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Based on observation, interview, policy review and record review the facility failed to ensure patients identified as suicidal were monitored according to the facility policy and procedure (A144). The cumulative affect of these systemic practices resulted in the facility's inability to ensure patient safety.

Findings include:

Refer to A144.

Patient #10 was found hanging from the EKG monitor by the monitor's electrical cord. The facility failed to follow their policy to provide 1:1 observation at all times for high risk suicidal patients on 07/26/13. Patient #10 was intubated and transferred in critical condition to another hospital.

On 08/05/13, Patient #11 identified as a high risk suicidal patient was observed in a "safe" room with an IV pump electrical cord, thermometer cord and a removable privacy curtain. Although the security officer was observed facing the patient, the chair was outside the patient's room. The facility failed to ensure safeguards were in place after event on 07/26/13 to prevent the potential for reoccurrence.

Based on observation, interview, policy review and record review the facility failed to ensure two of 6 patients identified as suicidal were monitored according to the facility policy and procedure. (Patients #10 and #11) On 07/26/13 there were a total of 127 patients seen in a 24 hour period of which four patients were diagnosed with suicidal ideation and on 08/05/13 there were a total of 145 patients seen in 24 hours of which two patients were diagnosed with suicidal ideation. Twelve total medical records were reviewed.

Findings include:

1. Review of the medical record for Patient #10 was completed on 08/05/13 at 2:00 PM. Patient #10 was admitted to the emergency room (ER) with diagnoses of suicidal/homicidal ideation and arm laceration. Patient #10 arrived to the emergency room via the squad and police at 2:31 PM. The patient was assessed by the triage nurse and placed in ER Room #19 as a high risk suicidal patient.
Patient #10 was to have 1:1 supervision at all times. All equipment was removed from the room except for the electrocardiogram (EKG) monitor and cord to the monitor which was attached to the wall.
Interview with community counselor B, on 08/05/13 at 10:09 AM revealed Patient #10 was assessed as suicidal. The counselor asked the security officer (Staff C) in the room with Patient #10, to leave to get Patient #10's insurance card as Staff C was the only person who had the keys to unlock Patient #10's personal belongings.
Review of the incident from 07/26/13 revealed Staff C did walk away from Patient #10's room to get Patient #10's insurance card, and in less than two minutes when Staff C returned to room, Patient #10 was found hanging from the electrocardiogram (EKG) monitor cord at 5:40 PM.
On 07/26/13 at 5:40 PM Staff D, Registered Nurse (RN) who was on duty documented "patient hanging in room from monitor with cord around neck, face dusky and cyanotic, pupils fixed and dilated, neck was red and the patient was non-responsive. Color returned to face when the cord was cut. Cardiac alert was called overhead. Patient was intubated and transferred to another hospital in critical condition at 7:10 PM.
Interview with the Vice President of Quality, Staff A, on 08/02/13 at 1:39 PM revealed the hospital staff began a root cause analysis (RCA) on 07/26/13 immediately after incident with Patient #10. The RCA revealed 19 of 19 security officers were in-serviced from 07/26/13 through 08/04/13 to never leave a patient unattended.

2. Review of the medical record for Patient #11 was completed on 8/6/13 at 2:25 PM. The medical record revealed diagnoses including suicidal ideation and major depression.
On 08/05/13 at 1:10 PM, observation was made of Patient #11 in ER room 5. Patient 11 ambulated into the ER on 08/05/13 at 12:05 PM and was identified as a high risk patient for suicide watch. The patient was assessed by community counselor G and also assessed by a hospital Social Worker, Staff E, as high risk for suicide.

Patient #11 was to have 1:1 observation according to the hospital policy and procedure for a high risk suicidal patient. Security Officer Staff F was observed sitting outside the patient's room facing the patient from the nurse's station. Observation inside ER room 5 revealed there was an intravenous pump (IV) pump attached to the pole on the patient's bed with the cord to the IV pump lying behind the back of the patient's bed. There was also a thermometer in the patient's room mounted to the wall with a detachable long coiled stretchy cord connected to the thermometer. The privacy curtain hanging in the patient's room was determined to be removable instead of a break away curtain.

The policy and procedure titled "Management of the High Risk Psychiatric Patient in the Emergency Department" revealed the patient will be assigned to a Safe room. In order to be a Safe room, all removable equipment and furniture must be removed from the room. The patient will be permitted to have a cart to sit on and the designated (1:1) observer may have a chair to sit on and (1:1) observation is required. The registered nurse may implement high risk precautions without a physician's order. The Emergency physician must be informed immediately regarding the patient's behavior and of the initiation of the high risk precautions and documented in the medical record. A physician order is necessary to discontinue all high risk precautions regardless of how the orders were initiated. Comprehensive mental health, social and medical evaluations will be completed in a timely manner through the collaborative efforts of Physicians, Nurses, Area Counseling Center staff and/or Emergency Department Social Worker.


The policy and procedure defined (1:1) observation as a hospital employee, security officer, or an employee secured from an agency paid to sit with a patient to provide care and or ensure safety of the patient. This person will be within direct contact with the patient at all times. A family member or friend is not an appropriate observer.


This finding substantiates complaint number OH00071255.