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Based on observation, interview and document review, the hospital failed to ensure all patient rights were protected when hospital staff failed to follow hospital policies for supervision of patients who were at risk for suicide.

See A0144.

An IJ was identified 10/4/20, related to patients receiving care in a safe setting. The IJ was removed 10/9/20, but the hospital remained out of compliance at the Condition of Patient Rights.

Based on observation, interview and document review, the hospital failed to ensure patients were provided care in a safe setting when staff failed to follow the hospital policies related to patients at elevated risk for suicide for 6 of 10 (P1, P2, P3, P5, P6 and P7) patient records reviewed. P1, who was not adequately supervised and was left alone in a bathroom for 25 minutes and cut herself, requiring 14 stitches. This deficient practice resulted in an immediate jeopardy (IJ). P2 and P3, who were not assessed for level of suicide risk. P5, P6, and P7, who were not placed on 1:1 staffing despite being assessed as high risk, This noncompliance had the potential to impact all patients seen in the emergency department (ED) who were at risk for suicide or self injurious behavior.

The IJ began on 10/4/2020, when staff failed to follow the hospital policies related to patients at elevated risk for suicide. P1 was not adequately supervised and she was left alone in a bathroom for 25 minutes and cut herself, requiring 14 stitches. Because the serious outcome was likely to recur and had the potential to impact all patients at the hospital, the hospital's Vice President of Operations, System Chief Nursing Officer and Chief Operations Officer, Systems Regulatory, Emergency Department Nurse Manager, Nursing Director and Chief Operations Officer were notified of the IJ finding on 10/8/2020 at 10:30 a.m.

A review of P1's history and physical, dated 10/4/2020, established that P1 was admitted to the hospital's emergency department (ED) on 10/4/2020. P1 came to the ED via Emergency Medical Services (EMS) after leaving goodbye letters, and attempting to jump off a stair rail into a glass structure. P1's diagnoses included suicidal ideation, self-injurious behavior, major depression, anxiety disorder and eating disorder.

P1's nursing assessment, dated 10/4/2020, included a suicide risk screen that was positive for suicide risk.

P1's Columbia Suicide Risk Assessment dated 10/4/2020 indicated P1 was at high risk for suicidal behavior.

P1's treatment plan from 10/4/2020 included interventions of video monitoring and a Diagnostic Evaluation Center(DEC), psychiatric consult.

During an interview on 10/7/2020 at 11:30 a.m., psychiatric associate (PA)-E stated that when P1 injured herself with a piece of metal from a mask in the ED bathroom she was not on 1:1 staffing. PA-E stated that when someone comes in to the ED for suicide ideation, they are initially put on 1:1 staffing for safety, meaning, that patient has a staff member who watches them at all times for safety. PA-E stated she did not know when P1 had been removed from 1:1 staffing, but that after that status is removed, then staff check patients frequently.

During an interview on 10/7/2020, at 11:50 a.m., PA-F stated that he was working when P1 entered the bathroom on 10/4/2020. PA-F stated that he thought P1 was there related to suicide risk, but that P1 was not on 1:1 staffing at the time of the incident. PA-F stated he thought P1 was on 1:1 initially, but was not on 1:1 staffing at the time of the incident. PA-F stated P1 was in the bathroom alone with the door locked. He was not sure how long she was in the bathroom. He stated he checked on her verbally by knocking on the door and asking if she was okay and she answered verbally. PA-F stated that it is appropriate for a patient to be alone in the bathroom with the door locked and to check them verbally as long as they are not on 1:1 staffing. Later he heard someone call out for help, and then saw that P1 was in the bathroom and had cut herself.

During an interview on 10/7/2020, at 12:10 p.m., P1's physician (DO)-G stated she was working when P1 cut herself. She stated that she heard yelling from the bathroom, and staff were in the bathroom trying to get a piece of metal out of P1's hand. P1 had a 5 centimeter (cm) laceration across the back of her left arm near her wrist. The wound was fairly deep and required stitches, but no underlying structures were damaged.

During an interview with registered nurse manager (RN)-D on 10/7/2020, at 12:25 p.m., she stated that the current practice in the ED for suicidal patients who are not on 1:1 staffing includes multiple staff in the ED being responsible for their care ands safety. Staff are not specifically assigned to monitor suicidal patients unless they are on 1:1 staffing. Patients who are at high risk for suicide but are not on 1:1 staffing can enter the bathroom alone and can be checked on verbally.

During an interview on 10/7/2020, at 12:40 p.m., social worker (SW)-H stated that she completed P1's DEC assessment on 10/4/2020. At that time P1 had a suicide plan, had written good bye notes and she was at high risk for suicide. SW-H stated that she did not recommend 1:1 staffing for P1 because her father was there, and because she could contact for safety in the hospital.

During an interview on 10/7/2020, at 1:25 p.m., RN-I stated that she was working on 10/4/2020, when P1 cut herself. RN-I stated at 9:30 a.m. safety rounds P1 was observed and safe. RN-I stated she was not sure whet time P1 went into the bathroom. At some point she knocked on the bathroom door and P1 said she was fine. A few minutes later she knocked again and told P1 she had to come out. At the point P1 said she needed help. RN-I got the key and opened the bathroom door and saw P1 in the bathroom cutting her posterior left wrist area with a piece of metal. P1 eventually let the piece of metal drop and went to her room with staff. P1 later told RN-I that she got the metal from a mask that EMS had given her in the ambulance. At the time of the incident there was no protocol related to how often to check on patients who are using the bathroom. RN-I stated it would have been better if someone would have opened the door when they checked on her in the bathroom. There is currently no protocol for opening the bathroom door to check patients for safety in the ED.

Video of 10/4/2020, was observed on 10/7/2020, at 1:45 p.m. The video established that P1 entered the ED bathroom on 10/4/2020, at 9:40 a.m. multiple ED staff are outside the bathroom door. At 9:53 a.m., a staff member knocks on the door to check P1 verbally. The staff member does not open the door. At 10:00 a.m., a staff member knocks on the door to check the patient verbally. The staff member does not open the door. At 10:06 a.m., 26 minutes from when P1 entered the bathroom, a staff member knocks on the door to check on P1, then gets a key to open the door. At 10:08 a.m. P1 leaves the bathroom with staff.

During an interview with RN-J on 10/8/2020, at 11:00 a.m., he stated that P1's Columbia-Suicide Severity Rating Scale on 10/4/2020 revealed she was at high risk for suicide behavior, and she should have been on 1:1 staffing according to the hospital policy at the time of the event.

Medical record review revealed P2 was seen in the ED on 10/1/2020. P2's diagnoses included Suicidal Ideation. P2's nursing assessment dated 10/1/2020, revealed P2 was at moderate risk for suicidal behavior. P2's Columbia-Suicide Severity Rating Scale was never completed. P2 was not placed on 1:1 monitoring or safety watch.

Medical record review revealed P3 was seen in the ED on 10/1/2020. P3's history and physical dated 10/1/2020, revealed P3's diagnoses included suicide ideation with a plan to drink antifreeze. P1's nursing suicide assessment dated 10/1/2020, was positive, but the Columbia-Suicide Severity Rating Scale was never completed. P3 was not placed on 1:1 monitoring or safety watch.

Medical record review revealed P5 was seen in the ED on 10/2/2020. P5's history and physical dated 10/2/2020, revealed her diagnoses included suicidal ideation and intoxication after she was found by EMS staff hanging from a balcony. Although P5 was assessed by hospital staff as being at high risk for suicide, P5 was not placed on 1:1 staffing for safety or safety watch.

Medical record review revealed P6 was seen in the ED on 10/2/2020. P6's history and physical dated 10/2/2020, revealed his/her diagnoses included suicidal ideation and self injurious behavior after s/he tried to injure his/herself with a pair of scissors. Although P6 was assessed by hospital staff as being at high risk for suicide, P6 was not placed on 1:1 staffing for safety or safety watch.

Medical record review revealed P7 was seen in the ED on 10/3/2020. P7's history and physical dated 10/3/2020, revealed his/her diagnoses included suicidal ideation after an attempted overdose. Although P7 was assessed by hospital staff as being at high risk for suicide and placed on a 72 hour emergency hold, P7 was not placed on 1:1 staffing for safety or safety watch.

The policy titled, Patients at Risk for Harm to Self or Others - Environmental Modification and Monitoring, Provided by hospital staff and dated approved 5/9/2019, revealed under the section titled:

Monitoring at Risk Patients,

1. Patients requiring a safety watch (ED only)

a. The following patients require a safety watch: Patients screening at moderate risk for suicide., non-lethal self-harm attempts, patients on a 72 hour hold without behaviors requiring 1:1 monitoring.

d. The patient will be observed in person, by clinical staff every 15 minutes,

f. For a patient toileting/showering, a clinical staff member must leave the restroom door open enough to be able to constantly visualize the patient.

Under the section Definitions: 2. Safety Watch: A staff member is assigned to watch one or more patients at the discretion of the charge nurse. The staff member maintains visual line of sight to the patient, which may be accomplished with direct observation or by video-monitoring.

2. Patients requiring 1:1 monitoring with continuous visual observation (1:1)

a. The following patients require 1:1 continuous monitoring: Serious suicidal ideation per Columbia-Suicide Severity Rating Scale.

The IJ was removed on 10/9/2020, when it could be verified the hospital had submitted and implemented an acceptable removal plan that included appropriate education and training of staff and review of policies and procedures.