HospitalInspections.org

Based on staff interview, review of 1 (one) of 1 (one) medical record and a review of facility policy and procedure, it was determined that the facility failed to implement their policy "Suicide Risk Assessment & (and) Prevention" by ensuring that patient monitoring is documented every 15 minutes by a dedicated 1:1 (one-to-one) patient observer (therapeutic sitter) upon identification of a patient at a high level of risk.

Findings include:

Reference: Facility policy titled, "Suicide Risk Assessment & Prevention" states: "... Policy: ... 2. The Colombia Suicide Severity Rating Scale (C-SSRS) is utilized to assess and screen for a patient's risk for suicide upon arrival to the ED [Emergency Department] ... The determined level of risk identified through screening aids the licensed provider and clinical nurse in determining clinical management and interventions to prevent patient self-harm. a. High Risk - Suicidal ideation with intent or intent with plan in the past one month ... AND/OR any suicidal behavior ... in the past three months ... indicates high risk. ... 5. The clinical nurse implements 1:1 patient observation [therapeutic sitter] upon identification of a patient at a high level of risk until the provider determines clinical management and interventions required to address the patient's care needs. 6. Patient monitoring is performed by a dedicated 1:1 patient observer [therapeutic sitter] and documented in the medical record every 15 minutes. ..."

1. On 5/27/2021 at 9:50 AM, a review of Patient #1's ED medical record was conducted with Staff #4 and revealed the following:

a. The patient arrived at the ED on 5/25/2021 at 12:34 AM. The patient's chief complaint was documented at 12:44 AM as, "Suicidal." A C-SSRS was conducted by the Registered Nurse (RN) at 12:49 AM and the determined level of risk was "High." At 12:58 AM, the RN stated, "CSSR high, ... area made safe, T 1:1 [therapeutic one-to-one] at bedside ..."

(i) At 1:06 AM, the Patient Care Technician (PCT), who Staff #4 indicated was the therapeutic sitter, documented, "Pt [patient] assisted to bathroom to be changed into green scrubs. ... Will continue to monitor."

(ii) The patient was evaluated by the ED provider at 2:36 AM and an order was placed for 1:1 Observation (Therapeutic Sitter) at 2:55 AM. Documentation of every 15-minute Patient Observation was initiated at 3:03 AM by the therapeutic sitter. There was no documentation of patient observation every 15 minutes by the therapeutic sitter from 1:06 AM until 3:03 AM. This was not in accordance with facility policy.

2. The above finding was confirmed by Staff #4 at the time of the finding.

Based on review of one (1) of four (4) medical records, staff interview, and review of the facility restraint policy, it was determined that the facility failed to ensure that a physician order is obtained upon initiation of restraints, in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Restraints and Seclusion" states, "... Procedure: ... II. Use of Restraints and Seclusion for Violent or Self Destructive Patients ... B. Assessment and Review of Responsibilities of the Licensed Provider (LP) and RN (Registered Nurse) ... 3. Because restraint/seclusion use is limited to emergencies/crises, the RN may initiate use, but must immediately notify the LP, ... and obtain an order. ... C. ... 3. A LP order is issued on initiation of restraints or seclusion. 4. Orders are entered into the electronic medical record. ..."

1. On 5/27/2021 at 2:00 PM, a review of Patient #7's medical record was conducted with Staff #24 and revealed the following:

a. The patient arrived at the Emergency Department (ED) on 5/7/2021 at 12:44 AM. The chief complaint was documented at 12:58 AM as, "Mental Health Problem."

b. On 5/8/2021 at 11:14 PM, a review of the ED Timeline indicated that the RN initiated restraints for violent or self destructive patients and that the provider was notified. The restraint type was documented as, "Secure Padded All Extremities." The restraints were discontinued on 5/9/2021 at 12:00 AM.

(i) The medical record did not contain an order issued by the LP for the initiation of the restraints.

2. The above finding was confirmed on 5/27/2021 at 2:30 PM by Staff #24 and Staff #31.