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Based on medical record review, policy review, document review, and interview, in five of sevent medical record reviewed, it was determined that facility staff failed to implement suicdie precautions (removal of self-harming objects) and failed to provide 1:1 observation for patients at high risk of suicide (Patient #11, #25, #26, #27, and #29). (A1104).

Cross Reference:
482.55 (a)(3)- Emergency Services Policies

Based on policy review, document review, medical record review, and interview, the facility failed to ensure the ongoing assessment of patient care provided in the emergency department, as evidenced by:
1. Strong Memorial Hospital West Brockport staff failed to perform belongings/safety checks for four of seven suicidal patients (Patient #11, #26, #27 and #29) and did not implement suicide precautions and 1:1 observation/sitter for five of seven suicidal patients (Patient #11, #25, #26, #27, and #29).
2. Strong Memorial Hospital West Brockport does not have a policy or staff guidance document that addresses the care and observation needs for patients with suicidal ideation being treated in the emergency department.

Findings #1:

Review of the policy "Care of The Suicidal Patient at Strong West Emergency Department," last revised on 07/05/22, indicated if a patient screens high risk for suicide based on the Columbus Suicide Severity Rating Scale (suicide risk assessment to determine patient interventions and needs), they will be removed from the waiting room and placed in the appropriate care area. If suicide precautions are ordered, frequent and direct visualization must be provided by the staff as assigned by the charge nurse. A registered nurse is assigned to coordinate the patient's care and another staff member (licensed practical nurse) may provide 1:1 coverage as available. The charge nurse must be notified for a 1:1 sitter.

Review of the medical record "Suicide Observation," flowsheet section indicated the registered nurse must document the following: if the 1:1 was initiated; if the order was reviewed/obtained for suicide observation; if the 1:1 staff member was in place; and the initial room and patient search. All clothing and belongings are searched by staff and removed from the area. Green socks and a wrist band must be placed on the patient. Staff will modify the patient care area to the safest possible way to prevent self-harm by removing all cords and medical equipment from the room; 1:1 status was explained to patient/family; if there was a suicide attempt within the last year; and if the patient had a suicide plan/ideation (thinking of committing suicide). Each shift (twice daily) nursing documentation on the flowsheet will include the following: a room search to provide a safe environment, patient search with items removed if found, visitation with family/friends, and any verbalization of suicide ideations. Hourly 1:1 documentation of the flowsheet will include: if the 1:1 observation was maintained; what behaviors were observed; was the patient having any unusual thoughts; the use of 1:1 observation interventions (coping skills taught, sleep, encouragement, distraction), and the use of distraction (TV, radio, family visitors, games, activities).

Medical record review, dated 09/23/23 at 10:18 AM, revealed Patient #11 presented to the facility for intentional drug overdose and a suicide attempt. The Columbia Suicide Severity Rating Scale indicated Patient #11 was high-risk for suicide. At 11:08 AM, Staff (MMM), Registered Nurse implemented suicide precautions with direct 1:1 observation. (From 11:08 PM to 12:01 PM, there was no documentation that suicide precautions, including room check/modification and belongings check were initiated and/or that 1:1 direct observation was maintained every hour while in the emergency department).

Medical record review, dated 10/02/23 at 09:44 PM, revealed Patient #25 presented to the facility for suicidal ideation and cutting the right wrist in an attempted suicide. Patient #25 was assessed using a pediatric suicide screening questions (used for patients ages 8-24) and deemed at "imminent risk" (high risk) of suicide. At 09:48 PM, Staff (I), Registered Nurse implemented suicide precautions with direct 1:1 observation. (From 10/02/23 at 09:48 PM to 10/03/23 at 12:01 AM, there was no documentation that 1:1 direct observation was maintained every hour while in the emergency department).

Medical record review, dated 11/01/23 at 11:50 AM, revealed Patient #26 presented to the facility for a suicide attempt. At 12:31 PM, the Columbia Suicide Severity Rating Scale indicated Patient #26 was at high-risk for suicide. (From 12:31 PM to 02:59 PM, there was no documentation that suicide precautions, including a room check/modification and belongings check were initiated and/or that 1:1 direct observation was initiated and maintained every hour while in the emergency department).

Medical record review, dated 09/20/23 at 08:49 PM, revealed Patient #27 presented to the facility for suicidal ideation. The Columbia Suicide Severity Rating Scale indicated Patient #27 was high-risk for suicide. At 09:04 PM, Staff (NNN), Registered Nurse implemented suicide precautions with direct 1:1 observation. (From 09/20/23 at 09:04 PM to 09/21/23 at 03:58 AM, there was no documentation that suicide precautions including room check/modification and belongings check were initiated and/or that 1:1 observation was maintained every hour while in the emergency department).

Medical record review, dated 10/19/23 at 06:59 PM, revealed Patient #29 presented to the facility for suicidal ideation. At 07:10 PM, Staff (NNN), Registered Nurse implemented suicide precautions with direct 1:1 observation. (From 07:10 PM to 09:52 PM, there was no documentation that suicide precautions, including room check/modification and belongings check were initiated and/or that 1:1 direct observation was maintained every hour while in the emergency department).

Interview on 12/15/23 at 02:25 PM with Staff (M), Registered Nurse Assistant Quality Officer verified these findings.

Findings #2:

Review of facility policies and procedures revealed no evidence of a policy or staff guidance document that describes 1:1 observation and/or the requirements of use in the emergency department. Policies only indicate 1:1 observation can be utilized.

Interview on 12/15/23 at 02:25 PM with Staff (L), Assistant Quality Officer, and Staff (M), Registered Nurse/Assistant Quality Officer, verified the findings and stated there is no specific 1:1 observation policy for the Strong Memorial Hospital West Brockport Emergency Department.