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Based on record review, policy and procedure review and interviews, the Hospital failed to protect and promote care in a safe setting for one patient, (Patient #1), out of a total sample of fifteen patients, when the close observation for Patient (Pt.) #1 with suicidal ideation was interrupted which resulted in Pt. #1 later being found with the string of his/her pajama pants around his/her neck in an attempt to strangle him/herself. Pt. #1 required stabilization and admission to the Intensive Care Unit for overnight monitoring.

Findings include:

Review of the Emergency Department (ED) Triage Note, timed and dated 3:03 P.M. on 6/18/14, indicated that Pt. #1 came to the ED with a chief complaint of suicidal ideation for several months and a history of a previous suicide attempt by hanging .

The Behavioral Health Specialist assigned to observe the patient closely, left the patient at 4:00 P.M. on 6/18/14, stating she notified the Security Officer who was monitoring a patient on 1:1 observation in the next room (Room 10), that she was going to get a menu.

The Hospital ED Behavioral Health Safety Assessment Signature Page identified Pt. #1 as a Level 3 Behavioral Health Patient. Level 3 requires by policy that Secuirty's presence is needed and that a visual contact must be made with the patient every 15 minutes. The Hospital ED Behavioral Health Safety Assessment Signature Page indicated that the Behavioral Health Specialist signed off to the Security Officer at 4:00 P.M. on 6/18/14 and did not sign back in until 5:00 P.M. whereupon she found Pt. #1 with the pajama cord around his/her neck.

Nurses notes indicated that the ED Physician responded immediately, Pt. #1's neck was stabilized, he/she was lifted to the stretcher, oxygen administered and his/her breathing improved. The Note indicated that Pt. #1 had baseline laboratory studies and x-rays and was sent to the Intensive Care Unit for overnight observation.

See A-0144 for details

Based on record review, policy and procedure review and interviews, the Hospital failed to ensure care in a safe setting for one patient, (Patient #1), out of a total sample of fifteen patients, when the close observation for Patient (Pt.) #1 with suicidal ideation was interrupted which resulted in Pt. #1 later being found with the string of his/her pajama pants around his/her neck in an attempt to strangle him/herself. Pt. #1 required stabilization and admission to the Intensive Care Unit for overnight monitoring.

Review of the Emergency Department (ED) Triage Note, timed and dated 3:03 P.M. on 6/18/14, indicated that Pt. #1 came to the ED with a chief complaint of suicidal ideation for several months and a history of a previous suicide attempt by hanging . The ED Triage Note indicated that a Behavioral Health Safety Assessment was conducted and Pt. #1 was identified as a Security Level 3.

The Security Levels for ED Patients Policy, last reviewed 5/15/13, indicated that Level 3 Security Measures included that: a) Security is notified and present, b) The patient is in a private room, c) A personal search is conducted, d) the patient must be accompanied to the bathroom if applicable and e) The patient is in control but verbalizes thoughts of hurting self/others with some plan.

The Patient Watches Policy, implemented 8/16/12, indicated that a Behavioral Health Level 3 ED Patient requires that Security's presence is needed and that a Security Officer will make visual contact with the patient every 15 minutes.

The Surveyor interviewed the Psychiatric Triage Clinician at 12:50 P.M. on 7/8/14. The Psychiatric Triage Clinician said that she knew Pt. #1 was coming to the ED because Pt. #1's psychiatrist had called to say Pt. #1 was coming and needed to be admitted. The Psychiatric Triage Clinician said that she knew Pt. #1 very well and Pt. #1 had an extensive psychiatric history with multiple hospitalizations. The Triage Clinician said that Pt. #1 was brought to a psychiatric safe room (Room 9) and the ED Physician medically cleared Pt. #1 for admission. The Psychiatric Triage Clinician said that the Behavioral Health Specialist was assigned to provide close observation for Pt. #1.

The Surveyor interviewed the Behavioral Health Specialist at 1:04 P.M. on 7/8/14. The Behavioral Health Specialist said that she knew Pt. #1 was assigned a Behavioral Health Level 3 Security Code which requires every 15 minute visual checks. The Behavioral Health Specialist said that she needed to get a menu for Pt. #1 and at 4:00 P.M. on 6/18/14, she notified the Security Officer monitoring a patient in the next room (Room 10), that she was going to get a menu.

The Hospital ED Behavioral Health Safety Assessment Signature Page, which identified Pt. #1 as a Level 3 Behavioral Health Patient (a patient currently in control but has verbalized thought of hurting self/others with some plan), indicated that the Behavioral Health Specialist signed off to the Security Officer at 4:00 P.M. on 6/18/14 and did not sign back in until 5:00 P.M. whereupon she found Pt. #1 with the pajama cord around his/her neck.

The Surveyor interviewed the Security Officer at 2:16 P.M. on 7/8/14. The Security Officer said that the Behavioral Health Specialist did not relay any specific information regarding Pt. #1's psychiatric history to him and only knew that Pt. #1 was a Security Level 3, requiring 15 minute visual checks. The patient he was monitoring was a 1:1 requiring direct observation at all times. The Security Officer said he checked on Pt. #1 but was not sure of the times or how often. The Surveyor noted that from where the Security Officer was sitting by Room 10, he did not have a direct line of vision on Pt. #1 in Room 9 at all times.

The ED Nursing Note, dated 5:04 P.M. on 6/18/14, indicated that Pt. #1 was found sitting on the floor of his/her room with the tie cord of the pajama pants around his/her neck. The Note indicated that the tie cord was removed immediately and that Pt. #1 was cyanotic (bluish discoloration due to lack of oxygen) about the face and was breathing slowly. The Note indicated that the ED Physician responded immediately, Pt. #1's neck was stabilized, he/she was lifted to the stretcher, oxygen administered and his/her breathing improved. The Note indicated that Pt. #1 had baseline laboratory studies and x-rays and was sent to the Intensive Care Unit for overnight observation. Pt. #1 was transferred to the Psychiatric Unit the next day.

The Hospital conducted a Root Cause Analysis and formulated a Corrective Action Plan.

The Root Cause Analysis was conducted on 7/1/14 and determined/defined the following:

1) Pt. #1's previous admission to the Hospital was in April of 2014 for an attempted hanging.

2) Pt. #1 was assessed as a Behavioral Level 3 requiring every 15 minute visual checks when he/she should have been a higher Level which requires strict 1:1 observation.

3) Pt. #1 was placed in a psychiatric safe room, his/her clothes were removed and he/she was given a hospital johnnie with strings and pajama pants with a tie cord around the waist.

4) There was a communication breakdown between the Behavioral Health Specialist (the sitter) and the Security Guard.

5) At the time of the incident there were three Level 3 patients in the ED and one Level 4 (actual or high potential for violence against self or others. 1:1 Security outside door) patient.

6) Clearer policies and procedures are needed to define constant observation.

7) There is a need to better define hand-off and SBAR (Situation, Background, Assessment, and Recommendations) communication to enhance patient safety.

8) There is a need to review best practice, clarify security level definitions and the role of 1:1 providers.

9) There is currently no documentation tool to verify that constant observation is being provided.

The Corrective Action Plan included:

1) Immediate removal of all hospital johnnies and pajama pants with string ties for the psychiatric patient. The Hospital is currently looking into the purchase of stringless johnnies. Presently the strings have been cut off all johnnies used for psychiatric patients and no pajama pants are being used. Psychiatric patient are given two johnnies so the second johnnie can act as a bathrobe (completed).

2) All patients entering the ED with a statement of suicidal ideation are immediately brought to a room and placed on 1:1 observation until evaluation by a Behavioral Health Clinician deems the patient is no longer at risk for self harm (completed and ongoing).

3) Eliminating the current Behavioral Health Safety Assessments and adopting the Modified SAD PERSONS suicide assessment scale which can aid in the prediction of suicide risk, however is not to be the determining factor in assessing risk (education and training in progress-not fully implemented at the time of the Survey).

4) Development of a Constant Observation Log which will verify that constant observation is being maintained and appropriate hand-off communication occurs when there is a change in the sitter or Security Guard (implemented with education and training in progress).

5) Development of a per diem pool for sitters (in progress).

6) Communication between the ED Charge Nurse and the Administrative Supervisor on each shift to identify in-house staff currently on duty that could be be utilized as 1:1 sitters if the need arises in the ED (implemented and ongoing).