HospitalInspections.org

Based on review of the clinical record, review of facility policies, observations, and interviews, the facility failed to ensure that all hazardous items were removed from the Emergency Department (ED) holding room of one of three patients, Patient #5, who presented to the ED with symptoms of suicidal ideation. The findings include:

a. Patient #5 was admitted to the Emergency Department (ED) on 10/12/11 at 4:49 PM with diagnoses that included depression and suicidal ideation. The clinical record further identified that Patient #5 had a history of multiple inpatient psychiatric admissions at different facilities. Patient #5 was assessed to be a high risk for suicide and was placed on constant observation in a holding room in the main ED. Review of the ED record dated 10/13/11 identified Patient #5's thoughts of suicide with interventions that included the provision of a safe environment. Although a staff member was seated in the doorway outside Patient #5's room, observation of the room assigned to the patient on 10/13/11 at 10:15 AM identified that the room contained potential hazards that included a long call bell cord and multiple cords from medical equipment that were observed within the patient's reach. A tour of the ED identified that the department had three "safe rooms" that utilized a pull down safety door that allowed staff to safeguard medical equipment on the wall that could be a potential hazard to the patient. Although one of the safe rooms was available, Patient #5 had not been transferred to that room. Interviews with facility staff at the time of the observation identified that safe rooms would usually be utilized for patients who reported suicidal ideation if there was no available space in the Emergency Crisis Area (ECA). The staff members were unable to explain why Patient #5 was in a regular ED holding room when the safe room was available. Subsequent to surveyor inquiry, Patient #5 was transferred to the safe room and the potentially hazardous medical equipment was secured behind the pull down door. Review of the Patient Rights policy directed that patients had the right to receive care in a safe setting.

Based on a review of clinical records, review of facility policies, observations, and interviews, the facility failed to ensure that the Quality Improvement/Performance Improvement Committee implemented and/or revised interventions after identification of concerns related to obtaining/completing crisis evaluations/treatment plan timely as directed by Emergency Department physicians. The clinical records for three of ten patients, Patient #3, #8, and #9, who were admitted to the Emergency Department and required treatment for substance abuse, were identified to have significant delays in the completion of a crisis evaluation in accordance with physician orders. The findings include:

a. Patient #3 was admitted to the Emergency Department (ED) on 10/11/11 with diagnoses that included Alcohol Intoxication, depression, and suicidal ideation. Upon medical clearance, Patient #2 was transferred into the Emergency Crisis Area (ECA). Review of the clinical record with facility staff on 10/13/11 at 10:04 AM identified that the record lacked documentation to reflect that a treatment plan had been developed to address Patient #3's substance abuse in accordance with facility policies. Interview with the Manager of the Crisis Clinicians on 10/13/11 at the time of the record review identified that facility policy directed that a treatment plan be developed within twelve hours of admission.

b. Review of Patient #3's physician's orders dated 10/12/11 at 6:08 AM directed that a crisis evaluation be obtained. Review of the clinical record identified that the crisis evaluation was not completed until 6:46 PM on 10/12/11, twelve hours later.

c. Patient #8 presented to the satellite ED on 4/8/11 at 6:13 PM with a suicide attempt and alcohol use. Physician's orders dated 4/8/11 at 7:20 PM directed that a crisis evaluation be obtained. The patient was transferred to the main ED and arrived at 9:40 PM. Review of the clinical record indicated that the crisis evaluation was not completed until 1:30 PM on 4/9/11, seventeen hours after the order.

d. Patient #9 presented to the ED on 6/19/11 at 2:26 AM with change of mental status, alcohol use, and a fall. Physician's orders dated 6/19/11 at 6:56 AM directed that a crisis evaluation be obtained. The clinical record indicated that the crisis evaluation was not started until 4:20 PM on 6/19/11, nine hours later.

Review of the facility policy indicated the crisis workers complete a psychiatric assessment as soon as possible. The policy indicated that the responsibilities of the crisis worker include responding to crisis phone calls made to the ED, EAP, mental health clinic, Partial Hospital Program, and Child/Family services. In addition they serve as a crisis service for the ambulatory psychiatric services after hours. Interview with Director of Behavioral Health on 10/14/11 at 1:45 PM indicated that the time frame between the order and completion of the crisis evaluation is monitored on a monthly basis and had been identified as a concern since April 2011. The Director indicted that there is a work group that meets monthly to discuss the issues and a part time position had been filled and a per diem position has been posted. Review of facility documentation that included the work group minutes identified that although the data regarding untimely crisis evaluations was documented in each monthly meeting since April of 2011, the minutes lacked documentation to reflect that revisions were made to the plan in more than five months in an effort to increase timeliness of obtaining the evaluations until all positions could be filled.

Based on a review of clinical records, review of facility policies, observations, and interviews, the facility failed to provide adequate nursing supervision to prevent injury to one patient, Patient #1, who although was identified as at low risk for suicide, was found hanging from a bed sheet in the Emergency Department holding room and subsequently expired. In addition, the facility failed to ensure that nursing documentation in Patient #1's clinical record was accurate and/or complete, and/or that assessments were documented.

Please reference A 395 and A 396

Based on review of the clinical record, review of facility policies, observations, and interviews, the facility failed to provide adequate nursing supervision to prevent injury to one patient, Patient #1, who although was identified as at low risk for suicide, was found hanging from a bed sheet in the Emergency Department and subsequently expired. The findings include:

a. Patient #1 was admitted to the Emergency Department (ED) on 10/11/11 at 9:16 PM with diagnoses that included Acute Alcohol (ETOH) intoxication. The clinical record identified that Patient #1 was found by local police to be walking in traffic and disoriented. Based on the patient's displayed behavior and suspicion of intoxication, Patient #1 was transferred to the ED for further evaluation via a Police Emergency Evaluation Report (PEER). Review of the ED admission note by Physician Assistant #1 (PA#1) identified that Patient #1 was alert, difficult to control from a behavior standpoint, and had a history of mental illness, depression and Post-Traumatic Stress Disorder (PSTD), and that his/her breathalyzer was 212 ( ETOH Level to be less than 80). An admission nursing assessment dated 10/11/11 identified that Patient #1 was at low risk for suicide and subsequently placed on fifteen minute checks in accordance with facility policies. Interview with ED Patient Care Technician #1 (PCT #1) on 10/19/11 at 8:30 AM identified that he/she was assigned to a one to one observation with another patient in the ED upon the start of his/her shift at 10:45 PM on 10/11/11. PCT #1 stated that he/she did not know Patient #1 but that he/she observed the patient walking unescorted to the bathroom sometime between 11:00 PM and 11:30 PM. PCT #1 stated that Patient #1 was displaying what he/she considered "bizarre behavior" that included the use of a blanket as a cape, was "animated," "silly," and was laughing. PCT #1 stated that Patient #1 stated "I'm not supposed to be doing this," but that he/she did not understand what the patient meant by the statement. PCT #1 stated that Patient #1 made another statement which PCT #1 was thought was "odd" in nature. PCT #1 stated that as he/she was unable to leave the constant observation of his/her assigned patient, that he/she reported his/her observations to RN #3 because RN #3 was nearby. Interview with RN #3 on 10/26/11 at 8:20 AM identified that he/she did not recall the conversation with PCT #1. RN #1 stated that based on Patient #1's admission diagnosis of intoxication, he/she may not have responded to the report of the patient's behavior. Review of the clinical record lacked documentation to reflect that Patient #1 was re-evaluated after PCT #1's observation and subsequent report to RN #3 for a possible change in behavior and the potential for a change in the level of observation. Review of facility policy directed that if a staff person observes a behavioral change in the patient, the assigned nurse is notified for further evaluation of the patient.

b. Interview with ED Paramedic #1 on 10/19/11 at 3:00 PM identified that he/she was responsible for securing Patient #1's belongings and ensuring that the patient changed into hospital attire at the time of the patient's ED admission. Paramedic #1 stated that Patient #1 made a comment about being assaulted prior to the transfer to the ED but that he/she did not question the patient about the comment as he/she believed that it was the ED staff's responsibility to follow up.

c. Interview with the Charge Nurse of the ED, RN #5, on 10/13/11 at 12:35 PM identified that at approximately 11:30 PM on 10/11/11, Patient #1 became agitated and began throwing magazines around the room. RN #5 stated that Patient #1 reported to him/her that he/she had not been totally truthful with the first physician he/she saw and now reported that he/she had been assaulted prior to his/her arrival in the ED. RN #5 stated that Patient #1 complained of right shoulder pain, denied sexual assault, and refused to have the police called regarding the alleged assault. Interview with MD #1 on 10/14/11 at 9:45 AM identified that he/she was made aware of Patient #1's allegation of assault by RN #5. MD #1 stated that he/she assessed Patient #1 for the reported right shoulder injury, that the patient had good range of motion, and that he/she did not believe that x-rays were warranted at that time. MD #1 stated that although he/she did question Patient #1 about the assault, Patient #1 was not clear about the details except to report that he/she had been pushed/punched. MD #1 stated that he/she did not document his/her assessment at that time as he/she was called away to attend to other patients in the ED. Interview with Patient #1's primary nurse, RN #1, on 10/13/11 identified that while he/she was aware of Patient #1's allegation of an assault, he/she did not follow up by questioning the patient as he/she believed that MD #1 had already addressed the issue with the patient. Review of the clinical record lacked documentation to reflect Patient #1's report of assault to RN #5 and/or of an assessment by RN #5 for possible injuries or anxiety based on the alleged assault. Review of facility policies directed that assessment of ED patients is ongoing until discharge or transferred based on the needs of the patients and will be documented in the medical record.

d. The admission nursing assessment dated 10/11/11 identified that Patient #1 was assessed to be at low risk for suicide and subsequently placed on fifteen minute checks in accordance with facility policies. Review of the ED record identified that on at least two occasions, Patient #1 was observed to have his/her curtain pulled across the doorway, obscuring the view of the patient, and that the assigned RN, RN #1, instructed the patient to keep the curtain open. Interview with RN #1 on 10/13/11 at 1:30 PM identified that although Patient #1 had been identified as at low risk for suicide, he/she did not want Patient #1 to close the curtain as he/she wanted to be able to visualize the patient due to the patient's intoxication. Documentation of the fifteen minute check sheet dated 10/11/11 identified that Patient #1 was "agitated" from 11:15 PM through 11:45 PM. Further interview with RN #1 on 10/13/11 identified that during that time, Patient #1 was pacing in his/her room and asking to go home. RN #1 stated that he/she was able to deescalate Patient #1 without further intervention and that the patient remained "quiet" after that time. The documentation identified that RN #1 completed fifteen minute checks including "safety checks" of Patient #1 from 12:00 AM through 1:15 AM on 10/12/11. However, after a review of a video surveillance tape dated 10/12/11 of the ED hallway outside Patient #1's room, the last time RN #1 actually entered Patient #1's room was at 12:35 AM. The surveillance video identified that at 1:23 AM, RN #1 only briefly looked into the doorway of Patient #1's room. RN #1 stated that he/she recalled that Patient #1 was lying on the stretcher at that time and that the patient's curtain was open. Review of the ED record with RN #1 on 10/13/11 identified that six minutes later at 1:29 AM, RN #1 observed that the curtain to Patient #1's room was closed again and that when he/she went to open the curtain, RN #1 found Patient #1 on his/her knees on the floor and that the patient had utilized a tied bed sheet to hang him/herself. Continued interview with RN #1 on 10/13/11 identified that he/she released the patient from the tied sheet as he/she called for assistance. Review of the ED clinical record identified that Patient #1 was found pulseless, apneic, and that despite resuscitative efforts, Patient #1 subsequently expired. Review of facility policies lacked specific direction for what was expected at the time of observation at each fifteen minute check of a patient who required frequent observation and/or what a safety check of a patient on frequent observation would entail. Review of the ED policy for the care of acutely intoxicated patients directed that facility's primary consideration was the safety of the patient.

Based on a review of clinical records, review of facility policies, observations, and interviews, the facility failed to ensure that the Emergency Department (ED) electronic medical record was accurate and/or complete for two of ten patients, Patients #1 and #3, who sought services in the ED for substance abuse. The findings include:

a. Patient #1 was admitted to the Emergency Department (ED) on 10/11/11 at 9:16 PM with diagnoses that included Acute Alcohol (ETOH) intoxication. The clinical record identified that Patient #1 was found by the local police department walking in traffic and disoriented and was transferred to the ED based on a Police Emergency Evaluation (PEER) for further evaluation. The admission nursing assessment dated 10/11/11, identified that Patient #1 was at low risk for suicide and subsequently placed on fifteen minute checks in accordance with facility policies. Review of the ED record identified that on at least two occasions, Patient #1 was observed to have his/her curtain pulled across the doorway and that the assigned RN, RN #1, instructed the patient to keep the curtain open. The ED record identified that at 1:29 AM, RN #1 observed that the curtain to Patient #1's room was closed again and that when he/she went to open the curtain, RN #1 found Patient #1 on his/her knees on the floor and that the patient had utilized a tied bed sheet to hang him/herself. Resuscitation efforts were unsuccessful and Patient #1 expired at 1:56 AM. Review of an entry into the clinical record by RN #1 at 2:01 AM on 10/12/11, subsequent to Patient #1's death, identified that RN #1 documented that he/she had last observed Patient #1's curtain closed at 1:02 AM on 10/12/11 and that he/she explained again to the patient that the curtain needed to remain open. However, review of a video surveillance tape dated 10/12/11 of the ED hallway outside Patient #1's room identified that the last time RN #1 actually entered Patient #1's room was at 12:35 AM. Interview with RN #1 on 10/17/11 at 10:50 AM identified that when he/she made the entry, he/she thought the time he/she had last spoken with the patient was shortly after 1:00 AM. Facility policies directed that documentation in the clinical record be accurate.

b. Patient #3 was admitted to the Emergency Department (ED) on 10/11/11 with diagnoses that included Alcohol Intoxication, depression, and suicidal ideation. Upon medical clearance, Patient #3 was transferred into the Emergency Crisis Area (ECA). Review of the clinical record identified that Patient #3's Breathalyzer Alcohol Level (BAL) was 0.22 (BAL) Level to be less than 80 at 6:00 AM on 10/12/11. However, a second entry into the clinical record identified that Patient #3's BAL was 233 at 7:05 AM on 10/12/11, one hour later. Interview with ED Nursing Manager #1 on 10/13/11 at 10:00 AM identified that he/she was unable to explain the discrepancy in the record. Further review of the electronic medical record identified that the 0.22 BAL identified as done at 6:08 AM on 10/12/11 was actually done at 3:36 PM on 10/12/11. Interview with the Director of Quality on 10/14/11 at 10:40 AM identified that facility policy directed that when an ED staff member opens a task in the electronic medical record to document that the task has been completed, the staff member must change the date and time of the entry or the task will appear to have been done at the time of the order entry. The Director of Quality stated that the ED staff members had not changed the times in Patient #3's record and therefore the BALs appeared out of sequence with the appearance of the last BAL obtained as elevated. The Director of Quality stated that although education for electronic medical record entries in the ED had been provided, the education may need to be reinforced.

Based on review of the clinical record, review of facility policies, observations, and interviews, the facility failed to provide adequate supervision to prevent injury for one patient, Patient #1, who although was identified as at low risk for suicide, was found hanging from a bed sheet in the Emergency Department and subsequently expired. In addition, the facility failed to ensure that documentation in Patient #1's ED record was accurate and/or complete, and/or that policies for ongoing monitoring and/or assessment clearly directed staff responsibilities for observation and/or safety checks of patients on frequent observation.


Please reference A 1103 and A 1104

Based on a review of clinical records, review of facility policies, observations, and interviews, the facility failed to ensure that a crisis plan of care was developed and/or that crisis evaluations directed by the physician were completed timely for three of ten patients, Patient #3, #8, and #9, who were admitted to the Emergency Department and required treatment for substance abuse. The findings include:

a. Patient #3 was admitted to the Emergency Department (ED) on 10/11/11 with diagnoses that included Alcohol Intoxication, depression, and suicidal ideation. Upon medical clearance, Patient #2 was transferred into the Emergency Crisis Area (ECA). Review of the clinical record with facility staff on 10/13/11 at 10:04 AM identified that the record lacked documentation to reflect that a treatment plan had been developed to address Patient #3's substance abuse in accordance with facility policies. Interview with the Manager of the Crisis Clinicians on 10/13/11 at the time of the record review identified that facility policy directed that a treatment plan be developed within twelve hours of admission.

b. Review of Patient #3's physician's orders dated 10/12/11 at 6:08 AM directed that a crisis evaluation be obtained. Review of the clinical record identified that the crisis evaluation was not completed until 6:46 PM on 10/12/11, twelve hours later.

c. Patient #8 presented to the satellite ED on 4/8/11 at 6:13 PM with a suicide attempt and alcohol use. Physician's orders dated 4/8/11 at 7:20 PM directed that a crisis evaluation be obtained. The patient was transferred to the main ED and arrived at 9:40 PM. Review of the clinical record indicated that the crisis evaluation was not completed until 1:30 PM on 4/9/11, seventeen hours after the order.

d. Patient #9 presented to the ED on 6/19/11 at 2:26 AM with change of mental status, alcohol use, and a fall. Physician's orders dated 6/19/11 at 6:56 AM directed that a crisis evaluation be obtained. The clinical record indicated that the crisis evaluation was not started until 4:20 PM on 6/19/11, nine hours later.

Review of the facility policy indicated the crisis workers complete a psychiatric assessment as soon as possible. The policy indicated that the responsibilities of the crisis worker include responding to crisis phone calls made to the ED, EAP, mental health clinic, Partial Hospital Program, and Child/Family services. In addition they serve as a crisis service for the ambulatory psychiatric services after hours. Interview with Director of Behavioral Health on 10/14/11 at 1:45 PM indicated that the time frame between the order and completion of the crisis evaluation is monitored on a monthly basis and had been identified as a concern since April 2011. The Director indicted that there is a work group that meets monthly to discuss the issues and a part time position had been filled and a per diem position has been posted.

1. Based on a review of clinical records, review of facility policies, observations, and interviews, the facility failed to provide adequate supervision to prevent injury for one patient, Patient #1, who although was identified as at low risk for suicide, was found hanging from a bed sheet in the Emergency Department and subsequently expired. The findings include:

a. Patient #1 was admitted to the Emergency Department (ED) on 10/11/11 at 9:16 PM with diagnoses that included Acute Alcohol (ETOH) intoxication. The clinical record identified that Patient #1 was found by local police to be walking in traffic and disoriented. Patient #1 reported to the police that he/she was taking medication but was not specific to the type of medication. Review of the Police Emergency Evaluation (PEER) dated 10/11/11 identified that it was unclear as to whether Patient #1 was taking his/her medication with alcohol and or was not taking the medication as prescribed, but that based on the patient's displayed behavior and intoxication, he/she was transferred to the ED for further evaluation. Review of the ED admission note by Physician Assistant #1 (PA#1) identified that Patient #1 was alert, difficult to control from a behavior standpoint, and had a history of mental illness, depression and Post-Traumatic Stress Disorder (PSTD), and that his/her breathalyzer was 212 (ETOH Level to be less than 80). Patient #1 was assessed by PA #1 to have no signs of trauma and denied suicidal or homicidal ideation at the time of the examination. Although PA #1's written plan in his/her ED dictation note dated 10/11/11 at 10:01 PM was to await Patient #1's sobriety and upon sobriety, discharge the patient home, no physician orders for continued care and/or monitoring were entered by PA #1. Interview with PA #1 on 10/13/11 at 2:45 PM identified that in order to follow up on the PEER report of the possibility of medication involvement, that he/she would have asked the patient about medications but that due to the intoxication, Patient #1's answers would not have been reliable. PA #1 stated that he/she did not believe that there was an indication for a toxicology screen upon admission as Patient #1's presentation was consistent with ETOH abuse. Review of facility policies identified that a Computerized Physician Order Entry (CPOE) set titled "ED Alcohol Intoxication Panel" had been developed in order to provide consistent intervention for patients presenting to the ED with Alcohol Intoxication that included orders to obtain vital sign every two hours, specific Blood Alcohol Levels (BAL) monitoring, initiation of the Clinical Institute Withdrawal Assessment (CIWA) scale, and drug screening. Interview with the Director of Risk Management on 10/18/11 at 10:45 AM identified that although the physician order set is available to provide a guideline for the care of intoxicated patients in the ED, there was no current direction to ensure that physicians and/or midlevel provider utilize the order set.

b. Interview with ED Patient Care Technician #1 (PCT #1) on 10/19/11 at 8:30 AM identified that he/she was assigned to a one to one observation for another patient in the ED upon the start of his/her shift at 10:45 PM on 10/11/11. PCT #1 stated that he/she did not know Patient #1 but that he/she observed the patient walking unescorted to the bathroom sometime between 11:00 PM and 11:30 PM. PCT #1 stated that Patient #1 was displaying what he/she considered " bizarre behavior " that included the use of a blanket as a cape, was "animated," "silly," and was laughing. PCT #1 stated that Patient #1 stated "I'm not supposed to be doing this," but that he/she did not understand what the patient meant by the statement. PCT #1 stated that Patient #1 then made a statement that PCT #1 thought was "odd." PCT #1 stated that as he/she was unable to leave the constant observation of his/her assigned patient, he/she reported his/her observations to RN #3 because RN #3 was nearby. Interview with RN #3 on 10/26/11 at 8:20 AM identified that he/she did not recall the conversation with PCT #1. RN #1 stated that based on Patient #1's admission diagnosis of intoxication, he/she may not have responded to the report of the patient's behavior. Review of the clinical record lacked documentation to reflect that Patient #1 was re-evaluated after PCT #1's observation and subsequent report to RN #3 for a possible change in behavior. Review of facility policy directed that if a staff person observes a behavioral change in the patient, the assigned nurse is notified for further evaluation of the patient.

c. Interview with the Charge Nurse of the ED, RN 5, on 10/13/11 at 12:35 PM identified that at approximately 11:30 PM on 10/11/11, Patient #1 became agitated and began throwing magazines around the room. RN #5 stated that Patient #1 reported to him/her that he/she had not been totally truthful with the first physician he/she saw and now reported that he/she had been assaulted prior to his/her arrival in the ED. RN #5 stated that Patient #1 complained of right shoulder pain, denied sexual assault, and refused to have the police called regarding the alleged assault. RN #5 stated that he/she immediately reported Patient #1's complaint to the ED physician on duty, MD #1. Interview with MD #1 on 10/14/11 at 9:45 AM identified that he/she was made aware of Patient #1's allegation of assault by RN #5. MD #1 stated that he/she assessed Patient #1 for the reported right shoulder injury, that the patient had good range of motion, and that he/she did not believe that x-rays were warranted at that time. MD #1 stated that although he/she did question Patient #1 about the assault, Patient #1 was not clear about the details except to report that he/she had been pushed/punched. MD #1 stated that he/she did not document his/her assessment at that time as he/she was called away to attend to other patients in the ED. Review of facility policies directed that assessment of ED patients is ongoing until discharge or transferred based on the needs of the patients and will be documented in the medical record.

d. The admission nursing assessment dated 10/11/11 identified that Patient #1 had been assessed to be at low risk for suicide and subsequently placed on fifteen minute checks in accordance with facility policies. Review of the ED record identified that on at least two occasions, Patient #1 was observed to have his/her curtain pulled across the doorway, obscuring the view of the patient, and that the assigned RN, RN #1, instructed the patient to keep the curtain open. Interview with RN #1 on 10/13/11 at 1:30 PM identified that although Patient #1 had been identified as at low risk for suicide, he/she did not want Patient #1 to close the curtain as he/she wanted to be able to visualize the patient due to the patient's intoxication. Documentation of the fifteen minute check sheet dated 10/11/11 identified that Patient #1 was "agitated" from 11:15 PM through 11:45 PM. Further interview with RN #1 on 10/13/11 identified that during that time, Patient #1 was pacing in his/her room and asking to go home. RN #1 stated that he/she was able to deescalate Patient #1 without further intervention and that the patient remained "quiet" after that time. The documentation identified that RN #1 completed every fifteen minute checks including "safety checks" of Patient #1 from 12:00 AM through 1:15 AM on 10/12/11. However, review of a video surveillance tape dated 10/12/11 of the ED hallway outside Patient #1's room identified that the last time RN #1 actually entered Patient #1's room was at 12:35 AM. The surveillance video identified that at 1:23 AM, RN #1 briefly looked into the doorway of Patient #1's room. RN #1 stated that he/she recalled that Patient #1 was lying on the stretcher at that time and that the patient's curtain was open. The ED record identified that six minutes later at 1:29 AM, RN #1 observed that the curtain to Patient #1's room was closed again and that when he/she went to open the curtain, RN #1 found Patient #1 on his/her knees on the floor and that the patient had utilized a tied bed sheet to hang him/herself. Continued interview with RN #1 on 10/13/11 identified that he/she released the patient from the tied sheet as he/she called for assistance. Review of the ED clinical record identified that Patient #1 was found pulseless and apneic and that despite resuscitative efforts, Patient #1 subsequently expired. Review of facility policies lacked specific direction for what was expected at the time of observation at each fifteen minute check of a patient who required frequent observation and/or what a safety check of a patient on frequent observation would entail. Review of the ED policy for the care of acutely intoxicated patients directed that facility's primary consideration was the safety of the patient.

2. Based on review of the clinical record, review of facility policies, observations, and interviews, the facility failed to ensure that the Emergency Department (ED) electronic medical record was accurate and/or complete for two of ten patients, Patients #1 and #3, who sought services in the ED for substance abuse. The findings include:

a. Patient #1 was admitted to the Emergency Department (ED) on 10/11/11 at 9:16 PM with diagnoses that included Acute Alcohol (ETOH) intoxication. The clinical record identified that Patient #1 was found by the local police department walking in traffic and disoriented and was transferred to the ED based on a Police Emergency Evaluation (PEER) for further evaluation. The admission nursing assessment dated 10/11/11, identified that Patient #1 was at low risk for suicide and subsequently placed on fifteen minute checks in accordance with facility policies. Review of the ED record identified that on at least two occasions, Patient #1 was observed to have his/her curtain pulled across the doorway and that the assigned RN, RN #1, instructed the patient to keep the curtain open. The ED record identified that at 1:29 AM, RN #1 observed that the curtain to Patient #1's room was closed again and that when he/she went to open the curtain, RN #1 found Patient #1 on his/her knees on the floor and that the patient had utilized a tied bed sheet to hang him/herself. Resuscitation efforts were unsuccessful and Patient #1 expired at 1:56 AM. Review of an entry into the clinical record by RN #1 at 2:01 AM on 10/12/11, subsequent to Patient #1's death, identified that RN #1 documented that he/she had last observed Patient #1's curtain closed at 1:02 AM on 10/12/11 and that he/she explained again to the patient that the curtain needed to remain open. However, review of a video surveillance tape dated 10/12/11 of the ED hallway outside Patient #1's room identified that the last time RN #1 actually entered Patient #1's room was at 12:35 AM. Interview with RN #1 on 10/17/11 at 10:50 AM identified that when he/she made the entry, he/she thought the time he/she had last spoken with the patient was shortly after 1:00 AM. Facility policies directed that documentation in the clinical record be accurate.

b. Patient #3 was admitted to the Emergency Department (ED) on 10/11/11 with diagnoses that included Alcohol Intoxication, depression, and suicidal ideation. Upon medical clearance, Patient #3 was transferred into the Emergency Crisis Area (ECA). Review of the clinical record identified that Patient #3's Breathalyzer Alcohol Level (BAL) was 0.22 (BAL) Level to be less than 80) at 6:00 AM on 10/12/11. However, a second entry into the clinical record identified that Patient #3's BAL was 233 at 7:05 AM on 10/12/11, one hour later. Interview with ED Nursing Manager #1 on 10/13/11 at 10:00 AM identified that he/she was unable to explain the discrepancy in the record. Further review of the electronic medical record identified that the 0.22 BAL identified as done at 6:08 AM on 10/12/11 was actually done at 3:36 PM on 10/12/11. Interview with the Director of Quality on 10/14/11 at 10:40 AM identified that facility policy directed that when an ED staff member opens a task in the electronic medical record to document that the task has been completed, the staff member must change the date and time of the entry or the task will appear to have been done at the time of the order entry. The Director of Quality stated that the ED staff members had not changed the times in Patient #3's record and therefore the BALs appeared out of sequence with the appearance of the last BAL obtained as elevated. The Director of Quality stated that although education for electronic medical record entries in the ED had been provided, the education may need to be reinforced.