HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interviews it was determined the facility failed to ensure a patient with documented suicidal ideations was provided a suicide sitter for one of one applicable medical record reviewed (MR1).

Findings include:

Review on August 2, 2019, of facility pamphlet, "Patient Rights and responsibilities," revised September 2018, revealed "...Patient rights ...41. A patient has the right to receive care in a safe setting. ..."

Review on August 2, 2019, of facility policy, "Safety Sitter Program," revised/reviewed October 23, 2018, revealed "Purpose: The purpose of the Safety Sitter Protocol is to provide a safe environment for adult patients during a time period of confusion and/or unsafe patient behavior. ...Definitions: Suicide sitter-NA or other hospital personnel as identified, that are required to monitor those patients with suicidal tendencies or those admitted from other facilities requiring constant observation. Suicide sitters require a physician's order. ..."

Review on August 2, 2019, of MR1 revealed progress note from OTH1 dated July 25, 2019, at 10:41 AM with plan of psych consult ordered after discussion with patient today who reported increased feelings of depressed mood and loneliness. Progress note dated July 25, 2019, at 11:06 AM from OTH2 revealed patient admitted having suicidal thoughts related to her medical condition and chronic pain. Patient would require a sitter for safety at this time. Mood was anxious and depressed. Thought Content was suicidal ideation. Recommendation from OTH2 was sitter 1:1 given active SI. No documentation 1:1 sitter was ordered by OTH2.

Continued review of MR1 on August 2, 2019, revealed a nursing progress note dated July 25, 2019 at 12:58 PM that stated at 12:45 PM the nurse entered MR1's room and noticed MR1 had the call bell wire held very tightly across her neck. The nurse placed a sitter with the patient and notified OTH2 and OTH3.

Continued review of MR1 on August 2, 2019 revealed an order for sitter at bedside on July 25, 2019, at 13:08 PM from OTH3.

Review on August 5, 2019, of CF1 revealed core privileges included writing orders and standing orders.

Interview with EMP1 on August 2, 2019, at approximately 10:45 AM confirmed OTH1 assessed MR1 on July 25, 2019, at 10:41 AM and ordered a psych consult after discussion with patient who reported increased feelings of depressed mood and loneliness. EMP1 confirmed a progress noted dated July 25, 2019, at 11:06 AM from OTH2 that revealed patient admitted having suicidal thoughts related to her medical condition and chronic pain; patient would require safety sitter at that time; mood was anxious and depressed; thought content was suicidal ideation. EMP1 confirmed recommendation was sitter 1:1 given active SI. EMP1 confirmed no 1:1 sitter was ordered by OTH2. EMP1 confirmed nursing progress note dated July 25, 2019, at 12:58 PM that stated 12: 45 PM the nurse entered MR1's room and noticed MR1 had the call bell wire held very tightly across her neck. EMP1 confirmed the nurse placed a sitter at that time with the patient and notified OTH2 and OTH3. EMP1 confirmed OTH3 placed the order for sitter at bedside on July 25, 2019, at 13:08 PM.

Interview with OTH2 on August 2, 2019, at approximately 2:55 PM confirmed she evaluated MR1 on July 25, 2019, at 11:06 AM. OTH2 confirmed no order was placed for a 1:1 sitter. OTH2 confirmed she had privileges to write orders.