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Based on interview, record review, policy review and video recording review the facility failed to:
- Protect one discharged suicidal patient (#21) of one discharged patient in the Emergency Department (ED) from attempted suicide while she was being monitored by video camera;
- Protect one discharged suicidal patient (#21) of one discharged patient in the ED from further suicidal attempts when she was left alone in the treatment room after she had attempted suicide while she was a patient within the ED;
- Provide an immediate physical assessment of one discharged suicidal patient (#21) of one discharged patient in the ED after she attempted suicide while she was a patient within the ED;
- Obtain signed physician orders every 24 hours as required by facility policy for continued restraint usage for five current patients (#27, #28, #31, #32 & #33) of nine current patients and one discharged patient (#18) of one discharged patient reviewed.
- Ensure that restraints were ordered only by a physician when the facility allowed Nurse Practitioners (NP) to order non-violent restraints for seven discharged patients (#36, #37, #38, #39, #40, #41 and #42) of seven discharged patient records reviewed.
These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition Participation: Patient Rights. The facility census was 354.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 01/18/18, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- All patients who present with suicidal, homicidal, or self-harm risk to the ED who are not in the Crisis Intake Unit of the ED will be assigned a 1:1 sitter.
- A log of all patients who are assigned a 1:1 sitter will be maintained by the CRN/CNL in the ED and kept in the ED administration office.
- Daily reports will be run by the Regulatory Coordinator/Quality Department to validate against the Staffing Office log compliance with the expectation.
- Co-worker's assigned to be 1:1 monitors will be monitored every one hour (documented on the Sitter Rounding Tool) for the following: Sitter has received report from the Registered Nurse (RN) and is aware of patient's monitoring status and can verbalized understanding of the patient's precautions and the risks for which they are monitoring the patient; appropriate observation; ASCOM phone present and a list of contact numbers for all ED staff, security, and shift director; need for break/relief; documentation is being consistently completed on the Clinical Status Sheet.
- Prior to or concurrent to arrival to main ED room, any patient with risk of self-harm or violent behavior will have an Acute to Behavioral Room Conversion Checklist completed by a co-worker (contraband checks/placement in scrubs in a part of the checklist and specifically identifies all clothing will be removed, including undergarments), and a second signature by the Primary RN validates the environment check.
- Education will happen prior to the first shift of all ED staff including providers related to self-harm/monitoring for safety event. Created by the Regulatory Coordinator and approved by the Chief Nursing Officer (CNO) for all ED staff to be presented in shift huddles or education in-service by leadership. A sign in sheet will be obtained as evident of attendance and compared to a comprehensive staff/provider list that will monitor compliance of all staff having the education completed.
- In the event of a patient at risk for harm to self or others in a unit outside of the ED, confirmation of Patient Care Technician (PCT), Unit Secretary or other personnel's education will take place prior to the next shift of assignment when sitting with suicidal or homicidal patients. Validation of this education will be done by the Staffing Office reviewing an education log prior to assignment.
- The current ED policy related to Behavioral Health Patients was edited for content by the Regulatory Coordinator with approval by the Director of the ED on 01/18/18. The policy reflects the identification of patients at risk for self-harm, the identification of environmental risk factors that includes contraband for patients at risk, and the department specific strategies to mitigate those risks. The ED Acute to Behavioral Room Conversion Checklist will be added as an addendum.
- In the event of an incident in which a patient were to attempt to self-harm while in the department, immediate action will include medical interventions, but not be limited to RN and provider assessment and documentation of a physical exam.

Based on observation interview, record review and policy review, the facility failed to:
- Protect one discharged suicidal patient (#21) of one discharged patient in the Emergency Department (ED) from attempted suicide while she was being monitored by video camera;
- Protect one discharged suicidal patient (#21) of one discharged patient in the ED when she was left alone in the treatment room after she attempted suicide while she was a patient within the ED; and
- Provide an immediate physical assessment of one discharged suicidal patient (#21) of one discharged patient in the ED after she attempted suicide while she was a patient within the ED. These failures could potentially place all suicidal patients at risk of harm when inadequate supervision was provided. The facility census was 354.

Findings included:

1. Record review of the facility policy titled, "Suicide Risk Assessment" created 05/01/02 showed the following:
- All patients being treated for emotional or behavioral disorders shall be assessed for potential suicidality.
- Emergency Department Patients:
- The following precautions shall be considered and implemented when deemed appropriate for patients who are a danger to themselves:
" When possible, the patient shall be placed in green scrubs.
" Patients found to be potentially suicidal shall be closely observed.
" If a family member is not available to observe the patient, an employed and trained observer shall be considered.
Management:
" The patient's immediate safety needs and most appropriate setting for treatment are addressed.
Examples of Environmental Features That May Increase the Risk of Suicide:
" Doors, door handles hinges;
" Electric beds, electrical cords; and
" TV, TV mounts.

2. Review of Patient #21's History and Physical dated 12/31/17, showed the following:
-Presented to the Emergency Department (ED) on 12/31/17 at 3:59 AM.
-Presented to the ED with OD (overdose) by prescription pills of onset two hours ago (12/31/17 at 1:43 AM).
-Patient stole mothers Xanax (a potent drug used to treat anxiety) and drank alcohol.
-Patient adds that she might have consumed pain pills.
-Patient adds that she uses Xanax and Fentanyl (a drug used for pain) off the street.
-Patient history of Bipolar disorder (a brain disorder that results in unusual shifts of mood, energy, activity levels and ability to carry out day to day tasks) but diagnosis is unconfirmed.
-Alert and oriented to person, place and time.
-She expresses suicidal ideation.
-Benzodiazepines and Cannabinoids lab test positive.
-Alcohol lab test positive.
Past medical History:
-Anxiety;
-Bipolar 1 disorder; and
-Depression.

Review of Patient #21's record showed the patient was placed in Room 2428 which is equipped with a camera and is monitored by a monitor tech.

Observation of Room 2428 on 01/16/18, showed it was not a psych safe room (a room that has been cleared of all equipment or supplies that could potentially harm a patient). The equipment would include cords from TV, monitors for vital signs, otoscopes (a device use to visually inspect ears) and call lights. Unlocked drawers in the room contained oxygen tubing, Nasogastric tubing (tubing passed through the nose to the stomach) and plastic patient belongings bag. All of these items could potentially be used for ligature (tying up).

Review on 01/17/18 at 11:05 of the video recording of patient #21 showed the following:
-9:34 AM- Social Worker (SW) and parents are with patient.
-9:35 AM - All leave the room. The patient is in bed.
-9:39 AM - SW enters room; sits down and talks with patient and types on computer.
-10:04 AM - Patient sits up in bed while talking with SW. Monitor partially obscures patient; head and knees seen.
-10:16 AM - SW leaves room. Patient alone in room.
-10:16 AM - Patient looks around room and pulls blanket up to her neck. The monitor obscures her face.
-10:26 AM - Patient gets up from bed and opens door.
-10:29 AM - Patient briefly brings blanket over her face.
-10:29.48 AM Staff opens door and speaks to patient. Patient in bed.
-10:31 AM - Unable to visualize patient due to her being down in bed.
-10:32 AM - Patient arises from bed and picks up drink cup from floor of room.
-10:33 AM - Brings blanket up to neck.
-10:36 AM - Blanket over face.
-10:36 AM - Patient goes to door and speaks to someone. Gets back in bed.
-10:53 AM - The patient is lying in the bed and then gets up and opens the door and looks out.
-10:54 AM - Closes the door and gets back into the bed.
-10:55 AM - Twists the end of the blanket and puts it around her neck and then removes the blanket.
-10:56 AM - Removes her green scrub pants and wraps them around her neck.
-10:57 AM - Wraps the scrub pants around her neck.
-10:58 AM - Sits up in the bed and then lies down with the blanket covering up to her neck.
-10:59 AM - Moving around in the bed.
-11:03 AM - Covered head with blanket and then uncovers head.
-11:04 AM - Under blanket and turns over.
-11:06 AM - Minimal movement seen under blanket.
-11:07 AM - SW and parents enter the room and SW is seen talking to patient.
-11:08 AM - SW leaves room.
-11:09 AM - Patient makes slight movement under blanket and mother and father approach patient and find and remove the scrubs which were knotted and wrapped around the patients' neck.
-11:09 AM - Mother goes to door and calls for help.
- Nurse seen speaking to patient.
- Staff seen removing items from room.
- Sheet removed from mattress and mattress placed on the floor.
-11:12 AM - All staff leave the room and leave the patient alone.

The patient was known to be suicidal and was left alone in a room with multiple ligature risks and unlocked drawers that held additional ligature risks. After her suicide attempt, the patient was again left alone.

During a telephone interview on 01/17/18 at 1:30 PM, Staff X, Monitor Tech (MT)/Unit Secretary (US), stated that:
-She had no training to be a monitor tech for behavioral health (BH) patients.
-She did not get a report from the preceding MT and did not know the particulars of their BH issues.
-She did not receive a list of phone numbers to contact their nurses in case of behavioral issues of the patients.
-She was monitoring two or three BH patients that day.
-A monitor in the room blocked the camera and sometimes prevented her from seeing the patient.
-Informed primary RN of the patient getting into drawers in the room and "she blew me off".
-She had a phone but when she used it; the call went to the 5th floor and not to the nurse of the patient.

During an interview on 01/16/18 at 1:50 PM Staff PP, Director of ED, stated that getting phones for sitters had been discussed but no phones were being used by sitters at this time. He stated that they could probably get some.

3. Review of the documentation by Staff KK, ED Physician, at 1:29 PM (two and half hours after the patient had attempted suicide in the ED) showed that he noted no injuries on exam after a face to face discussion with the patient.

During an interview on 01/18/18 at 8:35 AM, Staff KK, ED Physician, stated that he did not see the patient's attempted suicide but was told about it by the nurses. He stated that he did not see any marks or anything on the patient from her attempted suicide.

Review of the video showed Staff KK standing at the door of the patients' room talking with the patient who was approximately five to six feet away. Staff KK did not perform a physical assessment of the patient.

Review of the patients' medical record showed no documentation of a physical assessment by the primary RN after the patients attempted suicide.

4. Record review of the facility undated document titled, "Just in Time Education - Monitoring Patients for Safety" provided to Patient Care Techs, Sitters, Monitor Techs, Unit Secretaries and Nursing showed the following:
-You are VITAL to keeping our patient's safe! The patient you are assisting needs continuous observation to avoid falling, line removal, self-harm or any other unsafe event. you are responsible to monitor the patient and inform the RN of any concerns regarding the patient's behavior and actions.
-Always insist on having an ASCOM (wireless phone). You must have an ability to call for help if needed. If there are issues obtaining an ASCOM on the unit, contact the Shift Director.
-Document every 15 minutes on the Clinical Status Sheet.

This education was provided on 01/3/18 to all Patient Care Tech's, Sitters, Monitor Techs, Unit Secretaries and Nursing after the incident with Patient #21 on 12/31/17. The education specifically stated that all patients on constant observation would have a phone in order to call for help and would document on the Clinical Status Sheet.

Observation and concurrent interview on 01/17/18 at 10:20 AM with Staff U, Safety Companion, showed her sitting outside of a behavioral health patients room. She stated that she did not have a phone to use to call for help with the behavioral health patient. She stated she would have to yell for help or leave the patient to find help. She stated that when she came on shift to sit with the patient, she asked about a phone and was told there were none. She stated that she was not aware that she was to document the patient's behavior and did not have a Clinical Status Sheet.

During an interview on 01/17/18 at 10:30 AM, Staff OO, ED Nurse Manager, stated that there were no phones available yet but they could probably get some.

During an interview on 01/17/18 at 10:05 AM, Staff S, Registered Nurse (RN) stated that placement of a behavioral health patient on constant observation (1:1) was a collaborative decision with the physician. She stated that she was not aware that every BH patient was to be placed with a 1:1 sitter and was to document on the Clinical Status Sheet.

During an interview on 01/17/18 at 10:10 AM, Staff T, RN, stated that she was not aware of any change in practice for the monitoring of behavioral health patients since the incident in late December. BH patients were not always assigned 1:1.

During an interview on 01/17/18 at 10:00 AM, Staff R, ED Physician, stated that he had received no education related to the changes in procedure for placing a BH patient on 1:1. He stated that it was not a physician level intervention; it was a nursing intervention.

During an interview on 01/17/18 at 10:05 AM, Staff S, ED RN, stated that placing a patient on 1:1 was a collaborative decision between the physician and nurse. She stated that she was not aware that the sitter must document on the patient.

Based on observation, interview, and record review the facility failed to ensure that continued restraint usage for five current patients (#27, #28, #31, #32 & #33) of nine current patients reviewed and one discharged patient (#18) of one discharged patient reviewed were authorized by a physician and not modified by nursing within the 24-hour window. The facility also failed to ensure restraints were ordered only by a physician, when the facility allowed Nurse Practitioners (NP) and Physician Assistants (PA) to order non-violent restraints for seven discharged patients (#36, #37, #38, #39, #40, #41 and #42) of seven discharged patient records reviewed. This failure had the potential to cause poor nursing care outcomes for restrained patients. There were 56 patients who had been placed in non-violent restraints by Nurse Practitioners and/or Physician Assistants in the last three months. These failures had the potential for poor nursing care outcomes for all patients placed in non-violent restraints. The facility census was 354.

Findings included:

1. Review of the facility's policy titled, "Doctor's Orders, Telephone and Verbal," dated 1/31/2017, showed directives for staff to document the following:
- Date and time of order;
- Designate telephone order (T.O.) or verbal order (V.O.);
- Print the Physician's first initial and last name;
- Accepting person's name and title; and
- Physician's order(s).

Review of the facility's policy titled, "Restraint/Seclusion," dated 11/21/2016, showed that notification of the attending physician of when the restraint was applied was within 24 hours.

Review of the facility's document titled, "Amended and Restated Bylaws of the Medical, Dental and Podiatric Staff of St. Anthony's Medical Center," dated 6/01/2017, showed the following:
- Restraints must be authorized in writing by a physician after clinical assessment and when all alternatives have been exhausted.
- No order for restraints is valid for more than 24 hours.
- There shall be no standing or PRN (as needed) orders for restraints.
- Patients must be re-evaluated and the order rewritten every 24 hours if restraint is still indicated.
- Documentation supporting the restraint must be complete and include patient's behavior, therapeutic interventions attempted, reason for selecting and total time applied.

Record review of RSMO 630.175 showed that a Nurse Practitioner who is in a collaborative practice with a physician, can write restraint orders only for behavioral health patients.

2. Review of the restraint order instructions, in the medical records, for five current patients (#27, #28, #31, #32 & #33) and one discharged patient (#18) showed that the duration of the restraint order should not have exceeded 24 hours unless seen and assessed by a physician and a new order was written.

3. Review of Patient #27's medical record showed the following dates that restraint orders were modified by nursing, without new orders and new documentation that showed the physician was notified: 1/07/18, 1/09/18, 1/11/18 and 1/15/18.

During an interview on 1/17/18 at 2:15 PM, Staff JJ, Neuro Step Down Nurse, stated that modifying the restraint orders allowed the physician another 24 hours to assess the patient and that she put a nurses note in when she spoke with the physician.

4. Review of Patient #28's medical record showed the following dates that restraint orders were modified by nursing, without new orders and new documentation that showed the physician was notified: 12/26/17, 12/30/17, 1/02/18, 1/04/18, 1/05/18, 1/08/18, 1/10/18 and 1/15/18.

During an interview on 1/17/18 at 2:30 PM, Staff GG, Neuro Step Down Nurse, stated that he has restarted new orders in the past after contacting the physician and that he did not recall doing a modification.

5. Review of Patient #31's medical record showed the following dates that restraint orders were modified by nursing, without new orders and new documentation showing that the physician was notified: 1/14/18, 1/16/18, 1/17/18 and 1/18/18.

During an interview on 1//18/18 at 10:00 AM, Staff LL, Intensive Care Nurse, stated that nursing was supposed to put new orders in and not modify the restraint orders.

6. Review of Patient #32's medical record showed that on 1/16/18 Staff NN, Intensive Care Nurse, modified restraint orders without new orders and new documentation showing that the physician was notified.

During an interview on 1/18/18 at 10:03 AM, Staff NN, Intensive Care Nurse, stated that modifying the restraint orders, saved time and they had to modify or it made her go through the whole ordering process again. She also stated that she documented this in her progress notes.

7. Review of Patient #33's medical record showed the following dates that restraint orders were modified by nursing, without new orders and new documentation showing that the physician was notified: 1/10/18, 1/12/18, 1/13/18, 1/14/18 and 1/15/18.

8. Review of discharged Patient #18's medical record showed the following dates that restraint orders were modified by nursing, without new orders and new documentation showing that the physician was notified: 11/20/17, 11/25/17, 11/27/17 and 11/30/17.

During an interview on 1/17/18 at 2:13 PM, Staff II, Nurse Manager Neuro Step Down Unit, stated that if the restraint order was before the 24-hour window expiration, nursing went into the record and modified the order which renewed the order for another 24 hours.

During an interview on 1/25/18 at 5:40 PM, Staff OO, Intensive Care Physician, stated that she rounded on her patients daily and gave verbal orders to nurses to renew restraints. She expected the nurses to chart these orders by 10:00 AM daily.

9. Review of orders for Patient #36 showed a non-violent telephone restraint order, dated 01/14/18 at 11:14 PM, by Staff QQ, Nurse Practitioner (NP).

10. Review of orders for Patient #37 showed a non-violent telephone restraint order, dated 12/30/17 at 5:52 PM, by Staff RR, NP.

11. Review of orders for Patient #38 showed a non-violent telephone restraint order, dated 01/17/17 at 8:35 PM, by Staff SS, NP.

12. Review of orders for Patient #39 showed a non-violent telephone restraint order, dated 10/06/17 at 10:19 AM, by Staff TT, Physician Assistant (PA).

13. Review of orders for Patient #40 showed a non-violent telephone restraint order, dated 12/24/17 at 4:32 PM, by Staff TT, PA.

14. Review of orders for Patient #41 showed a non-violent telephone restraint order, dated 01/12/18 at 8:11 PM, by Staff UU, NP.

15. Review of orders for Patient #42 showed a non-violent telephone restraint order, dated 10/16/17 at 8:28 PM, by Staff VV, NP.

During an interview on 01/17/18 at 4:12 PM, Staff A, Regulatory Coordinator/Patient Safety & Regulatory Department, stated that her understanding was that only physicians could order non-violent restraints.

During an interview on 01/18/18 at 1:30 PM, Staff B, Regulatory Coordinator/Patient Safety & Regulatory Department, stated that Credential Files had been reviewed for two NP's and they were not credentialed to order non-violent restraints.









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