HospitalInspections.org

Based on documentation review, it was determined ED Staff failed to consistently provide, maintain and/or document Suicide Precautions in accordance with Standards of Practice and/or Hospital protocol during the time period of 2/15-4/7/10.

Findings included (but were not limited to):

One of the Hospital System ED Directors (Hospital System ED Director #1) was interviewed, in person, throughout the On-Site Investigation/Survey. She said a Hospital System committee recently developed a policy/procedure titled "Suicide, Psychiatric Diagnoses, Substance Abuse, Sections 12/35" , but the policy/procedure had not yet been approved and implemented. She also said there was no such prior policy/procedure.

A Hospital System document titled "Overview of TA/PCO Roles/Responsibilities" indicated TAs (Therapeutic Assistants; individuals who undergo a 13-hour training program that includes Crisis Prevention Institute and cardiopulmonary resuscitation training) are assigned to monitor suicidal patients and the TAs: monitor (only) 1 patient and provide "constant observation" ; are to keep their eyes on the patient continuously, checking behavioral and mental status every 15 minutes; are to assist the patient with turning, repositioning, walking and meals and; are to report changes in patient condition.

A Hospital System Form titled "Therapeutic Assistant Plan for Care of the Patient" that is utilized for all types of patients on safety monitoring included sections titled "Reason for Observation", "Location at the Therapeutic Assistant (Patient must be in full view at all times)", "Behavior to Watch for", "Activity Level", "Family Members or Significant Others", and "Accompanying patient off the unit to a procedure or test" with pre-printed options to be selected by the RN. The options within the "Reason for Observation" section included agitated/confused, Section 12, suicidal, risk for leaving, special needs (cognitive) and aggression; the options within the "Location at the Therapeutic Assistant (Patient must be in full view at all times)" section included at arm's length and inside the patient's room at the foot of the patient's bed (no closer than 4-6 feet from the patient's head); the options within the "Behavior to Watch for" section included agitation/aggressiveness, confusion, danger to self, danger to others, leaving room and other; the options within the "Activity Level" section included accompany patient to bathroom, leave door ajar (suicide/self-harm patient) - must be able to see patient at all times, restricted to room (cannot leave), walk with patient in room, walk with patient in hall, bedrest, may use bathroom alone and bedrail options; the options within the "Family Members or Significant Others" section included visitors allowed, visitors must check with RN before entering room and visitors must have all items including food/drinks checked by RN before entering room and; the options within the "Accompanying patient off the unit to a procedure or test" section included do not leave patient unattended at off-unit procedure (including being in Radiology Room with patient) and must be specifically relieved by another trained hospital staff person.

The Standard of Care for the monitoring of suicidal patients that are not on/in a psychiatric unit is: 1:1 observation; at arm's length, at all times. The patient's room/surroundings are also checked and relieved of materials that could be utilized to inflict self-harm.

1.) Patient #3 presented to the ED by ambulance at 7:58 PM following a suicide attempt (drug overdose). Documentation indicated Patient #3 was placed on 1:1 observation and the Therapeutic Assistant Plan for Care (TAPC) indicated: the reasons for Patient #3's observation were suicide risk and risk for leaving; the TA was to be inside the patient's room at the foot of the bed (no closer than 4-6 feet from patient's head); the behaviors the TA was to watch for were danger to self and leaving the room; Patient #3's activity level was restricted to room (cannot leave); visitors were to check with RN before entering room; Patient #3 was not to be left unattended at off-unit procedures and; the TA needed to be specifically relieved by another trained hospital staff person. The TAPC did not indicate the TA was to be within arm's length of Patient #3 at all times (including when using the bathroom) and/or that all items including food/drinks were to be checked by the RN before they were brought into the room.

Patient #3 was evaluated by an ED physician at 8:25 PM and diagnosed with depression and suicide attempt by drug overdose. Physician Orders did not include an Order for 1:1 observation/suicide precautions (but documentation indicated the 1:1 observation was continued).

Behavioral and mental status checks were documented for Patient #3 every 15 minutes except for at 9:30 and 9:45 PM.

Nursing documentation completed at 11:48 PM indicated Patient #3 was on 1:1 observation and continued to have suicidal ideation with a plan. Nursing documentation completed at 4:00 and 6:50 AM (ED day #2) indicated a 1:1 Sitter was at the door.

2.) Patient #5 presented to the ED at 12:04 PM with complaint of nightmares and indicted he/she couldn't take it anymore and was thinking of suicide. Documentation did not indicate Patient #5 was immediately placed on 1:1 observation, but nursing documentation completed at 2:20 PM indicated Patient #5 remained on 1:1 status, and there was a TAPC for the 7:00 AM-3:00 PM shift. The TAPC indicated: the reasons for observation were suicide risk and risk for leaving; the TA was to be inside the patient's room at the foot of the bed (no closer than 4-6 feet from patient's head); the behavior the TA was to watch for was danger to self; Patient #5 was to be accompanied to the bathroom, the door was to be left ajar and the TA needed to be able to see the patient at all times; visitors were to have all items including food/drinks checked by the RN before entering room and; Patient #5 was not to be left unattended at off-unit procedures. The TAPC did not indicate the TA was to be within arm's length of Patient #5 at all times and/or that the TA needed to be specifically relieved by another trained hospital staff person.

Patient #5 was evaluated by an ED physician at 2:45 PM and diagnosed with major depression with suicide ideation. The ED physician ordered Suicide Precautions.

Every 15 minute behavioral and mental status checks were not documented for Patient #5 during the time period of 12:04 and 3:00 PM.

Nursing documentation completed at 7:42 PM indicated Patient #5 continued to have suicide ideation and a 1:1 was in place. Nursing documentation completed at 11:15 PM and at 1:30, 3:25 and 5:25 AM (ED day #2) indicated a Safety Sitter was present at the doorway for 1:1 observation.

The ED Day #2 TAPC indicated: the reasons for Patient #5's observation were suicide risk and risk for leaving; the TA was to be at arm's length of the Patient; the behavior the TA was to watch for was danger to self; Patient #5 was to be accompanied to the bathroom, the door was to be left ajar and the TA needed to be able to see the patient at all times; visitors were to check with the RN before entering the room; Patient #5 was not to be left unattended at off-unit procedures and; the TA needed to be specifically relieved by another trained hospital staff person.

3.) Patient #10 presented to the ED by ambulance at 2:08 PM following a suicide attempt (ingestion of soap). Documentation indicated a TA was assigned to Patient #10 and a TAPC indicated: the reasons for Patient #10's observation were Section 12 and suicide risk; the TA was to be inside the patient's room at the foot of the bed (no closer than 4-6 feet from patient's head); the behavior the TA was to watch for was danger to self; Patient #10 was to be accompanied to the bathroom, the door was to be left ajar and the TA needed to be able to see the patient at all times; visitors were allowed; Patient #10 was not to be left unattended at off-unit procedures and; the TA needed to be specifically relieved by another trained hospital staff person. The TAPC did not indicate the TA was to be within arm's length of Patient #10 at all times and/or that all items including food/drinks were to be checked by the RN before they were brought into the room.

Patient #10 was evaluated by an ED physician at 3:00 PM and diagnosed with depression with suicide attempt and ideation. Physician Orders did not include an Order for 1:1 observation/suicide precautions (but documentation indicated the TA observation was continued).

Nursing documentation completed at 6:39 PM indicated a Safety Sitter was in the doorway of Patient #10's room. Nursing documentation completed at 9:00 PM indicated 1:1 observation was maintained and nursing documentation completed at 12:45, 2:47 and 5:07 AM (ED day #2) indicated a 1:1 sitter remained at the doorway.

The ED Day #2 TAPC indicated: the reasons for Patient #10's observation were agitation/confusion, Section 12, suicide risk, risk for leaving and aggression; the TA was to be at arm's length and inside the patient's room at the foot of the bed (no closer than 4-6 feet from patient's head); the behaviors the TA was to watch for were agitation/aggressiveness, confusion, danger to self, danger to others and leaving the room; Patient #10 was restricted to the room and on bedrest; visitors needed to check with the RN before entering the room; visitors were to have all items including food/drinks checked by the RN before entering room and; Patient #10 was on suicide precautions.

Nursing documentation did not indicate Patient #10 was ever agitated, confused or aggressive during his/her ED stay.