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Based on medical record review, review of video surveillance, interview, and policy and procedure review, the facility failed to have policies and procedures in place to ensure that all patients presenting to the emergency department (ED) are promptly identified and that patients presenting with suicidal ideation are placed under continuous observation.

Findings include:

Review of Patient #1's medical record dated 4/22/15 revealed the patient presented to the pre-triage area requesting a psychiatric evaluation at 5:17pm. At 5:42pm the patient was triaged as Emergent-Level 2 with a chief complaint of depression and suicidal ideation. At 6:01pm the trauma team was paged to the ED ramp after the patient was found to have jumped off the ramp, falling 10-15 feet. Cardiopulmonary resuscitation (CPR) was initiated without success and the patient was pronounced dead at 6:40pm.

Review of ED video surveillance dated 4/22/15 revealed Patient #1 is observed at the ED entrance at 1:10pm. The patient entered the ED and sat down in the corner of the ED waiting room. At 5:17pm the patient is observed walking up to the pre-triage window. At 5:42pm the patient is observed being lead back to the triage room and at 5:45pm the patient is placed in a room across from the triage room. At 5:49pm the triage nurse caring for the patient is observed leaving the area and four seconds later, the patient exits the triage room and the patient is observed exiting the ED. The patient is then observed exiting and entering the ED several times with a final exit recorded at 5:56pm. At 5:52pm the tech from the Comprehensive Psychiatric Emergency Program (CPEP) is observed presenting to the patient's room. At 5:53pm the tech is observed walking up to the triage nurse and at 5:56pm they are observed exiting the ED.

Interview on 4/28/15 at 3:47pm with Staff # 10, ED tech, revealed the tech was at the pre-triage desk from 3:00pm to 7:00pm on 4/22/15. The patient had not been noted in the waiting area prior to presenting to the desk requesting a psychiatric evaluation.

Interview on 4/29/15 at 9:00am with Staff #9, ED RN, revealed that on triage Patient #1 indicated she was there for a psychiatric evaluation as she was depressed and suicidal. Following triage, the patient was placed in a room across from the triage room and report was called to the CPEP nurse. Staff #9 then informed Staff #12, ED RN that she was leaving the area. A short while later, the CPEP tech presented and told Staff #9 that the patient was not in the room. They went outside, where they located the patient's walker and purse. They looked over the edge of the ramp and saw the patient on the ground, following which they radioed for help and CPR was initiated.

Interview on 4/28/15 at 4:12pm with Staff #12, ED RN, revealed that she was the second triage nurse in the ED on the day of the incident. Staff #12 stated that Staff #9 told her that she was leaving the area and that the patient was in the room across the hall. Staff #12 stated she could visualize Patient #1 from Triage Room #1, however, she had to close the door of Triage Room #1 in order to triage another patient.

Interview on 4/28/15 at 10:00am with Staff #7, RN-ED charge, revealed that the CPEP nurse is notified when a patient presents with suicidal ideation. The patient is then placed in the room across the hall with the door open. Staff #7 stated that there is always someone in the hallway.

Review on 4/28/15 of emergency department policies in effect at the time of Patient #1's ED visit on 4/22/15 did not show evidence of policies for identification of patients entering the ED, or for continuous monitoring of patients presenting at high risk for danger to self and/or others. This was confirmed by Chief Safety Officer Staff #1 on 4/28/15.

Based on medical record review, review of video surveillance, interview, and policy and procedure review, the hospital does not meet the emergency needs of patients in accordance with acceptable standards of practice related to continual observation of patients at risk for danger to self and/or others.

Refer to findings under Tags #A0144 and A1104.

Based on policy and procedure review and interview, the facility failed to have policies and procedures in place to ensure that all patients presenting to the emergency department (ED) are promptly identified, and that patients presenting at high risk for danger to self and/or others are placed under continuous observation.

Findings include:

Review of policy "Emergency Department Triage Policy #ED-010" (revised 10/4/13) revealed: "VI. Special considerations: (G) All patients that are considered high risk for and a danger to self and/or others (actual or suspected) shall be triaged as emergent (level 2) and placed in a treatment room and/or escorted to CPEP with staff and/or ECMC police or other law enforcement agencies, with prior notifications made to CPEP if safety permits."

During interview on 4/28/15 at 8:45 AM, Chief Safety Officer Staff #1 stated that at the time of Patient #1's ED visit on 4/22/15, the facility practice was that the ED triage registered nurse would place patients in triage room #1 or the room across from triage while awaiting the arrival of CPEP (Comprehensive Psychiatric Emergency Program) personnel. Staff #1 stated that patients awaiting CPEP transfer were not under constant supervision. Staff #1 additionally stated that the facility was now considering options for future access control of the ED to immediately identify persons entering the ED as being patients or visitors.