at 9:15 AM, the Director of Quality stated the locked unit opened on 7/19/22, but closed on 8/16/22 after a plumbing issue, but re-opened on 8/31/22. Observations on 08/31/2022 at 9: 25 AM in the Multipurpose locked unit revealed five (5) behavioral health patients, but both bathrooms in the Multipurpose locked unit had not been repaired and were closed. The behavioral health patients in the locked multipurpose unit had to exit the Multipurpose locked unit and use the restrooms (#1, #2, #3, or #4) with potential safety ligature risks located in the general ED areas.

Observations on 08/31/22 at 9:50 AM of the locked Multipurpose unit revealed five patients monitored by nursing staff, a security guard, and two sitters who were located outside of a patient room. Further observations revealed a sign on one bathroom that stated, "Out of Order" and the other bathroom door was locked.

On 8/31/22 at 9:55 AM, observations of the bathroom located outside of the Multipurpose unit revealed ligature risks: a long pull cord by the toilet, exposed piping on the back of the toilet, a hinged toilet seat, an open handrail, hand soap in a pump mounted on the wall, hand sanitizer in a pump mounted on the wall, and exposed sink knobs.

On 08/31/22 at 4:27 PM, the toilet in the locked bathroom in the Multipurpose unit with the ED Director revealed a hole in the wall and capped off plumbing with the toilet removed from the wall and sitting in the floor. During an interview on 8/31/22 at 09:55 AM with the ED Director stated, he/she stated, "Engineering stated that we can use the one bathroom, but I am afraid to because it causes gurgling sounds in the other bathroom that is out of order. The guard and/or a sitter escorts the patient to the bathroom outside of the unit which is in the observation unit".

During an interview on 9/01/22 at 11:35 AM with the Director of Engineering, stated, he/she "The multipurpose area is a newly renovated space. We have a work order that was put in and completed on 08/16/22. The ED Director made the decision to use the multipurpose unit. We assume that the functional bathroom is open to use, but we haven't checked it to see if it is tied into the line. We tore up the bathroom in the Multipurpose unit on 08/27/222, and it will be down until is is fixed. If there is another problem noted, then the entire area will need to be re-plumbed. If the area has to be re-plumbed, the bathroom in the multipurpose unit and the bathroom currently used by the multipurpose patients will be out of service as the three toilets are tied in together. The contractor, architect, and our plumber have been working on it."

Review of "Repair Work Order" log dated 08/16/22, revealed, "Repair, routine, completed, flooding toilet in ED psych 7:46:28 PM".

On 09/01/2022 at 9:30 AM, during an interview with Registered Nurse (RN) #3, RN #3 reported, "All ambulatory patients usually get up and walk down the hall to a restroom. Observations of that restroom with RN #3 revealed the restroom had an approximate 18 inch call light cord, and a plastic trash bag, and hinged toilet seat. RN #3 stated that if nurses assist the patient to the restroom, the nurse will stand outside the door of the restroom.

Patient #21
Observations on 8/30/22 at 2:00 PM revealed Patient #21 in Room #12 with Sitter #2 at the bedside. During an interview on 8/30/22 at approximately 2:05 PM, Sitter #2 stated, "I came on duty at 07:45 AM, and there had not been a sitter with the patient when I started work." The sitter stated the patient had been in Hall Bed #5 when he/she arrived. Patient #21 and Sitter #2 reported Patient #21 was in Hall Bed #2, and then Hall Bed #5 before transferring to Bed #12 which is a room with curtains. Patient #21 stated she/he did not have a sitter until Sitter #2 arrived about 7:45 AM that morning. When asked specifically if she/he had a sitter when admitted, Patient #21 stated "No". Patient #21 reported the hall bed was right in front of the nurse station, and the nurse checked on her/him about 4 times throughout the night by waking her/him up. Observations on 8/31/22 at 10:05 AM of the Major Care Front area where Hall Bed #2 is located revealed Hall Bed #2 is across from the nurse station, but close to patient bays and restrooms that had curtains, cords, monitoring equipment, IV (intravenous) poles, and other items that could pose a safety risk for a suicidal patient.

Record Review
Review of Patient #21's Emergency Department (ED) chart on 08/30/2022 revealed the 41 year old patient presented to the ED on 08/30/2022 at 2:44 AM via ambulance transport. The patient's Chief Complaint was "Suicide Attempt and ingestion (pt (patient) took 25 500 mg (milligrams) tabs(tablets) of Tylenol. Patient #21 was placed in a Hall Bed (#2) on 08/30/2022 at 0250 (2:50 AM). Review of nursing documentation on 08/30/2022 at 02:50 (2:50 AM) revealed the nurse assessed the patient's suicide risk using the Columbia Suicide Severity Scale which resulted as "Suicide Risk Screening High". There was no physician order for 1:1 observations or other nursing documentation that the patient was placed on 1:1 observation when the patient initially presented to the ED.

Review of the ED physician's HPI (History of Present Illness) documentation dated 08/30/2022 at 0427 (4:27 AM) revealed "Pt(Patient) with a history of depression and suicide attempts in the past presents for overdose. Pt states she took 25 x (times) 500 mg Tylenol so she wouldn't wake up in the morning. Daughter states ingestion occurred at 0130 (1:30 AM). Daughter states she has done similar in the past. Patient states she has an upset stomach and cramping at this time." Review of the patient's past medical history diagnoses included but was not limited to: anxiety, Bipolar 1 disorder, Depression, panic attack, Schizophrenia, Sickle Cell trait, Diabetes Mellitus, Hypothyroidism, non- compliance, and Asthma. Patient #21's medications included but were not limited to Proventil inhaler, Abilify 10 mg (milligrams), Neurontin 300 mg, Lithoum 300 mg, Zoloft, and Vraylar 3 mg. Review of the patient's "Physical Examination" showed "blood pressure 128/74, pulse 80, temperature 98.1 Fahrenheit (F), respirations 18, height 5 feet, and weight 321 pounds. Pt presents after taking 25 x 500 mg of Tylenol. We will get labs now and repeat Tylenol level at 0530 (5:30 AM) post ingestion. Pt will receive charcoal and antiemetics at this time. Pt is awake, alert, and no distress." Review of the ED note for 08/30/2022 at 0700 (7:00 AM) showed "4 hour Tylenol level is 74.6. Treatment is not medically indicated at that level. Considering this, pt is cleared to be seen by psychiatry". On 08/30/2022 at 07:01:01 (7:01 AM), the physician ordered "Consult Crisis Assessment and Treatment Team (CAT). Reason for Consult: Evaluation for commitment. Medically Cleared: Yes". In the section labeled "Communication with Psychiatrist", the nurse documented,"..... Patient meets criteria for IP (inpatient) treatment. ..... Call placed to Dr. (on call psychiatrist) concerning admission order. Awaiting return call." There was no physician order placed for 1:1 observation for the patient.

Review of a nurse note dated 08/30/2022 at 07:42:58 (7:42 AM) showed "Patient transferred from room Hall Bed #2 to room Hall Bed #5." Review of the hospital's ED on call physician schedule showed Psychiatrist #1 was on call from 1:00 PM on 08/29/2022 to 08:00 AM on 08/30/2022. Psychiatrist #2 was on call for the ED from 08:00 AM to 1:00 PM. There was no documentation of a psychiatric consultation for the patient. Review of a nurse note on 08/30/2022 at 8:53 AM revealed "CAT team at bedside". On 08/30/2022 at 08:28 (8:28 AM), review of nurse documentation showed the "Columbia Suicide Severity Rating" was documented as " High Risk". On 08/30/2022 at 08:31 (8:31 AM), documentation showed "Pt moved to rm (room) 12 at this time, (name), ED tech (technician) at bedside sitting." There was no documentation prior to the entry at 8:31 (8:31 AM) on 08/30/2022 that a 1:1 sitter had been assigned to this high risk suicidal patient. Documentation on 08/30/2022 at 0844 (8:44 AM) revealed "Ambulated to restroom at this time. Escorted by (name) Technician." The ED technician was male, and there was no documentation as to how the 1:1 observations were maintained when Patient #21 who was female was in the restroom.

Review of the ED's "Sitter Documentation Tool" provided by the Emergency Department Nurse Manager revealed the entries on the sitter documentation tool on 8/30/22 from 0000 AM to 0730 AM were blank. Documentation of every 15 minute sitter checks were on the form dated 8/30/22 from 07:45 AM through 11:00 AM. When the ED Nurse Manager was asked where the documentation for sitter checks for 08/30/2022 from 02:50 AM to 07:45 AM was, the ED Nurse Manager stated, " I believe they may have been sent to medical records to get scanned in." The ED staff did not present any further sitter 1:1 documentation from 2:50 AM until 7:45 AM for Patient #21. Review of Patient #21's medical record with the ED Director revealed there was no physician orders or nursing interventions documented to indicate the patient was on 1:1 observation with a sitter from 02:20 AM until 07:30 AM on 08/30/22. The ED Director and ED Nurse Manager reported "Nursing staff know the patient is on 1:1 due to documentation of high risk for suicide as this is annotated in the medical chart on the side board with a red circle." The ED Nurse Manager reported, "They(nursing) do not always put in a physician order for 1:1 supervision although the nursing staff are able to do this. The physician can sign off on it or the physician can put this order in".

Interview
On 8/30/22 at 2:12 PM, the ED Director and ED Nurse Manager were asked why a sitter had not been provided for Patient #21 whose chief compliant and Columbia Suicide Severity scale determined the patient was high risk for suicide. The Emergency Department Director stated she/he did not know that the patient did not have a sitter, but would contact the Charge Nurse on duty when the patient arrived. The patient's medical record revealed staff obtained the patient's vital signs, labs, etc., at different points in time, but the documentation did not always include where the patient was or what the patient was doing at the time. There was no documentation on 8/30/22 at 3:45 AM, 4:00 AM, 4:45 AM, 5:00 AM, 5:15 AM, 5:30 AM, 5:45 AM, 6:00 AM, 6:15 AM, 6:45 AM, 7:15 AM, and 7:30 AM. There was no physician order for 1:1 sitter and no documentation to show a sitter was provided for the patient until 08/30/2022 at 07:45 AM . The finding was verified by the Emergency Department Director during the record review on 8/30/22 at 2:15 PM. There was no documentation in the patient's medical record to indicate any potential safety risks were removed from Bed #12's bay. On 8/31/22 at 10:14 AM, the ED Director reported staff had not been able to find the documentation of sitter checks for the patient.

Patient #24
On 8/31/22 at 11:47 AM, review of Patient #24's ED chart revealed the patient presented to the ED on 8/16/22 at 7:50 PM with a Chief Complaint "mental health problem". Patient #24 was transported to the ED accompanied by EMS (Emergency Medical Services) and the Sheriff's personnel with a detention order to see a physician. The ED medical evaluation was ordered by a probate judge. Documentation dated 8/16/22 at 7:55 PM showed the patient was placed in Hall Bed #10 in the ED. Documentation dated 8/16/22 at 9:05 PM showed the nursing triage note stated "Pt (Patient) to ED via police with detention order. Police report pt(patient) has been in a couple of fights today, reportedly smoked crack and drank gasoline. Unknown amt (amount) reportedly occurred shortly prior to arrival. Per police, pt was altered and making threatening gestures. At arrival, pt aggressive and verbal abusive with security, but becomes more cooperative after a few minutes. Pt cooperative with meds(medications) given and blood drawn. .....". Review of the "Columbia Suicide Screen" dated 8/16/22 at 9:15 PM revealed "Unable to Assess".

Review of the ED physician's documentation for the patient dated 08/16/22 at 10:00 PM revealed, "This is a 50 year old male, past medical history as listed below (mental illness, hallucination, Shizoaffective disorder), who presents to the ED today for evaluation of altered mental status and inability to care for himself. Patient is brought in by local police who states the patient was found fighting and drinking gasoline. They also endorse that the patient stated that he smoked crack earlier today as well. Patient is acutely altered and appears to be responding to inward stimuli. Patient is noncooperative with exam".

Review of a Behavioral Health note documented by a Licensed Master Social Worker (LMSW) with the hospital's Critical Assessment Team (CAT) dated 8/17/22 at 7:27 AM revealed the LMSW reviewed the patient's initial nursing assessment/triage note. The LMSW documented "Patient was recently on 8 South (hospital's PPS psychiatric unit) has previous diagnosis of Schizo-affective Disorder, acute Psychosis, and is homeless. The patient has yet to provide a urine sample for the UDS (Urine Drug Screen) but it is forthcoming. There are no available beds on 8 South for a male so the patient will be sent out for treatment". The LMSW documented on "The Intake Assessment" on 8/16/22 at 7:33 AM that the patient's Chief Complaint is "Patient brought in by LE (law enforcement) for fighting and suicidal behaviors, patient also endorses smoking crack. Interpersonal: decrease in impulse control, ...not sleeping, ...tangential thinking. Poor insight/poor judgment ...obsessive...paranoid behavior ...auditory hallucinations ...calm; pleasant ...Pt needs to get back on ...meds ...Pt's mom is very supportive but also very concerned ...Patient Requires Inpatient admission: Yes ...". The patient was admitted to another facility due to no beds available on 8 South. A Columbia Suicide Severity Rating Scale documented by the SW on 8/17/22 at 7:33 AM revealed, the patient answered "No" to all questions, 1, 2, and 6. The screening tool indicated the patient was at no risk for suicide.

Review of the medical record for Patient #24 on 8/31/22 at 12:34 PM with the Nurse Manager of the Emergency Room Department revealed a Certification of Licensed Physician Examination for Emergency Admission, which had been signed by the ED physician and LMSW. It documented Patient #24 was currently mentally ill and currently was a substantial risk of physical harm to self and others to the extent that involuntary emergency hospitalization is recommended, based on threats and/or attempts at suicide or serious bodily harm. A handwritten note documented after the LMSW documented the Intake Assessment revealed "Pt to the ED w/ S/I and drug use. The pt endorsed crack cocaine use last night. Remains suicidal". The note had no time recorded.

Review of the patient's medical record with the ED Nurse Manager revealed the patient did not have 1:1 supervision documented or provided during the patient's ED visit and did not have 30 minute or 15 minute checks completed by the nursing staff. There was no sitter documentation sheets scanned into the patient's record. The Nurse Manager stated she/he assumed Patient #24 did not have a sitter at all. The Nurse Manager verified the above findings and stated there probably was no documentation of sitter and/or monitoring since there had been no risk per the Columbia Suicide rating scale completed on 8/17/22 at 7:33 AM by the LMSW. No Columbia Suicide Risk was completed on 08/16/2022 when the patient presented to the ED. There was no provider order for a supervision level or any documentation by nursing staff of any interventions placed by the nursing staff for suicidal ideation. The surveyor spoke with the Nurse Manager about the concern that nursing staff did not place interventions in place due to the detention order information that the patient was at risk of self harm and that the patient had drank gasoline. The medical record indicated Patient #24 was assessed and provided care during certain periods of time during the patient's ED stay, but these interventions did not always include observations of where the patient was and how or what the patient was doing. The finding was verified with the Nurse Manager. The patient's ED chart showed that on 8/16/22 between 9:30 PM and 11:00 PM, and between 11:00 PM and 12:00 AM, there was no documentation to indicate the patient was observed or monitored in relation to suicide ideation. On 8/17/22 between 1:00 AM and 4:00 AM, 4:30 AM and 6:30 AM; 7:00 AM-7:30 AM, and from 7:40 AM and 9:57 AM, and 10:00 AM and 10:45 AM, there was missing documentation related to any observations of the patient. There was no documentation to show that any potential safety risks had been removed from Patient #24's immediate surroundings or that the patient was monitored and/or had restricted access to certain areas of the ED.

Interviews
An interview on 8/31/22 at 2:45 PM with the Emergency Director and Emergency Room Nurse Manager, they revealed "We can't make the ED risk free." If the Multipurpose locked unit closes, then the high risk patient will be with a sitter. We will pull anything you can safely remove from the room. We would not pull out soap or hand sanitizer. For a low risk patient like this one with mental illness like Schizophrenia, staff won't clear the room. The ED staff do not always document removal of items. When asked, the Emergency Department Director stated, "There are certified screening tools that are used to determine if a patient is high or low risk like the Columbia Suicide Severity screening. There are different levels of risk when it comes to suicide risk."

Patient #3
Patient #3 presented to the ED via ambulance with Chief Complaint of "Suicidal Ideation". Observations on 8/29/22 at 1:30 PM revealed Patient #3 sitting on the stretcher at Hallway Bed #7 (Major Care Back) in the ED talking to her/himself. An intravenous pole was attached to the stretcher, and a vital signs monitor was behind the stretcher with wires. The potential safety risks had not been removed from the immediate vicinity of the patient. A restroom next to the patient's stretcher had a call light with a call light cord approximately 18 inches in length, a trash bag, and a hinged toilet seat. The patient was in a green gown and face mask. Observations revealed the patient going to a restroom down the hall which was not next to the patient's hall bed with Security Officer #1 who stood outside the restroom door and periodically knocked on the restroom door to check on the patient. Observations of the restroom showed a hinged toilet seat and plastic trash bag. During an interview on 8/29/22 at 2:22 PM, the ED Director stated Patient #3 had come in with Suicidal Ideation on 8/28/22, but had been scored as low risk for suicide on the Columbia Suicide Risk Assessment. The ED Director stated the patient was able to use other restrooms in the vicinity without 1:1 supervision due to the low suicide risk score.

Review of Patient #3's ED chart on 8/30/22 at 8:48 AM revealed the patient arrived to the Emergency Department on 8/28/22 at 06:20 PM by ambulance. A nurse note dated 8/28/22 at 6:21 PM documented, "Patient here due to SI (Suicidal Ideation), patient admits to
suicidal thoughts due to grieving over her mother. Patient denies a plan and denies any attempts at this time. Patient states she feels alone and needs help." A Suicide Risk Screening dated 8/28/22 at 6:44 PM with the use of the Columbia Suicide Severity Rating Scale showed the patient scored low risk. When the second suicide risk screening was completed at 6:45 PM, the patient changed the answer to the question "Have you actually had any thought of killing yourself" from "no" to "yes".

Review of the section of the patient's chart labeled History and Physical dated 8/29/22 at 1:09 AM revealed the patient presented with Suicidal Ideation and " ...Stated she watched church and then started feeling sad. States she had some suicidal thoughts but denies any self harm. Denies specific plan. Stated she called her sister, father, and then called EMS (Emergency Medical Services) on advice from her family. She denies HI (Homicidal Ideation), hallucinations. She denies any physical complaints ...Noted to have recent medical visit for heavy period, anemia. States she was hospitalized in Dec 2021 for grief related to her mother's death. States she saw mental health and came off her meds on advice from her/his therapist ...".

Review of the ED policy provided by the hospital revealed that if patients scored low risk on the Columbia Suicide Risk Assessment, the patient should have every 30 minute observations and documentation of these checks. Review of Patient #3's ED record on 8/30/22 at 11:45 AM with the ED Director revealed documentation was lacking related to monitoring of the patient. There was missing documentation related to every 30 minute observations. The patient's ED record was able to be pieced together to show during certain periods of time the patient was having tests run like labs and assessments to show someone had placed eyes on the patient, but the patient's ED record had no notes that specifically documented where the patient was and what the patient had been doing. There had been some nursing notes that documented the specific observation, but these had not been documented every 30 minutes. The following dates/approximate times of missing 30 minute observations were verified with the ED Director during a review of the policy provided by the hospital that revealed if patients scored low risk on the Columbia Suicide Risk Assessment, the patient should have every 30 minute observations and documentation of these checks. Review of the patient's medical record on 8/30/22 at 11:45 AM with the ED Director revealed that documentation was lacking related to monitoring of the patient. The ED Director, during an interview on 8/30/22, reviewed the patient's ED record and verified there was no physician order for observation/sitter or nursing safety interventions documented for every 30 minute monitoring or for 1:1 observations for a patient who presented for suicidal ideation.



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Patient #2
On 08/30/22 at 8:52 AM, review of Patient #2's chart revealed the patient presented to the ED on 08/15/22 with a chief complaint of "suicidal". After the medical screening exam (MSE) by the ED physician, the ED nursing staff conducted a "Columbia Suicide Severity Rating Scale" (CSSRS) assessment that identified the patient as low risk for suicide. Although the ED staff documented the patient had a sitter for one to one (1:1) observations while in the ED, there was no documentation of a physician order for the sitter. The findings were verified on 09/01/22 at 3:30 PM by ED Director #2.

Patient #33
On 09/01/22 at 12:41 PM, review of Patient #33's chart revealed the patient presented to the ED on 08/30/22 at 4:42 PM with a chief complaint of "suicidal ideation". After the ED physician conducted the MSE, ED staff conducted a CSSRS assessment that identified the patient as high risk for suicide. There was no documentation of a physician order for the 1:1 sitter provided when the patient was in the ED. The findings were verified on 09/01/22 at 3:40 PM by ED Director #2.

Patient #19
Review of Patient #19's chart on 08/30/22 at 12:00 PM revealed the 46-year-old male initially presented to the ED with generalized weakness, left hip pain, and left leg pain on 08/28/22 at 15:22 PM. On 08/28/22 at 17:16 PM, documentation showed the patient told ED staff, "I am suicidal and want to hang himself." A CSSR was completed at 17:20 PM by the Registered Nurse(RN) who documented the patient was "High Risk" for suicide. The CAT Team evaluated the patient at 18:19 PM and documented "Pt is 46-year-old male, well known to the Crisis Team who presented to the ED with suicidal ideation with a plan to hang himself." There were no physician orders in the for one-on-one sitter services for the patient. On 08/28/2022 at 22:59, the "Sitter Documentation Tool" was charted at 22:59 PM by the Registered Nurse (RN). The night shift RN charted the patient's observations every two hours electronically until 08/29/22. The day shift RN documented the "Sitter Documentation Tool" observations every one hour on 08/29/2022 until the patient was admitted on 08/29/2022 at 12:29 PM. It was not until after the patient's admission to the hospital's psychiatric unit on 08/29/2022 at 13:16 PM that the psychiatrist documented orders for the patient for Psychiatric Observation-Standard which included "Routine q (every)15 min (minutes)" observations. The findings were verified with the ED Director of Nursing on 09/01/22 at 2:35 PM.

Patient #9
Review of Patient #9's ED chart on 08/30/22 at 10:00 AM revealed the 20 year old patient presented to the Emergency Department (ED) on 08/23/33 at 14:13 PM with a Chief Complaint of "Mental Health Problem and Suicide Ideation". Review of the Columbia Suicide Risk" screening tool completed by the Registered Nurse (RN) on 08/23/22 at 14:25 PM revealed the patient was a moderate risk for suicide. The patient was placed in Hall Bed #9 on 08/23/22 at 14:17 PM, Hall Bed #7 on 08/23/22 at 14:23 PM, moved to Multi-Care Area (MC) room #4 at 00:12 AM on 08/24/22, and moved to Hall Bed #5 at 10:20 AM on 08/24/22. There was no physician order for 1:1 observations with a sitter and no 1:1 sitter documentation by a sitter while the patient was in the ED. On 08/24/2022 at 11:45 AM, after the patient's admission to the hospital's Behavioral Health Unit, documentation showed a sitter was provided and started documenting observations at 11:45 AM. The findings were verified with the Director of Nursing (DON) on 09/01/22 at 2:40 PM.



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Patient #23
On 8/31/2022 at 11:41 AM, review of Patient #23's ED chart revealed the patient presented to the ED on 8/20/2022 with a chief complaint of "Suicidal Ideation (SI) and deliberate self cutting". Review of the physician note dated 08/20/2022 at 1856 (6:58 PM) revealed "this is a 17-year old black female brought in by her mother for evaluation for suicidal ideation. She wrote on her mirror today that she was having suicidal ideation, patient tells me that she has no desire to live. She has been cutting herself and her mother just found out about this today. Her mother is very concerned that she might do something. Patient states that she has been feeling like this for several years. She does not know why. She is using marijuana." On 08/20/2022 at 21:30 (9:30 PM) the physician documented "Psychiatrist is recommending involuntary commitment for inpatient treatment. Patient was placed on Part 1." Review of the CSSRS completed on 08/20/2022 at 1809 (6:09 PM) showed C-SSRS Suicide Risk Level: No Risk." There was no physician order for 1:1 observation or nursing intervention for 1:1 observations for the patient. There was no documentation of 1:1 observation by a sitter. Patient #23 was discharged on 08/21/2022 at 1237(12:37 PM). On 9/01/2022 at 3:02 PM, Nursing Director #2 verified the findings.

Patient #25
On 08/31/22 at 11:30 AM, review of Patient #25's ED chart revealed the patient was a nine-year-old admitted for "suicidal" ideation on 08/16/22 at 23:45 PM. Review of the suicide risk assessment screen completed at 00:04 AM on 08/17/22 by the Registered Nurse(RN) revealed the patient's suicide risk level was "High Risk." There was no physician orders for one-on-one monitoring for the patient and no documentat

Based on observations, interviews, and review of the hospital policies and procedures, the hospital failed to ensure nursing staff documented every two hour monitoring for 2 of 2 patients in physical restraints. (Patient 17 and 18)

The findings include:

Review of the facility's policy, "Restraints & (and) Seclusion" dated 03/07/22, revealed, "Ongoing Patient Assessment and Care Interventions...IV. The continued need for the use of restraint for Non Violent/Non Self-Destructive behavior will be reassessed and documented in the medical record every 2 (two) hours or more often as the patient condition requires...".

Patient #17
On 8/29/2022 at 2:00 PM, observations of Patient #17 revealed the patient was confused and lying in bed with a lap belt restraint applied. On 8/30/2022 at 10:08 AM, review of Patient #17's chart revealed nursing documented observations and assessments of the patient in the roller belt restraint on 08/11/2022 at 10:37 AM, 8:37 AM, 4:37 AM, and 2:42 AM. There was no documentation for monitoring of the patient at 6:00 AM. On 8/13/2022, nursing documented observations and assessments of Patient #17 who was restrained in a roller belt restraint at 9:44 PM, 7:44 PM, 2:05 PM, and 6:03 AM. There was no documentation for monitoring at 4:00 PM and 6:00 PM. There was no documentation if the patient was off the unit during this time. On 8/14/2022, Patient #17 remained in the roller belt restraint. Nursing monitoring was documented at 10:00 PM, 8:00 PM, and then 10:00 AM. There was no documentation by nursing for monitoring the patient at 12:00 PM, 2:00 PM, 4:00 PM, and 6:00 PM and no documentation if patient was off the unit during any of these times. On 8/18/2022, nursing documented observations and assessment of Patient #17 in a roller belt restraint at 12:00 PM, 8:00 AM, and 6:03 AM. There was no documentation for monitoring of the patient at 10:00 AM. On 8/20/2022, Patient #17 remained in a roller belt and monitoring was documented for 7:40 AM, 5:15 AM and 3:15 AM. The time between 7:40 AM and 5:15 AM was over 2 hours. On 9/1/2022 at 3:01 PM, Nursing Director #2 verified the findings.

Patient #18
On 8/29/2022 at 2:25 PM, observations of Patient #18 revealed Patient #18 lying in bed and appeared to be dozing but arousals to name. The patient had a soft wrist restraint on right wrist, and no restraint to the left hand. Patient #18 had a 1:1 sitter at the bedside who reported "Just had lunch, maybe they (staff) forgot to tie the left wrist." A random Registered Nurse (RN) A entered the room and reapplied the left wrist restraint. The sitter reported Patient #18 frequently spits when agitated. In an interview with Registered Nurse (RN) #1 (6 floor) who was assigned to Patient #18 reported the patient was restrained due to "pulling out IVs (intravenous) catheter and unruly with the staff." Review of Patient #18's chart on 08/30/22 at 10:02 AM revealed Patient #18 presented to the ED for cold exposure. Further review of physician orders revealed bilateral wrist restraints and bilateral ankle restraints. Review of restraint monitoring revealed there was no documentation of every two hour monitoring by staff while Patient #18 was in restraints on 8/26/22 and 8/27/22. The findings were verified on 9/01/22 at 3:29 PM by Nurse Director #2.