HospitalInspections.org

A. Based on document review and interview it was determined that, for 1 of 3 (Pt. #1) patient clinical records reviewed for monitoring while on suicide precautions, the Hospital failed to provide care in a safe setting while the Safety Assistant (E #4) lacked to provide constant direct observation of Pt. #1. This resulted in Pt. #1 elopement from the Hospital.

Findings include:

1. On 9/18/19, the Hospital's policy "Initiating a Safety Assistant" (approved 4/1/19) was reviewed and included "1. The use of a Safety Assistant (SA) is required for patients with suicidal ideation (SI) ...Safety Assistant ...2. Direct observation is required at all times of all patients requiring a safety assistant and includes but not limited: While in/using the bathroom facilities ..."

2. On 9/19/19 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was transferred from (Hospital B) to the Surgical Intensive Care Unit (SICU) of the Hospital with a diagnosis of Tylenol (Acetaminophen) (medication for fever and pain management) toxicity (acute ingestion of high dosage of acetaminophen) and acute liver failure on 8/28/19. On 8/29/19 at 3:47 PM, Pt. #1 was transferred to the General Medicine Unit (9 Atrium). The clinical record included:

- The "Psychiatry Consultation" dated 8/28/19 at 3:25 PM, included " ...Reason for Consult: Concern for intentional overdose/suicidal attempt ...Suicide Risk Assessment: Based on this evaluation, (Pt. #1) is at high risk for suicide in the healthcare setting. Suicide Risk Formulation: There is a concern that patient may have recently intentionally overdosed on acetaminophen despite (Pt. #1) denial. Based on concerns from the girlfriend and the amount of acetaminophen ...ingested to cause this amount of liver damage ...I recommend we place a 1:1 safety assistant for suicide precautions ..."

- Pt. #1 physician's orders dated 8/28/19 at 4:32 PM for one to one constant visual observation for suicide.

-The "Nurse Progress Note" dated 8/31/19 at 4:16 PM, included, " ...SA reports that upon rechecking shower, approximately 30-60 seconds after visualization, (Pt. #1) to be absent from the bathroom. Security notified. Code Gold (the Hospital's alarm system to announce an elopement of a patient) called.

3. On 9/18/19 at approximately 12:57 PM, Pt. #1's "Safety Event" (Incident Report) dated 8/31/19 was reviewed. The report included the following: Occurred to: Inpatient; Time: 3:25 PM; Date: 8/31/19; Location: 9 South Atrium ...Reported by the nurse (E #3); Witnesses by PCT [Patient Care Technician] E #4; Incident Type: SI (Suicide Ideation)(Pt. #1) with 1:1(one to one) SA, absconded from unit ...Narrative...1:1 SA present at bedside during rounding. (3:37 PM) notified by charge nurse (per 1:1 SA) that (Pt. #1) not present in room. Per SA, (Pt. #1) had requested to take a shower, was last seen in the bathroom with shower running and door to the bathroom opened. (Pt. #1) last seen wearing scrubs and hospital socks. SA
reports that upon rechecking shower, approximately 30-60 seconds after visualization, (Pt. #1) noted to be absent in the bathroom ..."

4. On 9/17/19 at approximately 2:53 PM, the Patient Care Technician (PCT-E #4) was interviewed. E #4 was the assigned SA assigned to Pt. #1 at the time Pt. #1 eloped from the Hospital. E #4 stated "(Pt. #1) requested to take a shower. The nurse said it was ok...(Pt. #1) went to the shower. I (E #4) went to the computer (that is fixed to the wall in Pt. #1's room) approximately a foot from the door. When I turned to check on (Pt. #1), he was not in the room. I had to turn my back from (Pt. #1) to document in the computer. During that moment (30-60 seconds) Pt. #1 managed to leave the room. I informed the charge nurse and a code gold (elopement response plan) was called.

B. Based on document review and interview, it was determined that for 1 (Pt. #1) of 1 clinical records reviewed for suicidal precautions, the Hospital failed to ensure care in a safe setting by not removing personal belongings as required per policy.

Findings include:

1. On 9/17/19, the clinical record of Pt. #1 was reviewed. Pt. #1 was transferred from (Hospital B) to the Surgical Intensive Care Unit (SICU) of the Hospital with a diagnosis of Tylenol (Acetaminophen) (medication for fever and pain management) toxicity (acute ingestion of high dosage of acetaminophen) and acute liver failure on 8/28/19. On 8/29/19 at 3:47 PM, Pt. #1 was transferred to the General Medicine Unit (9 Atrium). The clinical record included:

. The clinical record included the following:

- The "Psychiatry Consultation" dated 8/28/19 at 3:25 PM, included " ...Reason for Consult: Concern for intentional overdose/suicidal attempt ...Based on this evaluation, (Pt. #1) is at high risk for suicide in the healthcare setting."

- The "Physician Orders" included an order dated 9/28/19 at 4:32 PM for one to one constant visual observation for suicide.

- The "Belongings/Valuables Form" dated 8/28/19 at 12:00 PM, was reviewed. included "...clothing: Sent home. This list does not indicate if Pt. #1 had a cellular phone at the time of admission.

- The "Nurse Progress Note" dated 8/28/19 at 7:19 PM, included, ...1:1 safety aide initiated for concern for...suicide attempt per psychiatry. Room prepared per policy and belongings taken per policy ..."

- The "Social Worker Progress Note" dated 8/30/19 at 3:25 PM, included " ... (Psychiatric Social Worker (E #5) returned to meet with (Pt. #1) this afternoon. (Pt. #1) was lying in bed and looking at his phone..."

2. On 9/18/19 at approximately 10:15 AM, the "Root Cause Analysis" (RCA) for Pt. #1's elopement (8/31/19) was reviewed. One of the areas of opportunity was that Pt. #1 was on suicide precautions and remained his cellular phone (personal belonging) during his admission.

3. On 9/18/19, the Hospital's policy titled "Search of a Patient Room, Property and Person" (approved on 4/1/19) included "1. The searching of a person or property is to be done in the interest and safety of patient, visitors and staff ...Search team: Conduct the search, inspect ... belonging ...Remove ...all prohibited items and give to security officer ...

4. On 9/18/19, the Hospital's Signage titled "Visitors Information Sheet when a patient has a Safety Assistant" was reviewed and included " ...you will not be able to bring them any of the following while they have a Safety Assistant: Electronics (cell phones ..."

5. On 9/19/19 at approximately 12:00 PM, the findings were discussed with the Associate Vice President , Regulatory and Clinical Effectiveness (E #9). E #9 stated that Pt. #1 should not have had his celular phone due to the provider's evaluation that assessed Pt. #1 as high risk for suicide.