HospitalInspections.org

Based on review of facility policy, medical records (MR) and interviews, it was determined the facility failed to ensure the staff followed physician orders for creating a safe environment in the emergency department (ED), complete and document all patient safety interventions as ordered to protect patients identified at a high risk for suicide.

These deficient practices affected 5 of 5 records reviewed for patients at high risk for self harm, including Patient Identifier's (PI) # 5, PI # 2, PI # 9, PI # 1, PI # 3 and had the potential to negatively affect all patients who receive care at this facility.

Findings include:

Facility Policy: Suicide Prevention, Suicide Attempt, Qualified Sitters for, Restricted Items Emergency Department/Inpatient Medical Management
Original Date of Approval: 8/96
Date of Approval...: 07/2018

Purpose: The purpose of this policy is to provide guidelines on minimizing the risk of suicide by a patient...

IV. Policy: It is the policy of Baptist Health for:

C. If a patient is identified to be "at risk" for suicide (based on the hospital's suicide screening assessment...), the physician is notified immediately and a physician order for 'Suicide Precautions' must be entered in to the patient's record and the patient will be placed on suicide precautions.

V. Procedure

A. Screening Criteria

2. Utilize suicide screening and assessment tools to identify patients with behaviors, mental status, or conditions that may indicate a risk of imminent suicide:

b. High Risk Factors such as medical/psychosocial concerns, intoxication with alcohol or drugs, chronic pain, or terminal illness. Any life changing event, acute trauma, PTSD (Post-traumatic stress disorder), semi-colon tattoo/previous suicide attempt, environmental stressors.

C. Reassessment Process

1. Ongoing continued assessment will be conducted every 15 minutes...

1. PI # 5 presented to the facility's ED on 2/4/19 at 9:56 AM via EMS (emergency medical services) with chief complaint of SI (suicidal ideation).

Review of the ED Triage documentation revealed EMS stated PI # 5 was transferred from another facility where patient was SI and had a plan. The ED Suicide High Risk Factors documented were environmental factors.

Review of ED orders dated 2/4/19 at 10:16 AM included Document Safe Room every 12 hours, Secure Environment/Items Not Allowed every 12 hours, Document Items Not Allowed, and Suicide Precaution Monitoring every 15 minutes.

Review of the safe room belongings checklist/patient items not allowed documentation dated 2/4/19 at 10:21 AM revealed 5 items were removed from PI # 5's possession which were belt/sashes, electronic device/cellphone, jewelry, shoe laces, and weapon (including knife).

Review of the ED record revealed Patient Care Documentation for Suicide Precaution Monitoring dated 2/4/19 which documented monitoring greater than every 15 minutes:

Between 10:38 AM and 10:59 AM, which was 21 minutes.
Between 11:02 AM and 11:28 AM , which was 26 minutes.
Between 12:02 PM and 12:40 PM, which was 38 minutes.
Between 12:40 PM and 1:01 PM, which was 39 minutes.
Between 1:01 PM and 1:31 PM, which was 30 minutes.
Between 4:09 PM and 4:32 PM, which was 23 minutes.
Between 5:10 PM and 5:35 AM , which was 25 minutes.
Between 5:35 PM and 5:59 PM, which was 24 minutes.
Between 5:59 PM and 6:37 PM, which was 38 minutes.

Further review of the ED record revealed no documentation of Patient Care Documentation between 2/4/19 at 6:37 PM to 2/5/19 at 6:10 AM which was 11 hours and 23 minutes.

There was no documentation staff completed Document Safe Room every 12 hours, Secure Environment/Items Not Allowed every 12 hours between 2/4/19 at 8:00 PM and 2/5/19 at 1:51 PM which was 17 hours and 51 minutes.

During an interview conducted on 2/14/19 at 8:45 AM, Employee Identifier (EI) # 2, ED Nurse Manager confirmed the above findings.

2. PI # 2 presented to the facility's ED on 1/2/19 at 3:19 PM via EMS with a chief complaint of SI.

Review of the ED Triage documentation revealed EMS stated PI # 2 had been cutting his/her wrist with laceration noted to right upper extremity. The ED Suicide High Risk Factors documented were medical/psychological concerns and previous suicide attempt.

Review of the ED orders dated 1/2/19 at 3:30 PM included, "Document Safe Room" every 12 hours, document items not allowed, and suicide precaution monitoring every 15 minutes.

Record review revealed staff documented safe room belongings checklist/patient items not allowed was completed at 4:44 PM. This was 1 hour 14 minutes after the staff verified the order.

Review of the safe room belongings checklist/patient items not allowed documentation revealed 5 items were removed from PI # 2's possession which were bras with underwire, call light/TV control, clothing with drawstrings, electrical cords and jacket/pants drawstring.

Review of the ED record revealed Patient Care Documentation for Suicide Precaution Monitoring dated 1/2/19 which documented monitoring greater than every 15 minutes:

Between 4:21 PM and 4:48 PM, which was 27 minutes.
Between 6:01 PM and 6:25 PM, which was 24 minutes.
Between 7:21 PM and 7:44 PM, which was 22 minutes.
Between 8:21 PM and 8:47 PM, which was 26 minutes.
Between 10:56 PM and 11:20 PM, which was 24 minutes.

Review of ED record revealed Patient Care Documentation for Suicide Precaution Monitoring on 1/3/19 was documented greater than every 15 minutes:

Between 4:15 AM and 4:40 AM, which was 25 minutes.
Between 7:00 AM and 7:30 AM, which was 30 minutes.

There was no documentation staff completed safe room-securing the environment every 12 hours as ordered between 1/2/19 at 8:13 PM and 1/3/19 at 8:13 AM. The patient was discharged from the ED on 1/3/19 at 10:55 AM to an inpatient psychiatric facility.

During an interview conducted on 2/14/19 at 9:24 AM, EI # 2, confirmed the above findings.

3. PI # 9 presented to the facility's ED on 2/6/19 at 12:38 PM with a complaint of thoughts of hurting self.

Review of the ED Triage documentation dated 2/6/19 at 12:51 PM revealed the patients' medical history included depression with current mental health treatment. The patient reported, just wants to go to sleep, has thoughts of hurting self. The ED Suicide High Risk Factors documented were PTSD.

Review of the ED orders revealed a suicide precautions set event orders dated 2/6/19 at 12:57 PM which included staff to document items not allowed, document safe room every 12 hours, and perform suicide precaution monitoring every 15 minutes.

Review of the ED record documentation revealed the physician evaluated PI # 9 on 2/6/19 at 1:26 PM, and documented SI with a suicidal plan to overdose.

Review of the Suicide Precautions Flow Sheet documentation dated 2/6/19 revealed at 2:00 PM suicide precaution monitoring every 15 monitoring began. This was greater than 1 hour after the every 15 minute monitoring order was generated.

Review of the ED Adult Assessment completed by nursing staff on 2/6/19 at 2:10 PM included an admission suicide risk assessment which revealed PI # 9 was a suicide risk with SI.

Medical record review revealed staff completed the items not allowed inventory on 2/6/19 at 3:21 PM, which was greater than 2 hours after suicide precaution orders were generated.

The patient was discharged to an inpatient psychiatric facility on 2/6/19 at 9:22 PM.

In an interview conducted on 2/13/19 at 9:50 AM, EI # 2 confirmed the above findings.

4. PI # 1 presented to the facility's ED on 2/1/19 at 10:48 AM with a family member with chief complaint of SI.

Review of the ED Triage documentation revealed the family stated PI # 1 attempted suicide approximately 2 hours prior to arrival to the ED. The ED Suicide High Risk Factors documented were environmental factors.

Review of ED orders dated 2/1/19 at 10:57 AM included Document Safe Room every 12 hours, Secure Environment/Items Not Allowed every 12 hours, Document Items Not Allowed, and Suicide Precaution Monitoring every 15 minutes.

Review of the safe room belongings checklist/patient items not allowed documentation dated 2/1/19 at 11:36 AM revealed 2 items were removed from PI # 1's possession which were electronic device/cellphone and electrical equipment with cords. This was 39 minutes after the order.

Review of ED record revealed Patient Care Documentation for Suicide Precaution Monitoring and the Suicide Precautions Flow Sheet dated 2/1/19 revealed no documentation of Suicide Precautions between 1:37 PM and 3:00 PM, which was 1 hour and 23 minutes.

An interview was conducted on 2/14/19 at 8:35 AM with EI # 2, who confirmed the above findings.

5. PI # 3 presented to the facility's ED on 1/14/19 at 10:32 AM with a family member with chief complaint of SI.

Review of the ED Triage documentation revealed PI # 3 stated plans to overdose, "was looking for pills this morning to do it..." The patient had a previous overdose attempt 11/30/18. The ED Suicide High Risk Factors documented were previous suicide attempt.

Review of the ED orders dated 1/14/19 at 10:46 AM included Suicide Precaution Monitoring every 15 minutes.

Review of ED record revealed Patient Care Documentation for Suicide Precaution Monitoring dated 1/14/19 revealed no documentation of Suicide Precautions Monitoring between:

1:16 PM and 1:44 PM, which was 28 minutes.
2:34 PM and 2:56 PM, which was 22 minutes.

An interview was conducted on 2/14/19 at 9:45 AM with EI # 2, who confirmed the above findings.

Based on review of facility policy and procedure, emergency department (ED) medical record (MR) documentation and staff interviews it was determined the facility failed to ensure nursing staff followed the hospital policy, physician orders and performed and documented pain assessments/reassessments.

This affected 5 of 10 ED records reviewed which included PI's (Patient Identifier) # 6, PI # 7, PI # 8 PI # 10, PI # 4 and had the potential to negatively affect all patients treated at the facility.

Findings include:

Subject: Pain Management (Nursing)
Revision Dates 10/18

I. Purpose:

a....to ensure safe and accurate pain control.

III.

d. Pain Scale-
i. Mild pain (1-3): nagging...doesn't really interfere with activities of daily living
ii. Moderate pain (4-7): interferes significantly with daily living activities
iii. Severe pain-(8-10): disabling, unable to perform daily living activities

IV. Guidelines:

a. A comprehensive pain assessment is conducted on admission with each episode of newly reported pain as appropriate to the patients condition and the scope of care, treatment and services provided. Pain will be reassessed following intervention and will include at a minimum pain level and location.

V. Procedure

a. Patient Assessment

i. Patients will have their pain assessed upon admission/encounter by a nurse...Assessment considers the following:
1. Pain history
2. Previously used methods for pain control
3. Is the pain acute or chronic
4. Pain intensity (scale)
5. Location, onset, duration, and quality
6. Acceptable level of the pain (the patient's comfort zone)

ii. If pain management is indicated...ordered or if communication with the attending physician is indicated to develop and initiate the pain management plan.
iii. The patient's pain level is to be documented in the electronic medical record (EMR)...The time of intervention is the be documented. Pain assessments/reassessments are documented in the EMR...

b. Medication Administration

ii. Dosage of pain medication administered must correspond to medication ordered for documented pain scale.

c. Pain Reassessment
i. Routine reassessment of pain by the nurse will occur during each shift assessment...The nurse will consider the patient's physiological responses (i.e. changes in heart rate, blood pressure...)
ii. Reassessment after intervention(s)...to manage pain is performed no more than one hour of the intervention and it is to be based on reassessment of pain score. The following timeframes ...are to be considered: 20 minutes after IV (intravenous) medications: 30 minutes following IM (intramuscular) medication...
iii. Documentation of pain reassessment must be completed prior to end of the shift...The actual time of the reassessment must be noted in the documentation...
v. Any time the prescribed pain management plan is ineffective, the physician...should be contacted to reevaluate the plan...

d. Pain Management Scale
i. The patient's self-report of pain will be used to measure pain...Documentation of the patient pain scale...including electronic documentation...
1. Patient Self Report
a. Visual/Verbal Analog Scale (VAS)
0-10 Numeric Pain Intensity Scale
0-no pain...5 moderate pain...10 worst possible pain

e. Treatment Continuum
i. Pain management intervention ranges from physical comfort measures to invasive delivery systems.
ii. Physical comfort measures can include...repositioning, deep breathing exercises, relaxation techniques...
iii. Treatment options can include...NSAIDS (nonsteroidal anti-inflammatories)...oral non-narcotics...narcotics...injections...

f....All analgesics ordered as "PRN" will have an associated scale assigned by the prescriber...


1. PI # 6 presented to the ED on 1/27/19 at 4:37 PM with a chief complaint of neck pain for 2 weeks which began after a nerve block on 1/14/19.

Review of the ED Triage Adult pain assessment documentation dated 1/27/19 at 4:54 PM revealed pain location was the neck, the numeric pain scale was 9, and the blood pressure (BP) was 193/119 (systolic/diastolic).

Record review revealed physician orders on 1/27/19 at 7:53 PM for Toradol 15 mg IVP (intravenous push). The numeric pain scale documentation at 8:04 PM was pain-9. The patient received Toradol 15 mg IVP at 8:05 PM.

Further ED record review revealed on 1/27/19 at 8:29 PM the nurse documented the patient was discharged in NAD (no acute distress).

There was no documentation the nurse completed a pain reassessment after the Toradol IVP was administered.

During an interview on 2/14/19 at 2:21 PM, Employee Identifier (EI) # 2, ED Nurse Manager confirmed the finding above.

2. PI # 7 presented to the ED on 1/15/19 at 10:06 PM with a chief complaint of nausea/vomiting and upper abdominal pain.

Review of the ED Triage on 1/15/19 at 10:14 PM revealed Adult Pain assessment documentation with the primary pain location, abdomen, and the numeric pain scale- 8.

Review of the ED Physician documentation on 1/15/19 at 10:20 PM revealed a complaint of vomiting x (for) 2 days, complaints of upper abdominal pain and diarrhea.

Record review revealed a physician order dated 1/15/19 at 10:25 PM for a pain assessment. There was no documentation the 10:25 PM pain assessment was performed.

Record review revealed on 1/16/19 at 12:08 AM Dilaudid 1 mg IVP was ordered and administered. This was 1 hour 53 minutes following the initial pain assessment. There was no documentation the nurse re-assessed the pain before administering IVP Dilaudid.

Further record review revealed on 1/16/19 at 12:27 AM, 19 minutes after Dilaudid administration, the nurse documented numeric pain scale-8, which was no change in the pain scale rating.

Review of the ED Depart (discharge) nurse documentation on 1/16/19 at 3:17 AM revealed no acute distress noted, no needs voiced. There was no pain reassessment documented prior to the ED discharge.

In an interview on 2/14/19 at 1:37 PM, EI # 2 confirmed staff failed to follow physician orders for pain assessment and the facility pain assessment/reassessment policy.

3. PI # 8 presented to the ED on 1/14/19 at 7:22 PM with a chief complaint of headache (HA) x (for) 2 days and elevated blood pressure. PI # 5 reported he/she was sent to ED from urgent care.

Review of the ED Triage adult pain assessment documentation dated 1/14/19 at 7:28 PM revealed the primary pain location was the head, numeric pain scale was 9, and the BP was 233/93.

Review of the ED Adult Assessment on 1/14/19 at 8:40 PM revealed diagnosis(active) for hypertension and headache. There was no pain assessment documented.

Review of the Medication Administration Record documentation revealed on 1/14/19 at 8:40 AM Hydralazine (an anti-hypertensive) 10 mg IVP was administered.

Record review revealed on 1/14/19 at 10:21 PM the nurse documented that (patient) states headache has decreased. There was no documentation staff completed a pain reassessment using the numeric pain scale after the intervention. There was no documentation an acceptable level of pain had been achieved.

PI # 8 was discharged from the ED on 1/14/19 at 10:21 PM with a prescription for Amlodipine 10 mg daily and instructions to follow up with primary care physician in 2 to 5 weeks.

In an interview on 2/14/19 at 1:32 PM, EI # 2 reported no pain intervention was performed and there was no documentation a pain reassessment using the numeric pain scale was performed.

PI # 8 presented to the ED on a return visit on 1/15/19 at 10:55 PM via EMS with a chief compliant of increased blood pressure and headache.

Review of the 1/15/19 10:55 PM ED Triage documentation completed by the nurse revealed adult pain assessment revealed the primary pain location-head. There was no documentation the patient self report numeric pain scale was completed. The blood pressure was 240/107 at 11:02 PM. The diagnoses (active) were High Blood Pressure and Headache.

Review of the ED Physician Documentation on 1/15/19 at 11:15 PM revealed PI # 8 presented to the ED with BP 203/115 and a headache. The physician documented a past history of hypertension and headache.

Review of the ED medication orders revealed Hydralazine 20 mg IVP was given on 1/16/19 at 12:26 AM and a second dose of Hydralazine 20 mg IVP was administered at 12:56 AM.

Review of the ED nurse documentation on 1/16/19 at 1:00 AM revealed numeric pain scale documentation was 10 (worst pain).

Review of the ED medication orders revealed Dilaudid 0.5 mg IVP (a narcotic pain reliever) and Zofran 4 mg (an anti-emetic) IVP was administered on 1/16/19 at 1:00 AM.

There was no documentation a pain reassessment was performed following the IVP Dilaudid pain intervention.

Review of the ED Discharge Documentation revealed PI # 8 was admitted to outpatient/observation services and transferred to the floor on 1/16/19 at 1:55 AM.

During an interview on 2/14/19 at 1:55 PM, EI # 2 confirmed nursing staff failed to perform and document patient pain assessment/reassessments per policy and procedure.

4. PI # 10 presented to the ED on 10/30/18 at 4:29 PM with a chief complaint of Chest Pain with an onset 15 hours prior.

Review of the ED Triage Adult pain assessment documentation dated 10/30/18 at 4:38 PM revealed pain location was the chest, the numeric pain scale was 10.

Record review revealed physician orders on 10/30/18 at 4:57 PM for Toradol 60 mg IM and 30 ml (milliliters) of Maalox Plus. The numeric pain scale documentation at 5:04 PM was pain-10. The patient received Toradol 60 mg IM and Maalox Plus 30 ml at 5:04 PM.

Further ED record review revealed on 10/30/18 at 5:47 PM the nurse documented the patient was discharged in NAD.

There was no documentation the nurse completed a pain reassessment after the Toradol IM was administered.

An interview was conducted on 2/14/19 at 2:00 PM with EI # 2, who confirmed the finding above.

5. PI # 4presented to the ED on 1/18/19 at 4:05 AM with a chief complaint of N/V and Abdominal Pain which began at midnight.

Review of the ED Triage Adult pain assessment documentation dated 1/18/19 at 4:11 AM revealed pain location was the abdomen, the numeric pain scale was 7.

Record review revealed physician orders on 1/18/19 at 4:21 PM for Toradol 60 mg IM. The patient received Toradol 60 mg IM at 4:31 AM.

The numeric pain scale documentation at 4:35 AM was pain-8.

Further ED record review revealed on 1/18/19 at 5:45 AM the nurse documented the patient was discharged in NAD.

There was no documentation the nurse completed a pain reassessment after the Toradol IM was administered.

PI # 4 presented back to the ED on 1/18/19 at 1:30 PM with a chief complaint of Abdominal Pain which began 3 days ago.

Review of the ED Triage Adult pain assessment documentation dated 1/18/19 at 1:49 PM revealed pain location was the abdomen, the numeric pain scale was 8.

Record review revealed physician orders on 1/18/19 at 2:26 PM for Morphine 2 mg IVP. The patient received Morphine 2 mg IV at 2:59 PM.

Review of the nurse's pain assessment documentation revealed the next pain scale documented was at 4:12 PM, which was 1 hour and 13 minutes after the Morphine IV, and was a 9.

Review of the physician orders dated 1/18/19 at 4:02 PM revealed an order for Dilaudid 1 mg IVP. There was no documentation of a pain scale at 4:02 PM. The Dilaudid 1 mg IVP was administered at 4:12 PM.

Further ED record review revealed on 1/18/19 at 5:01 PM the nurse documented the patient was discharged in NAD.

There was no documentation the nurse completed a pain reassessment after the Dilaudid IV was administered.

An interview was conducted on 2/14/19 at 1:20 PM with EI # 2, who confirmed the finding above.