HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the QAPI program established clear expectations related to patient safety as evidenced by failing to implement and document preventive educational actions throughout the hospital using effective and measurable methods to assess the competency of staff related to a suicide attempt.
Findings:

Review of the hospital's document titled serious safety event last updated on 09/14/2023 revealed, in part, on 08/27/2023 at 1:54 p.m., Pt. #3 left his room in the observation unit, walked to the patient parking garage, climbed over the railing on the 5th floor, and stepped off at 2:04 p.m. falling to the 2nd floor emergency department ramp and sustained numerous fractures to his pelvis and lower extremities requiring surgical interventions as well as an intracranial hemorrhage managed conservatively.

Review of the hospital's serious safety event further revealed, in part, lack of escalation of suicidal ideation; lack of communication of concerns to unit team/leadership included suicidal ideation voiced by patient were not addressed. The action included, in part, multidisciplinary conference developed with a focus on this case review aspects of identifying and caring for suicidal risk patients with a completion date of 11/30/2023 and meeting scheduled with planning team on 10/05/2023.

In an interview on 10/02/2023 at 1:07 p.m., S2PS indicated a patient safety alert went out to all department heads regarding suicidal ideation and those department heads were expected to communicate with their staff related to this topic. S2PS further indicated there was no documented evidence that department heads provided the training to staff.

In an interview on 10/02/2023 at 1:13 p.m. S4RN indicated S16RN failed to notify the MD of Patient #3's comment related to wanting to kill himself if he didn't get his pain medication. S4RN further indicated that staff education related to this incident was completed in safety huddles 2x/day for 7 days, however, there was no documented evidence of completion of the education.

Review of an email dated and timed 10/03/2023 at 1:02 p.m. from S17HR to S1QM revealed a subject line Registered Nurse Staffing with 512 Full Time, 42 Part Time and 132 PRN nursing staff employed by the hospital.

In an interview on 10/03/2023 at 1:36 p.m., S2PS provided documentation of a staff meeting on unit a dated 08/31/2023 which included an agenda item titled, "Patient Safety/Serious Safety Events". Further review revealed a sign-in sheet consisting of 12 signatures with no title or staff position identified. Also presented at this time was a document titled Safety Huddle Quick Points dated 09/04/2023 including 6 signatures with no title or staff position identified. S2PS further indicated there was no additional documentation from any of the other units/departments related to education regarding the suicide attempt on 08/27/2023.