HospitalInspections.org

Based on observation, review of one of four medical records (#4), staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure that all patients are cared for in a manner that keeps them safe and there is documentation to ensure that patient safety is maintained.

Findings include:

1) The facility failed to ensure that continuous visual observation is maintained for patients on one-to-one (1:1) observation for suicide risk, as indicated in facility policy. (Cross refer to Tag A-144)

2) The facility failed to ensure that electrical outlets in areas accessible to patients on the Inpatient Psychiatric Unit (IPU), are tamper proof. (Cross refer to Tag A-144)

3) The facility failed to ensure that documentation on the "Frequent Observation Flow Sheet" is complete for all patients on 1:1 observation, in accordance with facility policy. (Cross refer to Tag A-144)

Based on observation, staff interviews, review of one of four medical records (#4) of patients on 1:1 observation for suicide risk, and review of facility policy and procedure, it was determined the facility failed to ensure that: 1) continuous visual observation is maintained for patients on one-to-one (1:1) observation for suicide risk, as indicated in facility policy; 2) electrical outlets in areas accessible to patients on the Inpatient Psychiatric Unit (IPU) are tamper proof; and 3) documentation on the "Frequent Observation Flow Sheet" is complete for all patients on 1:1 observation, in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Suicide Risk Assessment and Interventions in an Acute Care Setting" states, " ... Suicide Risk Interventions (Levels 1-3/Immediate-Moderate Risk) ... For Suicide Risk Level 1 Immediate Risk - Continuous visual surveillance (line of sight) with 1:1 direct observation by staff at all times. ... Guidance: Requires immediate life-saving intervention, immediate risk to self or others, violent/self-destructive act with harm, severe behavioral disorder, reported verbal commands to do harm to self or others ... For Suicide Risk Level 2 High Risk - Continuous visual surveillance (line of sight) with 1:1 direct observation: Observation by staff at all times with direct line of sight ... Probable risk of danger to self or others. ... Guidance: Suicidal ideation with or without a plan; acute drug or alcohol intoxication. ... Required Action Steps: Utilize the Frequent Observation Flow Sheet for visual surveillance and close observations. ... Guidance: Psychiatric patients requiring medical care in a non-psychiatric setting (medical inpatient units, ED, ICU, etc.) must be protected when demonstrating suicidal ideation or suicide risk. Patients with serious suicidal ideation who are admitted to medical/surgical inpatient settings often require equipment to monitor and treat their medical conditions, so it is impossible to make their environment truly ligature-resistant. The protection would be that of utilizing safety measures such as 1:1 monitoring with continuous visual observation ... ."

1) During a tour of the Emergency Department (ED) on 10/21/22 at 10:40 AM, in the presence of Staff #1 (Interim Chief Nursing Officer), the following was indicated:

Upon interview at 10:51 AM, Staff #1 indicated that the ED contained five "Crisis Rooms" used for Behavioral Health patients. Staff #1 identified the five Crisis Rooms as Rooms #1, #2, #9, #17, and #18. Rooms #1, #2, #17, and #18 were observed immediately adjacent to one another. Room #9 was located at the opposite end of the hallway from the other rooms.

At 10:53 AM, Staff #6 (Safety Sitter) was observed sitting outside of Room #1. Upon interview, Staff #6 stated that he/she was performing 1:1 observation for the patient in Room #1. Upon interview, Staff #6 stated that if the patient on 1:1 observation needed to use the bathroom, he/she would escort them to the bathroom. Staff #6 stated, "I walk them to the restroom and wait outside the bathroom door. I leave the bathroom door closed to give them privacy. The door doesn't lock." Staff #6 was asked if he/she can see the patient with the door closed. Staff #6 stated, "No, I can't see the patient from the outside." Staff #6 was asked if he/she would close the door if the patient was on 1:1 observation for suicide risk. Staff #6 stated, "Yes, for privacy."

Observation of the bathroom used for patients in Crisis Rooms #1, #2, #17, and #18 revealed that the bathroom contained anti-ligature and safety features to protect patients from harm. Upon interview at 10:55 AM, Staff #6 was asked if all Behavioral Health patients use the same bathroom. Staff #6 stated, "The patients in Rooms #1, #2, #17, and #18 use this bathroom [the bathroom adjacent to Room #1 with anti-ligature and safety features]. There is another bathroom down the hall across from Room #9. The patients in Room #9 use that one."

An observation of the bathroom located across from Room #9 was conducted at 11:03 AM, in the presence of Staff #1. The bathroom contained ligature and safety risks that included: two glass mirrors, grab bars that are not ligature resistant, a toilet and sink that are not ligature resistant, a toilet seat cover, paper towel dispenser, and soap dispenser that can be pulled off the wall and used as weapons, and a plastic liner in the trash can. Upon interview, Staff #1 stated, "If suicidal/homicidal patients go in this bathroom, staff have to go in with them."

Upon interview at 11:06 AM, Staff #9 (Licensed Practical Nurse) confirmed that he/she sometimes performs 1:1 observation for suicidal patients. Staff #9 was asked where he/she would escort a suicidal patient assigned to Room #9 if they needed to use the bathroom. Staff #9 pointed to the bathroom across the hall from Room #9 [bathroom with unmitigated ligature and safety risks]. Staff #9 was asked where he/she stands when the patient is in the bathroom. He/she stated, "I stand by the door and wait for them to come out." Staff #9 was asked if the door was closed. He/she stated, "Yes, absolutely for patient privacy. They may be taking a long time to go to the bathroom, so if I think there's suspicious activity, I knock."

Upon interview at 11:08 AM, Staff #8 (ED Technician) confirmed that he/she performs 1:1 observation for suicidal patients. Staff #8 was asked if he/she ever performed 1:1 observation for a suicidal patient assigned to Room #9. He/she stated, "Yes I have." Staff #8 was asked what he/she does if the suicidal patient in Room #9 needs to go to the bathroom. Staff #8 stated, "I would walk them to the bathroom (Staff #8 pointed to the bathroom across the hall from Room #9), then I would sit outside the door. I try to give people privacy. I gain a lot of people's trust, so I know they're not going to do anything. The door doesn't lock, but it is closed. I can't see the patient, but I can hear them."

On 10/21/22 at 4:17 PM, an Immediate Jeopardy (IJ) finding was identified for the facility's failure to maintain continuous visual observation of suicidal patients placed on one-to-one observation. The facility was notified of the IJ and provided with the IJ template on 10/21/22 at 4:17 PM. On 10/24/22 at 3:00 PM, an acceptable IJ removal plan was received. Implementation of the IJ removal plan was verified on 10/24/22 at 10:45 AM. Verification methods included the following: a tour of the Emergency Department (ED), 3rd floor Medical/Surgical Unit, and Inpatient Psychiatric Unit (IPU), review of staff re-education on the facility's policy regarding 1:1 observations, staff interviews confirming re-education on the facility's 1:1 policy, and review of the facility's updated policy on 1:1 observations. On 10/24/22 at 3:30 PM, the IJ was lifted.

2) During a tour of the IPU on 10/24/22 at 11:10 AM, in the presence of Staff #1 and Staff #10, multiple beige-colored electrical outlets were observed in patient rooms, large and small group rooms, and in the hallways of the unit. Staff #1 and Staff #10 were asked if the electrical outlets were tamper proof. Staff #1 indicated that he/she believed they were, but would contact Staff #15 (Assistant Vice President of Support Services) to confirm. At 11:27 AM, Staff #15 arrived to the unit and stated the beige-colored outlets were tamper proof. Staff #15 stated, "The outlets have a distinct shape and will only work when accessed by the exact shaped plug. They will not work if they (the patients) stick something into them."

At 11:30 AM, a "red outlet" (outlet reserved for emergency power in the event of a power outage) was observed in the hallway of the IPU, adjacent to a small group room. The "red outlet" was located on the wall approximately five feet high and was easily accessible to patients walking in the hallway. The "red outlet" did not have a distinct shape and appeared to be a regular outlet. Staff #15 was asked if the "red outlet" was a tamper proof outlet. At 11:40 AM, Staff #15 confirmed that the "red outlet" was "live" and was not tamper proof. Staff #15 stated, "We will have the outlet changed by the end of the day."

3) Reference: Facility policy titled, "Suicide Risk Assessment and Interventions in an Acute Care Setting" state, " ... Suicide Risk Interventions (Levels 1-3/Immediate-Moderate Risk) ... For Suicide Risk Level 2 High Risk - Continuous visual surveillance (line of sight) with 1:1 direct observation ... Required Action Steps: Utilize the Frequent Observation Flow Sheet for visual surveillance and close observations ... Performed By: RN, Observer, or Sitter."

Review of the medical record for Patient #4 (P4) on 10/24/22 at 12:56 PM, in the presence of Staff #3 (Clinical Educator), revealed the following:

P4 arrived to the ED on 08/06/22 at 16:06 (4:06 PM) accompanied by law enforcement. ED nurse's notes entered 08/06/22 at 16:06 state, "Presenting complaint: Law enforcement states: call to PD (police department) from HCI (Crisis Screening Service) for invol (involuntary) comit (commitment) for patient - patient texting people that [he/she] is going to kill [him/herself]. Police arrive at house and cannot find patient. Upon further investigation found patient sleeping in the woods. Patient found with many pill bottles."

A suicide screening assessment was completed at 16:20 (4:20 PM) and the patient was placed on Level 2 suicide interventions. A physician's order for 1:1 observation was entered on 08/06/22 at 16:07 (4:07 PM). There was no evidence in the medical record of documentation on the "Frequent Observation Flow Sheet" which is not in accordance with facility policy. Upon interview at 3:40 PM, Staff #3 confirmed that there was no "Frequent Observation Flow Sheet" completed for the patient on 08/06/22. Staff #3 stated, "If a patient is on 1:1, there must be an order and an observation sheet filled out. They (staff performing 1:1 observation) are supposed to document on the 1:1 observation sheet every 15 minutes. It doesn't look like the observation sheet is here."