HospitalInspections.org

Based on observation, interview, record review, policy review and video review, the hospital failed to:
- Ensure the safety of all patients when they failed to appropriately investigate and educate all staff in response to the attempted suicide (to cause one's own death) of one current patient (#17) of one self-report reviewed. (A-0145)
- Ensure the safety of all patients when they failed to remove contraband (items that are illegal, forbidden, or that can be used to harm self or others) from one current patient's room (#17) on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) of four patients on suicide precautions observed. (A-0144)

These failures resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

Based on observations, policy review and interviews, the hospital failed to provide care in a safe setting for one (#17) out of 4 patients observed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm), when they allowed a visitor to bring personal belongings to the patient's bedside. This failure placed the safety of all patients and visitors at risk.

Findings included:

Review of the hospital's policy titled, "STL ADMIN Suicidal Patients: Admission Assessment, Level of Care, and Suicide Precautions Policy," dated 06/20/24, showed the patient is not allowed to keep personal belongings with them. Items may be sent home with family or sent with Public Safety to be secured in a locked area.

Observation on 07/02/24 at 9:10 AM, in Trauma Neuro ICU (an intensive care unit devoted to the care of patients with immediately life-threatening nervous system problems) showed Patient #17's visitor had her personal belongings with her at the patient's bedside.

During an interview on at 07/01/24 at 3:00 PM, Staff H, RN, stated that the policy for patients on suicide precautions was that they were allowed visitors, but the visitors are not allowed to bring their belongings into the patient room. Visitors were instructed to leave their belongings in their vehicles, at the nurse's station or outside of the patient's room.

During an interview on 07/02/24 at 9:25 AM, Patient #17's sister, stated that since her brother was admitted to the hospital, she had been allowed to bring her purse and other personal belongings into the room. She was never stopped and instructed to leave her belongings outside of the room.

During an interview on 07/02/24 at 3:10 PM, Staff SS, Nurse Educator, stated that the policy did not specifically state that visitors were not allowed to bring their belongings into the room of a patient on suicide precautions. Staff were educated that visitors along with the and/or patient were not allowed to have personal belongings at the patient's bedside.

During an interview on 07/02/24 at 9:00 AM, Staff EE, Nurse Manager, stated that visitors were not allowed to bring personal items into a patient's room when suicide precautions are ordered.

During an interview on 07/02/24 at 9:05 AM, Staff Y, RN, stated that patients on suicide precautions were allowed visitors, but the visitors were not allowed to bring any personal items into the patient's room. The visitor would be asked to leave their items outside of the room.

During an interview on 07/02/24 at 9:15 AM, Staff Z, RN, stated that patients on suicide precautions were allowed to have visitors, but visitors were not allowed to bring any of their belongings into the room. They were required to leave their personal belongings outside of the patient's room.







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Based on interview, record review, policy review and video review, the hospital failed to appropriately investigate and educate all staff in response to the attempted suicide (to cause one's own death) of one current patient (#17) of one self-report reviewed. This failed practice placed all patients admitted to the hospital at increased risk for their safety.

Findings included:

Review of the hospital's policy titled, "Performing Event Reviews (Root Cause Analysis [RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause])," dated 08/16/22 showed:
- An RCA provided a structured and facilitated team process where root causes, of an event that resulted in an undesired outcome, are identified.
- An event review process focused on identifying breakdowns in processes and systems.
- Corrective actions are developed, from the identified root causes, to prevent future events.
- Serious reportable events are reviewed by the hospital's event review process.
- An RCA focused on process and/ or performance improvement.
- It is expected that designated timelines for the event review process are followed.
- The action items determined the duration and frequency of post-event review follow-up.

Review of the hospital's policy titled, "Patient Safety Evaluation System (PSES)," dated 07/02/24 showed:
- Patient safety activities are performed where patient cases, events or issues are reviewed and opportunities for improvements are identified.
- Safety events are reported, by staff involved, the day the event occurred or the day it was discovered.
- Patient safety events are investigated thoroughly.

Review of the hospital's undated safety event report for Event ID: 390855, showed:
- The house manager was notified by Staff XX, ICU Supervisor, that Patient #17 had been able to push past his sitter and run out of his Medical-Surgical ICU room.
- Patient #17 had a one-to-one (1:1, continuous visual contact with close physical proximity)
sitter and was being constantly observed.
- The two co-workers, Staff KKKK, PCT, and Staff IIII, RN, who witnessed the event, provided written statements.

Review of video surveillance from the stairwell for 06/20/24, showed:
- At 1:48:17 AM, Patient #17 is observed running up to the seventh floor, ignored the chain placed to prevent continued access up to the eighth floor and proceeds to the eighth floor.
- At 1:48:45 AM, Staff IIII, RN, Staff DDDD, RN and Staff KKKK, PCT, arrived on the seventh floor and are observed looking up to the eighth floor attempting to locate the patient.
- At 1:49:21 AM. Staff IIII and Staff DDDD are observed waving their hands and talking to Patient #17. Staff IIII removed the chain and started up the stairs to the eighth floor.
- A 1:49:36 AM, Patient #17 is observed falling from the eighth floor to the seventh; Staff HHHH arrived on the scene.
- At 1:50:00 AM, the door to the seventh floor is opened and staff within the stairwell, yelled out to seventh floor staff for assistance
- At 1:50:55 AM, Staff DDDD moves to the patient's head and bends down; Staff HHHH is on the phone.
- At 1:52:47 AM, the rapid response team nurse arrives on the scene.
- At 1:55:39 AM, a code blue (emergency situation where a patient's heart or breathing has stopped and staff quickly respond to attempt to restore the heartbeat or breathing) cart arrives and the defibrillator (a device that controls the heartbeat by applying an electric current to the chest wall or heart) pads are placed on Patient #17's chest.
- At 1:56:39 AM, Patient #17 is log-rolled onto a sheet and removed from the stairwell.

Review of the hospital's document, "RCA Summary for RCA 2445," dated 06/20/24, showed:
- On 06/19/24 at 8:37 AM, Patient #17 was medically cleared for discharge to behavioral health.
- At 11:04 AM, behavioral health (BH) was consulted.
- At 1:14 PM, a BH assessment was performed. Patient #17 met criteria for inpatient BH treatment with a high risk for suicide.
- On 06/20/24 at approximately 1:50 AM, Patient #17 pushed past his sitter, Staff KKKK, Patient Care Technician (PCT), and ran to the stairwell at the back of the unit.
- Staff KKKK yelled for help and a Behavioral Intervention Response Team (BIRT, a rapid response of team members trained in BH de-escalation [the reduction of the intensity of a conflict or potentially violent situation]) was called overhead.
- Patient #17 ran up the stairs to the eighth floor and was observed, by nursing staff, intentionally falling from the eighth floor down to the seventh floor.
- At 3:12 AM Patient #17 was transferred to the Trauma-Neuro ICU (an intensive care unit devoted to the care of patients with immediately life-threatening nervous system problems) Unit. Patient #17's sister was notified of the event that occurred.
- At 3:25 AM all computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scans were negative for any acute (sudden onset) findings.
- No opportunities for improvement were identified prior to survey.
- No staff education had been provided at the time of the survey.

During an interview on at 07/01/24 at 1:45 PM, Staff G, Medical-Surgical ICU Nurse Manager, stated that they had not performed an RCA on the event that occurred with Patient #17 on 06/20/24. Staff G stated that there had not been any opportunities for improvement identified, all the precautions had been in place. She stated that they completed a debriefing immediately following the event and offered emotional assistance to the staff involved. She stated there had not been any education provided to staff following the event.

During an interview on 07/02/24 at 9:25 AM, the complainant (Patient #17's sister), stated the hospital's president spoke to her several days after the event. He informed her that the hospital would be doing an investigation into the event. She has not been updated on the progress of the investigation.

During a telephone interview on 07/09/24 at 2:55 PM, Staff XX, ICU Supervisor, stated that after the event, education was not provided to staff about caring for patients on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm)
During an interview on 07/09/24 at 3:35 PM, Staff B, Quality Management Director, stated that when a serious event occurs, an RCA was performed. A patient safety team was formed which included, patient relations, administration, and other staff involved. When the patient safety team met, a leader and group facilitator was assigned. An RCA was to be performed within a few weeks after an event. When an RCA has been completed, the findings were reported to the Sentinel Event (actual events that could or did cause patient harm) Committee. The Sentinel Event Committee determined how much follow-up was required to resolve the RCA. The patient safety team and those involved in the RCA reported back to the Sentinel Event committee until they were satisfied with the completion of the RCA's action items.
During an interview on 07/10/24 at 12:50 PM, Staff DDDD, RN, stated she believed the staff, provided to sit with high-risk suicide patients would benefit from additional education related to suicide precautions. She noticed that the sitters did not remain as close to the patient as they should be or closely observe them. Staff DDDD stated no education had been provided prior to the survey.




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