HospitalInspections.org

Based on observation, staff interviews, review of one of one medical record (Patient (P) 1), and review of facility documents, it was determined that the facility failed to ensure the rights of each patient is protected.
Findings include:
1. The facility failed to ensure that patients receive care in a safe setting. (Refer to Tag A 144)

Based on observation, staff interview, review of one of ten medical records (Patient (P) 1) and review of facility documents, it was determined that the facility failed to ensure a safe patient environment by ensuring a patient admitted with Suicidal Ideation (SI) with a plan, identified as High-Risk, is placed on 1:1 (one-to-one) observation to prevent patient harm and death, in accordance with facility policy.

Findings include:

Reference #1: Facility policy titled "Admission Procedure," Last Revised 3/2020, states, "... Procedure: ... 2. When the determination is made that a patient requires admission, the Needs and Assessment staff will communicate information concerning the patient's clinical condition and treatment needs prior to the patient's arrival to the unit. ... 5. The nurse will review the admission packet from the Needs Department including the high risk alert form, ... 6. The nurse will sign the high risk alert form to validate that this information was communicated during hand off. ... 9. The registered nurse [RN] will complete the Admission Assessment and initiate the treatment plan. The physician (LIP) [Licensed Individual Practitioner] will be notified of critical patient assessment information and additional orders received as appropriate. ... "

Reference #2: Facility policy titled "Suicidal/Homicidal Patient management risk Reduction Guidelines," Last Revised 6/2020, states, "... Procedure: 2. Needs Assessment staff should contact the physician for individuals assessed to be at risk for harm to self/others. The physician should utilize the information from the Needs Assessment Evaluation of Risk to self/others to determine the appropriate level of care. ...4. The attending physician will order a degree of staff supervision ...consistent with the risk identified and as deemed appropriate by the patient's condition. The level of precautions is a matter of clinical judgement. The basis for that clinical judgement should be specified in the medical record. The levels of care are as follows: 1. Level I - Continuous Observation on 1:1 Basis Patient indicates suicidal/homicidal ideation and 1. Has a formulated plan which could have the feasibility to produce harm to self or others within the hospital setting, or 2. Has had a history of attempting suicide by a particularly lethal method of perceived or actual lethality, ... Restrictions include: 1:1 staff continuous accompaniment at arms length no more than one yard away, 24 hours a day. ... "

Reference #3: Facility policy titled "Special Precautions Guidelines," Last Revised 1/2017, Next Review 5/2023, states, "... Procedure: Physician: ...2. Special precautions may be initiated by either a physician or Registered Nurse. ... Charge Nurse/Nurse Manager: 1. When patients are assessed to be at a level of risk requiring increased precautions or observation, the charge RN will implement the precautions or observation and notify the attending physician or designee as soon as possible. ... Registered Nurse: ... 2. Implements special precautions. ... "

Reference #4: Facility policy titled "Suicide Prevention Plan," Last Revised 5/2020, states, "... Assessment and Re-Assessment ... Assessment of Risk: 1. The admitting RN will screen every patient being admitted for suicidality risk factors utilizing the Full Columbia Suicide Severity Rating Scale [C-SSRS]. ... 3. This assessment will include identification of patients that may be in one of the identified high risk groups: Adolescent ... transgendered individuals ... major depression ... 4. Further consideration of risk will be given to patients presenting with general risk factors that apply across demographics: Previous attempt(s), current of recent self harm ... Presence of a plan for suicide ... 8. Any clinician completing the Columbia Suicide Severity Rating Scale must include a summary of risk which includes an action plan and documentation of notification to the physician if indicated. ... Heightened Observations: 1. ... Patients who are assessed to be at high risk for suicidality must be assessed by a physician for the need of a one to one (1:1) observation status. The nurse will document which physician was notified and at what time the notification occurred. If the need for 1:1 is indicated there will be a physician order for 1:1 status. ... "

P1's medical record was requested and reviewed in the presence of Staff #1, Chief Executive Officer (CEO), Staff #2, the Divisional Director of Corporate Clinical Services, Staff #3, the Director of Risk Management and Performance Improvement, Staff #4, the Chief Operating Officer (COO), and Staff #5, the Chief Nursing Officer (CNO). P1's medical record revealed the following:

P1, a 16-year-old female to male transgender, who identified as male, was admitted to the TU4 adolescent unit on 9/23/22 at 11:16 AM, with an admitting diagnosis of Major Depressive Disorder, recurrent, and Transsexualism.

The "TRIMS" (Telephone Referral Information Management System) form dated 9/22/22 at 20:01 [9:01 PM] stated, " ... Comments: Direct admission from a (name of hospital). ... PT [Patient] presents due to suicidal ideation with a plan to use peanut butter allergy to die and to hang himself from ceiling fan in her room. PT has a recent hospitalization to (name of hospital) this past spring due to intentional overdose on Benadryl. PT has a history of cutting. ... PT reviewed with (physician name) [Staff #8, the Chief Medical Officer (CMO)] and accepted for admission to TU4. ... " Staff #4 indicated that the "TRIMS" form is an intake form.

The "Psychiatric SBAR (Situation, Background, Assessment, and Recommendation) Intake to Unit Patient Report Worksheet" dated 9/22/22 at 19:00 [7:00 PM] stated, " ... Reviewed with doctor: (physician name) [Staff #8]. ... " Staff #4 indicated that the SBAR form is used to communicate between the intake staff and the accepting unit.

The "High-Risk Notification Form" stated, " ... High risk Factors: Suicidal ..." The form was signed by the Intake staff on 9/22/22 at 18:00 [6:00 PM], as well as the unit staff member, Staff #7, a Licensed Practical Nurse (LPN), on 9/23/22 at 11:50 AM. The medical record lacked evidence that Staff #7 initiated 1:1 observation for P1, in accordance with the above referenced policies.

The "History and Physical" (H&P) dated 9/23/22 stated, " ... Chief Complaint (in patients own words) 'I wanted to kill myself' ... Yes, I have reviewed the Nursing Assessment and I have addressed the significant findings. ..." The H&P was signed by Staff #9, an APN (Advanced Practice Nurse) on 9/23/22 at 16:00 [4:00 PM]. The medical record lacked evidence that Staff #9 initiated 1:1 observation for P1, or notified a physician/psychiatrist that P1 was identified as High-Risk for Suicide.

During the entrance conference at 9:45 AM, Staff #5 indicated that when a patient is a transfer (direct admission from a hospital), upon arrival the patient goes directly to the unit and the nurse has to complete a comprehensive nursing admission assessment, which includes the Columbia Suicide Severity Rating Scale (C-SSRS), within 8 hours of patient arrival. Once the assessment is completed the nurse calls the physician for orders. Staff #5 stated that all nurses are trained to complete the assessment and are trained in the C-SSRS. Staff #5 also indicated that the patient must receive a psychiatric evaluation within 24 hours of admission. Staff #5 stated that if identified as high-risk for suicide, a nurse or a physician can initiate 1:1 observation.

The "Hospital Nursing Admission Assessment-Youth" form contained a "Summary Risk Assessment Treatment Interventions" section which indicated "yes" to the Suicide/Self Injury Risk Assessment. The "New Presenting Symptoms" section stated, "Assessment reveals indicators for Suicide Risk." The "RN Recommended Action for All Yes Answers" section stated, "Contact the provider for orders as necessary. If orders are obtained for Suicide/Self Injury Precautions, Add Suicide/Self Injury to Treatment Plan."

The "Initial Treatment Plan" signed by Staff #6, an RN, on 9/23/22 at 1:50 PM indicated Suicidal/Self-Injurious under the Problem/Short-Term Goals section. The Specific Intervention Focus section which contained a check box titled "1:1 observation level to prevent self-injurious behavior" was not marked.

The "Hospital Nursing Admission Assessment-Youth" form contained a "Nursing Admission Narrative Summary" section which stated, " ... Patient rec'd [received] a/a/ox4 [awake, alert and oriented times 4]. Patient is calm and cooperative during assessment. Patient states he is having suicidal thoughts with a plan and some intent to act. ..." The hand written note was signed by Staff #6 and dated 9/23/22 and timed 1400 [2:00 PM].

The C-SSRS, which was part of the nursing admission assessment completed by Staff #6, indicated the following:

Suicidal Ideation: 1. Wish to be dead: was marked yes in the Lifetime and past 1 month section. 2. Non-Specific Active Suicidal Thoughts: was marked yes in the Lifetime and past 1 month section. 3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act: was marked yes in the Lifetime and past 1 month section. 4. Active Suicidal Ideation with Some Intent to Act, without a Specific Plan: marked yes in the Lifetime and past 1 month section. 5. Active Suicidal Ideation with Specific Plan and Intent: marked yes in the Lifetime and past 1 month section.

Intensity of Ideation: Frequency: "How many times have you had these thoughts" was marked "4" in the Lifetime and past 1 month section. Four (4) indicates Daily or almost daily. The Reasons for Ideation was marked "5" in the Lifetime and past 1 month section. Five (5) indicates "Completely to end or stop the pain (you couldn't go on living with the pain or how you are feeling).

Suicidal Behavior: Actual Attempt: was marked yes in the Lifetime and past 3 months section. Total of attempts was marked "3" in the Lifetime section and "2" in the past 3 months section.

Actual Lethality/Medical Damage: Most recent attempt x2 (times two); May 31st, 2022.

The "Summary of Current Suicide Risk" section at the end of the C-SSRS has three check boxes, "No change in Clinical Presentation, Decrease in Suicide risk, Increase in Suicide Risk." The box indicating "No change in Clinical Presentation" was marked. Under the three boxes, there is a section for physician notification which states, "If Increase: Notify Physician Name of Physician: Date/Time contacted: Outcome: Notification by: Date/Time." The physician notification section was blank.

Based on the Nursing Admission Assessment and the C-SSRS, Staff #6 failed to identify an increased risk of suicide, failed to notify the physician of the increased risk and failed to place the patient on 1:1 observation, in accordance with the above referenced policies.

Staff #4 and Staff #5 both confirmed that the medical record lacked documented evidence that the nurse called the physician after the nursing assessment and C-SSRS were completed.

On 9/28/22, the personnel file for Staff #6 was requested and reviewed. Staff #6's hire date was 3/15/22. Staff #6 completed orientation and competency testing. Staff #6 completed C-SSRS training on 9/18/22. Staff #6 also completed the R.I.G.H.T [Responsibility, Individual, Guarding, How, Trust] Suicide Prevention Post Test and scored 100 %.

The Physician Orders were reviewed and indicated the following:

Admission: Admit to inpatient adolescent psychiatric unit Entered by: (Name) [Staff #7] as a telephone order on 9/23/22 at 16:36 [4:36 PM]. Ordered by: (Physician Name) [Staff #8] at 9/23/22 16:36 [4:36 PM].

Level of Observation: Q15 minute Observations Entered by: Staff #7 as a telephone order on 9/23/22 at 16:37 [4:37 PM]. Ordered by: (Physician Name) [Staff #8] at 9/22/22 16:37 [4:37 PM].

Precautions: Self harm Risk Entered by: Staff #7 as a telephone order on 9/23/22 at 16:36 [4:36 PM]. Ordered by: (Physician Name) [Staff #8] at 9/22/22 16:36 [4:36 PM].

Precautions: Suicide Precautions Entered by: Staff #7 as a telephone order on 9/23/22 at 16:36 [4:36 PM]. Ordered by: (Physician Name) [Staff #8] at 9/22/22 16:36 [4:36 PM].

Staff #4 indicated that (name) [Staff #7] realized that originally there were only medication orders entered and he/she called the physician to obtain additional orders. Staff #4 indicated that telephone orders need to be verified and signed off by a physician. During an interview on 9/28/22 at 3:00 PM, Staff #4 indicated that although the telephone orders were not yet signed off by the physician, he/she confirmed with the physician [Staff #8] that he/she [Staff #8] gave the orders to the nurse.

Staff #4 indicated that when placing orders, the physician has not yet spoken with the patient and relies on the nursing assessment.

On 9/28/22 at 2:34 PM, during an interview, Staff #8 stated that he/she gave the orders in person, not over the telephone. Staff #8 also confirmed that he/she was not aware of P1's history when placing the orders. Upon questioning Staff #8, if he/she inquired about P1's history prior to placing the level of observation orders, Staff #8 stated that it is up to the nurse doing the comprehensive nursing assessment to determine if there is a higher need. Staff #8 failed to utilize the information from the Needs Assessment Evaluation of Risk to self/others to determine the appropriate level of care, in accordance with Reference #2 policy listed above.

During an interview on 9/28/22 at 3:00 PM, Staff #4 stated that Staff #8 indicated that he/she did not accept the patient for admission. Staff #4 indicated that the admitting physician does not have to sign any type form to accept a patient. The admitting orders is the acceptance. The "TRIMS" form dated 9/22/22 at 20:01 [9:01 PM] stated, "... PT reviewed with (physician name) [Staff #8] and accepted for admission to TU4. ... " The "Psychiatric SBAR Intake to Unit Patient Report Worksheet" dated 9/22/22 at 19:00 [7:00 PM] states, " ... Reviewed with doctor: (physician name) [Staff #8]. ... "

Staff #8's credentialing file was also reviewed and found to be complete.

The Nursing Daily Progress Note, dated 9/23/22 at 2050 [8:50 PM], entered by Staff #10, an RN, stated, "PT received AAOx4 calm and cooperative. Adjusting to unit and unit rules well. Pt is visible on the unit and social with peers. ... Denies any SI/HI/AVH, [Suicidal Ideation/Homicidal Ideation/Auditory Verbal Hallucinations] or urges to self harm. Pt states that he can seek out staff support in the event that he has thoughts of hurting himself. ... "

The Nursing Daily Progress Note, dated 9/23/22 at 0324 [3:24 AM], entered by Staff #10 stated, "At 2217 [10:17 PM], pt was found with sheet tied around neck and tied on corner of room door. Pt was brought down and sheet was removed from around pt's neck. Pt was assessed for pulse and respirations; no pulse present, no respirations present. Pt unresponsive. Code Medic called at 2218 [10:18 PM]. 911 called at 2219 [10:19 PM]. CPR [cardiopulmonary resuscitation] initiated. AED [Automated External Defibrillator] applied. BVM [Bag Valve Mask] applied. Supervisor arrived on unit. CPR continued until first responders arrived to scene. First responders arrived to scene at approximately 2230 [10:30 PM]. Pt was transferred from hospital at approximately 2240 [10:40 PM] on stretcher, accompanied by EMS [Emergency Medical Services]. Mother was notified via telephone." On 9/28/22 during an interview, Staff #4 indicated that the patient had passed away.

Review of the 24-hour observation record indicated the following:
Time of arrival to unit: 1148 [11:48 AM] Date: 9/23/22 Patient Room: 245D Precautions: was blank. The form indicated that the patient was observed every 15 minutes starting on 9/23/22 from 12:00 PM until 10:00 PM. Staff #4 stated that upon the 10:15 PM observation check is when the patient was found unresponsive with a sheet around his/her neck.

Staff #4 and Staff #5 confirmed that the patient had not yet received a physician psychiatric evaluation prior to the incident.

A tour of the TU4 unit was conducted on 9/28/22 at 10:52 AM, in the presence of Staff #3 and Staff #5. During an observation of P1's room, no ligature risks were identified. Staff #3 pointed out how the patient slid a sheet over the top of the room door and slid the sheet into the jam of the door and closed the door. Staff #3 stated that the corner of the doors, where it meets the door jam, are flat and angled as to not create a ligature risk.

The facility failed to implement the above policies and procedures and ensure that P1, a patient identified through the Needs Assessment, Nursing Admission Assessment, and C-SSRS, as having SI with a plan, that was feasible of being acted out within the facility, was placed on 1:1 observation, to protect the patient from harm and death.

The above finding resulted in an Immediate Jeopardy (IJ) on 9/28/22.

The Chief Operating Officer and Chief Executive Officer were informed of the IJ and were provided with the IJ template on 9/28/22 at 3:46 PM, and a removal plan was requested at that time.

An acceptable removal plan was provided by the facility on 9/28/22 at 4:39 PM.

On 9/28/22, while on-site, it was verified that the facility implemented the following: supplemented the Columbia Suicide Severity Rating Scale to include a risk level (low, moderate or high) and section for provider notification and justification for q15 minute observation vs. 1:1 observation, provided immediate re-education to staff present on the adolescent unit on the changes to the form and the suicide prevention and management policy, educated the physicians, the Needs Assessment Staff and nursing staff that all admissions will be required to be reviewed by the physicians and will not be admitted to the unit until physician notification is verified, amended the SBAR form to include a "Time of physician notification" section, re-educated all Needs Assessment staff on the addition of the amended SBAR form and the new process. The facility will continue to re-educate all staff at the start of their next shift and obtain a read and sign attesting to understanding. The attestations completed on 9/28/22 were reviewed for verification. Staff were able to verbalize, through interview the importance of identifying patients that are high-risk for suicide, notifying the physician, and placing the patient on 1:1 observation.

The facility was found to have implemented the IJ removal plan and the IJ was removed on 9/28/22 at 5:45 PM.