HospitalInspections.org

Based on observation, interview, record review, policy review, and video review, the facility failed to:
- Ensure a safe environment when facility staff failed to follow policies related to Suicidal Precautions (SP, interventions put into place to prevent self-harm or death), Elopement Precautions (EP, interventions put into place to prevent someone from running away who may be unable to provide safety for themselves), and Code White (term announced to notify staff to respond to an area to calm someone who is agitated) policy for one patient (#16) of one patient reviewed who was on suicide precautions, who eloped from the facility and committed suicide (to cause one's own death) with a gun (A 0144).
- Ensure a safe environment when one patient (#16) of one patient reviewed, was allowed to elope from the Medical Care Unit in shorts, no shirt, and with an intravenous (IV, in the vein) catheter (small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) which remained in his arm, after suicidal comments were made to Staff R, Physician, and after he was placed on suicide precautions (A 0144).
- Ensure staff were immediately educated/re-educated about Suicidal Precautions, Elopement Precautions, and the facility's Code White Policy, to include direction if high-risk patients became non-compliant or exhibited behaviors that escalated, after the substantiated self-report of Patient #16's elopement and suicide (A 0144).

These failures had the potential to affect all high-risk patients, when policies and procedures in place to protect patients were not followed.

The facility census was 91.

Based on observation, interview, record review, policy review, and video review, the facility failed to:
- Ensure a safe environment when facility staff failed to follow policies related to Suicidal Precautions (SP, interventions put into place to prevent self-harm or death), Elopement Precautions (EP, interventions put into place to prevent someone from running away who may be unable to provide safety for themselves), and Code White (term announced to notify staff to respond to an area to calm someone who is agitated) policy for one patient (#16) of one patient reviewed who was on suicide precautions, eloped from the facility and committed suicide (to cause one's own death) with a gun.
- Ensure a safe environment when one patient (#16) of one patient reviewed, was allowed to elope from the Medical Care Unit in shorts, no shirt, and with an intravenous (IV, in the vein) catheter (small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) which remained in his arm, after suicidal comments were made to Staff R, Physician, and after he was placed on suicide precautions.
- Ensure staff were immediately educated/re-educated about Suicidal Precautions, Elopement Precautions, and the facility's Code White Policy, to include direction if high-risk patients became non-compliant or exhibited behaviors that escalated, after the substantiated self-report of Patient #16's elopement and suicide.

These failures had the potential to affect all high-risk patients in the facility, when policies and procedures in place to protect patients were not followed. The facility census was 91.

Findings included:

1. Review of the facility's undated policy titled, "Suicide Precautions," showed that patients determined at risk for suicide must be continually monitored and would automatically be placed on Elopement Precautions.

Review of the facility's undated policy titled, "Elopement Risk Assessment and Interventions," showed that staff should activate Code White if a patient was non-compliant or exhibited behaviors that escalated.

Review of the facility's undated policy titled, "Code White: Emergency Management of Violent Persons," showed that:
- The Code White Team would only consist of staff members who have successfully completed the Safe Training and Responsible Restraints (S.T.A.R.R., specialized training in a team approach to assist an escalated person through verbal de-escalation or physical restraint) control system training.
- Code White was designed for incidents that occurred anywhere in the hospital, lobbies and common areas included. A Code White may be initiated for any patient, visitor, or staff member.
- The Code White Team would implement/utilize appropriate actions as trained in the S.T.A.R.R. course.

Review of Patient #16's Electronic Medical Record (EMR), showed that Patient #16 was a 62-year-old male admitted on 02/26/19 at 8:34 PM, for Acute Gastro-Intestinal (GI, stomach) bleeding and Community Acquired Pneumonia. On 02/27/19, Staff R, Hospitalist, Medical Doctor (MD), visited the patient's room to discuss his treatments, Patient #16 stated he wanted to go home, he was tired of living, and he wanted to kill himself. When Staff R asked if he had a plan or if he had a gun, he refused to answer. Staff R, immediately began suicide precautions, notified the nurse, ordered a one-to-one (1:1, continuous visual contact with close physical proximity) sitter and a psychiatric consult.

Review of documentation by Staff L, Registered Nurse (RN), Case Manager, dated 02/27/19 at 3:46 PM, showed that during an interview with Patient #16, after he had made the suicide comments to Staff R, MD, he stated "how shitty life was." He stated that he had been in prison, had been divorced three times, and he was now unable to ride his motorcycle. He further stated that he lived with his mom and took care of her. He stated that he was just joking when he made the suicide comment to the doctor. He stated that he was suicidal five years ago and "saw a shrink at a mental health center," but that he stopped going. Patient #16 denied having a gun due to being an ex-convict. He was agreeable to find a new psychiatrist, but not at the mental health center in which he had previously received services. A female friend was present during the interview and stated that Patient #16 had been sad because everything [he enjoyed] had been taken away. Soon after the interview, Patient #16 demanded to leave the facility and refused to stay. Security was called and Patient #16 walked out, accompanied by Staff E, Security Officer.

During an interview on 03/12/19 at 4:00 PM, Staff L, RN, Case Manager, stated that when she was told that Patient #16 was placed on suicide precautions, she went to his room to speak with him. When she arrived to his room, a male visitor was present. The patient stated that he was joking when he made the suicide comment to the doctor. Staff L, stated that the patient continued to talk as though this were all a big joke. A female friend entered the room. and Staff L, RN, the male visitor, the female visitor, and the patient continued to talk pleasantly while Staff Q, Patient Care Technician (PCT), completed the suicide precaution checklist, which included removal of his clothes. Hospital scrubs were provided for the patient to wear. Staff L stated that even though the patient said it was all a joke, she felt his suicide comment that was made to the physician might have had some validity to it because the female visitor stated that the patient had been sad due to pain, his health condition, his inability to ride his motorcycle due to the pain in his legs, and lost socialization with his friends because they all rode motorcycles. Staff L stated that she left the room and approximately five to ten minutes later, she was notified that Patient #16 had left the facility with his visitors.

During an interview on 03/12/19 at 1:15 PM, Staff B, RN, stated that she was the nurse for Patient #16 on 02/27/19. She stated that when Staff R, MD, made rounds, she was notified that the patient made a suicide comment to him. She immediately went to his room and he recanted his comment and said it was not a big deal, that it was a joke. He stated that he meant he felt that way in the past, about five years ago. Staff Q, PCT, had gotten the patient some paper hospital scrubs to wear, per hospital policy, but Patient #16 refused. A female visitor was present and told the patient that he should have never made that comment to the doctor. A male visitor was also present in the room and both visitors told the patient, "We don't have to put up with this, we're leaving." They gathered his belongings and the patient stated, "We're out of here." Staff P, RN, House Supervisor, arrived, and the patient and visitors continued to say they would leave. The patient had an IV catheter in his arm and demanded it be removed. The female visitor said that if nursing didn't remove it that was ok because she would remove it at home. Staff B called security to come to the room, but by the time security arrived they had left the patient's room and walked toward the elevator. The patient walked out with the IV in his arm and dressed in only his shorts. Staff B stated that she now realized a Code White should have been called. She stated that staff who were S.T.A.R.R. trained would have arrived to assist.

During an interview on 03/12/19 at 2:05 PM, Staff H, RN, stated that a Code White can be initiated any time a staff member feels there is the potential for harm.

During an interview on 03/12/19 at 2:05 PM, Staff C, RN, Assistant Nurse Manager, stated that she was notified that the patient was placed on suicide precautions and she went to the unit to assist Staff B, RN. She stated that she told Staff B to call security when she heard the patient refuse to put on the paper scrubs. The patient then walked to the elevator accompanied by his two visitors, with Staff E, Security Officer, a few steps behind them. They all entered the elevator and the doors closed. Staff C stated that she did not feel the need to call a Code White because a security officer and house supervisor were already present. She stated that a Code White would be called in high-risk situations, when a patient lost control and threatened to harm self or others.

During an interview on 03/12/19 at 2:30 PM, Staff D, PCT, stated that she was assigned to sit 1:1 with Patient #16 who was on suicide precautions. When she arrived to the room there were two visitors present and Staff Q, PCT. She went to get an elopement armband and paper scrubs for the patient, per hospital policy. The patient refused the scrubs and she told him she would let the nurse know that he didn't want to wear them. Staff D stated that the patient said he would leave and tried to get someone to remove his IV. The patient had on shorts, no shirt, and slip-on shoes. The male visitor offered his coat, but the patient refused. The House Supervisor arrived and the patient requested to have his IV removed and stated he was leaving. The female visitor told the patient that she would remove the IV at home. The patient walked to the elevator with his visitors and left.

2. During an interview on 03/12/19 at 3:00 PM, Staff E, Security Officer, stated that he was called by a nurse to come to the patient's room. When he arrived, Patient #16 told him that he would leave. Patient #16 held his arm out, showed his IV, stated that he wanted it out, and threatened to take it out himself. The female visitor stated that she would remove it later. The patient wasn't dressed and it was very cold outside, so Staff E offered him a blanket, but he declined. Staff E stated that the patient shook his hand, told him he was "one of the good ones", and then he left the hospital with his visitors. When Staff E arrived back on the unit to tell nursing he had left the hospital, the staff told Staff E that he was on suicide precautions and 1:1. He was not aware that the patient was on suicide precautions. He stated that if he had known, he would have called for help.

During an interview on 03/13/19 at 10:10 AM, Staff O, Director of Security, reviewed video footage as the patient walked out of the front door of the hospital on 02/27/19 at 2:32 PM, accompanied by two visitors and the security officer. Staff O stated that Staff E, Security Officer, received a phone call from nursing staff and security presence was requested, however, they did not indicate it was a Code White situation. Staff O was then called by Staff P, House Supervisor, and informed there was a patient that was going to leave against medical advice (AMA) and asked if he would come. Staff O stated when he arrived in the lobby, Patient #16 was already gone and it wasn't until after the patient had exited the facility that security staff was made aware by nursing staff that the patient was on suicide precautions. Staff O stated that, in his opinion, a Code White should have been called. He further stated that security staff is aware and trained to the definition of Code White, and well-versed in its policy and procedure.

During an interview on 03/11/19 at 3:00 PM, Staff A, Director of Patient Safety and Quality, stated that when the security officer responded per nursing request, his visual cues were that the patient did not wear an elopement risk band or blue scrubs. The security officer was not aware at the time the patient and his visitors attempted to leave that the patient was on suicide precautions. Nursing staff failed to communicate the patient's precautionary status to security staff when their assistance was requested.

During an interview on 03/12/19 at 11:00 AM, Staff P, RN, House Supervisor, stated that Staff B was the nurse in charge, and Staff B notified her that Patient #16 was agitated and threatened to leave the hospital. When she arrived, Patient #16 denied that he meant the suicide comments that he had made. There were two visitors present in his room and he requested that she remove the IV from his arm. Staff P stated that she felt overwhelmed and frightened as Patient #16 was a big man. She stated that Staff E, Security Officer, arrived and she then texted Staff O, Security Director, and informed him that the patient left and that Staff E, Security Officer, was with him. Staff P, RN, stated that she had not participated in any recent education huddles or mock scenarios related to the incident since the elopement.

During an interview on 03/12/19 at 2:15 PM, Staff Q, PCT, stated that she was assigned as a 1:1 sitter for Patient #16. She stated when she asked the patient to put the paper scrubs on, he became angry and said, "I'm not wearing no fucking scrubs." She stated that his demeanor changed and he became mean. He said, "I'm getting the fuck out of here." Staff Q reported to Staff B, RN in charge, and then called security. Staff Q stated that any staff can call a Code White if a patient screamed, cursed, or became angry. She stated that there was no need to call a Code White because he wasn't physically aggressive and didn't seem irate enough. Staff Q stated that she had not had any recent education related to the incident, but that she did receive S.T.A.R.R. training last year, in March, 2018.

During an interview on 03/12/19 at 3:07 PM, Staff J, PCT, stated a Code White was called when someone was combative or had the potential to become violent.

During an interview on 03/12/19 at 2:30 PM, Staff R, Hospitalist, MD, stated that when he made rounds and visited with Patient #16, the patient stated, "I want to go home and kill myself." He spoke of his health concerns and indicated his mother was also in the hospital with health concerns. He stated that Patient #16 refused to answer when questioned further about a plan or if he possessed a weapon. Staff R, stated that he immediately implemented orders for suicide precautions, which included a 1:1 sitter. Staff R stated that from a physician's point of view, the patient left AMA as he had been advised of the potential risks to his health, up to and including death, if he were to leave the facility against the advice of his physician, as well as the potential benefits to his health if he remained at the facility and received the recommended medical treatment. He stated technically the difference between AMA and elopement is in paperwork only.

During a telephone interview on 03/12/19 at 3:30 PM, the County Medical Examiner stated that Patient #16 died on 02/27/19 at 6:49 PM, from a self-inflicted gunshot wound to his head.

3. During an interview on 03/12/19 at 1:55 PM, Staff G, Patient Care Technician (PCT), stated in the previous two week period, she had not received any education nor was she involved in mock scenarios related to the event.

During an interview on 03/12/19 at 2:05 PM, Staff H, RN, stated that not all staff were aware of the situation that occurred with Patient #16, and that facility administration had not sent any information out to staff.

During an interview on 03/12/19 at 2:58 PM, Staff I, RN, Charge Nurse, stated she had not received any information or notification that new training was available and to be completed online.

During an interview on 03/12/19 at 1:25 PM, Staff C, RN, Assistant Nurse Manager, stated that education related to the incident, specific to suicide, elopement, and Code White, to prevent recurrence, was not provided to staff prior to 03/11/19.

During an interview on 03/12/19 at 1:30 PM, Staff F, Patient Care Services Director, stated the facility had not implemented an audit process to evaluate staff compliance with policies related to inpatient suicide or elopement precautions, prior to 03/12/19.



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