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Based on review of the medical record and staff interviews, Resident Physician #1 failed to immediately inform the ED staff of a Section 12 Order (involuntary commitment of a person based on the expression of desire or plan to harm oneself) for one of one applicable Patients, Patient #1, who made a suicide attempt while in the bathroom of the Emergency Department (ED) on 10/24/11.

Findings include:

1) It was reported that Patient #1 attempted to commit suicide on 10/24/11 by piercing the side of his/her neck with a metal fork in the bathroom of the Emergency Department (ED). Patient #1 did not verbalize thoughts of suicidal ideation or plans to ED Attending Physician #1, Resident Physician #1 or the nursing staff during Triage or the initial medical screening.

2) Patient #1 was evaluated in the ED two days earlier on 10/22/11. Patient #1 complained of ineffective pain management. A emergency mental health clinician determined that Patient #1 was safe for discharge. On 10/24/11, Patient #1 returned to the ED with the same complaint and reported that his/her infusion pump device for pain control was empty. Patient #1 told Resident Physician #1 that if pain management did not improve, he/she wanted to amputate his/her right leg. After consultation with ED Attending Physician #1, a Section 12 Order was written and placed on the chart. However, the order was not communicated to other ED staff. Some time later, RN #2 found the order and rushed to check on Patient #1 who had been in the bathroom for an extended period of time. Patient #1 had self-inflicted wounds to the neck and required surgery.

3. ED Attending Physician #1 was interviewed by telephone on 01/23/12 at 8:30 A.M. through 8:40 A.M. and Resident Physician #1 was interviewed by telephone on 01/23/12 from 9 A.M. through 9:20 A.M. respectively. Resident Physician #1 said that he evaluated Patient #1 on 10/24/11 at 10 A.M. and he did not initially assess that Patient #1 was a suicide risk. Resident Physician #1 said that Patient #1 was frustrated with his/her pain management because of continued severe pain. Resident Physician #1 was aware that this was the second visit in 48 hours for the same complaint. Resident Physician #1 said that he consulted with ED Attending Physician #1 again between 12 P.M. and 12:30 P.M. because Patient #1 talked about cutting off his/her right leg to stop the pain and at that time, he issued the Section 12 Order and placed it on the chart.

4.. Resident Physician #1 did not immediately inform the ED staff that he issued a Section 12 Order. Patient #1 asked to use the bathroom and brought his/her personal belongings because the ED staff were unaware of the Section 12 Order.

5. Review of the ED record dated 10/24/11 indicated that Patient #1 expressed suicidal ideation. Patient #1 reported thoughts of amputating the right lower extremity because of unrelieved severe pain. Resident Physician #1 indicated that a Section 12 Order and 1:1 observation were required for the safety of the Patient, but he did not immediately communicate this to ED staff and implement the safety plan in a timely manner.

6. Registered Nurse (RN) #2 was interviewed on 01/19/12 from 11:10 A.M. through 11:50 A.M. RN #2 said she assumed care of Patient #1 at 11 A.M. RN #1 said there was no communication from the physician regarding Patient #1 being a suicide risk. RN #1 said that at 12:15 P.M, Patient #1 requested to use the bathroom and brought along his/her belongings. RN #2 said that Patient #1 had complained of being constipated and seemed to be in the bathroom a long time. RN #2 checked in on Patient #1 a couple of times. RN #2 said that when she noticed the Section 12 Order on the chart, she immediately returned to the bathroom. RN #2 said that she entered the bathroom and found that Patient #1 had self-inflicted wounds to the neck made by a fork that was in his belongings.

7. Patient #1 was brought to the operating room for surgery to repair the self-inflicted wounds to the neck.

Based on review of the medical record and interviews with the physician, one of one applicable medical records, for Patient #1, did not contain documenation of the Section 12 Order made by Resident Physician #1 on 10/24/11.

Findings include:

1. Resident Physician #1 said that he filed a Section 12 Order for Patient #1 between 12 P.M. and 12:30 P.M. on 10/24/11.

2. Resident Physician #1 said that the Section 12 Order was filed because Patient #1 expressed suicidal ideation by stating that he/she would amputate the right leg due to continued severe pain.

3. Review of the medical record for Patient #1's ED visit dated 10/24/11 indicated there was no copy of the Section 12 Order for involuntary admission.