HospitalInspections.org

Based on review of facility documents, observation, review of medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure care in a safe environment in the Emergency Department's (ED) locked behavioral health unit; the facility failed to ensure staff were watching surveillance monitors used to ensure patient safety in the ED locked behavioral health unit; and the facility failed to ensure a staff member was performing a patient required 1:1 direct visual observation for one of one medical record reviewed (MR1) in the ED locked behavioral health unit.

Findings include:

Review on August 27, 2019, of the facility's "Patient rights & responsibilities" brochure dated September 2018, revealed "... 7. A patient has the right to good quality care and high professional standards that are continually maintained and reviewed. ... 41. A patient has the right to receive care in a safe setting. ..."

Review on August 27, 2019, of the facility's "Personal Media/Cell Phone" policy, last approved December 26, 2018, revealed "Purpose: To promote and maintain a professional environment for our patients, their families and coworkers, in order to ensure patient care without interruption and efficiency within the department. Policy: 1. The use of personal digital devices or other media should be limited to use during appropriate downtime. 2. All devices are to be kept at a sound level that does not distract coworkers. 3. The use of any device to take pictures is not permitted to protect patient and employee privacy."

Review on August 26, 2019, of the facility's "Psychiatric Unit Video Surveillance Policy," last approved June 19, 2015, "Purpose: To establish a process to utilize close circuit video surveillance for patients in the Emergency Department who are at risk for self-injurious behavior or elopement while being cognizant of patients' rights to privacy. ... Procedure: ... 6. Requirements for continuous monitoring include but are not limited to the following: a. Patient has expressed suicidal or homicidal ideation b. History of present visit to the Emergency department involves self-injurious behavior (overdose, cutting, suicide attempt, etc.) c. patient is being held on a 201 or 302 warrant d. Patient is under evaluation for psychiatric issues and is at risk for elopement from the Emergency Department ..."

Review on August 26, 2019, of the facility's "Guidelines for the Care of Behavioral health Patients in the Emergency Department" policy, last reviewed/revised October 2017 revealed "Purpose: To Provide care for patients with behavioral health complaints or psychotic manifestations including homicidal or suicidal ideation. To provide guidelines for a comprehensive assessment and maintenance of patient safety during their time in the Emergency Department (ED). This includes but is not limited to the completion of a suicide risk screening, medical screening exam (MSE), assessment of the environment and referral for behavioral health evaluation. ... 9. Safety watch or suicide precautions will be initiated as indicated by suicide risk screening or nursing judgement. ..."

Review on August 27, 2019, of the facility's "Suicide/Self-harm Precautions" policy, last approved May 8, 2019, "Purpose: To provide guidelines for caring for patients when there is a reasonable risk the patient may endanger themselves and/or others. Patients presenting with acute medical care needs may also be assessed for exhibiting acute psychiatric conditions, chronic mental disturbances, substance abuse and be at risk of self-harm. Definitions: ... 1:1 Direct visual Observation: The provision of a member of the hospital's staff to be in constant attendance and in close proximity to the patient, even during bathroom use (patient will be accompanied by appropriate clinical staff). The staff member must have a clear and unobstructed view of the patient at all times. Suicidal Behavior/Thoughts: a spectrum of activities related to self-reported thoughts and behaviors that include suicidal thinking, actions, or suicide attempts. ... Emergency Department Procedure ... 2. The 1:1 direct visual observation will be provided by personnel from the healthcare team, which may consist of: nursing personnel, ED technician, companion, and/or Security. The personnel will be determined based on the assessment of the patient. ..."

1) Observation on August 26, 2019, of the ED's locked behavioral health unit lounge area revealed an empty plastic slipper bag on the chair.

Interview with EMP1 on August 26, 2019, at the time of the observation confirmed the empty plastic slipper bag on the chair in the lounge area.

Observation on August 26, 2019, of the ED's locked behavioral health unit patient rooms 28, 29, 30 and 31 revealed square louvered ceiling vents near the bed in each of these patient rooms. These square louvered vents had 1" gaps between each slot on the louvered vent.

Interview with EMP1, EMP5 and EMP7 on August 26, 2019, at the time of the observation confirmed the square louvered ceiling vents near the bed in the ED's locked behavioral health unit patient rooms 28, 29, 30 and 31. EMP1 revealed these louvered vents are not break away vents. EMP1, EMP5 and EMP7 confirmed the louvered ceiling vents pose a safety risk to patients with suicidal thoughts.

Observation on August 26, 2019, of the ED's locked behavioral health unit bathroom revealed a square louvered ceiling vent directly above the toilet in the patient bathroom.

Interview with EMP1, EMP2 and EMP5 on August 26, 2019, at the time of the observation confirmed the square louvered ceiling vent directly above the toilet in the patient bathroom. EMP1 revealed this louvered vent is not a break away vent. EMP1 confirmed the louvered ceiling vent pose a safety risk to patients with suicidal thoughts.

Observation on August 26, 2019, of the ED's locked behavioral health unit bathroom revealed a fire alarm box extending approximately 2 inches from the wall in the patient bathroom.

Interview with EMP1, EMP2 and EMP5 on August 26, 2019, at the time of the observation confirmed the fire alarm box extending approximately 2 inches from the wall in the patient bathroom. EMP1 confirmed the fire alarm box extending approximately 2 inches from the wall pose a safety risk to patients with suicidal thoughts.

Observation on August 26, 2019, of the Environmental Service (EVS) closet door in the ED's locked behavioral health unit revealed a door handle plate with silver tape under this door plate. Further observation revealed a hole in the plate measuring approximately the size of half an orange. The surface of this hole was sharp to touch.

Interview with EMP1, EMP2 and EMP5 on August 26, 2019, at the time of the observation confirmed the EVS closet door in the ED's locked behavioral health unit with silver tape under this door plate; the hole in the plate measuring approximately the size of half an orange and the surface of this hole was sharp to touch.

2) Review of MR1 on August 26, 2019, revealed the facility admitted this patient on August 26, 2019, at 17:43 PM for evaluation of increasing depression, suicidal ideations with plans to jump off a bridge. There was a physician order instructing nursing staff to place this patient on Suicide Precautions and this patient met the criteria for 1:1 Direct Visual Observation.

Review of MR1 on August 26, 2019, revealed nursing documentation dated August 26, 2019, at 17:46 PM indicating nursing staff placed this patient in 1:1 Direct Visual Observation Room Check for Suicide Watch.

Observation of EMP3 and EMP8 on August 26, 2019, at 19:43 PM revealed these staff members on their personal cell phones while sitting at the nurse's station in the ED's locked behavioral health unit. There was one patient in the locked unit. This patient had a physician order for suicide precautions.

Interview with EMP3 and EMP8 on August 26, 2019, at 19:43 PM confirmed these staff members were on their personal cell phones.

Interview with EMP3 on August 26, 2019, at 19:43 PM revealed this employee was assigned to watch the surveillance monitors to ensure MR1's safety in the ED's locked behavioral health unit.

Interview with EMP6 on August 26, 2019, at 19:43 PM confirmed the surveillance monitors were not watched during the time EMP3 was on their personal cell phone; MR1 was on suicide precautions and that MR1's safety was compromised with no one watching the surveillance monitors.

3) Observation of EMP9 on August 26, 2019, at 19:43 PM revealed this employee at the nurse's station in the ED's locked behavioral health unit talking to EMP3 and EMP4. EMP9's back was toward the window which separated the nurse's station and the locked behavioral health unit.

Interview with EMP6 on August 26, 2019, at 19:43 PM confirmed EMP9 was at the nurse's station in the ED's locked behavioral health unit talking to EMP3 and EMP4 and that EMP9's back was toward the window which separated the nurse's station and the locked behavioral health unit

Interview with EMP6 on August 26, 2019, at 19:43 PM revealed EMP9 was the assigned staff member to sit as the 1:1 Direct Visual Observation Room Check for MR1's Suicide Watch. EMP6 confirmed EMP9 was not performing MR1's 1:1 Direct Visual Observation Room Check as assigned.