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Based on interviews and document review, the facility failed to ensure the safety of 3 of 4 patients reviewed who presented for suicidal ideations to the emergency department (Patients #12, #19 and #26). The failure resulted in Patient #12 attempting suicide while in the care of the facility.

Findings include:

Facility policy:

The policy, Suicide Precautions, read it was a protocol for a safe environment during the immediate care of an actual and/or potential suicidal patient. The patient will be provided a safe environment during the stay in the emergency department. Patients exhibiting suicidal ideation/attempt will be subject to the following suicidal precautions to include, patients being assigned to a bed which was easily visible from the nurses' station. If this was not possible a bed where continuous 1:1 observation will be provided. The patient's clothing and personal effects will be inventoried and removed from the patient's proximity. Hospital attire will be worn by the patient. Any items in the patient's room which may be used as a potential weapon will be removed from the immediate area where the patient is located (glass, clothing, belts, shoestrings, silverware, telephones and cords of any type, plastic trash can liners). Medications may not be kept at the patient's bedside.

1. The facility failed to implement suicide precautions and provide a safe environment for patients who presented to the emergency department (ED) with a complaint of suicidal ideation.

a. On review of Patient #12's medical record, the patient presented to the emergency department on 11/21/17 at 10:50 a.m. Patient #12 was triaged and a primary and secondary assessment were completed at 10:56 a.m. by Registered Nurse (RN) #1, which was documented on the emergency nursing record. RN #1 documented Patient #12's chief complaint as suicidal with a specific plan.

At 11:14 a.m., the physician documented, on the ED Provider Assessment, that Patient #12 was brought in by ambulance with a history of bipolar, schizophrenia, anxiety, depression, post traumatic stress disorder and a recent admission to a psychiatric facility for suicidal ideations and with worsening suicidal ideations. The patient was seen at a clinic yesterday, 11/20/17, and was noted to "currently struggle with suicidal ideation."

At 11:41 a.m., RN #1 documented under the nursing assessment notes, Patient #12 was suicidal with a plan to overdose on her medications and complained of increased depression, anxiety and sadness.

At 1:10 p.m., on the vitals signs flow sheet, it was documented Patient #12 took pills approximately 10-15 minutes ago. Review of the Emergency Nursing Record revealed RN #1 documented the patient came up to the nurses station and said she took approximately 60 pills about 15 minutes ago.

At 1:38 p.m., a tube was inserted into the patients nose to perform a gastric levage (also commonly called stomach pumping, the process of cleaning out the contents of the stomach). This procedure continued until 2:00 p.m. when the tube was removed from Patient #12's nose.

At 2:35 p.m., a crisis evaluation was conducted. In the crisis evaluation, the crisis clinician documented Patient #12 reported she was feeling frustrated that no one understood or was taking how she felt seriously, so she took her pills from her purse.

b. On 5/16/18 at 1:37 p.m., an interview was conducted with RN #1, who cared for Patient #12 on 11/21/17. RN #1 stated Patient #12 was placed in a room located behind the nursing station and approximately 31 feet down the hall from the nursing station (room #2). RN #1 confirmed there was no direct visualization from the nursing station of Patient #12, while in room #2. Additionally, there was no documentation the patient was on continuous 1:1 observation. This was in contrast to the suicide precautions policy which stated patients exhibiting suicidal ideation will be assigned to a bed which was easily visible from the nurses' station. If this was not possible a bed where continuous 1:1 observation will be provided.

RN #1 stated Patient #12 was left alone in room #2 with her belongings to include her purse on 11/21/17. RN #1 further stated there was no 1:1 observations implemented for Patient #12 from 10:50 a.m. until after she overdosed on her own medications. This was two hours and twenty minutes after the patient arrived stating she was suicidal and had a plan to overdose on her medications. RN #1 was unsure why suicide precautions for Patient #12 were not implemented to ensure a safe patient environment.

c. On 5/16/18 at 5:04 p.m., an interview was conducted with Chief Nursing Officer (CNO) #3. CNO #3 stated on 11/21/17, Patient #12 presented to the emergency department and she remembered the patient was placed in room #2. CNO #3 was unsure if Patient #12 had 1:1 observations conducted prior to her overdose at the facility. CNO #3 stated staff should have removed Patient #12's purse from the patient's room, but due to the patient's demeanor of being calm, staff did not identify the patient was a safety risk because it wasn't the "expected presentation of someone wanting to kill themselves."

d. On 5/17/18 at 9:38 a.m., an interview and tour of room #2 was conducted with RN #2. RN #2, who had worked at the facility for four years, stated she was tasked daily with taking care of emergency department patients and inpatients at the same time. RN #2 stated all suicidal patients would require direct observation, which would include being moved closure to the nurses station or having a sitter with the patient for 1:1 observations to ensure the patient's safety.

RN #2 stated patients who presented to the facility with suicidal ideations did not always have direct observations or 1:1 continuous monitoring implemented while at the facility due to staffing issues. RN #2 stated this was unsafe, as patients could harm themselves or wander off if not observed. RN #2 further stated there had been no process changes for suicidal patients in the last year.

During the tour of room #2, RN #2 confirmed the room was used for suicidal patients and was not in direct sight of the nurses station. RN #2 further stated the bathroom call light, the hospital bed cords and the cord to the glass window blinds would not be removed from the room for a suicidal patient all of which she confirmed could be a danger for patients.

e. Review of Patient #26's medical record showed the patient was brought in by ambulance to the emergency department at 4:10 p.m. on 1/16/18 for attempted suicide. The patient had ingested 20 pills of her antipsychotic medication. The patient was evaluated by a physician at 4:15 p.m. and reported feeling depressed about life stressors, multiple losses, feeling manic with decreased sleep and constant racing thoughts. The patient reported an attempted suicide at 19 years old and denied any psychiatric hospital admissions.

Approximately 4 1/2 hours later, at 8:55 p.m., the physician documented the patient had been evaluated by mental health crisis person and determined not to require psychiatric inpatient care, as she was no longer suicidal. At 11:08 p.m., Patient #26 was discharged home. There was no documentation suicide precautions were implemented until it was determined Patient #26 was no longer suicidal, approximately 4 1/2 hours after presenting to the ED.

f. Review of Patient #19's medical record revealed the patient was brought by family to the emergency department after the patient slit her left wrist in a suicide attempt on 10/29/17. At 2:55 a.m., the physician documented the patient had a laceration with weakness, numbness, depression, anxiety and suicidal thoughts. Record documentation revealed the patient would need a mental health evaluation and counseling. At 4:43 a.m., the patient was transferred to a higher level of care.

There was no documentation suicide precautions were implemented for the patient prior to the transfer.

g. On 5/17/18 at 8:50 a.m., an interview was conducted with a certified nursing assistant (CNA #5). CNA #5, who had worked for the facility for two years, stated she was responsible for conducting observations of patients who presented to the facility with suicidal ideations. CNA #5 stated she was tasked daily with caring for emergency department patients and inpatients at the same time while on shift.

CNA #5 stated she remembered Patient #12, but was unsure if she had cared for her on 11/21/17. CNA #5 stated, due to past personal experiences, if a person was suicidal you could "coddle them as much as you want, if they were going to kill themselves, they would do it." CNA #5 stated there had been no process changes for providing care to suicidal patients since she started two years ago.

h. On 5/17/18 at 10:40 a.m., an interview was conducted with the Chief Medical Officer (CMO) #6. CMO #6 stated a patient could be calm and still be suicidal. CMO #6 further stated her expectation was for staff to follow the facility's suicide precautions for suicidal patients to include direct observation while in the facility. CMO #6 stated patient observations were a key component in ensuring patient safety and not allowing patients to harm themselves while at the facility.

CMO #6 reviewed Patient #12 and Patient #26's medical records. After review, CMO #6 confirmed there was no documentation Patient #12 was directly observed by staff until after the patient overdosed on medications from her purse while in room #2. On review of Patient #26's medical record, CMO confirmed again, there was no documentation suicide precautions were in place, per her expectations and facility policy, to ensure a safe environment was maintained.