HospitalInspections.org

Based on observation, interview and record review, the facility failed to meet the Conditions of Participation for Patient Rights when:

1. Following a suicide attempt at home, Patient 1 was brought to the facility's Emergency Room by law enforcement officers for a 5150 hold (a 72-hour protective hold for evaluation and treatment of people in danger of harming themselves or others). Patient 1's 5150 status was not communicated to all members of the care team. (Refer to A-0144.)

2. In accordance with national standards, the facility did not use a validated or evidence-based suicide risk assessment tool to detect the severity of Patient 1's risk for suicide. (Refer to A-0144.)

3. Nursing staff did not implement suicide-risk safety interventions per facility Policies and Procedures (P&Ps):
a. Patient 1's belongings were not searched for contraband or items that could cause harm, and Patient 1 used a belt in his possession as a ligature (an item to tie or bind tightly) to attempt suicide by hanging.
b. Patient 1 was allowed to wear his jeans (a potential hiding place) under his gown.
c. House Supervisor (HS) A initially assigned Patient 1 to a room on the second floor (a jumping hazard) away from the nurses' station (limiting monitoring and supervision capabilities of the nursing staff).
d. A patient sitter was not requested for direct observation of Patient 1, which had the potential to reduce Patient 1's risk of self-harm. (Refer to A-0144.)

4. Patient 1 was able to lock the door to his bathroom, where he attempted suicide. A master key was not readily available for the bathroom door, which delayed the entry of nursing staff and delayed resuscitative efforts and thereby transferred to the Intensive Care Unit for evaluation and monitoring. (Refer to A-0144.)

The cumulative effect of these systemic problems had the potential to cause serious injury or death to Patient 1 and had the potential to compromise the safety, quality of care, and lives of all patients at risk for suicide.

Based on observation, interview and record review, the licensed nursing staff failed to implement suicide-risk safety interventions per facility Policies and Procedures (P&Ps): a high-risk-suicide patient (Patient 1).

These deficient practices resulted in Patient 1 to be found with bluish-purple skin, bulging eyes, not responding to questions, hanging from a weightbearing shower fixture. Licensed nursing staff called a Code 99 (a medical emergency code). Patient 1 "woke up," was able to walk, and was transferred to a high-visibility bed in the Intensive Care Unit (ICU) with a one-to-one sitter in "guarded" condition (serious with an uncertain outcome).

Findings:

A review of P&P titled, "Suicide Precautions" by Nursing Services, dated 8/2023, indicated its purpose was to outline procedures to put in place when a patient's suicide precaution assessment determines further interventions are necessary. The P&P indicated, "Suicide risk increases in patients who have made prior attempts." Common modes of suicide include hanging, overdose, and jumping. The P&P indicated patients are assessed on admission for suicide risk, with suicide precautions to include:
A. A room near the nurses' station, preferably on the First Floor.
B. The door and curtain of the room open.
C. Complete hourly rounding or more often as needed.
D. Belongings (including clothing and property) will be carefully inspected for contraband and/or denied articles that could potentially be used to harm. Removed items will be placed in a secured area.
E. A patient sitter may be implemented with approval from the Nurse Manager and/or physician's order.

A review of facility Policy and Procedure (P&P) titled, "Psychiatric Patient Care" by Emergency Services, dated 7/2024, indicated its purpose was to establish a standard of care for psychiatric and behavioral health patients.
Procedure:
A. Patients presenting with psychiatric complaints will be interviewed by the Registered Nurse (RN) to determine patient's need for safety.
B. Patient will be asked to undress and placed into a gown. Belongings will be searched and kept outside the room at the discretion of the primary nurse.
C. A Social Services consult will be placed, or Mobile Crisis staff (outside emergency mental health services) notified of patients needing a mental health evaluation.
D. The Emergency Services Department physician will evaluate patient and determine if crisis intervention is needed. If the patient is found to be a danger to self or others, law enforcement and/or Social Services will be contacted to evaluate the patient for a 72-hour hold (5150).

A review of record titled, "Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment" (5150), dated 8/6/24, indicated Patient 1 was taken into custody by law enforcement officers on 8/6/24 at 9:34 am, at his home. Patient 1 admitted to officers he consumed a poisonous substance "because he wanted to die." Patient 1 was a "danger to self" because of a mental health disorder. Patient 1 was transported to the facility by ambulance for a 5150 hold.

A review of record titled, "Emergency Room (ER) Nurse Note" by Registered Nurse (RN) A dated 8/6/24 at 10:29 am, indicated Patient 1 arrived by ambulance as a Triage Level 2 (emergency, potentially life-threatening) with a chief complaint of ingestion of oleander and sulfur (poisonous life threatening) substances. The record indicated Patient 1 was considered a 5150.

A review of record titled, "Emergency Room (ER) Nurse Note" by RN A, dated 8/6/24 at 10:29 am, indicated Patient 1 answered "NO" to Suicide Risk Assessment questions: (1) "Having suicidal thoughts" and (2) "Any items or objects that could be used to harm yourself or others." There was no validated or evidence-based suicide risk assessment tools available for staff to use for Patient 1.

During a concurrent interview and record review on 8/8/24 at 11:40 am, with Chief Nursing Officer (CNO), stated the internal document indicated Patient 1 was being admitted for "MHE/OD" - a mental health evaluation for overdose. CNO stated there was a "misstep" in communication as the intake form did not indicate Patient 1's 5150 hold. CNO stated she was in the process of amending the facility's form, noting, "Suicidal ideation needs to be added." CNO stated the facility does not have a suicide risk checklist, but that they have identified an "appropriate" one for nursing staff. CNO stated it will be implemented after being approved in committee.

During an interview with RN J on 8/8/24 at 12:32 pm, RN J stated he had seen patients in conjunction with the facility psychiatrist, Doctor (DOC) A. RN J stated it was his opinion that Patient 1 was not being honest when he stated he was not suicidal in the ER, and he would like to see the facility implement a suicide risk checklist.

During an interview with Director of Medical-Surgical Department (RN F) on 8/8/24 at 4:15 pm, RN F stated the facility should implement a safety checklist.

A review of All Facilities Letter "AFL 23-2," a letter from California Department of Public Health dated 1/18/23, indicated the letter served to notify all general acute care hospitals about California Assembly Bill (AB) 1394 (Chapter 101, Statutes of 2022). AB 1394 will require hospitals to have written P&Ps by 1/1/25 that establish screening for risk of suicidal ideation and behavior in patients 12 and older. The letter indicated the intent of AB 1394 was to have hospitals adopt validated or evidence-based suicide risk assessment tools as recommended by the Joint Commission.

A review of a Social Service Referral note dated 8/6/24 at 1:37 pm, indicated Patient 1 was a 5150 overdose. The note indicated Patient 1 intentionally ingested oleander and sulfur to end his life. Family member indicated Patient 1 had suffered from depression and suicidal ideation. The plan was to admit Patient 1 for further monitoring and medical intervention. Social Services will follow Patient 1 in conjunction with psychiatry to treat.

During an interview with RN C on 8/8/24 at 2:20 pm, RN C stated RN A called to give her report on Patient 1. RN C stated she was not told that Patient 1 was 5150, only that he was wearing a telemetry monitor (a portable device that allows healthcare professionals to continuously monitor a patient's heart activity) and had had [suicidal] "tendencies" before. RN C stated she did not learn of Patient 1's 5150 status until he had arrived to the floor and reviewed his medical chart.

A review of the facility's nursing staff training module titled, "SafetyQ: Patient or Resident Safety Basics, Patient-Facing," dated 2024, indicated checking risk of harm to themselves or others is important for suicidal patients. Look for items patients may use to cause harm. Protect people when they have thoughts of suicide. Notify others right away. One-to-one continuous monitoring may be needed. Facilities are to show how to check people at risk and how they are reducing those risks by using national standards. Hazards include ligatures (belts, shoelaces, oxygen tubing), poor staffing levels for direct observation of patients, sharp objects (glass, syringes, breakable windows), medicines and harmful substances (drugs, cleaning agents), and light fixtures (electrocution). Safety events that end in harm or the death of a person are called Sentinel, Adverse, or Serious Events. An Adverse Event is any safety event that reaches the person, an unsafe condition that increases the chance of a safety event, or a near miss that did not negatively affect the person. Serious Reportable Events (SREs), including suicide or attempted suicide, signal the need for immediate attention and response.

A review of doctor's orders dated 8/6/24 at 11:47 am, Patient 1 was admitted to inpatient Medical Surgical Floor (Unit 3-Second Floor) using adult standard admission orders. Condition was guarded (serious condition).

A review of a RN Note dated 8/6/24 at 3:40 pm, Patient 1 arrived to Room 301B from the ER. At 3:45 pm, RN C documented that she spoke with Charge Nurse and "I voiced my urgent very strong concern over this patient coming to our floor.'' RN C documented Patient 1 should not be so far away from the nurse's station due to not being easily observed. Five minutes later, RN C contacted the House Supervisor (HS) related to finding in that Patient 1's chart was a 5150 and had history of multiple suicidal tendencies. HS informed RN C that she would try to get Patient 1 a room on Floor 1. RN C documented this was a good idea and needs to have a sitter to observe Patient 1. At 4:15 pm, RN C was informed that Patient 1 could be transferred to Room 106, a private room near charge nurse.

During an interview with RN C on 8/8/24 at 2:20 pm, RN C stated Patient 1 was transferred from the ER to Unit 3 on 8/6/24 at 3:40 pm, to Room 301B (not the preferred room for a suicidal ideation patient). RN C stated Patient 1 could have stayed in the ER until an appropriate room was available. RN C stated there was frequent patient "shuffling" between rooms, a "lot of chaos." RN C stated, "This is not protecting patients. It's not safe for nursing or patients. "RN C stated Patient 1 was wearing jeans, a gown, a telemetry monitor, and wool socks. RN C stated she did not search Patient 1's belongings. RN C stated Patient 1 repeatedly tried to close the door to his room, but she informed him he needed to keep it open for his safety. RN C stated she noted as he was going back to his bed that his jeans kept falling off, and she did not believe he had a belt.

During an interview with Director of the ER, (RN D), on 8/8/24 at 4:45 pm, RN D stated RN E was the acting charge nurse in the ER on 8/6/24 when Patient 1 arrived. RN D stated law enforcement officers brought in the substances Patient 1 ingested; RN E gathered Patient 1's belongings and put them in a biohazard bag. RN D stated, "We don't write down an inventory" when belongings are gathered. RN D stated the facility did not do strip searches and "We can't go through their bags." RN D stated suicidal patients' belongings were typically bagged in the ER and taken to the radio room (charge nurse and physicians only have access) located behind the nurses' station. RN D stated safety hazards like cords are removed, but it "depends on the severity of the patient."

During an interview with RN D on 8/8/24 at 4:45 pm, RN D stated Room 301B was "not appropriate" for Patient 1. RN D stated, "It's safe in the ER." RN D stated a patient's risk for suicide should be determined so as to decide best placement. RN D stated, "I wish we had more resources."

During an interview with HS A on 8/9/24 at 7:37 am, HS A stated Patient 1's intake form did not indicate a 5150 hold. HS A stated 8/6/24 started with a code (a patient requiring emergent life-saving measures), she was busy moving other patients, and she "didn't have a chance" to go through Patient 1's orders. HS A stated, "All 5150s need to go to Unit 1" but that she was unaware of his 5150 status. HS A stated she assigned Patient 1 to Room 301B (Unit 3) on the second floor at the end of a hallway out of line of sight from the nurses' station. HS A stated she moved Patient 1 to Unit 1 as soon as possible after RN C called to request a safer room.

During an interview with RN J on 8/8/24 at 12:32 pm, RN J stated staff did not know where Patient 1 got the belt he used as a ligature to attempt suicide. RN J stated Patient 1 had been in prison for nine years and "was probably good at hiding things."

During an interview with DOC A on 8/8/24 at 1:42 pm, DOC A stated she "wants to know where the belt came from" as the ER staff reported they "found nothing" when they collected Patient 1's belongings. DOC A stated Patient 1 had been in prison and "knew how to hide things."

During an interview with RN A on 8/13/24 at 3:28 pm, RN A stated the suicide risk assessment she used for Patient 1 was the two questions in the computer template (a predesigned document) of the "ER Nurse Note." RN A stated Patient 1 answered "no" to having suicidal thoughts and having any objects that could hurt himself or others. RN A stated nursing staff "legally" have to write down what patients say, even if they say no. RN A acknowledged concern for Patient 1 despite his "no" answers because he had a flat affect (lack of emotion), denied his suicide attempt, and he told her he only wanted to see what oleander tasted like. RN A stated she frequently checked Patient 1 because it was "the only way to keep him safe." There was no validated or evidence-based suicide risk assessment tools available for staff to use for Patient 1.

During an interview with CNO on 8/16/24 at 2:40 pm, CNO stated Patient 1 "was telling us what we wanted to hear" when he stated he was not suicidal. CNO stated the facility has a lot of new nurses who were timid to ask suicidal ideation questions, so they were "developing a script." CNO stated they were also creating a "risk stratification tool" (identifies safety risks, predicts outcomes) because "we had to have one before 1/1/25" according to All Facilities Letter 23-2 (AFL 23-2). CNO acknowledged she was not aware Patient 1 was 5150. CNO stated her computer dashboard will give her an idea why each patient was here, but stated, "I don't think I had looked when he came in that day."

A review of a Physician Critical Event (Code 99) note dated 8/6/24 4:51 pm, DOC A was notified that Patient 1 hung himself from shower with belt. Patient 1 was found on the ground outside the bathroom after nurses promptly took him down when he started breathing. Plan of care: Patient 1 transferred to Intensive Care Unit.

A review of "Doctor's Orders," dated 8/6/24 at 7:06 pm, indicated "one to one sitter" ordered by DOC C, only after the suicide attempt in the patient's room. There was no initial order for one to one sitter upon admission for Patient 1.

A review of "Social Services Inpatient Follow-up," dated 8/7/24 at 11:23 am, indicated Patient 1 was considered at "acute risk of suicide" due to planned suicide attempt prior to admission, additional suicide attempt in the hospital, extremely depressed presentation and continued statements of suicidal ideation.

During an interview with CNO on 8/16/24 at 2:40 pm, stated "Suicide Precautions" orders may be in placed by the doctor or by Social Services in conjunction with the psychiatrist which included a one-to-one-sitter. DOC C's admission order of 8/6/24 at 11:31 am showed a diagnosis of suicidal/self-harm ideation, oleander/sulfur ingestion. This order would indicate "Suicide Precautions should be in place." CNO stated sitters were used if a patient was a "flight risk," wander, suicide risk, traumatic brain injury and with cognitive impairments. CNO further stated she was unsure if DOC C felt a sitter was warranted for Patient 1. CNO stated staff who asked were never denied a one-to-one sitter. CNO stated, the nurse made the determination it was a safe environment for Patient 1 without a sitter.