HospitalInspections.org

Based on patient chart reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure that its nursing staff removed all potential hazards such as call bell cords from its emergency department patient rooms for 1 of 20 closed patient charts(Patient 5) and 1 of 1 concurrent patient chart (Patient 18).

The findings are:

Hospital policy and procedure, titled, "Emergency Center Suicide Precautions", reads, "....2.2 Continuous visual contact by a competent associate. 2.2.1 Visual monitoring may include a direct line of sight or visualization through video monitoring. 2.3 Modify the patient's environment to ensure safety. Focus on the patient's access to means of self injury such as hanging, suffocation, and jumping....".

Observations of the emergency department on 5/15/2018 from 9:30 a.m. to 19:30 a.m. revealed video monitoring is only available to those patients housed in the emergency department's behavioral health beds the emergency department women's unit. Observations revealed the emergency department has a triage area, major care area, chest pain area, and trauma bays that were not video monitored but suicidal patients could be placed into a bed in any of the area.

Patient 18
On 5/17/2018 at 1:30 p.m., review of Patient 18's emergency department chart revealed the patient arrived in the hospital's emergency department to room 66M(Major Care Area) on 5/15/2018 at 08:03 a.m. via ambulance with a chief complaint of "Suicidal Ideation". Triage was initiated on 5/15/2018 at 0807 and completed on 5/15/2018 at 0818. Review of the nurse's triage assessment dated 05/15/2018 at 0824 revealed in the section labeled, "Psychosocial" Assessment note Pt(Patient) presents to EC(Emergency Center) with c/o (complaint of) suicidal ideations this morning. Pt states he just moved here from .... 3 weeks ago and has been out of his medications during this time. ..... Pt states he thought about "running outside in traffic". Pt states he called EMS himself. Pt admits to drinking a whole bottle of rubbing alcohol last night to end his life. Pt reports having SI (Suicidal Ideation) in the past......". In the section of the triage assessment form labeled "Safety", the nurse documented "Precautions: Suicide, Self Destructive, Interventions Call bell within reach, Visual checks Continuous 1:1". There was no documentation that the call light cord or any other potential hazards were removed from room 66M during the patient's tenure in the room.

Patient 5
On 5/15/2018 at 11:00 a.m., review of Patient 5"s emergency department chart revealed the 14 year old patient presented to the hospital's emergency department on 5/8/2018 at 16:30 via ambulance with a chief complaint of "Suicidal" and "Violent episode and threats to family". Patient 5 was admitted to emergency department bed 54M (Major Care area). Review of the emergency department triage nursing assessment dated 5/8/2018 at 16:57 revealed in the triage assessment section labeled "Precautions" that the nurse documented "Suicide: Call bell within reach; ...." On 5/8/2018 at 4:55 p.m., the nurse documented in the nurse assessment section that the patient had been educated on the use of the call light. There was no documentation that nursing removed potential hazards from the patient's room. On 5/15/2018 at 3:50 p.m., the Nursing Director verified the findings.

During a telephone interview on 5/17/18 at 10:45 a.m., Registered Nurse(RN) 5 who was assigned to Patient 5 when the patient was in room 54M in the Major Care area of the emergency department reported that he/she could not recall if he/she had removed the call light cord from the room when the patient was in room 54M, but stated it should be removed if the patient could use it to harm themselves.

On 5/16/18 at 11:49 a.m., Registered Nurse(RN) 5 and RN 6 reported suicidal patients can go to any bed in the emergency department in order to be cleared for medical problems, and when a patient with suicidal ideation presents with suicidal ideation, the Nursing Supervisor, the Primary Nurse, and the Technician are notified. Security would be called to wand the patient in their own clothes to check for any objects that could cause harm. The nurse or technician would remove any cords out of the room or anything that could be potentially used by the patient to harm themselves such as needles.


28883

Hospital Policies and Procedures: 1/2018, 4/2018, and 5/2018

The current emergency department policy dated 5/2018, entitled, "Emergency Center Suicide Precautions" replaced the 4/17/2018 policy.

Hospital policy, entitled, "Emergency Center Suicide Precautions" effective 5/2018 revealed, "1. The RN will initiate suicide precautions and notify an EC provider of the following: 1.1. Patients found to be at risk of self-harm or suicide during the initial RN assessment or reassessments during the EC visit. 1.2. Patients presenting to the EC for a suicide attempt or suicidal ideations 2. The EC provider will place an order for Suicide Precautions. Suicide Precautions include: 2.1. The EC Behavioral Health Unit (BHU) is designated as a safe environment. Suicidal Patients meeting criteria ... should be placed into the Behavioral Unit. Patients unable to be placed in the EC BHU due to capacity or medical reasons will have the following precautions implemented: 2.2. Continuous visual contact by a competent associate. 2.2.1. Visual monitoring may include a direct line of sight or visualization through video monitoring. 2.3. Modify the patient's environment to ensure safety. Focus on controlling the patient's access to means of self-injury, such as hanging, suffocation, and jumping. 2.3.1. Equipment necessary for the medical care of the patient will remain in the room. 2.4. Security personnel will conduct a patient search for potentially dangerous items and paraphernalia ....3. Associates will document the continuous observation in the patient's medical record. 4. The RN will communicate with the patient and visitors regarding the observation process. 5. Reassessments will be performed by the RN to assess the patient's condition. Changes in the patient's medical or behavioral health condition will be communicated to the Emergency Center provider. 6. Suicide precautions will remain in effect until a provider deems the patient no longer a risk. An order for discontinuation of Suicide Precautions will be placed by the provider."

Review of the emergency department policy, entitled, "EC Special Observation Policy", revealed the policy was developed and implemented on 4/17/2018 to clarify the monitoring of suicidal patients. The emergency department policy required staff that are assigned to observe patients at risk for harm to provide a line of sight observation.

Hospital policy EC0002, titled, "Emergency Center Behavioral Health Assessment", Effective Date 1/20018, reads in part, "
2. All patients presenting to the ED requesting an examination or treatment for a medical or behavioral health condition will be triaged according to policy.
3. When patients have been triaged with a behavioral health complaint staff will initiate precautionary measures and interventions immediately: 3.1 Security will conduct a patient search for potentially dangerous items and paraphernalia:
The policy details guidelines for patient placement in the emergency department's behavioral health beds and vaguely addresses patients presenting to the emergency department with psychological issues such as suicidal or homicidal ideation when placed in emergency department beds not located in its behavioral health unit.

Hospital policy and procedure, titled, "Emergency Center Suicide Precautions", Effective 5/2018, reads, "....2.2 Continuous visual contact by a competent associate. 2.2.1 Visual monitoring may include a direct line of sight or visualization through video monitoring. 2.3 Modify the patient's environment to ensure safety. Focus on the patient's access to means of self injury such as hanging, suffocation, and jumping....".

Based on chart reviews, interview, and review of the hospital's policy and procedure, the hospital failed to ensure staff in its emergency department completed incident/occurrence reports capturing near miss events for 1 of 20 closed patient charts reviewed for care and services. (Patient 2)

The findings are:

On 5/16/18 at 11:00 a.m., review of the closed emergency department chart for Patient 2 revealed the patient presented to the hospital's emergency department on 3/7/18 at 2:50 a.m. via ambulance with a chief complaint of 67 Threats of Suicide and was assigned a room in the Major Care Unit. Documentation showed the patient was wanded by security and safety searched on 3/7/2018 at 3:03 a.m.. On 3/7/2018 at 3:10 a.m., the registered nurse documented, "patient attempted to wrap the call bell light around his neck. All cords removed from room." There was no documentation that emergency department staff completed an incident report or any other report that captured the incident. On 5/17/18 at 1:35 p.m., Risk Management stated, "There is no incident report related to the incident."

Hospital policy and procedure, titled, "Incident Reporting (Patient)", reads, " .... Near Miss -unplanned event that did not result in harm but has the potential to do so if repeated. ....3.2 None - incidents resulting in no visible injury. Examples include a medication that is no given on time, but does not affect patient outcome, or the patient found on the floor and the assessment reveals no injury ....".

Based on record reviews, interviews, and review of the emergency department's policies and procedures, the emergency department nursing staff failed to ensure that hazards such as call light cords were removed from the rooms of patients presenting to the emergency department with a chief complaint of suicidal ideation for 1 of 20 closed patient charts(Patient 5) and 1 of 1 concurrent patient chart (Patient 18).

The findings are:

Patient 18
On 5/17/2018 at 1:30 p.m., review of Patient 18's emergency department chart revealed the patient arrived in the hospital's emergency department to room 66M(Major Care Area) on 5/15/2018 at 08:03 a.m. via ambulance with a chief complaint of "Suicidal Ideation". Triage was initiated on 5/15/2018 at 0807 and completed on 5/15/2018 at 0818. Review of the nurse's triage assessment dated 05/15/2018 at 0824 revealed in the section labeled, "Psychosocial" Assessment note Pt(Patient) presents to EC(Emergency Center) with c/o (complaint of) suicidal ideations this morning. Pt states he just moved here from .... 3 weeks ago and has been out of his medications during this time. ..... Pt states he thought about "running outside in traffic". Pt states he called EMS himself. Pt admits to drinking a whole bottle of rubbing alcohol last night to end his life. Pt reports having SI (Suicidal Ideation) in the past......". In the section of the triage assessment form labeled "Safety", the nurse documented "Precautions: Suicide, Self Destructive, Interventions Call bell within reach, Visual checks Continuous 1:1". There was no documentation that the call light cord or any other potential hazards were removed from room 66M during the patient's tenure in the room.

Patient 5
On 5/15/2018 at 11:00 a.m., review of Patient 5"s emergency department chart revealed the 14 year old patient presented to the hospital's emergency department on 5/8/2018 at 16:30 via ambulance with a chief complaint of "Suicidal" and "Violent episode and threats to family". Patient 5 was admitted to emergency department bed 54M (Major Care area). Review of the emergency department triage nursing assessment dated 5/8/2018 at 16:57 revealed in the triage assessment section labeled "Precautions" that the nurse documented "Suicide: Call bell within reach; ...." On 5/8/2018 at 4:55 p.m., the nurse documented in the nurse assessment section that the patient had been educated on the use of the call light. There was no documentation that nursing removed potential hazards from the patient's room. On 5/15/2018 at 3:50 p.m., the Nursing Director verified the findings.

During a telephone interview on 5/17/18 at 10:45 a.m., Registered Nurse(RN) 5 who was assigned to Patient 5 when the patient was in room 54M in the Major Care area of the emergency department reported that he/she could not recall if he/she had removed the call light cord from the room when the patient was in room 54M, but stated it should be removed if the patient could use it to harm themselves.

On 5/16/18 at 11:49 a.m., Registered Nurse(RN) 5 and RN 6 reported suicidal patients can go to any bed in the emergency department in order to be cleared for medical problems, and when a patient with suicidal ideation presents with suicidal ideation, the Nursing Supervisor, the Primary Nurse, and the Technician are notified. Security would be called to wand the patient in their own clothes to check for any objects that could cause harm. The nurse or technician would remove any cords out of the room or anything that could be potentially used by the patient to harm themselves such as needles.

Hospital policy, entitled, "Emergency Center Suicide Precautions" effective 5/2018 revealed, "1. The RN will initiate suicide precautions and notify an EC provider of the following: 1.1. Patients found to be at risk of self-harm or suicide during the initial RN assessment or reassessments during the EC visit. 1.2. Patients presenting to the EC for a suicide attempt or suicidal ideations 2. The EC provider will place an order for Suicide Precautions. Suicide Precautions include: 2.1. The EC Behavioral Health Unit (BHU) is designated as a safe environment. Suicidal Patients meeting criteria ... should be placed into the Behavioral Unit. Patients unable to be placed in the EC BHU due to capacity or medical reasons will have the following precautions implemented: 2.2. Continuous visual contact by a competent associate. 2.2.1. Visual monitoring may include a direct line of sight or visualization through video monitoring. 2.3. Modify the patient's environment to ensure safety. Focus on controlling the patient's access to means of self-injury, such as hanging, suffocation, and jumping. 2.3.1. Equipment necessary for the medical care of the patient will remain in the room. 2.4. Security personnel will conduct a patient search for potentially dangerous items and paraphernalia ....3. Associates will document the continuous observation in the patient's medical record. 4. The RN will communicate with the patient and visitors regarding the observation process. 5. Reassessments will be performed by the RN to assess the patient's condition. Changes in the patient's medical or behavioral health condition will be communicated to the Emergency Center provider. 6. Suicide precautions will remain in effect until a provider deems the patient no longer a risk. An order for discontinuation of Suicide Precautions will be placed by the provider."

Review of the emergency department policy, entitled, "EC Special Observation Policy", revealed the policy was developed and implemented on 4/17/2018 to clarify the monitoring of suicidal patients. The emergency department policy required staff that are assigned to observe patients at risk for harm to provide a line of sight observation.

Hospital policy EC0002, titled, "Emergency Center Behavioral Health Assessment", Effective Date 1/20018, reads in part, "
2. All patients presenting to the ED requesting an examination or treatment for a medical or behavioral health condition will be triaged according to policy.
3. When patients have been triaged with a behavioral health complaint staff will initiate precautionary measures and interventions immediately: 3.1 Security will conduct a patient search for potentially dangerous items and paraphernalia:
The policy details guidelines for patient placement in the emergency department's behavioral health beds and vaguely addresses patients presenting to the emergency department with psychological issues such as suicidal or homicidal ideation when placed in emergency department beds not located in its behavioral health unit.

Hospital policy EC0002, titled, "Emergency Center Behavioral Health Assessment", Effective Date 1/20018, reads in part, " .....
2. All patients presenting to the ED requesting an examination or treatment for a medical or behavioral health condition will be triaged according to policy.
3. When patients have been triaged with a behavioral health complaint staff will initiate precautionary measures and interventions immediately: 3.1 Security will conduct a patient search for potentially dangerous items and paraphernalia: