HospitalInspections.org

Based on review of ten (10) medical records, facility policies and procedures, staff interviews and documentation related to staff training, it was determined that the Governing Body failed to implement and monitor policies and procedures related to the care and treatment of suicidal patients.

Findings were:

Review of medical record (MR) #1 revealed that the patient was brought to the Emergency Department (ED) by ambulance after having been picked up at a local pain clinic for expressing intent to kill him/herself. Upon arrival to the ED, the patient was triaged where it was determined that he/she was experiencing thoughts of suicide. The patient's history included a past attempt at suicide. After an ED bed became available, the patient was moved to that bed and a volunteer was assigned to watch him/her. A nurse was assigned to provide care, but this nurse was not notified of the patient's suicide ideations. The patient was allowed to go alone to the bathroom where the volunteer stood outside the door. A loud "pop" was heard coming from within the bathroom and when the door was opened, the patient was found sitting on the toilet, bleeding from the mouth, with a gun on the floor nearby. The patient was transferred to another local hospital for continued care, where he/she subsequently died.

Facility policy #HW-PC-210 entitled, Suicide Risk Assessment and Mitigation Activities, last revised November 2014, required the following:
1. A suicide risk assessment would be provided for patients who presented with a past or present suicide attempt or a clear statement of suicidal intent. The assessment would be performed using the "Sad Person Suicide Screen" tool in order to "assist in determining additional safety precautions", which would include placement in a room proximal to the nurses' desk, screening the room for potential hazards, one-on-one (1:1) staffing, asking the patient to undress and change into a hospital gown, searching the patient's clothing for potentially harmful contraband, and being wanded by security.
2. Notification of the physician or LIP (Licensed Independent Practitioner- Physician's Assistant or Nurse Practitioner) as soon as possible;
3. High risk suicide patients were not to be left alone at any time.
4. Modifications to the patient's plan of care would be made to address the patient's risk level and/or physician's order;
5. Staff training in deescalation techniques to reduce the need for use of restraints;
6. Performance Improvement activities to include monitoring the consistent use of the suicide screens for patients with a primary psychiatric diagnosis.

Documentation in the patient's medical record failed to reveal evidence that the patient's clothing had been removed; that the patient had been searched for dangerous contraband; that the physician or LIP was notified according to policy requirements; that the patient was not left alone; and that the patient's plan of care addressed the patient's identified level of risk.

Facility policy #HW-NSG-311 entitled, Sitters, last revised July 2014, documented that "Security Officers and any employee who has completed sitter training education may function as patient sitters.". The policy did not address the use of volunteers as sitters.

Review of the training records for five ED Registered Nurses, (#1, 2, 3, 4 and 5) revealed that each RN had undergone training related to the care of the psychiatric patient within the previous year.

Review of the volunteer's record (#7) documented that the sitter had begun volunteering in the hospital the day of the incident (6/29/15), but failed to reveal documented evidence that the he/she had undergone any training in the care of the psychiatric patient.

The above information was supported through interviews on 7/06/15 with RN #6 at 4:20 pm and on 7/07/15 with the ED Manager (interview #10) at 9:40 am, RN #3 at 10:10 am, RN (interview) #12, and RN #7 at 10:45 am.

Cross refer to A0115 as it relates to failure of the Governing Body to protect and promote each patient's rights.

Cross refer to A0144 as it relates to failure of the Governing Body to ensure that patient care was provided in a safe environment.

Cross refer to A0263 as it relates to failure of the Governing Body to ensure that safety measures related to care of the suicidal patient in the ED were monitored for implementation.

Cross refer to A0385 as it relates to failure of the Governing Body to provide proper oversight of patient care.
Cross refer to A0392 as it relates to failure of the Governing body to ensure that patient care delivery was overseen and provided by trained and qualified staff.

Cross refer to A0396 as it relates to failure of the Governing Body to ensure that a care plan specific to the identified needs of each patient was implemented in a timely manner for patient #1.

Cross refer to A0397 as it relates to failure of the Governing Body to ensure that personnel with the appropriate education, experience, licensure, competence and specialized qualifications were assigned to provide nursing care for each patient in accordance with the individual needs of each patient.

Based on review of records, observation, and interviews, the governing body failed to provide oversight of the facility's Governing Body, Patient Rights, QAPI, and Nursing Service to ensure that that the patient's right to receive care in a safe environment was protected for one (medical record # 1) of ten (10) patients whose medical records were reviewed (#s 1-10). Patient # 1, who entered the Emergency Room (ER) for evaluation and treatment of suicide ideations, was not provided with the care and oversight to ensure his/her safety, as follows:

a) Proper communication was not provided between staff located in separate areas of the ER, but who were responsible for the patient's care and safety;
b) Persons responsible to provide care and monitoring of the patient were not qualified through training and experience to do so; and
c) Facility policies and procedures, already in place and current, were not followed by the staff responsible to ensure the patient's safety.

The suicidal patient (patient #1) entered the ER with a gun, was not searched, and was monitored by a new Volunteer untrained to provide the monitoring essential to ensure the patient's protection. Communication between staff of the patient's risk for suicide did not occur until after the self-injury. The patient was left unmonitored in the bathroom, shot him/herself, and later died of the injuries.

Findings include:
Cross refer A-144 as it relates to patient care in a safe setting.

Based on review of patient records, facility policies, interviews and staff training records, the facility failed to provide care in a safe setting in one (1) of ten (10) patient medical records reviewed, resulting in the patient self-harming.

Findings include:

A review of the medical record for patient #1 revealed that an 89 year old presented to the Emergency Department via ambulance at 11:40 AM on 6/29/15. Triage was begun at 11:41 AM. The patient signed consent for treatment. He/she had a history of three weeks of headache and stated in part "...I took all of my Norco (a narcotic pain reliever) and all of my [spouse's] percocets (another narcotic pain reliever) or...I would have ended it..." EMS had been called by the pain clinic across town because the patient was threatening to self-harm if unable to get some relief. Patient #1 had a personal history of a past suicide attempt and sinus surgery. The patient was assigned to a room at 11:52 AM and was brought back by a volunteer (interviewee #4).

Policy HW-PC-210, revision date 11/2014 and approved by the Chief Nursing officer, Policy and Procedure Council, Infection Prevention Patient Safety Officer, and Emergency Department Committee Chair documented in part: "...this applies to all patients at risk for suicide surveillance seeking treatment at (this facility)...if it is apparent the patient has a previous history or is currently severely depressed...past or present suicide attempt...a 'Sad Person Suicide Screen' will be done...one on one (1:1) staffing til (sic) a lesser level of observation is ordered by the physician...as soon as possible, the staff will search the clothing...and place all of this in a bag by two (2) staff members..."

A Memorandum, dated 7/6/15, presented to the team on 7/7/15 at 4:00 PM, Effective Immediately, documented the following: "If/when a patient presents to our ED expressing suicidal/homicidal ideations, they are NEVER to be left unattended and must have
one on one observation at all times. This includes the restrooms, treatment rooms, triage room and any other area where a procedure may be done. The one on one observation may be performed by a nurse, ED tech, sitter, security guard or with a police/guard if in custody.

All suicidal/homicidal patients are to be undressed immediately and placed in a hospital gown. All belongings are to be searched and removed from the patient. The patient will be scanned with the hand held metal detector wand by a security guard. This is to be done prior to the physician seeing the patient and or a 1013/2013 being initiated."

Attached to the memorandum was an e-mail dated 7/6/15 at 6:00 PM, which directed in part, "...Please find the attached memo regarding our immediate process regarding ED suicidal/ homicidal patients. Please post and communicate at shift change pass down, in your unit/department communication books. Copies of this memo are being distributed to Security, ED and Overhouse (supervisor) this evening..."

Review of employee records:

Staff training records for RNs #1, #2 and #3 addressed the training module required for ER staff for patient care safety, which included high risk patients, monitoring of those high risk patients on different levels, including one-to-one monitoring (patient is arm length from the assigned staff member at all times), every fifteen (15) minute observation (patient is observed every fifteen (15) minutes) in close proximity, and de-escalation techniques (measures to calm patient down in the least restrictive measures). All the nurses had taken the course within the past year.

Interviews were as follows:

During an interview at 4:20 PM on 7/6/15 in the conference room, RN #6 stated, "I was with a patient in room 4 (bays 1-4 are in one large room.) I am not sure how [patient #1] got back to room 3. [RN #6] had given him a urinal. He/she used the urinal and insisted he/she needed to have a bowel movement in the bathroom. "I did not know about his/her history until after the incident. The triage nurse sometimes is unable to give us report. I was not made aware of the status of this particular patient... The nurse or physician assigns someone to sit with a patient if need be without a physician's order. Employee #6 reviewed the chart and verified he/she could not find any notations where patient #1 was placed on observation or with a sitter.

During an interview in the conference room at 10:00 AM on 7/7/15, Volunteer #4 stated, "That was my first day to volunteer in the hospital anywhere. The patient used the urinal and he was insistent on going to the restroom. I told him I would be outside the rest room. I was outside the room and heard a gunshot go off."

During an interview in the conference room at 10:10 AM on 7/7/15, RN #3 stated, "I had gotten him after the gunshot and was told in report that he had a past suicide attempt. They were doing CPR on him and cutting off his clothes."

During an interview at 10:20 AM on 7/7/15 in the conference room, RN #12 stated that ...I was on Triage (initial assessment). There were two MDs (physicians), one physician assistant, and four registered nurses on duty in the Emergency Department. Patient #1 came in via wheelchair via EMS. A local pain clinic called EMS... because the patient threatened to kill himself if he did not get something for pain. After triage at level 2 (urgent second priority), I called the nurses' station to tell them to make room for a suicidal patient. It took 10 minutes to make room for him and he was placed into a treatment room...a volunteer and a tech took him back to his room. They take the information (a print out of the first sheet of triage). As the Triage Nurse, I cannot leave the Triage area. I do not do the SAD assessment- in this case the primary nurse does the assessment. We are directed that volunteers can take patients via transport...I filled out the incident report for that day and put it in my supervisor's (employee #10) mailbox.

During an interview at 11:15 AM on 7/7/15, Security guard #9 stated in part"...I was with another 1013 (legally committed patient). The patient (#1) went to T-3 (bay 3 of 4)...It sounded like a gunshot or porcelain popping. The nurse opened the door. I saw patient (#1) sitting on the stool (toilet) slumped over. I notified my supervisor and he/she secured the gun.

During a review of the facility Quality Assurance Performance Improvement (QAPI) plan on 7/7/15 at 11:45 a.m. with the Chief Nursing Officer (CNO), the CNO acknowledged that the facility had a program for performance improvement which met quarterly; part of the plan included Emergency Room (ER) safety care interventions. Included in the staff training was how to care for patients presenting to the ER with high risk behaviors such as suicidal ideations. The QAPI plan indicated that the Governing Body was responsible for oversight of the facility and QAPI plan.

Based on review of the facility's policies and procedures, staff interviews, and quality data, it was determined that the facility failed to ensure that measures required by policy to protect patient safety in the Emergency Department (ED) were monitored.

Findings were:

Facility policy #HW-PC-210 entitled, Suicide Risk Assessment and Mitigation Activities, last revised November 2014, required that patients with past or current suicide ideations would be screened using the SAD Person Suicide Screen tool to determine what additional measures, if any would be taken to ensure the patient's safety. According to the tool, measures to be taken could include that patients determined to be at risk could be placed in a hospital gown, their clothing and personal effects be searched for unsafe contraband, that the patients be placed on a one-to-one level of observation, and that they never be left alone. The policy required that the consistent use of the suicide screen for every patient with a primary psychiatric diagnosis would be monitored as part of the facility's performance improvement activities.

During a review of the facility's Quality Assurance Performance Improvement (QAPI) plan on 7/7/15 at 11:45 a.m. with the Chief Nursing Officer (CNO), the CNO acknowledged that the facility had a program for performance improvement which met quarterly, and that part of the plan included Emergency Room (ER) safety care interventions. Included in the staff training was how to care for patients presenting to the ER with high risk behaviors such as suicidal ideations. The QAPI plan indicated that the Governing Body was responsible for oversight of the facility and QAPI plan. This was supported through review of the facility's QAPI documentation. However, review of the documentation failed to reveal evidence that the use of the Sad Person Suicide Screen and the implementation of the measures required by policy were being monitored for effectiveness and patient safety.

Based on review of medical records, training records, and interviews, the facility failed to provide proper oversight of patient care resulting in the subsequent fatal injury of a patient.
Patient # 1, who entered the Emergency Room (ER) for evaluation and treatment of suicide ideations, was not provided with the care and oversight to ensure his/her safety, as follows:
a) Proper communication was not provided between staff located in separate areas of the ER, but who were responsible for the patient's care and safety;
b) Persons responsible to provide care and monitoring of the patient were not qualified through training and experience to do so; and
c) Facility policies and procedures, already in place and current, were not followed by the staff responsible to ensure the patient's safety.

The suicidal patient entered the ER with a gun, was not searched, and was monitored by a new Volunteer untrained to provide the monitoring essential to ensure the patient's protection. Communication between staff of the patient's risk for suicide did not occur until after the self-injury. The patient was left unmonitored in the bathroom, shot him/herself, and later died of the injuries.

During an interview at 4:20 PM on 7/6/15 in the conference room, RN #6 stated, "I was with a patient in room 4 (bays 1-4 are in one large room.) I am not sure how [patient #1] got back to room 3. [RN #6] had given him a urinal. He/she used the urinal and insisted he/she needed to have a bowel movement in the bathroom. "I did not know about his/her history until after the incident. The triage nurse sometimes is unable to give us report. I was not made aware of the status of this particular patient... The nurse or physician assigns someone to sit with a patient if need be without a physician's order. Employee #6 reviewed the chart and verified he/she could not find any notations where patient #1 was placed on observation or with a sitter.


Findings include:
Cross refer to A-0392 Staffing and Delivery of Care
Cross refer to A-0396 Nursing Care Plan
Cross refer to A-0397 Patient Care Assignments

Based on review of facility records, policies, staff training records and staff interviews, the facility failed to provide proper oversight of delivery of patient care, contributing to the subsequent fatal injury of one (1- patient #1) of ten (10) records reviewed.

Findings include:

A review of the medical record for patient #1 revealed that an 89 year old presented to the Emergency Department via EMS ambulance at 11:40 AM on 6/29/15. Triage was begun at 11:41 AM. The patient signed consent for treatment. He/she had a history of three weeks of headache and stated in part "...I took all of my Norco (a narcotic pain reliever) and all of my [spouse's] percocets (another narcotic pain reliever) or...I would have ended it..." EMS had been called by the pain clinic across town because the patient was threatening to self-harm if unable to get some relief. Patient #1 had a personal history of a past suicide attempt and sinus surgery. The patient was assigned to a room at 11:52 AM and was brought back by volunteer (interviewee #4).

Policy HW-PC-210, revision date 11/2014, approved by the Chief Nursing officer, Policy and Procedure Council, Infection Prevention Patient Safety Officer, and Emergency Department Committee Chair documented in part: "...this applies to all patients at risk for suicide surveillance seeking treatment at (this facility)...if it is apparent the patient has a previous history or is currently severely depressed...past or present suicide attempt...a 'Sad Person Suicide Screen' will be done...one on one (1:1) staffing til (sic) a lesser level of observation is ordered by the physician...as soon as possible, the staff will search the clothing...and place all of this in a bag by two (2) staff members..."

Staff training records for RNs #1, #2 and #3 addressed the training module required for ER staff for patient care safety - included high risk patients, monitoring of those high risk patients on different levels, one-to-one (staff is arm-length from the patient at all times), every fifteen(15) minutes observation (patient is observed every fifteen (15) minutes) in close proximity and de-escalation techniques (measures to calm patient down in the least rest restrictive measures). All the nurses had taken the course within the past year.

The ED Volunteer Orientation Checklist was reviewed and failed to reveal documentation that volunteer #4 had undergone training related to the Emergency Medical Training and Labor Act (EMTALA) or how to transport or care for patients with self-harm ideations.

Interviews were as follows:

During an interview at 4:20 PM on 7/6/15 in the conference room, RN#6 stated, "I was with a patient in room 4 (bays 1-4 are in one large room.) I am not sure how [patient #1] got back to room 3. [RN #6] had given him a urinal. He/she used the urinal and insisted he/she needed to have a bowel movement in the bathroom. I did not know about his/her history until after the incident. The triage nurse sometimes is unable to give us report. I was not made aware of the status of this particular patient... The nurse or physician assigns someone to sit with a patient if need be without a physician's order. Employee #6 reviewed the chart and verified he/she could not find any notations where patient #1 was placed on observation or with a sitter.

During an interview with the Chief Nursing Officer (CNO- employee #13) at 4:45 PM in the conference room on 7/6/15, it was related in part "...this was the first day of this person as a volunteer (#4). He/ She had never worked in the emergency department before. Shadowing is done with the nursing staff where the volunteer follows around and observes for a time.

During an interview at 10:00 AM on 7/7/15 in the conference room, Volunteer #4 stated, "That was my first day to volunteer in the hospital anywhere. The patient used the urinal and he was insistent on going to the restroom. I told him I would be outside the rest room. I was outside the room and heard a gunshot go off."

During an interview at 11:15 AM on 7/7/15, Security guard #9 stated in part "...I was with another 1013 (legally committed patient). The patient (#1) went to T-3 (bay 3 of 4)...It sounded like a gunshot or porcelain popping. The nurse opened the door. I saw patient (#1) sitting on the stool (toilet) slumped over. I notified my supervisor and he/she secured the gun.

During a review of the facility Quality Assurance Performance Improvement (QAPI) plan on 7/7/15 at 11:45 a.m. with the Chief Nursing Officer (CNO), the CNO acknowledged that the facility had a program for performance improvement which met quarterly; part of the plan included Emergency Room (ER) safety care interventions. Included in the staff training was how to care for patients presenting to the ER with high risk behaviors such as suicidal ideations. The QAPI plan indicated that the Governing Body was responsible for oversight of the facility and QAPI plan.

Based on review of facility records, policies, staff interviews and training records, the facility failed to modify the plan of care to meet the urgent needs in one (1) of ten (10) medical records reviewed.

Findings include:

Facility policy #HW-PC-210 entitled, Suicide Risk Assessment and Mitigation Activities, last revised November 2014, required the following:
1. A suicide risk assessment would be provided for patients who presented with a past or present suicide attempt or a clear statement of suicidal intent. The assessment would be performed using the "Sad Person Suicide Screen" tool in order to "assist in determining additional safety precautions", which would include placement in a room proximal to the nurses' desk, screening the room for potential hazards, one-on-one (1:1) staffing, asking the patient to undress and change into a hospital gown, searching the patient's clothing for potentially harmful contraband, and being wanded by security.
2. Notification of the physician or LIP (Licensed Independent Practitioner- Physician's Assistant or Nurse Practitioner) as soon as possible;
3. High risk suicide patients were not to be left alone at any time.
4. Modifications to the patient's plan of care would be made to address the patient's risk level and/or physician's order;
5. Staff training in deescalation techniques to reduce the need for use of restraints;
6. Performance Improvement activities to include monitoring the consistent use of the suicide screens for patients with a primary psychiatric diagnosis.

Facility policy #HW-NSG-311 entitled, Sitters, last revised July 2014, documented that "Security Officers and any employee who has completed sitter training education may function as patient sitters.". The policy did not address the use of volunteers as sitters.

During an interview at 10:20 AM on 7/7/15 in the conference room, RN #12 stated that ...I was on Triage (initial assessment). There were two MDs (physicians), one physician assistant, and four registered nurses on duty in the Emergency Department. Patient #1 came in via wheelchair via EMS. A local pain clinic called EMS... because the patient threatened to kill himself if he did not get something for pain. After triage at level 2 (urgent second priority), I called the nurses' station to tell them to make room for a suicidal patient. It took 10 minutes to make room for him and he was placed into a treatment room...a volunteer and a tech took him back to his room. They take the information (a print out of the first sheet of triage). As the Triage Nurse, I cannot leave the Triage area. I do not do the SAD assessment- in this case the primary nurse does the assessment. We are directed that volunteers can take patients via transport...I filled out the incident report for that day and put it in my supervisor's (employee #10) mailbox.

Review of documentation in MR #1 failed to reveal documentation that safety measures, as required by the patient's admitting diagnosis and facility policy, had been implemented as part of the patient's plan of care.

Based on record reviews, policy reviews, training records, and interviews, the facility failed to provide proper staff assignment for competent delivery of patient care contributing to the subsequent fatal injury of one (1- patient #1) of ten (10) records reviewed.

Findings include:

A review of the medical record for patient #1 revealed that an 89 year old male presented to the Emergency Department via EMS ambulance at 11:40 AM on 6/29/15. Triage was begun at 11:41 AM. The patient signed consent for treatment. He/she had a history of three weeks of headache and stated in part "...I took all of my Norco (a narcotic pain reliever) and all of my spouse's percocets (another narcotic pain reliever) or...I would have ended it..." EMS had been called by the pain clinic across town because the patient was threatening to self-harm if unable to get some relief. Patient #1 had a personal history of a past suicide attempt and sinus surgery. The patient was assigned to a room at 11:52 AM and was brought back by volunteer (interviewee #4).

Policy HW-PC-210, revision date 11/2014 and approved by the Chief Nursing Officer, Policy and Procedure Council, Infection Prevention Patient Safety Officer, and Emergency Department Committee Chair documented in part: "...this applies to all patients at risk for suicide surveillance seeking treatment at (this facility)...if it is apparent the patient has a previous history or is currently severely depressed...past or present suicide attempt...a 'Sad Person Suicide Screen' will be done...one on one (1:1) staffing til (sic) a lesser level of observation is ordered by the physician...as soon as possible, the staff will search the clothing...and place all of this in a bag by two (2) staff members..."

Staff training records for RNs #1 , #2 and #3 addressed the training module required for ER staff for patient care safety - and included high risk patients, monitoring of those high risk patients on different levels, including one-to-one (staff is arms-length from the patient at all times), every fifteen (15) minutes observation (patient is observed every fifteen (15) minutes) in close proximity and de-escalation techniques (measures to calm patient down in the least rest restrictive measures). All the nurses have taken the course within the past year.

The ED Volunteer Orientation Checklist was reviewed and failed to reveal documentation that volunteer #4 had undergone training related to the Emergency Medical Training and Labor Act (EMTALA) or how to transport or care for patients with self-harm ideations.

Interviews were as follows:

During an interview at 4:20 PM on 7/6/15 in the conference room #6, RN stated, "I was with a patient in room 4 (bays 1-4 are in one large room. I am not sure how (patient #1) got back to room 3. (RN #6) had given him a urinal. He/she used the urinal and insisted he/she needed to have a bowel movement in the bathroom. "I did not know about his/her history until after the incident. The triage nurse sometimes is unable to give us report. I was not made aware of the status of this particular patient... The nurse or physicians assigns someone to sit with a patient if need be without a physician's order. Employee #6 reviewed the chart and verified he/she could not find any notations where patient #1 was placed on observation or with a sitter.

During an interview with the Chief Nursing Officer (CNO- employee #13) at 4:45 PM in the conference room on 7/6/15, it was related in part "...this was the first day of this person as a volunteer (#4). He/ She had never worked in the emergency department before. Shadowing is done with the nursing staff where the volunteer follows around and observes for a time.

During an interview at 10:00 AM on 7/7/15 in the conference room Volunteer #4 stated that, "That was my first day to volunteer in the hospital anywhere. The patient used the urinal and he was insistent on going to the restroom. I told him I would be outside the rest room. I was outside the room and heard a gunshot go off."

During an interview at 11:15 AM on 7/7/15 Security guard #9 stated in part"...I was with another 1013 (legally committed patient); the patient (#1) went to T-3 (bay 3 of 4)...It sounded like a gunshot or porcelain popping. The nurse opened the door. I saw patient (#1) sitting on the stool (toilet) slumped over. I notified my supervisor and he/she secured the gun.

During a review of the facility Quality Assurance Performance Improvement (QAPI) plan on 7/7/15 at 11:45 a.m. with the Chief Nursing Officer (CNO), the CNO acknowledged that the facility had a program for performance improvement which met quarterly; part of the plan included Emergency Room (ER) safety care interventions. Included in the staff training was how to care for patients presenting to the ER with high risk behaviors such as suicidal ideations. The QAPI plan indicated that the Governing Body was responsible for oversight of the facility and QAPI plan.

Review of documentation in MR #1 failed to reveal documentation that safety measures, as required by the patient's admitting diagnosis and facility policy, had been implemented as part of the patient's plan of care, to include assignment of staff to monitor the patient who were qualified by education and training to provide a one-on-one level of observation.