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Based on interview, clinical record review and hospital policy review, the hospital failed to ensure stabilizing treatment, and safety and security relevant to a psychiatric emergency medical condition (EMC) for 1 out of 28 sampled patients when: a patient (Patient 1) presented to the Emergency Department (ED) with suicidal ideation (thinking about or planning suicide) and self-inflicted wounds. The patient was placed on a 5150 hold (a psychiatric hold - where the patient cannot be safely released from the hospital as a result of being a danger to themselves, or a danger to others, or gravely disabled) for danger to self, and was able to continue acts of self-harm by cutting herself with a razor while lying on an ED gurney.

This failure resulted in injury to Patient 1 and had the potential to cause additional serious harm and death to the patient.

Findings:

A review of Patient 1's clinical record revealed the following documents:

An ED Triage note, dated 12/4/20 at 3:00 p.m., indicated the patient was brought to the ED from home by ambulance for suicidal ideation. The note indicated the patient's acuity on arrival was a level "2-Emergent" (a rating system used to identify severity of illness where level 1 is the most ill and level 5 is the least ill). The note further indicated the patient had evidence of a self-inflicted wound to the left wrist and had not been taking her psychiatric medications for the past two weeks.

An ED Physician Note, dated 12/4/20 at 3:12 p.m., indicated the patient had a history of anxiety, depression, and prior suicide attempts and presented to the ED for feeling suicidal for the past week. The note further indicated the patient had been applying toilet bowl cleaner to her left arm, which had caused a wound, in an attempt to harm herself. The note indicated Patient 1 had a plan to overdose on alcohol and drugs.

A Columbia Suicide Severity Rating Scale (C-SSRS - an evidence-based screening tool where a list of questions is used to assess the severity and immediacy of a person's risk of suicide), dated 12/4/20 at 4:17 p.m., indicated, in the past 30 days the patient had started to work out details of how to kill herself and intended to carry out the plan. Additionally, the patient suicide severity rating was documented as "High" and listed prevention interventions as: "Direct Observation [where a competent staff member is assigned to directly observe the patient], Secure Environment [A safe environment where potentially harmful objects are removed], and Safety Attendant ..."

A Suicide Risk Safety Attendant Observation Form, dated 12/4/20, had hourly documentation beginning at 3:00 p.m. and ending at 11:00 p.m. The hourly documentation contained a safety attendant's initials for each hour Patient 1 was on "Continuous Visual Observation," defined as "The patient is within line of sight of a staff member at all times. At times, more than one patient may be under continuous observation of a single staff member ...During times when the patient is using the toilet or is showering, the patient may be outside of line of sight ..." The form contained the option for "Continuous 1:1 Observation," defined as "The patient is within line of sight of a staff member at all times. A staff member is assigned to observe only one patient at all times including while the patient uses the toilet or showers." The continuous 1:1 hourly documentation area was left blank.

An Application for up to 72-Hour assessment, evaluation, and crisis intervention or placement for evaluation and treatment (5150 hold), initiated 12/4/20 at 6:00 p.m., indicated Patient 1 was a danger to self.

The Suicide Risk Safety Attendant Observation form indicated on 12/4/20 at 9:00 p.m., Patient 1 used the restroom. The same form indicated at 10:00 p.m., "Saw patients [sic] arm was bleeding and called the nurse."

An additional ED Physician Note, dated 12/4/20 at 10:39 p.m., indicated the physician was notified at 10:30 p.m. that the patient, "had resumed cutting both of her forearms using a utility blade which she had brought with her. Patient's possessions had been taken from her ...but she states 'it was in my hand.'" The note further indicated the patient was taken to the restroom with a patient safety chaperone and the patient had two utility knives, a box of razor blades, and a zip lock bag with two medication tablets hidden in her sanitary napkin.

The Suicide Risk Safety Attendant Observation form indicated on 12/4/20 at 11:15 p.m., "Patient took out her nose ring and tried to poke her (L) [left] eyes. Took the ring from her."

An interview was conducted with Licensed Nurse (LN) 1 on 3/29/23 at 1:31 p.m. LN 1 indicated he recalled Patient 1 had been placed in a hospital gown and was under observation by a safety attendant but could not recall if the attendant was watching more than one patient at a time. LN 1 stated he recalled being alerted to the patient's room when the safety attendant called out that there was blood on the blanket covering the patient. LN 1 further stated, when he pulled back the blanket, the patient was holding a razor and had cut her arms, and he recalled the physician was notified and the cuts had to be sutured by the doctor. LN 1 stated the patient was then taken to the bathroom with two female staff members to remove her undergarments, where additional razors were found.

An interview was conducted with Safety Attendant (SA) on 4/12/23 at 1:02 p.m. The SA confirmed she had been assigned to observe Patient 1 upon her arrival to the ED. The SA stated her role in the ED was to keep patients safe by watching them and then notifying the nurse if their behavior changes. SA indicated she recalled when the incident happened with Patient 1, she was assigned to observe two patients at one time in the ED. SA indicated she did not recall if all of Patient 1's clothing was removed when placed in a hospital gown but did remember alerting the nurse when she saw blood on the sheet that covered the patient.

An interview was conducted with the Director of the Emergency Department (DED) on 6/6/23 at 10:10 a.m. The DED indicated patients will receive a C-SSRS assessment upon arrival and based on the patient's risk a safety attendant will be assigned to observe the patient. The DED indicated a C-SSRS identified as a "high" risk patient will be assigned a 1:1 safety attendant observation according to facility policy.

An interview with LN 2 on 6/6/23 at 10:40 a.m., was conducted. LN 2 indicated when a patient arrives to the ED with suicidal ideation, they are considered emergent and brought to a behavioral health cohort area. LN 2 further stated the patient is changed into a purple gown to help identify them as a safety risk and all undergarments are removed to make sure they do not have anything in their possession that could be used to harm themselves or someone else. LN 2 further indicated the patient's jewelry is also removed, such as nose rings, to remove the patient's access to sharp objects and the patient would remain on 1:1 observation.

A concurrent interview and patient record review was conducted with DED on 6/6/23 at 2:24 p.m. The DED confirmed the patient was a high risk of suicide and harm to self upon arrival to the ED based on review of the triage and physician admission notes. DED indicated based on Patient 1's high risk suicide assessment, interventions to keep Patient 1 safe such as placement on 1:1 observation, all jewelry removed, and undergarments checked should have been implemented. DED was unable to find documented evidence in the record the interventions were implemented to prevent the patient from further self-harm, according to facility policy.

A review of facility policy titled "Safety Attendant: For Patients at Risk for Harm to Self or Others 100.8.018," effective date 7/18/18, indicated "2. When a screening indicates an imminent risk of harm to self or others, the nurse shall: a. Complete a full body skin assessment, including placing the patient in a hospital gown (preferably without strings), removing undergarments to ensure that no items are hidden. b. Secure all personal belongings including bags and purses. No belongings will be kept at the bedside (e.g., clothing/belt, cell phone, purse, jewelry, shoes with shoestrings, etc.)."

Review of the same policy indicated, "Patients assessed as an imminent risk of harm to self or others, due to a suicide attempt with a continued active suicide plan with ideations and intent to succeed, and/or uncontrolled violent behavior placing others at risk of imminent harm, will be placed on one-to-one observation with a dedicated Safety Attendant until the patient or others are no longer at imminent risk."

A review of facility policy titled "Emergency Medical Care/ Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy," effective date 9/25/18, indicated "Except where otherwise permitted by law, Emergency Medical Screening and stabilizing treatment will be provided to all individuals presenting at [Name of Health Organization] Dedicated Emergency Departments (DED) requesting examination and treatment of a medical condition, and to individuals presenting on hospital property (including parking lots, sidewalks and driveways on all Dignity Health campuses) within 250 yards of the hospital requesting examination or treatment of an Emergency Medical Condition, and if one exists, either to stabilize the emergency condition or to Transfer the individual appropriately and in conformity with the legal and regulatory requirements, without regard to their age, race, color, creed, national origin, immigration status, insurance, disability, handicap, diagnosis, sexual orientation or ability to pay."

The same policy further indicated "'Emergency Medical Condition' means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably result in: 1. Placing the health of the individual ...in serious jeopardy; a. Serious impairment to bodily functions; or b. Serious dysfunction of any bodily organ or part..."

A review of facility policy titled "Triage Procedure, Initial Assessment, Reassessment and Documentation Guidelines," approval date 1/24/19, indicated "Patients who are suicidal, homicidal, psychotic, violent, or are an elopement risk should be considered ESI Level 2 due to their high-risk presentation. The Charge RN and security will be notified to expedite appropriate placement and for the patient to remain under observation." The policy defined "ESI Level 2: High risk condition that could easily deteriorate or present with symptoms suggestive of a condition requiring time-sensitive treatment. This is a patient who has a potential threat to life, limb or organ."

A review of facility policy titled "Identifying and Assessing Patients at Risk of Suicide/Self-harm," effective date 12/12/19, indicated "It is the policy of [organization name] to provide a safe environment for patients." The policy further directed "Patients screened/assessed and found to be at HIGH risk will be monitored under direct one-to-one (1:1) observation according to policy (See Safety Attendant Policy #100.8.018) by a qualified observer (safety attendant) (a staff member trained to attend to patients at risk for suicide). i. The safety attendant is assigned to observe only one patient at all times. This allows the safety attendant to immediately intervene should the patient attempt harm."