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701 N FIRST ST

SPRINGFIELD, IL 62702

PATIENT RIGHTS

Tag No.: A0115

Based on observation, document review and interviews, it was determined that the Hospital failed to protect and promote patient rights to ensure the patient's emotional health and safety as well as his/her physical safety. Therefore, the Condition of Participation 42 CFR 482.13, Patient Rights was NOT met, as evidenced by:

Findings Include:

1. The Hospital failed to ensure that for the ligature risks identified in the Emergency Department (ED), that safety interventions were maintained for patients to be free from risk of causing self-harm or injury. See A-0144.

An Immediate Jeopardy (IJ) was identified for Complaint #IL 00131682/211204. The IJ began on 3/11/2021 due to the Hospital's failure to: ensure that for the ligature risks identified in the Emergency Department (ED), that safety interventions were maintained for patients to be free from risk of causing self-harm or injury. The IJ was identified on 3/16/2021, at 42 CFR 482.13, Patient Rights, and was announced 3/16/21 at 12:35 PM, during a meeting with the President/CEO (E #6), Administrator Emergency Room/Trauma (E#7), System Director Patient Safety (E#3) and Chief Nursing Officer (E#6). The Immediate Jeopardy was cited at A-0144 and was not removed by the survey exit date of 3/18/2021.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on observation, document review, and interview it was determined for 1 of 6 ( Pt #2) psychiatric patients in the Emergency Department (ED), the Hospital failed to ensure that for the ligature risks identified in the Emergency Department (ED), that safety interventions were maintained for patients to be free from risk of causing self-harm or injury. Subsequently, Pt. #2 was found hanging by the neck in the ED room #3, by utilizing a soft restraint and a ceiling hook. This has the potential to affect the safety of psychiatric patients in the ED, as evidenced by:

Findings include:

1. On 3/15/2021 between 9:00 AM to 10:00 AM, an observational tour of the Emergency Department was conducted. Ceiling hooks attached to metal beams were noted in Emergency Department rooms #1-#3

2. On 3/15/2021 at 11:00 AM, the document titled "Emergency Department Ligature Risk Assessment" (completed on 3/3/2021), by the Hospital was reviewed. The assessment included documentation that the ceiling hooks in Emergency Rooms #1-#3 were identified as ligature risks and included an intervention to have "direct observation one on one" of suicidal patients when occupying the Emergency Department Rooms where the ceiling hooks are present

3. Pt #2's record was reviewed throughout the survey. According to Pt #2's record Pt #2 was admitted to the ED with suicidal ideation's and aggression. Pt #2 was to be on a one on one sitter due to suicidal risk per "Emergency Department Ligature Risk Assessment. The SIU Progress Psych Progress Note authored by Southern Illinois University (SIU) Psychiatrist (MD #3) on 3/10/2021 at 1:23 PM, indicated: Pt#2 remains a risk of harm to others and self at this time and would benefit from voluntary psychiatric placement. SIU Psychiatric Resident (MD #2) placed an order on 3/10/2021 at 9:35 AM for elopement precautions and Suicide Precautions. According to Pt #2's record "soft restraints" were applied for aggression on 3/10/2021 at 3:25 PM and restraints were removed on 3/10/2021 at 5:30 PM. On 3/10/2021 at 1:23 PM, MD #3's psych progress notes stated that; "1:1 sitter, suicide/elopement precautions" The computerized psychiatry observation check list indicated Pt #2 had all restraints removed on 3/10/2021 at 5:30 PM.

4. According to the physician's progress notes documented by MD #2 on 3/11/2021. Pt #2 was admitted from a group home to the ED on 3/7/2021 with diagnoses of: Autism Spectrum Disorder, ADD, ADHD, PTSD and a history of attempts of suicide by hanging and battery ingestion. Pt #2 was on a "one on one sitter" due to suicide risk. The document stated that: Pt #2 "is considered at high risk to harm self and others and as such has been recommended for involuntarily psychiatric admission." ... "On the morning of 3/11/2021 at 12:26 AM, ED Registered Nurse paged SIU psychiatric resident ( MD #1) to inform that patient had managed to fashion the soft restraints into a noose, secured it on a ceiling hook in the ED treatment room #3 and hung Pt #2 by the neck. Staff was able to pull Pt #2 down and lay Pt #2 on the floor. "It is unknown how long Pt #2 had been hanging, but it is suspected to be less than five minutes... Nurse report that patients face was red and starting to turn blue. There were red ligature marks around the neck ... patient regained consciousness shortly after they laid patient down .... Continue one on one sitter" Pt #2 record lack documentation that the sitter was present in the ED room, when Pt #2 attempted suicide.

5. The Psychiatric Observation Check list was reviewed and indicated, the Environmental Safety check was performed on 3/10/2021 at 7:00 PM by E#2, Registered Nurse, which is to be conducted every eight hours per policy.

6. According to Pt #2's record: the "Trauma Admission H&P" created by MD#2 dated 3/11/2021 at 3:43 AM, indicated, "19-year-old male Trauma Consult after the patient was found by patient care tech hanging from a soft restraint cord from a metal hook on the ceiling, reportedly with feet dangling in midair. The patient was reportedly unconscious, with his eyes rolled back in his head, with a severely erythematous face, not breathing. There is uncertainty as to the length of time the patient was hanging from the ceiling, approximately 2-5 minutes. In order to get patient down, the tech (E#9), tore down the ceiling fixture and gently guided the patient to the ground, as soon as (E #9) released the pressure on the patients neck and heard an audible gasp from the patient. Patient was then placed in a cervical collar and a back-board. The patient is currently an inpatient psychiatric hold for both suicidal and homicidal ideation. Upon evaluation, the patient was complaining of severe neck, upper back pain in addition to weakness in the lower extremities bilaterally."

7. The hospital lacks documentation that this suicide attempt was identified as a sentinel/adverse event or that a corrective action plan was implemented.

8. On 3/16/2020 between 11:00 AM and 11:50 AM, the video of the Emergency Hallway in front of ED treatment rooms 1-5 was viewed: Safety Monitor (E#1) was assigned to monitor the patients in ED rooms #2, #3 and a patient lying on bed in hallway. Unable to confirm direction E#1 was facing to monitor the three patients. Unable to see if curtain across glass doors were pulled shut in treatment room #3. The following was noted on the video: 12:07:28 E#1 was standing at the door of treatment room #3 (Pt #2's room); 12:07:54 E#1 is sitting in the hall across from treatment room #2 and treatment room #3; 12:14:48 Patient in room #2 sitting on chair in doorway waving arms at staff ( apparently Pt #2 had hung self);12:16:30 Safety Monitor E#1 enters treatment room #3- Patient #2's room; 12:16:39 Safety Monitor (E#9) runs into treatment room #3; 12:16:45 Charge Nurse (E#11) enters the room-(E#1, E#9, and E#11 in treatment room #3); 12:16:52 Registered Nurse (E#2) assigned to Pt #2 is in hall in front of treatment room #3; 12:17:07 Registered Nurse (E#2) assigned to Pt #2 enters treatment room #3.


9. On 3/16/2021 at 9:00 AM, the policy titled "Care of the Patient who is Suicidal or Suspected to be Suicidal" was reviewed. The policy requires, "1:1 monitoring with continuous visual observation...a dedicated staff member is assigned to observe one patient at all times ... Staff will use the Suicide Precautions Environmental Check (form #MR2-704) to identify potential ligatures, sharp objects, harmful substances, and equipment that could be used as a weapon[on. Staff will identify whether the safety rick was removed, retained for medical necessity, or secured in the room ...i. When suicide Precautions are initiated, preferably before arrives in room. ii. At least every 8 hours"


10. On 3/172021 at approximately 2:30 PM, the job description for the "Patient Safety Monitor" (dated 08/2020) was reviewed; Under "Principle Duties and Responsibilities the following is required: Under no circumstances is a patient on continuous observation to be left unattended. Visual Contact at all times must be maintained. Follows safety checklists as appropriate and assists with ensuring an ongoing safe environment for a patient on continuous observation."


11. During an interview on 3/15/2021 at approximately 11:00 AM, the Emergency Department Manager (E #5), stated that "all patients in restraints or suicidal are on one on one direct observation".

12. During an interview on 3/16/2021 at 9:30 AM, the Director of Patient Safety (E #3) stated, "we did not consider that an adverse event, therefore we did not implement a corrective action plan. We just started an investigation the event on 3/15/2021"

13. During an interview on 3/15/2021 at approximately 1:25 PM-1:40 PM, on the psychiatric unit; Pt #2 stated; "I was there (Emergency Department) because of being suicidal and bad behaviors. They put me in wrist restraint because I was aggressive and biting. I had someone in the room with me, staff named (Pt #2 gave a name of the staff member), but when the staff member left in the room I took the restraints left in the room and tied them around my neck, then I put the other end on a hook on the ceiling, then I jumped off the bed. I passed out and that is all I remember until I was here on the psych unit".

14. During an interview on 3/17/2021 at approximately 9:00 AM-9:15 AM, via telephone, E#1 stated "I normally monitor "2" patient at a time on continuous observation if they are calm and sleeping on my 7 PM-7 AM shift. If watching more than 3 "continuous" observations, I will need help. On 3-11 I was assigned to the patients in treatment rooms #2, #3 and the patient in the hallway C bed to monitor. I was scanning the patient's room (Pt#2) when I noticed he climbed on the bed, the curtain was open, but the sliding glass doors were closed. I got up and went into the room (treatment room #3), and he had already jumped off the bed. I screamed for help as I couldn't hold the patient up. A tech (ED Technician-E #9) came in the room and held the patient up. I did not know there were restraint's left in the room. When I went in the room, I saw part of a restraint around the patient's neck (Pt#2) and after the event I saw another part of attached to the bed. I do not have restraint training that is the nurse's or tech's job. I have had environmental round education to check the room for safety."

15. During an interview on 3/17/2021 at approximately 9:20 AM-10:00 AM, E#9 stated that "I was in front of room #24, saw that the Safety Monitor was dealing with something and then saw her get up, and go into room #3. Then I heard the Safety Monitor (E#1) yell "help me" and I ran to room. The patient was hanging from the ceiling hook, his face red and eyes were closed. I bear hugged him with my left arm to lift him up. I couldn't get the patient off the ceiling hook, so I grabbed the IV hook with my right hand and pulled with all my weight and the ceiling bent in and came down enough, so I could take the noose off the patients neck. The patients' face had started to be purple. I slid the patient to the floor and could see the red welt on the neck. Not sure if patient lost consciousness. The Safety Monitor was stationed in the hall at the computer and had a line of site into treatment room #3, but the sliding doors were closed, and the curtain was 3/4/closed, the opening was the width of a door. I could not see the patient until I got into the room. I'm 6 foot 4 inches so I was able to lift the patient."


16. On 3/18/2021 at 9:30 AM, the hospital submitted a corrective action plan.

17. On 3/18/2021 at approximately 10:45 AM-11:00 AM, a tour of Emergency Room was conducted with the Administrator of Emergency (E#7), Vice President of Clinical Operations E#12) and Patient Safety Coordinator (E#13). There are 56 rooms in the ED. At time of the tour, ED rooms # 1-12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, S1, S2, C1, and C2 contained the ceiling hook ligature risks. Pt #11 was currently in room #2 alone. No staff were near room #2's door.

18. During the tour, E#7 stated there are no designated behavioral health treatment rooms in the Emergency Room. Any room in the Emergency Department could have a behavioral health patient. E#7 stated the patient in room #2 is a low risk suicide patient and is on continuous observation, not on one to one direct observation. ED seclusion orders mean that the patient is at risk for suicide or homicide."

19. Pt #2's record was reviewed on 3/18/2021 at approximately 11:35 AM. The record indicated: patient was admitted to the ED on 3/17/2021 at 9:40 PM. Record indicated: The nursing assessment dated 3/17/2021 at 9:52 PM, indicated that the patient was at low risk for suicide. The ED record authored by ED Physician (MD #4) on 3/17/2021 at 10:57 PM, indicated that: patient was admitted with diagnoses of depression and intentional overdose. The physicians note indicated: "Patient did acknowledge to me that that the patient took the medicine in an attempt to end patient's life." "ED Psychiatric Response Assessment Form" dated 3/18/2021 at 9:15 AM, indicated: "presenting to the ED after ingesting 12 Tylenol tablets in an attempt to end patient's life. Patient tells writer that patient took the Tylenol in an attempt to end patient's life ...Dangerous to self or others: patient is at high risk." "Physician orders indicated that last "ED seclusion orders for risk of harm to self" was on 3/18/2021 at 9:30 AM.