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Based on medical record review and staff interviews facility staff failed to communicate a patient's behavioral health history to care staff creating an unsafe environment that allowed the patient opportunities to perform self-injurious behaviors and failed to complete an incident report for 1 of 1 patients with a history of self-injurious behaviors (Patient #17).

The findings included:

Closed medical record review, on 08/14-15/2019, revealed Patient #17 arrived to the ED (Emergency Department) by private vehicle on 05/16/2019 at 0039 with a chief complaint of "SI, (suicidal ideations) throwing up blood." Triage notes, performed 05/16/2019 at 0041, stated the patient complained of "Abdominal Pain (with blood in emesis, blood in stool) Suicidal." The triage assessment note revealed Patient #17 had a positive suicide screening. Vital signs were recorded as Temperature (T) 98.5, Pulse (P) 74, Respirations (R) 20, Blood Pressure (BP) 121/78, and SpO2 100% on room air. A pain score of 9 (on scale of 1-10, with 10 being worst pain) was documented, with pain location noted as "abdomen." The patient was triaged as level 2 emergent. Patient #17 was roomed at 0050 and seen by a provider. Review of the Nurse Practitioner #1 (NP) documentation at 0102, revealed "...39 y.o. male with PMH (Past Medical History) of COPD (Chronic Obstructive Pulmonary Disease), stomach ulcers, bipolar disorder, antisocial personality disorder, asthma, depression and anxiety presents with abdominal pain., vomiting blood, blood in stool and suicidal thoughts. He reports that his SI started this morning....He reports abdominal pain for the past two days. ..." Review of the nursing assessment on 05/16/2019 at 0100 revealed "Patient Reports: Nausea; Vomiting; Loss of appetite (Patient states that he has been vomiting blood. Patient denies swallowing any objects. Patient is not currently vomiting here in ED) ...Patient Behaviors/Mood/Affect: Calm; Cooperative; Appropriate for situation; SUICIDAL ..." Review revealed Patient #17 at 0100 was searched and changed into paper scrubs and his belongings were collected. Review revealed Patient #17 was monitored every 15 minutes. Review of the "Columbia-Suicide Severity Rating Scale" (scale to determine risk of suicide) at 0100 revealed Patient #17 resulted as high risk for suicide. Review of the "Fecal Occult Blood" (test to determine if blood is present in stool) results collected at 0133 revealed Patient #17 was negative for fecal occult blood. Review of the Social Worker #1 (SW) note at 0222 revealed "39 yo (year old) male significant for antisocial/borderline DO (disorder) presents to ED with increasing SI. Pt (patient) has hx (history) of swallowing razors/sharps and cutiing (sic). Most recent attempted while incarcerated in March. He has multiple presentations at (Hospital Name) for same- last one yesterday. He also has hx of drug seeking and generally does not avail himself of outpatient resources. He reports decrease in sleep and appetite and is not able to contract for safety at this time. Further evaluation recommended to assess risk of self-harm at this time and reviewed w (with) (Nurse Practitioner) Med rec (reconcilitaion) requested." Review of the "Lifetime/Recent Suicide Screening" at 0229 by SW #1 revealed " ...5. Have you had any active suicidal ideation with specific plan and intent?: No ...BH (Behavioral Health) Access Recommendations: BH Access Suicide Risk Recommendations: Moderate risk Environmental Restrictions:: remove objects that may be swallowed ...continue SI protocol ..." Review of the abdominal x-ray, resulted at 0230 revealed "...XR ABDOMEN ACUTE SERIES ....IMPRESSION: No acute findings in the chest or abdomen. ..." Review of a nursing note at 0309 revealed "Attempted to call report to ED BH, states that they will look at his stuff and will call back ..." Review revealed at 0359 Patient #17 was transferred to the Behavioral Health ED Holding Area. Review of a nursing note at 0422 revealed "Pt walked up to the nurse's station and said 'You might want to send me downstairs to the ED, I just swallowed the batteries in my TV remote.' On inspection, the batteries were missing. Pt's ED Provider was notified. Said she'll put in an order for an Xray." Review revealed an order for an abdominal x-ray was placed by NP #1 at 0425. Review revealed Patient #17 was transferred to the main ER at 0453 and an abdominal x-ray resulted at 0456. Review of the abdominal x-ray revealed "...INDICATION: Swallowed battery.... FINDINGS: ....6.3 cm radiopaque foreign body is projecting overlying midline of the abdomen at L4-L5 level....IMPRESSION: 1. Radiopaque foreign body projecting overlying mid abdomen. 2. Nonobstructive bowel gas pattern. 3. Lungs are clear. ..." Further review of Nurse Practitioner Notes revealed "...Discussed results with patient Consulted GI (Gastroenterology), Discussed case with Dr. (name), reviewed HPI (history of present illness), PMH and results of work up here Patient will return to EDBH... ." Review revealed at 0606 Patient #17's disposition was set to AMA (against medical advice). Review of the nursing notes at 0606 revealed "Patient refusing to go back up to behavioral health and denies being suicidal. Patient continues to state that he only said that he wanted to hurt himself so that he would be seen for his stomach. Patient ripped his IV (intravenous) catheter out and threw it across the room. Security already at bedside, as they were called to escort patient with sitter back up to behavioral health. Patient given his belongings per provider and patient refused to wait for AMA form and discharge papers. Patient escorted out by security. Patient refused to have vital signs checked." Review of the "Refusal of Care-Patient Choice" at 0609 by NP #1 revealed "Patient Choices/Refusals To be hospitalized ...Refused ...The benefits of the recommended care are::Evaluation by GI, psychiatric help ...The risks of declining the recommended care are:: Continuing abdominal pain, inability to pass foreign body ...The patient stated the decision not to have the recommend care is because:: Other ...'I want the batteries out now.'" Review revealed Patient #17 left the hospital at 0610. Review of SW #1's notes at 0610 revealed "Consulted w ED provider concerning pt requesting d/c (discharge) after returning to ED from EDBH. Pt denying any SI and states he only said that to get in hospital for stomach pain. Confirmed with provider that pt never endorsed any plan or intent at assessment and was low risk for suicide ..."

Interview on 08/15/2019 at 1030 with RN #7 revealed she cared for Patient #26 in the ED. Interview revealed RN #7 did not complete an incident report and was not sure if anyone else did. Interview revealed the Behavioral Health RN would have done it since the incident occurred there. RN #7 stated social workers generally reported information to the physicians not to the nurse who cared for the patient. Interview revealed RN #7 could review the medical record if needed. Interview revealed the ED Behavioral Health RN stated she would review the ED record. RN #7 stated she did not recall what information was relayed during report prior to transfering Patient #17 to the ED Behavioral Health Unit.

Request for interview with the ED Behavioral Health nurse revealed the nurse was not available for interview.

Interview on 08/14/2019 at 1715 with Nurse Manager #1 revealed patient's in the behavioral health emergency department get television remotes for the televisions in their rooms. Interview revealed television remotes were given to patients based on nursing judgement. Interview revealed if a patient threatened to throw their remote it would be removed from their use. Interview revealed an incident report was not completed for this patient. Interview revealed staff do not always put incident reports in for patient's behaviors. Interview revealed Nurse Manager #1 did not recall any changes being put into place after Patient #17 swallowed batteries. Interview revealed Nurse Manager #1 would not expect an incident report to be completed after Patient #17 swallowed batteries.

NC00154609