HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 (Pt #1) clinical records reviewed for patients that presented to the Emergency Department with suicidal ideation, the Hospital failed to ensure that adequate qualified nursing personnel was available to meet the written emergency procedures and needs of a patient that required 1:1 monitoring (direct supervision).

1. The Hospital's policy titled, "Suicide Precautions Outside of Behavioral Medicine Units" (dated 9/2019), was reviewed on 8/9/2021, and required, " Purpose: To maintain the safety of a patient who is assessed to be at risk for suicide ...Suicide Precautions: A physician's order for 1:1 continuous monitoring by a trained staff that remains within arm's length of the patient and can observe the face and hands at all times and documents the patient's behaviors and location every 15 minutes ...1. Upon entry to triage, acute care units or outpatients treatments areas, patients are assessed for potential suicide risk by a licensed clinician ...Procedure: 2. If the assessment is positive for suicidal ideation, the patient is immediately placed on suicide precautions ..."

2. The clinical record for Pt #1 was reviewed on 8/9/2021. Pt #1 presented to the ED (Emergency Department) on 7/29/2021 at 8:06 PM, with a chief complaint of suicide ideation. Pt #1 was transferred from the Nursing Home to the ED under an Involuntary Admission.

- The HPI (History of Present Illness), dated 7/29/2021 at 8:07 PM, documented by the Attending ED Physician (MD #2), included, "Patient brought to ER by paramedics for evaluation of suicidal [ideation]. Patient [with] suicidal ideation prior to arrival today, and patient was petition[ed] by nursing home staff. Patient wanted to leave AMA [against medical advice] and then says that she wanted to harm herself ...Addendum: (dated 7/30/21 at 12:46 AM), Patient eloped as staff was busy taking care of trauma and also a cardiac arrest. Patient found and she admits to cutting herself with a piece of glass. Patient has laceration to the left wrist of about 3 cm [centimeters] ..."

- Pt #1's Triage Assessment (dated 7/29/2021 at 8:11 PM), documented by the ED Charge RN (E #2/Registered Nurse) included, "Pt was sent to ER from nursing home under petition for admission for suicidal thoughts without a plan. Patient requested to d/c [discharge] so she can leave and kill herself ...Suicide Assessment: 1. In the past month, have you wished you were dead or wished you could go to sleep and not wake up? Yes 2. In the past month, have you had any actual thoughts of killing yourself? Yes ..."

Pt #1 presented to the ED with suicidal ideation. The clinical record lacked documentation of a physician's order for 1:1 continuous monitoring, as required per policy.

The clinical record lacked documentation that Pt. #1 was monitored on 1:1 (one staff to one patient) by ED staff before eloping on 7/29/2021.

3. On 8/9/2021 at 2:00 PM, an interview was conducted with the ED Director (E #5). E #5 stated that any patient that comes in with suicidal ideation should be placed on 1:1 monitoring because the reason they come to the ED is so that we can keep them safe. E # 5 stated that when a patient comes in petitioned (involuntary admission), they should be placed on elopement precautions as well.

4. On 8/10/2021 at 9:00 AM, an interview was conducted with the ED Charge RN (E #2/Registered Nurse). E #2 stated that Pt #1 came in via ambulance, had suicidal ideation and was feeling suicidal. E #2 stated that Pt #1 was placed in a behavioral health room but later had to move to a hallway bed. E #2 stated that Pt #1 eloped from the ED while the the staff were busy. E #2 stated that she called the police and Pt #1 was returned about 30 minutes later with a cut to the wrist. E #2 stated that Pt #1 was not placed on 1:1 monitoring because she called the Nursing Supervisor (E #4) requesting a sitter, but there was no one available. E #2 stated that all patients that come in suicidal need a sitter.

5. On 8/10/2021 at 9:15 AM, an interview was conducted with the ED Attending Physician (MD #2). MD #2 stated that Pt #1 came to the ED petitioned from the nursing home, with suicidal ideation. MD #2 stated that she was initially placed in the seclusion room but had to be moved later due to another psych patient that came in with aggressive behaviors. MD #2 stated that Pt #1 did state that she wanted to harm herself. MD #2 stated that Pt #1 remained in the ED while awaiting medical clearance. MD #2 stated that precautions that should be put in place for suicidal and/or elopement risk patients are to put them in scrubs that are a particular color; provide a sitter; and put them in a seclusion room. MD #2 stated that there was not a sitter available for Pt #1 that night (7/29/2021).