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Based on review of facility documents, medical records (MR1), and staff interview (EMP), it was determined the facility failed to ensure a patient with suicidal thoughts was on a 1:1 direct visual observation by a facility staff member while using the bathroom in the Emergency Department (ED) and the facility failed to ensure a facility staff member maintained a 1:1 visual observation on a patient with suicidal thoughts while in a patient room in the ED (A0144).

This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient. The IJ was identified on October 18, 2024, at 1:44 PM.

On October 18, 2024, the survey team reviewed the revised policy #P6 was revised on 10/18/2024 at 0700 hours, to say "Patient will be directly observed as they change into disposable clothing and all belongings including sock, belt, under wear, cell phone/other devices, valuables, medications, and potentially dangerous equipment/items are removed from the room. Security will assist as required and patient will be scanned head to toe, for weapons with a metal detector and mouth inspected to objects. Toileting options will include use of bedside commode, urinal, bedpan, etc. if a restroom is utilized, the door latch is to be disabled and observer must position themselves in the doorway to avoid loss of visual contact with patient while positioning the door in a manner that provides privacy from passersby. Only bathrooms with disabling latches may be utilized. Signatures of all staff being educated will be obtained on education sheets starting on 10/18/2024. Staff that were educated on the evening and night of 10/17/2024 will be re-educated by reviewing the revised policy #P6 and confirming their understanding of these changes by signing by education sheets."

The immediate education sign-in sheets were reviewed on October 18, 2024, to determine compliance for the removal of the immediate jeopardy.

The survey team verified these immediate interventions were implemented and confirmed the facility's IJ was removed October 18, 2024, at 6:56 PM.

Continuing deficiency
October 17, 2024

Cross reference
482.13 (c)(2) -Patient Rights: Care In Safe Setting

Based on review of facility documents, medical records (MR), observation, and staff interview (EMP), it was determined the facility failed to ensure a patient with suicidal thoughts was on a 1:1 direct visual observation by a facility staff member while using the bathroom in the Emergency Department (ED) for one of one applicable medical record reviewed (MR1) and the facility failed to ensure a facility staff member maintained a 1:1 visual observation on a patient with suicidal thoughts while in a patient room in the ED for one of one applicable medical record reviewed (MR2).

Findings include:

Review on October 18, 2024, of the facility policy, "Patient's Rights and Responsibilities," reviewed November 28, 2023, revealed "Policy: It is the policy of Wayne Memorial Hospital to inform each patient (inpatient and outpatient), or when appropriate, the patient's representative, of their rights and responsibilities, in advance of furnishing or discontinuing patient care, whenever possible ...Your Rights...As our patient, you have the right to safe, respectful and dignified care at all times. You will receive services and care that are medically suggested and within the hospital's services, its stated mission, and required law and regulation .... "

Review on October 18, 2024, of facility, "Standard Of Care Violence, Potential For, Self-Directed Or Directed At Others (Suicidal Or Homicidal)" revised October 2018, revealed "...Nursing Directives Emergency Department Management...Continuous Observations-Requires a staff/patient ratio where one person can continuously view a patient, or group of patients and alert staff if patient(s) in danger. 1:1/Arm's length observation-(for immediate violent/self-destructive behavior)-Requires 1 to 1 staff to patient ratio where the staff person is at the bedside (or just outside the room) and is only monitoring 1 patient....Special Circumstances: One to One (1:1) observation may be implemented in situations where there is no immediate violent/self-destructive behavior identified, but neither close or continuous observation are adequate to protect the patient from harm. Examples may include, but are not limited to, high fall risk, at risk to wander, disorientation, etc. ..."

Review on October 19, 2024, of the facility's "Chief Of Patient Care Services" job description, last revised July 2009, revealed "Primary Purpose Of The Position: Organizes the Department of Nursing in such a way that its policies and procedures assure that quality nursing care is delivered to patients in a safe, effective and consistent manner...Responsibilities...Make nursing rounds to assess the quality of patient care and to identify problems and needs...Maintains compliance with nursing care standards, hospital policies and procedures and regulatory agency requirements...continually evaluates the care delivered by regular review of management reports, direct observation and patient rounds, results for quality assurance studies, review charts..."

Review on October 19, 2024, of the facility's "Nurse Manger II" job description, last revised November 8, 2022, revealed "...Responsibilities...Assesses all departmental activities, identifies problems and any need for improvement...Implementation:...Ensures that the Emergency Room Standards of Nursing Practice are implemented and assists in monitoring those standards as necessary. Holds self and staff accountable for the delivery of quality nursing care. Acts rapidly and effectively, follows hospital policies and procedures, and utilizes principles of management in any emergency situation..."

Review on October 18, 2024, of the facility's "Psychiatric Emergencies: Voluntary/Involuntary Commitment 201/302 Policy: P-6", last revised September 2024, revealed "Policy: It is the policy of Wayne Memorial Hospital to evaluate and stabilize patients suffering from a psychiatric emergency by addressing immediate medical needs and providing a safe environment that reduces potential harm to both the patient and others in conjunction with available county resources...Purpose: To ensure a safe and secure environment for patient, staff and visitors...Definitions:...Voluntary Commitment (201): Agreement by patient to consent to inpatient psychiatric care. Involuntary Commitment (302): Completion of warrant for patient in crisis who does not voluntarily consent to treatment... Guidelines of Practice For Emergency Department Care of Patients With Psychiatric Disorders And / Or Behavioral Issues: At the time of triage, if the patient is found to be a threat to themselves or others, or is under a 302 warrant, the patient will be placed in a designated area in ED where he/she can be continually observed...Patients will change into disposable clothing and all clothing (including socks, belt, underwear, and cell phone) valuables, medications and potentially dangerous equipment/items are removed from the room..."

Observation of the ED bathroom on October 18, 2024, revealed the following:
A rigid trash can measuring 20 inches high,
A clear plastic bag lining the rigid trash can,
A wall mounted light measuring 48 inches long with a gap between the light and the wall,
A wall mounted paper towel holder,
Two open back wall mounted handrails, one measuring 53 inches and the second one measuring 36 inches,
A glass mirror,
A wall mounted soap dispenser
A louvered vent directly above the commode,
A goose neck faucet with louvered handles for the hot and cold water.

EMP1 and EMP2 on October 18, 2024, revealed this bathroom is utilized by ED patients.

Interview with EMP1 and EMP2 on October 18, 2024, confirmed the above findings in the ED bathroom. EMP1 and EMP2 confirmed the above items pose a risk of hanging or harm to a patient with suicidal thoughts. EMP1 confirmed this bathroom is used for all patients in the ED including those admitted for mental health evaluations related to suicidal thoughts.

1. Review of MR1 on October 18, 2024, revealed this patient presented to the ED on October 17, 2024, at 1126, for a mental health evaluation due to cutting self and having suicidal thoughts for the past couple of days. MR1's nursing documentation revealed this patient had multiple lacerations on the left arm in varying stages of healing; this patient had a history of harming self and has had multiple previous admissions for attempts of harming self. The facility assessed MR1 and determined this patient met the criteria for an ESI level of 2 and a 1:1 direct observation sitter was assigned to this patient.

Review of MR1 on October 18, 2024, dated October 17, 2024, revealed the following timeline:

1214 - EMP8 documented the facility wanded this patient upon arrival to the ED; MR1 was changed into paper scrubs, given a pair of non-skid socks and all belongings including
electronics, personal supplies and jewelry were placed in a bag and secured.

1215 - EMP8 documented MR1 kept belongings at the bedside which included kindle, chap stick, paper with phone numbers and insurance card. Items labeled and moved by security to valuable room.

1803 - EMP9 documented MR1 requested and was escorted to the restroom. While using the restroom MR1 took a razor that was taped to the bottom of the foot and cut their left forearm.

1820 - EMP8 documented a microblade was confiscated from MR1. MR1 reported the microblade was kept in the back case of the kindle when they arrived in the ED.

1820 - EMP10 documented MR1 informed this staff person the microblade was hidden in the kindle case when they arrived in the ED then placed into the sock before being escorted to the bathroom.

Review of MR1 on October 18, 2024, dated October 17, 2024, at 1820 revealed this patient requested to use the bathroom; was taken to the bathroom by nursing staff and the bathroom door was closed behind the patient leaving MR1 out of direct 1:1 observation. When MR1 opened the bathroom door, MR1 had blood coming from new superficial lacerations to this patient's left upper arm.

Interview with EMP1, EMP2 and EMP3 on October 18, 2024, confirmed the above findings. EMP1, EMP2 and EMP3 confirmed MR1 was taken to the ED bathroom by EMP8; EMP8 closed the bathroom door and allowed MR1 to be behind a closed bathroom door and EMP8 did not maintain 1:1 direct observation of MR1 while in the bathroom.

2. Review of MR2 on October 18, 2024, revealed this patient was admitted to the ED on October 18, 2024, at 2051 with suicidal thoughts and wanting to kill self. MR2 had a history of suicidal attempts. The facility assessed MR2 and determined this patient met the criteria for an ESI level of 2 and a 1:1 direct observation sitter was assigned to this patient. EMP11 was assigned to MR2 for 1:1 direct observation.

Observation on October 18, 2024, at 0910 revealed EMP11 sitting in the doorway of MR2's room facing the hallway and having a conversation with EMP12.

Interview with EMP1, EMP2 and EMP3 on October 18, 2024, confirmed the above finding at the time of the observation. EMP2 and EMP3 confirmed MR2 was not under the constant 1:1 visual observation to protect this patient from potential self-harm. Further interview with EMP2 and EMP3 revealed EMP11 received training on the requirement of maintaining a 1:1 direct visual observation of patients with suicidal thoughts at the beginning of this employees shift on October 18, 2024.

Continuing deficiency
October 17, 2024

Cross reference
482.13 Patient Rights

Based on review of facility documents, medical records (MR1), and staff interview (EMP), it was determined the facility failed to ensure a patient with suicidal thoughts was wanded and physically inspected for sharps; the facility failed to ensure all electronics were removed from a patient with suicidal thoughts (A1104) and the facility failed to ensure all clothing, including socks, were removed, and secured by staff and all patient belongings, including electronics, were secured while a patient is under 1:1 constant visual observation (A1112).

This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient. The IJ was identified on October 18, 2024, at 1:44 PM.

On October 18, 2024, the survey team reviewed the revised policy #P6 was revised on 10/18/2024 at 0700 hours, to say "Patient will be directly observed as they change into disposable clothing and all belongings including sock, belt, under wear, cell phone/other devices, valuables, medications, and potentially dangerous equipment/items are removed from the room. Security will assist as required and patient will be scanned head to toe, for weapons with a metal detector and mouth inspected to objects. At no time will a patient under a 1:1 observation be permitted to possess an electronic device. (cell phone, tablets, i-pod, kindle, etc.) If a patient requires a use of a phone, one will be provided and used only under the direct supervision of an observer. In these situations, the phone will be removed when call is complete. Signatures of all staff being educated will be obtained on education sheets starting on 10/18/2024. Staff that were educated on the evening and night of 10/17/2024 will be re-educated by reviewing the revised policy #P6 and confirming their understanding of these changes by signing by education sheets."

The immediate education sign-in sheets were reviewed on October 18, 2024, to determine compliance for the removal of the immediate jeopardy.

The survey team verified these immediate interventions were implemented and confirmed the facility's IJ was removed October 18, 2024, at 6:56 PM.

Cross reference
482.55 (a)(3) Emergency Services Policies
482.55 (b)(2) Qualified Emergency Services Personnel

Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined the facility failed to ensure a security office received training regarding the use of a metal detector to scan patients, belongings, and visitors for metal objects that could potentially be used by patients with suicidal thoughts for one of one applicable personnel files reviewed (PF2).

Findings include:

Review on October 19, 2024, of the "Security In-Service Training PN-01" policy, last revised May 2024, revealed "Training: Development of training of Security Department Personnel must be a continuing process. Development in security is largely accomplished by a thorough training program to improve the Security Officer's skills and knowledge and to keep him/her current in the field. The merits of training will be reflected in his/her attitude, better morale and increased incentive. Training provides a better understanding of his/her relationship to management and the objectives of his/her job..."

Review on October 19, 2024, of the facility's "Detection Principles and Capabilities of the [Name of metal detector]" manual, no date, revealed "...The [name of metal detector] is an active hand-held metal detector with very high sensitivity to all metals including ferrous, non-ferrous and stainless steel. Detection and alarming takes place when the instrument is passed in close proximity to metal objects. Detection range is dependent upon the size and conductivity of the metal object. The larger the object, the greater the detection distance. The [name of metal detector] is factory preset to nominal sensitivity with no operator adjustments required. This ensures that the detector will be used at the proper operating level established for the particular security need...When metal objects are encountered, the red LED is activated along with an audible alarm or the vibration alarm...Recommended Body Scanning Procedure double check pocket areas." The diagram illustrates front scanning beginning at the right shoulder proceeding down the right arm to the right leg and top of the right foot to the top of the left foot to the left leg then the left arm and ending at the left shoulder. The diagram illustrates back scanning beginning at the back of the head proceeding down the right arm to the right leg to the left leg to the left arm then down the middle of the back..."

A request was made of EMP1 and EMP5 on October 19, 2024, for PF2's training regarding the use of the facility's metal detector. None was provided.

Interview with EMP1 and EMP5 on October 19, 2024, revealed PF2 did not receive training on the facility's metal detector.

Cross reference
482.55 Emergency Services
482.55 (b)(2) Qualified Emergency Services Personnel

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to prevent self-harm of a patient with suicidal thoughts while in their care for one of one applicable medical record reviewed (MR1).

Findings include:

Review on October 19, 2024, of the "Chief Facilities Officer" job description, revised July 2009, revealed "Primary Purpose Of The Position: Administers and directs programs to maintain the buildings, grounds and equipment and procure or generate all utilities and their distribution systems. Has administrative responsibility for Maintenance, Environmental Services, Security, Bio-medical, Food and Nutrition Services and Materials Management Departments...Responsibilities... Assures that departmental employees are adequately trained to properly perform assigned responsibilities...Competency Assessment The process of ensuring that each employee demonstrates continued ability to perform the tasks, duties, and responsibilities of his/her position in a competent fashion. Following are the competency standards for the position...Effectively encourages and promotes staff education, develops training needs assessments for staff, maintains employee training records, communicates mandatory training requirements..."

Review of MR1 on October 18, 2024, revealed this patient presented to the Emergency Department (ED) on October 17, 2024, at 1126, for a mental health evaluation due to cutting self and having suicidal thoughts for the past couple of days. MR1's nursing documentation revealed this patient had multiple lacerations on the left arm in varying stages of healing; this patient had a history of harming self and has had multiple previous admissions for attempts of harming self. The facility assessed MR1 and determined this patient met the criteria for an ESI level of 2 and a 1:1 direct observation sitter was assigned to this patient.

Review of MR1 on October 18, 2024, dated October 17, 2024, revealed the following timeline:

1214 - EMP8 documented the facility wanded this patient upon arrival to the ED; MR1 was changed into paper scrubs, given a pair of non-skid socks and all belongings including
electronics, personal supplies and jewelry were placed in a bag and secured.

1215 - EMP8 documented MR1 kept belongings at the bedside which included kindle, chap stick, paper with phone numbers and insurance card. Items labeled and moved by security to valuable room.

1803 - EMP9 documented MR1 requested and was escorted to the restroom. While using restroom took a razor that was taped to the bottom of the foot and cut left forearm.

1820 - EMP8 documented a microblade was confiscated from MR1. MR1 reported the microblade was kept in the back case of the kindle when they arrived in the ED.

1820 - EMP10 documented MR1 informed this staff person the microblade was hidden in the kindle case when they arrived in the ED then placed into the sock before being escorted to the bathroom.

Review of MR1 on October 18, 2024, dated October 17, 2024, at 1820 revealed this patient requested to use the bathroom; was taken to the bathroom by nursing staff and the bathroom door was closed behind the patient leaving MR1 out of direct 1:1 observation. When MR1 opened the bathroom door, MR1 had blood coming from new superficial lacerations to this patient's left upper arm.

Interview with EMP5 on October 18, 2024, revealed it is the security officer that is responsible for completing the metal detection on patients, on patient's belongings, and on visitors.

There was no documentation in MR1 indicating the security officer completed metal detection of MR1's feet or MR1's belongings.

Interview with EMP1 and EMP5 on October 18, 2024, confirmed the above findings at the time of the review.

Cross reference
482.55 Emergency Services
482.55 (a)(3) Emergency Services Policies