HospitalInspections.org

Based on interview, medical record review and policy review, it was determined the facility failed to protect patients rights and ensure the safety of suicidal patients by not providing continuous monitoring to prevent elopement (A144) and failed to follow policy for the use of restraints (A167). The cumulative effect of this systemic practice resulted in the facility's inability to ensure the safety of suicidal patients.

Based on medical record review, policy review and interview, the facility failed to provide continuous monitoring of suicidal patients to prevent elopement. This deficient practice affected three patients (#11, #12 and #16) of eight medical records reviewed of patients who were suicidal with the potential to affect every patient who arrives to the Emergency Department with suicidal attempts or ideations. The facility's Emergency Department evaluates approximately six patients per month with suicidal ideations or suicide attempts. The total hospital census was 118 patients.

Findings include:

1. The medical record review for Patient #11 revealed the patient arrived at the Emergency Department (ED) on 3/28/15 at 3:21 AM. Staff F, a physician, documented Patient #11 had a history of psychiatric illness since childhood. Patient #11 reported thoughts of suicide and occasionally performs self-mutilating behavior, which has increased recently. Patient #11 reported being under a lot of stress and had been thinking a lot about dying. Patient #11 reported not having a specific plan but reported having thoughts about inflicting serious stab wounds and/or overdose with medications and alcohol. On 3/28/15, police were summoned when Patient #11 became out-of-control threatening suicide and physical violence toward family members. Patient #11 arrived to ED with EMS and police in handcuffs. Staff F documented the presenting symptoms as aggressive behavior, depression, self-mutilation, suicidal thoughts, suicidal threats and suicide attempt. Staff F's review of systems reported Patient #11 as positive for suicidal ideas and self-injury.

The medical record for Patient #11 contained a pink-slip (an Application for Emergency Admission) signed by Staff G on 3/28/15 at 3:30 AM and contained an order for suicide precautions on 3/28/15 at 4:09 AM.

On 3/28/15 at 10:36 AM, Staff E documented Patient #11 reported he/she was leaving. On 3/28/15 at 8:36 PM, Staff C documented Patient #11 was not in room, gown was on the bed and Protective Services was notified.
On 3/28/15 at 8:42 PM, Staff C documented Patient #11 was found standing at the doors to the Emergency Department and escorted back to patient's room (Room 10).
On 3/28/15 at 8:45 PM, Staff C documented Patient #11's heplock was found on the bed.


2. Patient #12 walked into the facility's Emergency Department on 3/28/15 at 4:28 PM with a chief complaint of being suicidal with a plan. Staff F, documented Patient #12 presented to the Emergency Department for depression and suicidal ideation beginning several weeks ago. Patient #12 reported being seen on 3/27/15 at the facility and discharged home. The patient states he is homeless, feels helpless, depressed, suicidal and has a plan to confront his drug dealer and steal dope so that the drug dealer will shoot and kill him. Staff F documented after completing the physical exam and history of present illness, I felt the patient would require a medical screening examination. If the medical exam and screening examination were normal, then the patient would be cleared for further psychiatric assessment by an Group C an acute behavioralhealth service.. Based on the statements Patient #12 made to Staff F, Staff F was planning on completing a pink slip. After Staff F left the patient's bedside and before Staff F could complete a pink slip, the patient eloped with his mother. The charge nurse was going to notify the authorities the patient eloped and was suicidal. The medical record review revealed Patient #12 was discharged from the computer system on 3/28/15 at 5:09 PM after Patient #12 eloped.

On 3/30/15 at 3:36 PM, Staff D was interviewed regarding Patient #11's and Patient #12's elopements. Staff D reported an incident report should have been filed and stated an incident report had not been entered into the reporting system.

On 3/28/15 at 3:22 PM, Staff C was interviewed regarding Patient #11 and Patient #12. Staff C reported the facility has "stopped hundreds of people from getting away". Staff C reported Patient #11 and #12 were placed in direct view of a secretary. Staff C was not certain on the timing of the monitoring which is required for suicidal patients. Staff C reported the facility needs appropriately trained staff to handle patients who are suicidal. Staff C reported calling protective services upon discovery of Patient #11 and Patient #12 leaving. Staff C reported staff could benefit from annual in-services on monitoring of suicidal patients. Staff C reported no measures have been implemented since the elopements of Patient #11 and #12.

3. Patient #16 walked in to the facility's Emergency Department on 11/24/14 at 6:44 PM. On 11/24/14 at 9:11 PM, Staff H documented the chief complaint as suicidal and documented patient "states everything is wrong" and "states he wants to blow his brains out". On 11/24/14 at 10:05 PM, Staff H documented Patient #16's family member reported Patient #16 was threatening suicide. Family member was told the physician will be informed and will see what we can do to get a bed. Before that could be pursued, Staff H was informed by registration that Patient #16 and the family member had left the Emergency Department. The medical record did not contain a medical screening examination. Patient #16 was discharged from the electronic medical system at 10:05 PM on 11/24/14.

Staff H was interviewed on 3/31/15 at 4:06 PM. Staff H was unable to recall the specific events from Patient #16's Emergency Department visit on 11/24/14. Staff H reported he/she did not know the protocol for the frequency of monitoring suicidal patients. Staff H reported the facility needs a sitter, observer or monitor for suicidal patients.

The facility's Rights and Responsibilities of Patients policy was reviewed. The policy states the patient has the right to receive care in a safe setting.

The facility's policy titled Suicidal Patients and Those at Risk for Behavioral Emergencies: Admission and Care Outside of Behavioral Services was reviewed. The policy stated all patients with a primary diagnosis or complaint of an emotional or behavioral disorder including substance abuse are screened for suicide using the Columbia Suicidality Severity Rating Scale (C-SSRS) upon arrival to the Emergency Department, on admission to the hospital and at critical junctions during their stay. In cases where a patient has attempted suicide, an initial screening is not necessary because the patient is already assumed to be at high risk for self-harm. The purpose of this screen is to provide crucial information to the physician who has the ultimate responsibility for judging suicidal risk based upon his/her assessment of the risk factors and protective factors (prohibitions to suicide) present.
Nursing responsibilities include:
- Identify high risk indicators for suicidal patients (i.e. excessive substance/alcohol abuse, severe emotional and chronic medical issues, planned or history of suicide attempts).
1. Implement suicide precautions by:
a. Placing the patient in an area where continuous visual monitoring can occur.
Assign a room close to the nursing station when possible.
b. Calling for additional staffing to provide the constant observation.
- Assessing for elopement risk (i.e. wandering behavior, previous attempts, verbalization they will leave, and physical mobility to transport self-off unit).
Notify security if patient is an elopement risk. If patient elopes, call Code Brown and notify Security.
- Accompanying the patient to the bathroom and/or any off unit activities ( diagnostic tests, physical therapy).
- Frequent (at least every hour) verbal contact when awake.

Ordering Providers Responsibilities include:
-Order suicide precautions and constant observation if patient assessed to be a suicide risk.
- Strict constant observation (observer must be within arm's reach of patient) can be initiated by nursing if necessary.
- A physicians order is required to discontinue suicide precautions.

Based on medical record review, review of the restraint policy, and staff interviews, the facility failed to follow the policy for restraint use in one of two patients reviewed with physician orders for restraints. (Patient #23)

Findings include:

1. On 04/02/15 Patient #23's medical was reviewed with Staff Y. Per the medical record, the patient was restrained with bilateral soft wrist restraints for pulling at medical equipment (BiPAP mask and intravenous lines) from 03/25/15 at 5:00 AM through 03/26/15 at 4:00 PM. The medical record revealed range of motion was not performed and lacked evidence the restraints were released by staff during the following times: 03/25/15 at 8:00 AM and 12:00 PM and on 03/26/15 between 12:00 AM and 12:00 PM. The documentation at those times revealed the patient was asleep and no range of motion was performed. The soft bilateral wrist restraints were discontinued on 03/26/15 at 4:00 PM.

2. On 03/26/15 at 1:15 PM, review of the facility policy titled Restraints, Use for Non-Violent Non Self-Destructive Reasons, approved 04/06, revealed the following: Patients in restraints for non-violent non self-destructive reasons are reassessed based upon individual patient's needs and are not to exceed two hours. This includes removal of extremity restraints for evaluation of circulation, skin integrity, sensation and range of motion. Clinical justification reassessment is completed every shift and as needed. Narrative statement is required.

3. An interview was conducted with Staff Y on 03/26/15 between 1:15 PM and 1:45 PM. Staff Y confirmed the aforementioned facility policy. Staff Y also confirmed there was no documentation of the release of the soft bilateral wrist restraints on 03/25/15 at 8:00 AM and 12:00 PM, and on 03/26/15 between 12:00 AM and 12:00 PM. Staff Y confirmed the nursing staff failed to document a narrative statement regarding clinical justification reassessment of the restraint on the night shift of 03/25/15 and 03/26/15 and day shifts on 03/25/15 and 03/26/15.

Based on interview, medical record review and policy review, it was determined the facility failed to follow policies for monitoring and ensuring the safety of suicidal patients presenting to the Emergency Department (A 1112). The cumulative effect of this systemic practice resulted in the facility's inability to ensure the safety of suicidal patients.

Based on medical record review, policy review and interview, the facility failed to ensure adequate medical and nursing personnel qualified in emergency care were available to meet the written emergency procedures and needs anticipated by the facility for three suicidal patients (Patient #11, #12 and #16) of eight medical records reviewed of patients who were suicidal. This had the potential to affect every patient who arrives to the Emergency Department with suicidal attempts or ideations. The facility's Emergency Department evaluates approximately six patients per month with chief complaints of suicidal ideations or suicide attempts. The total hospital census was 118 patients.

Findings include:

1. The medical record review for Patient #11 revealed the patient arrived at the Emergency Department on 3/28/15 at 3:21 AM. Staff F, a physician, documented Patient #11 had a history of psychiatric illness since childhood. The patient reported he/she often thinks of suicide and occasionally performs self-mutilating behavior, which has increased recently. Patient #11 reported being under a lot of stress and had been thinking a lot about dying lately. Patient #11 reported not having a specific plan but reported having thoughts about inflicting serious stab wounds and/or overdose with medications and alcohol. On 3/28/15, this evening, police were summoned when Patient #11 became out-of-control threatening suicide and physical violence toward family members. Patient #11 arrived with EMS and police in handcuffs. Staff F documented Patient #11's presenting symptoms as aggressive behavior, depression, self-mutilation, suicidal thoughts, suicidal threats and suicide attempt. Staff F's review of systems reported Patient #11 as positive for suicidal ideas and self-injury.

The medical record for Patient #11 contained a pink-slip (an Application for Emergency Admission) signed by Staff G on 3/28/15 at 3:30 AM. The medical record contained an order for suicide precautions on 3/28/15 at 4:09 AM.

On 3/28/15 at 10:36 AM, Staff E documented the patient stated he/she was leaving. On 3/28/15 at 8:36 PM, Staff C documented Patient #11 was not in room, gown was on the bed and Protective Services was notified. On 3/28/15 at 8:42 PM, Staff C documented Patient #11 was found standing at the doors to the Emergency Department and escorted back to Patient #11's room. On 3/28/15 at 8:45 PM, Staff C documented Patient #11's heplock was found on the bed.


2. Patient #12 walked into the facility's Emergency Department on 3/28/15 at 4:28 PM with a chief complaint of being suicidal with a plan. Staff F, documented Patient #12 presented to the Emergency Department for depression and suicidal ideation beginning several weeks ago. Patient #12 reported being seen on 3/27/15 at the facility and discharged home. The patient states he/she is homeless and feels helpless, depressed and suicidal. Patient #12 states that his/her plan would be to confront his drug dealer and steal dope so that drug dealer will shoot him and kill him. Staff F documented after completing a physical exam and history of present illness, Staff F felt the patient would require a medical screening examination.

Based on the statements made by Patient #12 Staff F was planning on completing a pink slip (involuntary admission). After Staff F left the patient's bedside and before Staff F could complete a pink slip, the patient eloped with Patient #12's mother. The charge nurse was going to notify the authorities the patient eloped and was suicidal. The medical record review revealed Patient #12 was discharged from the computer system on 3/28/15 at 5:09 PM after Patient #12 eloped.

On 3/30/15 at 3:36 PM, Staff D was interviewed regarding the elopement of Patient #11 and Patient #12. Staff D reported an incident report should have been filed and stated an incident report had not been entered into the reporting system.

On 3/28/15 at 322 PM, Staff C was interviewed regarding Patient #11 and Patient #12. Staff C reported the facility has "stopped hundreds of people from getting away". Staff C reported Patient #11 and #12 were placed in direct view of a secretary. Staff C reported Staff C was not certain on the timing of the monitoring which is required for suicidal patients. Staff C reported the facility needs appropriately trained staff to handle patients who are suicidal. Staff C reported calling protective services upon discovery of Patient #11 and Patient #12 leaving. Staff C reported staff could benefit from annual in-services on monitoring of suicidal patients. Staff C reported no measures have been implemented since the elopements of Patient #11 and #12.

3. Patient #16 walked in to the facility's Emergency Department on 11/24/14 at 6:44 PM. On 11/24/14 at 9:11 PM, Staff H documented the chief complaint as suicidal and documented patient "states everything is wrong" and "states he wants to blow his brains out". On 11/24/14 at 10:05 PM, Staff H documented Patient #16's family member reported Patient #16 was threatening suicide. Family member was told the physician will be informed and will see what we can do to get a bed. Before that could be pursued, Staff H was informed by registration that Patient #16 and the family member had left the Emergency Department. The medical record did not contain a medical screening examination. Patient #16 was discharged from the electronic medical system at 10:05 PM on 11/24/14.

Staff H was interviewed on 3/31/15 at 4:06 PM. Staff H was unable to recall the specific events from Patient #16's Emergency Department visit on 11/24/14. Staff H reported he/she did not know the protocol for the frequency of monitoring suicidal patients. Staff H reported the facility needs a sitter, observer or monitor for suicidal patients.


4. The facility's policy Suicidal Patients and Those at Risk for Behavioral Emergencies: Admission and Care Outside of Behavioral Services policy was reviewed. The policy stated all patients with a primary diagnosis or complaint of an emotional or behavioral disorder including substance abuse are screened for suicide using the Columbia Suicidality Severity Rating Scale (C-SSRS) upon arrival to the Emergency Department, on admission to the hospital and at critical junctions during their stay. In cases where a patient has attempted suicide, an initial screening is not necessary because the patient is already assumed to be at high risk for self-harm. The purpose of this screen is to provide crucial information to the physician who has the ultimate responsibility for judging suicidal risk based upon his/her assessment of the risk factors and protective factors (prohibitions to suicide) present.
Nursing responsibilities include:
- Identify high risk indicators for suicidal patients (i.e. excessive substance/alcohol abuse, severe emotional and chronic medical issues, planned or history of suicide attempts).
1. Implement suicide precautions by:

a. Placing the patient in an area where continuous visual monitoring can occur.
Assign a room close to the nursing station when possible.
b. Calling for additional staffing to provide the constant observation.
- Assessing for elopement risk (i.e. wandering behavior, previous attempts, verbalization they will leave, and physical mobility to transport self-off unit).
Notify security if patient is an elopement risk. If an inpatient elopes, call Code Brown and notify Security.
- Accompanying the patient to the bathroom and/or any off unit activities ( diagnostic tests, physical therapy).
- Frequent (at least every hour) verbal contact when awake.

Ordering Providers Responsibilities include:
-Order suicide precautions and constant observation if patient assessed to be a suicide risk.
- Strict constant observation (observer must be within arm's reach of patient) can be initiated by nursing if necessary.
- A physicians order is required to discontinue suicide precautions.