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Based on review of the medical record, policies and procedures, facility tour, and staff interviews, it was determined that the facility failed to establish an effective system to ensure that the patient's condition was monitored for continuous safety for 1 of 1 (#1) patient whose record was reviewed.

Findings were:

A review of the medical record for patient #1 revealed that the patient presented to the emergency department with complaints of depression and suicidal thoughts. The mental health assessment revealed that the patient reported having marital and monetary problems and indicated that he/she had a plan to overdose or drive car in front of a train. The patient also expressed thoughts about hurting spouse. The mental health assessment indicated that the patient had experienced similar symptoms previously and had made previous attempts to hurt self. The patient was moved to an involuntary status with a determination that in-patient care was needed due to behavior that was life threatening and destructive to self or others. The patient also presented with diabetes and reported not having taken any medication for the condition in approximately one (1) month. The patient received, per physician order, medication for the diabetes along with intravenous (IV) fluids. Notes from the behavior assessment therapist indicated that the patient should not be allowed to return home due to lack of support and some related abuse issues. Several referrals were made to facilities for placement of the patient, but as of the third day of the patient having been in the emergency department, a placement had not been found. Nursing notes at the time of admission indicated that the patient was gowned in paper scrubs and suicide precautions maintained. Nursing notes throughout the three (3) days, revealed documentation regarding the patient's behavior but no mention after admission of suicide precautions being maintained. Progress notes were maintained on the patient but notes were not consistently documented every hour.

On the third day the progress note for the patient indicated that at 4:08 a.m. the patient was calm and sleeping and had no adverse reactions. At 6:04 a.m. the patient related no complaints and was resting quietly. At 8:11 a.m. the charge nurse (employee #1) documented that the patient reported no complaints and was calm. Patient reported no pain. The note indicated that the patient's status had improved and the patient stated he/she felt better. The patient was alert and oriented to time, place, and person. In addition the note indicated that there was no respiratory distress, skin warm and dry and color within normal limits and the patient's affect appeared normal. At 9:45 a.m. the note by the same nurse indicated that the patient reported no complaints and was calm. At 11:10 a.m., a note written by another nurse (employee #2), indicated that the nurse went to the room to check the patient and did not see the patient. The nurse called for the charge nurse and they found the patient hanging with a sheet. The physician was called, the patient was moved to the trauma room and cardiopulmonary resuscitation (CPR) was started. A physician progress note, written approximately an hour after the incident, noted that when the physician arrived, the patient was unresponsive and without a pulse. Abrasions were noted around the patient's neck. Emergency interventions were initiated but to no success. The patient's death was declared at 11:53 a.m.

An interview at 11:30 a.m. on 12/21/2010 with the day charge nurse in the emergency department (#1) revealed that on the day of the incident the department was staffed with five (5) nurses rather than the usual six (6) nurses plus the charge nurse. The charge nurse, due to the situation, assigned himself/herself three (3) patients. The three (3) patients, which included patient #1, were all in the emergency department with psychiatric issues and were waiting for placement outside the facility. The nurse reported that patient #1 had refused breakfast and had indicated that he/she wanted to go home. The nurse asked the security guard to talk with the patient, stating that the security guard related well to the patients and was helpful in calming them down. After having checked on the assigned patients, the charge nurse stated that he/she went to the desk and made attempts to find additional staffing. The interviewee indicated that it was approximately 9:30 a.m. when he/she started that task. The charge nurse confirmed that there was a unit secretary at the desk who was to be monitoring the three (3) patients via camera. At 11:00 a.m. additional nurses were scheduled and another nurse was assigned to the three (3) psychiatric patients. A short time later the charge nurse reported that the other nurse (#2) was unable to locate the patient. The charge nurse went to assist the nurse and they found the patient sitting on the floor at the side and behind the bed with the sheet wrapped around his/her neck and tied to the IV pole that was attached to the bed. They attempted to arouse the patient and untie the sheet. An emergency code was called, the patient was moved to the trauma room and resuscitative measures were attempted. The nurse related that psychiatric patients were generally placed in the three (3) rooms that were equipped with camera monitors that were monitored continuously at the desk by the unit secretary. If the three (3) rooms were occupied and a psychiatric patient was placed in another room, a sitter was utilized to help monitor patient's behavior/condition. When questioned about the frequency of patient monitoring by the nurse, the interviewee indicated that assessment of the patient was to be done hourly. The charge nurse did not think that there were policies related specifically to the monitoring of psychiatric patients. Instead, he/she related that the practice was for psychiatric patients to be continuously monitored by the unit secretary and hourly checks by the nurse. The interviewee stated that observation orders were not ordered by the emergency physicians. The nurse also stated that equipment was not generally in the psychiatric patient's room. If equipment, such as IV pole, was used, the patient was to be monitored and the equipment removed after completion of treatment.

An interview at 12:30 p.m. on 12/21/2010 with the emergency room (ER) nurse (#2) who was assigned the care of the patient at 11:00 a.m. by the charge nurse revealed that, after having received report on the patient, ER nurse #2 went to check on the patient. The nurse related that it was about 11:10 a.m. The nurse indicated that he/she was unable to locate the patient and, after checking in the bathroom, notified the charge nurse. Both nurses went back to the patient's room and then found the patient sitting on the floor with a sheet tied around the patient's neck. The nurse stated that emergency measures were then taken in response to the patient's condition. The nurse related also that the psychiatric patients were placed in the three (3) rooms that were to be continuously monitored by the unit secretary via camera. According to the nurse, measures to keep psychiatric patients safe were in place. The psychiatric patients were placed in paper gowns, wanded by security, and were not allowed personal belongings. The nurse reported that he/she had not used equipment with the psychiatric patient but believed that if equipment was needed (IV poles, cardiac monitoring etc.), the patient was moved to another room and monitored by the nurse while the equipment was used. The nurse was unsure if IV poles were on each bed.

An interview at 12:52 p.m. on 12/21/2010 with the unit secretary (#3) who was in the emergency department on the day of the incident revealed that he/she was aware that there were three (3) psychiatric patients who were awaiting placement. The secretary confirmed that there were cameras in the three (3) rooms and that the monitor was at the desk and to be monitored by the unit secretary. The secretary related that he/she had been busy with physician orders, call lights, telephone calls, etc. At approximately 11:00 a.m., another person took over the secretary duties and the interviewee was preparing to take on patient care responsibilities. It was shortly after that time, that the interviewee became aware of the incident with the patient. The interviewee related that he/she had viewed the patient on the monitor at about 9:00 a.m. and the patient was sitting on the bed. The secretary was unable to remember if he/she had observed the patient on the monitor after 9:00 a.m. The interviewee stated that the unit secretary duties required the secretary to leave the desk at times to go to the fax machine. During this time, the monitor was not in sight. Other staff covered for the secretary while at lunch but not when he/she left the desk momentarily. According to the secretary, the monitoring of psychiatric patients had not been a part of the secretary's responsibility until approximately a year ago. At that time the secretary had been told it was part of the duties. The secretary stated that he/she tried to do their best to monitor the patients, but other duties made it very difficult.

An interview at 3:00 p.m. on 12/21/2010 with the security guard (#7) revealed that on the day of the incident, the security guard had made rounds to the emergency department at approximately 7:00 a.m., 9:00 a.m., and around 10:00 a.m. The guard stated that he/she saw the patient at each of these times and the patient was in his/her room. The patient had related to the guard that he/she was tired. The guard indicated that the patient had not related anything to him that seemed out of the ordinary. The security guard became aware of the incident in the emergency department when an emergency code was called.

A review of facility policy number HW 1049, entitled "Patient Requiring Psychiatric Evaluation", last reviewed and revised 2/09, revealed that patients who presented to the emergency department and the primary complaint was mental health related, including suicidal or homicidal ideation, or depression, was to be triaged as an acuity level 2 which was emergent and were to have a harm-risk assessment completed by the nurse. The policy also addressed measures that the facility were to implement to keep the patient safe, however the responsibility and the frequency of monitoring was not addressed in the policy.

A review of facility policy number HW 220, entitled "Patient Assessment/Reassessment", last reviewed and revised 5/2010, revealed that patients presenting to the emergency department were assigned an acuity level based on their chief complaint. Triage levels ranged from level 1-level 5, level 1 being the most urgent and level 5 being non-urgent. Level 2 was designated as emergent and required hourly reassessment.

Further review of facility policies as well as a review of the job description for unit secretary revealed no documented evidence of the continuous monitoring having been a responsibility of the unit secretary. A review of the unit secretary's competency checklist lacked evidence of the unit secretary demonstrating knowledge or understanding of that specific job responsibility.

An interview at 12:00 p.m. on 12/21/2010 with the nursing director for the emergency department (#4) confirmed that the psychiatric patient, including those with suicidal ideation, were triaged as emergent and required hourly reassessment. The director also confirmed that the psychiatric patients were to be continuously monitored via camera monitor by the unit secretary. The nursing director stated that the emergency room physician does not write an order for any level of observation for the suicidal patient; the observation level was based on triage level. The practice was hourly assessment by the nurse and continuous monitoring by the unit secretary. The nursing director indicated that if a psychiatric patient became agitated or uncooperative, security may be called. If a psychiatric patient was in need of a bed and the three (3) designated rooms were full, another room was used and a sitter was utilized. According to the director, if a patient was receiving IV fluids or needed cardiac monitoring, a staff member was to remain with the patient when equipment was used. The nursing director indicated that the IV poles were attached to some of the beds and that the three (3) rooms used for psychiatric patients should not have beds that had IV poles.

On a tour of the emergency department at 12:10 p.m.- 12:40 p.m. on 12/21/2010, the three (3) designated rooms for psychiatric patients were identified and all had patients in the rooms. The beds in the rooms revealed no evidence of IV poles or equipment, however, another patient who was exhibiting psychiatric behavior and had been placed in another room had an IV pole on the bed. A sitter was assigned to monitor the patient but the sitter was observed sitting in an area that did not provide for full view of the patient. The unit secretary was observed from 12:15 p.m. until 12:30 p.m. and was involved in various task. Although the unit secretary remained at the desk involved in duties, the secretary failed to observe the monitoring screen of the three (3) psychiatric patients throughout the time period.

Based on review of the medical record, policies and procedures, facility tour, and staff interviews, it was determined that the facility failed to establish an effective system to ensure that the patient's condition was supervised and evaluated to provide for continuous safety for 1 of 1 (#1) patient whose record was reviewed.

Findings were:

A review of the medical record for patient #1 revealed that the patient presented to the emergency department with complaints of depression and suicidal thoughts. The mental health assessment revealed that the patient reported having marital and monetary problems and indicated that he/she had a plan to overdose or drive car in front of a train. The patient also expressed thoughts about hurting spouse. The mental health assessment indicated that the patient had experienced similar symptoms previously and had made previous attempts to hurt self. The patient was moved to an involuntary status with a determination that in-patient care was needed due to behavior that was life threatening and destructive to self or others. The patient also presented with diabetes and reported not having taken any medication for the condition in approximately one (1) month. The patient received, per physician order, medication for the diabetes along with intravenous (IV) fluids. Notes from the behavior assessment therapist indicated that the patient should not be allowed to return home due to lack of support and some related abuse issues. Several referrals were made to facilities for placement of the patient, but as of the third day of the patient having been in the emergency department, a placement had not been found. Nursing notes at the time of admission indicated that the patient was gowned in paper scrubs and suicide precautions maintained. Nursing notes throughout the three (3) days, revealed documentation regarding the patient's behavior but no mention after admission of suicide precautions being maintained. Progress notes were maintained on the patient but notes were not consistently documented every hour.

On the third day the progress note for the patient indicated that at 4:08 a.m. the patient was calm and sleeping and had no adverse reactions. At 6:04 a.m. the patient related no complaints and was resting quietly. At 8:11 a.m. the charge nurse (employee #1) documented that the patient reported no complaints and was calm. Patient reported no pain. The note indicated that the patient's status had improved and the patient stated he/she felt better. The patient was alert and oriented to time, place, and person. In addition the note indicated that there was no respiratory distress, skin warm and dry and color within normal limits and the patient's affect appeared normal. At 9:45 a.m. the note by the same nurse indicated that the patient reported no complaints and was calm. At 11:10 a.m., a note written by another nurse (employee #2), indicated that the nurse went to the room to check the patient and did not see the patient. The nurse called for the charge nurse and they found the patient hanging with a sheet. The physician was called, the patient was moved to the trauma room and cardiopulmonary resuscitation (CPR) was started. A physician progress note, written approximately an hour after the incident, noted that when the physician arrived, the patient was unresponsive and without a pulse. Abrasions were noted around the patient's neck. Emergency interventions were initiated but to no success. The patient's death was declared at 11:53 a.m.

An interview at 11:30 a.m. on 12/21/2010 with the day charge nurse in the emergency department (#1) revealed that on the day of the incident the department was staffed with five (5) nurses rather than the usual six (6) nurses plus the charge nurse. The charge nurse, due to the situation, assigned himself/herself three (3) patients. The three (3) patients, which included patient #1, were all in the emergency department with psychiatric issues and were waiting for placement outside the facility. The nurse reported that patient #1 had refused breakfast and had indicated that he/she wanted to go home. The nurse asked the security guard to talk with the patient, stating that the security guard related well to the patients and was helpful in calming them down. After having checked on the assigned patients, the charge nurse stated that he/she went to the desk and made attempts to find additional staffing. The interviewee indicated that it was approximately 9:30 a.m. when he/she started that task. The charge nurse confirmed that there was a unit secretary at the desk who was to be monitoring the three (3) patients via camera. At 11:00 a.m. additional nurses were scheduled and another nurse was assigned to the three (3) psychiatric patients. A short time later the charge nurse reported that the other nurse (#2) was unable to locate the patient. The charge nurse went to assist the nurse and they found the patient sitting on the floor at the side and behind the bed with the sheet wrapped around his/her neck and tied to the IV pole that was attached to the bed. They attempted to arouse the patient and untie the sheet. An emergency code was called, the patient was moved to the trauma room and resuscitative measures were attempted. The nurse related that psychiatric patients were generally placed in the three (3) rooms that were equipped with camera monitors that were monitored continuously at the desk by the unit secretary. If the three (3) rooms were occupied and a psychiatric patient was placed in another room, a sitter was utilized to help monitor patient's behavior/condition. When questioned about the frequency of patient monitoring by the nurse, the interviewee indicated that assessment of the patient was to be done hourly. The charge nurse did not think that there were policies related specifically to the monitoring of psychiatric patients. Instead, he/she related that the practice was for psychiatric patients to be continuously monitored by the unit secretary and hourly checks by the nurse. The interviewee stated that observation orders were not ordered by the emergency physicians. The nurse also stated that equipment was not generally in the psychiatric patient's room. If equipment, such as IV pole, was used, the patient was to be monitored and the equipment removed after completion of treatment.

An interview at 12:30 p.m. on 12/21/2010 with the emergency room (ER) nurse (#2) who was assigned the care of the patient at 11:00 a.m. by the charge nurse revealed that, after having received report on the patient, ER nurse #2 went to check on the patient. The nurse related that it was about 11:10 a.m. The nurse indicated that he/she was unable to locate the patient and, after checking in the bathroom, notified the charge nurse. Both nurses went back to the patient's room and then found the patient sitting on the floor with a sheet tied around the patient's neck. The nurse stated that emergency measures were then taken in response to the patient's condition. The nurse related also that the psychiatric patients were placed in the three (3) rooms that were to be continuously monitored by the unit secretary via camera. According to the nurse, measures to keep psychiatric patients safe were in place. The psychiatric patients were placed in paper gowns, wanded by security, and were not allowed personal belongings. The nurse reported that he/she had not used equipment with the psychiatric patient but believed that if equipment was needed (IV poles, cardiac monitoring etc.), the patient was moved to another room and monitored by the nurse while the equipment was used. The nurse was unsure if IV poles were on each bed.

An interview at 12:52 p.m. on 12/21/2010 with the unit secretary (#3) who was in the emergency department on the day of the incident revealed that he/she was aware that there were three (3) psychiatric patients who were awaiting placement. The secretary confirmed that there were cameras in the three (3) rooms and that the monitor was at the desk and to be monitored by the unit secretary. The secretary related that he/she had been busy with physician orders, call lights, telephone calls, etc. At approximately 11:00 a.m., another person took over the secretary duties and the interviewee was preparing to take on patient care responsibilities. It was shortly after that time, that the interviewee became aware of the incident with the patient. The interviewee related that he/she had viewed the patient on the monitor at about 9:00 a.m. and the patient was sitting on the bed. The secretary was unable to remember if he/she had observed the patient on the monitor after 9:00 a.m. The interviewee stated that the unit secretary duties required the secretary to leave the desk at times to go to the fax machine. During this time, the monitor was not in sight. Other staff covered for the secretary while at lunch but not when he/she left the desk momentarily. According to the secretary, the monitoring of psychiatric patients had not been a part of the secretary's responsibility until approximately a year ago. At that time the secretary had been told it was part of the duties. The secretary stated that he/she tried to do their best to monitor the patients, but other duties made it very difficult.

An interview at 3:00 p.m. on 12/21/2010 with the security guard (#7) revealed that on the day of the incident, the security guard had made rounds to the emergency department at approximately 7:00 a.m., 9:00 a.m., and around 10:00 a.m. The guard stated that he/she saw the patient at each of these times and the patient was in his/her room. The patient had related to the guard that he/she was tired. The guard indicated that the patient had not related anything to him that seemed out of the ordinary. The security guard became aware of the incident in the emergency department when an emergency code was called.

A review of facility policy number HW 1049, entitled "Patient Requiring Psychiatric Evaluation", last reviewed and revised 2/09, revealed that patients who presented to the emergency department and the primary complaint was mental health related, including suicidal or homicidal ideation, or depression, was to be triaged as an acuity level 2 which was emergent and were to have a harm-risk assessment completed by the nurse. The policy also addressed measures that the facility were to implement to keep the patient safe, however the responsibility and the frequency of monitoring was not addressed in the policy.

A review of facility policy number HW 220, entitled "Patient Assessment/Reassessment", last reviewed and revised 5/2010, revealed that patients presenting to the emergency department were assigned an acuity level based on their chief complaint. Triage levels ranged from level 1-level 5, level 1 being the most urgent and level 5 being non-urgent. Level 2 was designated as emergent and required hourly reassessment.

Further review of facility policies as well as a review of the job description for unit secretary revealed no documented evidence of the continuous monitoring having been a responsibility of the unit secretary. A review of the unit secretary's competency checklist lacked evidence of the unit secretary demonstrating knowledge or understanding of that specific job responsibility.

An interview at 12:00 p.m. on 12/21/2010 with the nursing director for the emergency department (#4) confirmed that the psychiatric patient, including those with suicidal ideation, were triaged as emergent and required hourly reassessment. The director also confirmed that the psychiatric patients were to be continuously monitored via camera monitor by the unit secretary. The nursing director stated that the emergency room physician does not write an order for any level of observation for the suicidal patient; the observation level was based on triage level. The practice was hourly assessment by the nurse and continuous monitoring by the unit secretary. The nursing director indicated that if a psychiatric patient became agitated or uncooperative, security may be called. If a psychiatric patient was in need of a bed and the three (3) designated rooms were full, another room was used and a sitter was utilized. According to the director, if a patient was receiving IV fluids or needed cardiac monitoring, a staff member was to remain with the patient when equipment was used. The nursing director indicated that the IV poles were attached to some of the beds and that the three (3) rooms used for psychiatric patients should not have beds that had IV poles.

On a tour of the emergency department at 12:10 p.m.- 12:40 p.m. on 12/21/2010, the three (3) designated rooms for psychiatric patients were identified and all had patients in the rooms. The beds in the rooms revealed no evidence of IV poles or equipment, however, another patient who was exhibiting psychiatric behavior and had been placed in another room had an IV pole on the bed. A sitter was assigned to monitor the patient but the sitter was observed sitting in an area that did not provide for full view of the patient. The unit secretary was observed from 12:15 p.m. until 12:30 p.m. and was involved in various task. Although the unit secretary remained at the desk involved in duties, the secretary failed to observe the monitoring screen of the three (3) psychiatric patients throughout the time period.

Based on review of the medical record, policies and procedures, facility tour, and staff interviews, it was determined that the facility failed to establish an effective system to ensure that the emergency needs of psychiatric patients were met and that the patients were monitored for continuous safety in accordance with acceptable standards of practice for 1 of 1 (#1) patient whose record was reviewed.

Findings were:

A review of the medical record for patient #1 revealed that the patient presented to the emergency department with complaints of depression and suicidal thoughts. The mental health assessment revealed that the patient reported having marital and monetary problems and indicated that he/she had a plan to overdose or drive car in front of a train. The patient also expressed thoughts about hurting spouse. The mental health assessment indicated that the patient had experienced similar symptoms previously and had made previous attempts to hurt self. The patient was moved to an involuntary status with a determination that in-patient care was needed due to behavior that was life threatening and destructive to self or others. The patient also presented with diabetes and reported not having taken any medication for the condition in approximately one (1) month. The patient received, per physician order, medication for the diabetes along with intravenous (IV) fluids. Notes from the behavior assessment therapist indicated that the patient should not be allowed to return home due to lack of support and some related abuse issues. Several referrals were made to facilities for placement of the patient, but as of the third day of the patient having been in the emergency department, a placement had not been found. Nursing notes at the time of admission indicated that the patient was gowned in paper scrubs and suicide precautions maintained. Nursing notes throughout the three (3) days, revealed documentation regarding the patient's behavior but no mention after admission of suicide precautions being maintained. Progress notes were maintained on the patient but notes were not consistently documented every hour.

On the third day the progress note for the patient indicated that at 4:08 a.m. the patient was calm and sleeping and had no adverse reactions. At 6:04 a.m. the patient related no complaints and was resting quietly. At 8:11 a.m. the charge nurse (employee #1) documented that the patient reported no complaints and was calm. Patient reported no pain. The note indicated that the patient's status had improved and the patient stated he/she felt better. The patient was alert and oriented to time, place, and person. In addition the note indicated that there was no respiratory distress, skin warm and dry and color within normal limits and the patient's affect appeared normal. At 9:45 a.m. the note by the same nurse indicated that the patient reported no complaints and was calm. At 11:10 a.m., a note written by another nurse (employee #2), indicated that the nurse went to the room to check the patient and did not see the patient. The nurse called for the charge nurse and they found the patient hanging with a sheet. The physician was called, the patient was moved to the trauma room and cardiopulmonary resuscitation (CPR) was started. A physician progress note, written approximately an hour after the incident, noted that when the physician arrived, the patient was unresponsive and without a pulse. Abrasions were noted around the patient's neck. Emergency interventions were initiated but to no success. The patient's death was declared at 11:53 a.m.

An interview at 11:30 a.m. on 12/21/2010 with the day charge nurse in the emergency department (#1) revealed that on the day of the incident the department was staffed with five (5) nurses rather than the usual six (6) nurses plus the charge nurse. The charge nurse, due to the situation, assigned himself/herself three (3) patients. The three (3) patients, which included patient #1, were all in the emergency department with psychiatric issues and were waiting for placement outside the facility. The nurse reported that patient #1 had refused breakfast and had indicated that he/she wanted to go home. The nurse asked the security guard to talk with the patient, stating that the security guard related well to the patients and was helpful in calming them down. After having checked on the assigned patients, the charge nurse stated that he/she went to the desk and made attempts to find additional staffing. The interviewee indicated that it was approximately 9:30 a.m. when he/she started that task. The charge nurse confirmed that there was a unit secretary at the desk who was to be monitoring the three (3) patients via camera. At 11:00 a.m. additional nurses were scheduled and another nurse was assigned to the three (3) psychiatric patients. A short time later the charge nurse reported that the other nurse (#2) was unable to locate the patient. The charge nurse went to assist the nurse and they found the patient sitting on the floor at the side and behind the bed with the sheet wrapped around his/her neck and tied to the IV pole that was attached to the bed. They attempted to arouse the patient and untie the sheet. An emergency code was called, the patient was moved to the trauma room and resuscitative measures were attempted. The nurse related that psychiatric patients were generally placed in the three (3) rooms that were equipped with camera monitors that were monitored continuously at the desk by the unit secretary. If the three (3) rooms were occupied and a psychiatric patient was placed in another room, a sitter was utilized to help monitor patient's behavior/condition. When questioned about the frequency of patient monitoring by the nurse, the interviewee indicated that assessment of the patient was to be done hourly. The charge nurse did not think that there were policies related specifically to the monitoring of psychiatric patients. Instead, he/she related that the practice was for psychiatric patients to be continuously monitored by the unit secretary and hourly checks by the nurse. The interviewee stated that observation orders were not ordered by the emergency physicians. The nurse also stated that equipment was not generally in the psychiatric patient's room. If equipment, such as IV pole, was used, the patient was to be monitored and the equipment removed after completion of treatment.

An interview at 12:30 p.m. on 12/21/2010 with the emergency room (ER) nurse (#2) who was assigned the care of the patient at 11:00 a.m. by the charge nurse revealed that, after having received report on the patient, ER nurse #2 went to check on the patient. The nurse related that it was about 11:10 a.m. The nurse indicated that he/she was unable to locate the patient and, after checking in the bathroom, notified the charge nurse. Both nurses went back to the patient's room and then found the patient sitting on the floor with a sheet tied around the patient's neck. The nurse stated that emergency measures were then taken in response to the patient's condition. The nurse related also that the psychiatric patients were placed in the three (3) rooms that were to be continuously monitored by the unit secretary via camera. According to the nurse, measures to keep psychiatric patients safe were in place. The psychiatric patients were placed in paper gowns, wanded by security, and were not allowed personal belongings. The nurse reported that he/she had not used equipment with the psychiatric patient but believed that if equipment was needed (IV poles, cardiac monitoring etc.), the patient was moved to another room and monitored by the nurse while the equipment was used. The nurse was unsure if IV poles were on each bed.

An interview at 12:52 p.m. on 12/21/2010 with the unit secretary (#3) who was in the emergency department on the day of the incident revealed that he/she was aware that there were three (3) psychiatric patients who were awaiting placement. The secretary confirmed that there were cameras in the three (3) rooms and that the monitor was at the desk and to be monitored by the unit secretary. The secretary related that he/she had been busy with physician orders, call lights, telephone calls, etc. At approximately 11:00 a.m., another person took over the secretary duties and the interviewee was preparing to take on patient care responsibilities. It was shortly after that time, that the interviewee became aware of the incident with the patient. The interviewee related that he/she had viewed the patient on the monitor at about 9:00 a.m. and the patient was sitting on the bed. The secretary was unable to remember if he/she had observed the patient on the monitor after 9:00 a.m. The interviewee stated that the unit secretary duties required the secretary to leave the desk at times to go to the fax machine. During this time, the monitor was not in sight. Other staff covered for the secretary while at lunch but not when he/she left the desk momentarily. According to the secretary, the monitoring of psychiatric patients had not been a part of the secretary's responsibility until approximately a year ago. At that time the secretary had been told it was part of the duties. The secretary stated that he/she tried to do their best to monitor the patients, but other duties made it very difficult.

An interview at 3:00 p.m. on 12/21/2010 with the security guard (#7) revealed that on the day of the incident, the security guard had made rounds to the emergency department at approximately 7:00 a.m., 9:00 a.m., and around 10:00 a.m. The guard stated that he/she saw the patient at each of these times and the patient was in his/her room. The patient had related to the guard that he/she was tired. The guard indicated that the patient had not related anything to him that seemed out of the ordinary. The security guard became aware of the incident in the emergency department when an emergency code was called.

A review of facility policy number HW 1049, entitled "Patient Requiring Psychiatric Evaluation", last reviewed and revised 2/09, revealed that patients who presented to the emergency department and the primary complaint was mental health related, including suicidal or homicidal ideation, or depression, was to be triaged as an acuity level 2 which was emergent and were to have a harm-risk assessment completed by the nurse. The policy also addressed measures that the facility were to implement to keep the patient safe, however the responsibility and the frequency of monitoring was not addressed in the policy.

A review of facility policy number HW 220, entitled "Patient Assessment/Reassessment", last reviewed and revised 5/2010, revealed that patients presenting to the emergency department were assigned an acuity level based on their chief complaint. Triage levels ranged from level 1-level 5, level 1 being the most urgent and level 5 being non-urgent. Level 2 was designated as emergent and required hourly reassessment.

Further review of facility policies as well as a review of the job description for unit secretary revealed no documented evidence of the continuous monitoring having been a responsibility of the unit secretary. A review of the unit secretary's competency checklist lacked evidence of the unit secretary demonstrating knowledge or understanding of that specific job responsibility.

An interview at 12:00 p.m. on 12/21/2010 with the nursing director for the emergency department (#4) confirmed that the psychiatric patient, including those with suicidal ideation, were triaged as emergent and required hourly reassessment. The director also confirmed that the psychiatric patients were to be continuously monitored via camera monitor by the unit secretary. The nursing director stated that the emergency room physician does not write an order for any level of observation for the suicidal patient; the observation level was based on triage level. The practice was hourly assessment by the nurse and continuous monitoring by the unit secretary. The nursing director indicated that if a psychiatric patient became agitated or uncooperative, security may be called. If a psychiatric patient was in need of a bed and the three (3) designated rooms were full, another room was used and a sitter was utilized. According to the director, if a patient was receiving IV fluids or needed cardiac monitoring, a staff member was to remain with the patient when equipment was used. The nursing director indicated that the IV poles were attached to some of the beds and that the three (3) rooms used for psychiatric patients should not have beds that had IV poles.

On a tour of the emergency department at 12:10 p.m.- 12:40 p.m. on 12/21/2010, the three (3) designated rooms for psychiatric patients were identified and all had patients in the rooms. The beds in the rooms revealed no evidence of IV poles or equipment, however, another patient who was exhibiting psychiatric behavior and had been placed in another room had an IV pole on the bed. A sitter was assigned to monitor the patient but the sitter was observed sitting in an area that did not provide for full view of the patient. The unit secretary was observed from 12:15 p.m. until 12:30 p.m. and was involved in various task. Although the unit secretary remained at the desk involved in duties, the secretary failed to observe the monitoring screen of the three (3) psychiatric patients throughout the time period.

Immediate corrective actions submitted by the facility at the time of the survey:

1. Each behavioral health patient in the emergency department has been assigned an individual sitter- one patient to one sitter.
2. Director of Plant Operations has contacted the vendor to move the camera monitor to the other side of the nurse's station. Facility is in the process of purchasing new monitor system, including audio.
3. The unit secretary will no longer be assigned the responsibility for monitoring the patients via the monitor screen. A monitor tech will be assigned monitoring responsibilities. Once the monitor techs are in place, a sitter will not need to be assigned to the patients in the three (3) rooms with cameras, unless the patient is uncooperative, violent, etc. Sitters will continue to be assigned to any patient in the emergency department that is in another room where a camera is not present.
4. Emergency Director provided staff education on 12/20/2010 and this will be ongoing. Added education instructions that IV poles cannot be in rooms where behavioral patients are placed and that all behavioral patients must be monitored at all times.
5. Signage posted in behavioral health rooms that no IV poles are to be in the room. If IV fluids or medications are needed, the nurse will monitor the patient until the procedure is completed and remove the equipment.
6. Policy review in process and includes: how to request sitters, monitor training and competency, equipment, and monitoring of patients. A competency form has been drafted for the monitor techs.
7. Policy changes include physician order for type of monitoring and a minimum of 15 minute monitoring by a staff member.