HospitalInspections.org

Based on review of medical records (MR), facility policies and procedure, facility event documentation, and interviews with the staff, it was determined the facility failed to ensure all patients at risk for suicide were provided a safe environment.

This deficient practice affected six of six MR's reviewed including PI (Patient Identifier) # 2, PI # 4, PI # 5, PI # 3, PI # 1, and PI # 6.

Refer to A 144 for findings.

Based on review of facility policies and procedures, medical records (MR), facility Adverse Event/Occurrence investigation documentation and interviews it was determined the facility failed to ensure:

1. All patients presenting to the ED (emergency department) were screened using the Columbia Suicide Severity Rating Scale (C-SSRS) per policy.
2. Staff re-assessed patients identified at risk for suicide, identified worsening of the patient's mental condition, and intervened when there were changes in patient behaviors.
3. All patients identified as high-risk for suicide were placed on 1:1 (one patient to one staff) observation as directed per policy.
4. Physician orders for high-risk suicide patient monitoring included the specific safety measures such as suicide precautions, homicide precautions, elopement precautions, and aggression precautions required to ensure patient, and staff safety.
5. All staff and persons responsible for suicide risk screening and conducting 1:1 observation had documented evidence of training.
6. Care Companion documentation for 1:1 observation monitoring was accurate and complete.
7. Behavioral Health (BH-Mental Health (MH) consult documentation was complete, and available in the patient's MR for care planning purposes.

The deficient practice affected six of six MR's reviewed and included Patient Identifier (PI) # 2, PI # 4 PI # 5 PI # 3, PI # 1, PI # 6, and had the potential to affect all patients high-risk for suicide.

Findings include:

Facility Policy and Procedure Title: Suicide Risk Assessment
Filing Number-blank, no number documented
Revised Date 03/22
Applies to: Patient Care Areas

Purpose:
To guide staff in identifying patients at risk for suicide, identifying environmental safety risks and establishing a process to minimize the risk of suicide.

Policy:
Adolescent and adult patients, ages 10 (ten) years and older, treated in the ED...and/or admitted to Monroe County Hospital (MCH) should be screened for the risk of suicide. The screen...take place during the triage process in the ED, the triage and/or admission process...for inpatients...If the patient cannot be assessed upon arrival due to medical status, the screening may be postponed and performed as soon as condition permits. The C-SSRS will be used to screen patients for suicidal risk. Patients who screen high for suicide risk should have a full risk assessment complete by the physician or behavioral health provider. Patients should be placed in the observation level that is associated with the level of risk identified by the C-SSRS screening:

1. Low Risk...Routine patient care.
2. Moderate Risk...Notify physician on admission and for any changes in behavior, consider a behavioral health consult.
3. High Risk...Immediate notification of physician. Request a BH consult. The patient should remain in 1:1 observation with a safety companion until disposition by the physician. Safety precautions (Ligature Checklist and the Environmental Safety Guidelines Checklist) should be completed for the patient's room (ED, Labor and Delivery-L&D), and/or ICU (intensive care unit), mitigate the risk of suicide by removing objects that pose risks for self-harm when possible, and documentation every 15 (fifteen) minutes on the Care Companion Behavioral Observation Flowsheet.

1:1 monitoring of the patient should be maintained until there is clear documentation from the physician that the patient is no longer a high suicide risk. This may be delayed until a MH health assessment has been completed. Ultimately, the physician must use his/her judgement regarding the clinical and mental stability of the patient and the decision as to whether or not 1:1 monitoring can be discontinued.

If the patient presents to the hospital in custody of law enforcement, and the law enforcement officer will be with the patients at all times, 1:1 observation with a care companion does not have to be implemented. The law enforcement officer should document, if willing on the Care Companion Behavioral Observation Flow Sheet (CCBOF) for continuity of care.

The patient low/moderate risk should be re-screened if s(he) begins to develop signs of worsening suicidal ideation (SI) after hospital admission. The physician should be notified of the screen results and the need for a mental health assessment.

When a patient screens high risk for suicide:
1. Initiate safety precautions (Ligature Room Safety Checklist and the Environment Guidelines checklist)...completed every shift by the Registered Nurse (RN).
2. Explain procedures to patient and family members...inform them of restrictions and rationale for the precautions.
3. Remove all belongings...hold in a secure location...document a list of personal items...
4. Do not allow visitors until the physician...decision...should be documented.
5. Remove the patient's clothing...place in a hospital gown.
6. Meals...served on disposable products.
7. Assign a safety companion to provide 1:1 observation until disposition. Nursing...must accompany patient to the restroom.
...9. Initiate chain of command, call Code...Security and/or law enforcement...if the patient becomes aggressive or violent or presents an elopement risk...

Facility Policy and Procedure Title: Forensic Guidelines of Care
Filing Number: 550-027
Effective Date: 9/98
Revised Date: no date documented

Policy:
The purpose of this policy is to establish guidelines under which MCH will care for the inmates/patient...

Procedure
All inmates/patients will be under direct observation of a correctional officer at all times while being treated at MCH. For safety of the staff and community, a prisoner should NEVER be separated from the Correctional Officer (CO). Therefore, a prisoner's right to privacy will not be the same as the non-prisoner patient.

Duties and Obligations of the COs:
It will be the responsibility of MCH to provide orientation of the hospital facility to the COs. This orientation shall include:
1. When to contact the nurse
2. Infection Control
3. Emergency Codes
4. Fire-actual or drill
5. Electrical safety
6. Severe weather/tornado
7. General information
8. Restraint distinctions
9. Channels of communication (for unresolved issues)
10. Interacting with patient

Standards of Care
Inmate/patients are entitled to and will receive the same level of care provided to the general public in the Hospital... Should any prisoner/inmate become a problem (harassing the staff, making threat, asserting himself in such a manner which is offensive)...to be reported to the CO immediately and the prisoner will be taken back to the correctional facility.

...CO/Inmate Ratio
The ratio for inmate/patient to officer will be 1:1 at all times.

...Medical Record (MR)
The MR is the property of MCH...Under no circumstance is the patient/inmate to be informed of the date or time of any follow-up visits...communicated through the correctional facility.

Rights and Responsibilities
Inmates have the same rights as any patient treated at MCH..., however the guard is to be present during all time(s), including those times when the patient may be receiving a physical exam.

...Compliance with Hospital Policies:
All CO's area expected to comply with Hospital policies and procedures as they apply to patient care areas...

1. PI # 2 presented to the ED on 7/18/23 at 11:07 PM, via ambulance accompanied by the police. The cc (chief complaint) was laceration to right arm, from stabbing caused by metal. The ED nurse documented the information source was emergency medical service (EMS) provider, and police.

Review of the ED "Nursing Record" documentation revealed triage and assessment time was 11:08 PM, at presentation at 11:20 AM, blood pressure 126/85, heartrate 100 beats per minute, respirations 20 per minute, oxygen saturation 100% on oxygen, the patient (pt) arrived covered in blood, ill-appearing, in moderate distress, no speech present, skin cold and clammy, color pale, no response to orientation, officer at bedside.

Review of the ED Nurse "Treatment Notes" dated 7/18/23 at 11:20 PM revealed md (medical doctor) at bedside, pt responsive to painful stimuli, skin cold, officer at bedside.

MR review revealed on 7/19/23 the ED nurse documented the following:
At 12:00 AM physician and 2 (two) RN's at bedside, pt remains alert...follows verbal commands...but does not verbally answer questions..."
At 12:16 AM, officer remains at bedside.
At 12:25 AM, pt complains of severe pain to site md notified orders received.
On 7//19/23 at 12:30 AM, Morphine 2 milligram was administered.

Review of the ED record revealed on 7/19/23 at 1:20 AM, the nurse documented, "pt now awake and alert and speaking. pt states cut himself on purpose but will not tell this rn why. md notified, no new orders...officer remains at bedside...". At 1:49 AM, the nurse documented, alert, oriented, cooperative with care.
At 2:26 AM, pt provided with food tray, pt pleasant and cooperative with care, officer remains at bedside.
At 4:00 AM, resting on stretcher, easily arouses to verbal stimuli, no needs voiced, finished meal tray, officer at bedside.

Review of the ED record revealed Nursing Record documentation dated 7/19/23 at 5:15 AM, no alcohol screening, and no mental health screening was assessed, reason was "pt not verbally responsive."

Review of the ED Provider Physician Record documentation dated 7/19/23 at 6:32 AM revealed PI # 2 presented in severe distress, positive for laceration, affect was appropriate, psychiatric history of depression, the physician's impression, attempted suicide, and disposition was 24-hour observation admit to ICU.

There was no C-SSRS completed during the ED stay for a patient presenting with a confirmed self-inflicted stab wound and suicide attempt. There were no orders for 1:1 care while in the ED, no documentation 1:1 observation was performed, and no safety/suicide precautions measures were documented.

MR review revealed physician documentation, Adult General Admission Orders dated 7/19/23 at 6:40 AM, an observation stay in ICU, diagnosis-suicide attempt, "Need One to One" (1:1 observation/patient monitoring-1 patient to 1 staff), MH consultation, reason suicide.

Review of the ICU RN Patient Progress Notes (PPN) dated 7/19/23 revealed PI # 2 was admitted to ICU at 8:25 AM, diagnosis, suicide attempt. Deputy in room, placed in paper gown. Breakfast tray placed in front of patient.

There was an ICU Ligature/Room Safety Checklist/Environmental Guidelines completed by the RN on 7/19/23, but the time the room safety check was performed was not documented.

Review of the Nursing Initial Interview (NII) and Initial Physical Assessment (IPA) dated 7/19/23 at 8:45 AM, revealed PI # 2 was oriented to the environment, call light, bed controls, telephone, television, mealtime, side rails, hand hygiene/infection control.

Further review of the NII dated 7/19/23 at 8:45 AM revealed a neurological/MH assessment included anxiety, depression, Suicide Ideations (SI)/Attempt, psychiatric illness, PTSD (post-traumatic stress disorder), Bipolar with manic episodes, night terrors. There was a fall assessment completed, which revealed a risk for falls, place on fall precaution, and the Skin Risk Assessment revealed minimal risk for skin breakdown. The IPA Nurse's Note documentation revealed "denies suicidal or homicidal at this time, Deputy at bedside.

Review of the record reveaked PI # 2's admitting diagnosis to ICU was Suicide Attempt. There was no documentation the C-SSRS was completed upon admission to ICU. There was no documentation the CO was oriented to the hospital policies and procedures including 1:1 observation and hospital policies for duties/obligations of the CO.

Review of the 7/19/23 ICU Nurse Physical Assessment, hospital Case Management/Social Services, and BH SW (social worker) Mental Status Exam Pre-Hospitalization Screening documentation revealed the following:
At 10:25 AM, BH provider notified of a MH consult.
At 11:18 AM, pt sitting on side of bed talking to deputy, no distress noted.
At 11:36 AM, case management-anticipated discharge needs per recommendation of MH.
At 11:45 AM, lunch tray to bedside, pt pleasant and talking to CO.

Review of the BH provider Mental Status Exam Pre-Hospitalization Screening dated 7/19/23 from 1:18 to 2:12 PM, revealed PI # 2 was cooperative, alert, mood was depressed and irritable, thought content was delusions, auditory hallucinations, suicidal thoughts with plan, and homicidal thoughts, with no plan. Hospitalization recommended, no.

Further review revealed BH screening documentation included transfer to a BH unit was not possible due to charges of 'assault 1st (degree) and assault with a deadly weapon filed last night', client is an inmate, deputy with him/her in ICU, waiting in ICU 306. The BH provider documented a history of bipolar diagnosis, on no medication for over a year and half, with suicidal and homicidal thoughts for a long time, "always trying to figure ways to do it." The BH provider documented plans to restart outpatient counseling over the phone, see the center psychiatrist for medication for mental illness, discussed with the client who agreed with the plan, return to jail after MCH discharge, continue on suicide watch.

Review of MCH Care Companion check sheet documentation (no date documented) revealed from 8:30 AM to 2:15 PM, every 15 minutes staff documented PI # 2 was awake, in bed, calm. At 2:30 PM, staff documented PI # 2 was awake, pacing, and calm.

MR review revealed Discharge Instructions dated 7/19/23, printed 2:24 PM, and signed by the CO/Deputy, to return to county jail.

Further MR review revealed documentation dated 7/19/23 at 2:44 PM (amended 7/19/23 at 6:10 PM by the nurse), pt is standing at the door with one arm holding top of door frame and one arm holding cup of coffee. Patient is smiling and seems calm drinking coffee. At 2:45 PM-nurse is sitting at desk when blinds in room shuffled and made a loud noise. Nurse then stood up to see what was happening then saw pt stand near doorway and started backing up, then pt proceeded to place a gun to right side of head smiling at nurse and pulled trigger...Nurses ran out through breakroom door. called 911. Code orange...called...ER (emergency room)physician, ER nurse, and administrators ran to ICU...placed pt on monitor...pt was asystole (no electrical heart activity) ...Dr (doctor) pronounced pt death a 2:53 PM. Law enforcement in room...secured the scene and secured the weapon.

Review of the facility Adverse Event/Occurrence documentation revealed on 7/19/23 at 2:43 PM, "...pt requests a cup of coffee from nurse. At 2:44 PM, coffee to pt. Pt standing in doorway of room, CO sitting right by him/her in chair. Pt takes a swallow of coffee, smiles at nurse and appears calm. 2:45 PM, nurse sitting at desk, hears loud noise, gets up to see what's happening, CNA (certified nurse assistant) states "pt throws hot coffee on CO, pushes him/her to floor, scuffle...CO states...he/she has my gun. Nurse stands up from desk-makes eye contact with pt. States pt had gun pressed to head behind right ear, smiled...backed up into room by sink and shot him/herself in the head. 2:50 PM Code Orange and 911 called..."

An interview was conducted on 7/23/23 at 2:25 to 3:07 PM with (Employee Identifier) EI # 5, ICU, RN. EI # 5 confirmed he/she was assigned to care for PI # 2 on 7/19/23. EI # 5 reported he/she was notified in morning report of PI # 2's Suicide attempt and Homicide attempt while incarcerated. EI # 5 stated the CO was present in PI # 2's ICU while PI # 2 was in the ICU, except during the MH evaluation and the CO was outside the door. EI # 5 reported the CO had hand cuffs on his/her belt and a gun, and PI # 2 was not cuffed/restrained in any way during the ICU stay. EI # 5 reported PI # 2 stayed in the bed until after the MH consult, then was out of bed, holding on to the door frame and pacing. EI # 5 stated PI # 2 exhibited no behaviors that met the criteria for hospital restraint, and was pleasant and cooperative. EI # 5 confirmed he/she asked PI # 2 about SI/HI (homicial ideation) during initial interview, and PI # 2 denied both. EI # 5 confirmed a complete C-SSRS was not completed and documented. EI # 5 confirmed he/she did not perform 1:1 observation but checked in on PI # 2 every 15 minutes.

In addition, EI # 5 confirmed he/she did not provide training for the CO for 1:1 observation. EI # 5 was not aware other staff provided the CO with 1:1 observation training on 7/19/23. The surveyor asked EI # 5 if he/she or other hospital staff asked the CO to cuff/restrain PI # 2 during the ICU stay? EI # 5 reported no, and that PI # 2 stayed in the bed until after the MH consult then PI # 2 was out of the bed, pacing, holding on to the door frame. EI # 5 reported PI # 2 was on cardiac telemetry, and PI # 2's heart rate had been in the 70's (beats per minute), but just before the event increased to 140's.

There was no documentation the staff identified and responded to changes in PI # 2's behavior and the heart rate increase.

An interview was conducted on 7/25/23 at 2:39 PM with EI # 2, Interim Chief Nursing Officer, who confirmed there was no documentation during PI # 2's stay, staff completed a C-SSRS and after identifying the laceration was a suicide attempt. There was no reason documented why PI # 2 was not placed in 1:1 observation while in the ED. EI # 2 confirmed hospital staff were not conducting the 1:1 observation while in ICU, and staff who completed ICU 1:1 observation documentation had additional patients/duties on 7/19/23 and did not provide 1:1 observation per policy. EI # 2 confirmed there was no documentation the CO was agreeable to provide 1:1 observation and was trained on the facility policy for 1:1 observation, or other policies as per the hospital Forensic Guideline policy. There was no documentation staff identified and responded to PI # 2's behavior and heart rate changes.

EI # 2 also confirmed MR documentation failed to include the time staff completed the Ligature/Room Safety inspection Checklist and the date of the Care Companion check sheet.

2. PI # 4 presented to the ED on 6/22/23 at 11:48 PM, cc was psychiatric problem.

Review of the ED RN Current Visit Notes documentation revealed "...states he/she had a gun in the parking lot to shoot him/herself with but gave it to a man in the parking lot..." Bag taken and searched. No gun seen.

Review of the ED Nursing Record documentation revealed triage/assessment on 6/22/23 at 11:59 AM and included cc-psychiatric problem, onset 2 (two) weeks ago, described to be feelings of hopelessness and confusion, experiencing auditory hallucinations, upset because he/she has messed up with family.

Further review of the 6/22/23 ED Nursing Record revealed Depression Screening documentation, are you having thoughts of killing yourself now? Yes, shooting self with gun, admits to SI, physician notified, patient room assessed for safety. The C-SSR result documentation was high risk, placed in line of site visibility, provider notified of risk level.

Review of the ED Treatment Notes documentation dated 6/23/23 at 12:07 AM revealed patient placed in gown, cords/trashcan removed, and at 12:20 AM MH after hours called, MH provider on the phone with patient, and at 12:43 AM, MH working to get a MH facility bed.

Review of the ED Provider documentation of history of present illness, cc, psychiatric problem, psychiatric history, panic attacks, PTSD, Suicide attempt and SI, agree with the nursing treatment notes.

There was no documentation why PI # 4 was not placed in 1:1 observation, and no documentation that staff completed a Ligature/Safety Room and Environmental Checklist.

MR review revealed a physician order for Adult General Admission dated 6/23/23 at 6:40 AM, Observation admit to ICU, diagnosis SI, No one on one, Consultation: MH, Consultation reason; Suicidal.

Review of the ED Nurse Disposition documentation dated 6/23/23 at 8:00 AM revealed the pt left ED in wheelchair, all pt belongings taken to ICU, including two lighters, WD 40 (Water Displacement on the 40th, a lithium-based grease that provides superior lubrication and corrosion protection in wet and moist environments) can, pill bottle with multiple pills, and scattered pills in bag.

Record review revealed ICU Physical Assessment documentation dated 6/23/23 at 8:05 AM, diagnosis SI, states does not have no one who cares. At 9:00 AM, the nurse called MH, states aware, attempting inpatient psychiatric admission.

Further MR review revealed nurse documentation on 6/23/23 regarding transportation arrangements difficulties at 12:30 PM, and at 4:05 PM. At 8:09 PM, the nurse documented, "patient voiced that he/she still wants to kill self...gave gun to an old man, and all he/she has is bullets..."

PI # 4 was discharged 6/23/23 at 10:55 PM to an inpatient psychiatric hospital.

There were no documentation PI # 4's current thoughts of SI while in the ICU were reported to the physician and no documentation PI # 4 was re-assessed using the C-SSRS with worsening of SI. There was no documentation suicide precautions including 1:1 observation was implemented to prevent self-harm. There was no documentation of the MH consult and MH recommendations for patient safety during the ED/ICU stay.

An interview was conducted on 7/25/23 at 12:40 PM with EI # 2, who confirmed there was no MH consult documentation, no documentation of the rationale/reason 1:1 observation was not ordered when the nurse C-SSRS and Depression screening revealed high-risk for suicide. There was no documentation staff completed a safety plan to prevent self-harm during the ED/ICU stay and no documentation staff performed room safety inspections, completed the Ligature/Room Safety checklist and MCH Environmental Guidelines documentation per policy.

3. PI # 5 presented to the ED on 5/31/23 at 2:04 PM, accompanied by family, cc was "psychiatric problem (suicidal thoughts)".

Review of the ED Nurse Record documentation dated 5/31/23 revealed pt complaining of suicidal thoughts, going on for about a year, worse today, tearful, stated "just feel like sometimes my family would be better off without me", denies attempting to act on SI. The C-SSRS screening risk was protocol item 5, (high risk), Immediate Notification of Physician and/or Behavioral Health and Safety Precautions. At 2:08 PM, the nurse documented, MD (medical doctor) at bedside, "no 1:1 observation needed".

Review of the ED physician documentation dated 5/31/23 at 2:25 PM revealed pt complains of persistent feelings of worthless, hopelessness, positive for depression, and SI.

Further review of the ED Nurse Record documentation dated 5/31/23 at 3:30 PM revealed the BH provider reported having seen PI # 5 earlier today, completed a MH evaluation with recommendation for inpatient care, but no beds available until tomorrow. At 3:52 PM, the ED Nurse documented significant other at bedside.

There was no documentation staff performed a room safety inspection, removed potentially harmful equipment/items and ensured the patient's environment was safe for this patient with a high-risk suicide screening. There was no documentation the family/significant other was instructed to notify the nurse when he/she exited PI # 5's room.

MR review revealed physician documentation on 5/31/23 at 4:30 PM for Adult General Admission, ICU Observation, diagnosis Depression, consultation MH, "does not need one-on-one".

There was no MH consultation documentation in PI # 5's record.

MR documentation revealed pt belongings including clothes were given to pt, and PI # 5 departed the ED at 5:22 PM to the ICU.

Review of the ICU Nurse PPN dated 5/31/23 revealed at 5:50 PM, the spouse was at bedside. However, there was no documentation staff conducted a safety inspection of the ICU room and removed potential harmful items from the environment and no documentation staff instructed the spouse to notify the staff if he/she exited the patient room.

Review of the Discharge Note dated 6/1/23 signed by the physician at 8:42 AM revealed documentation pt presented to the ER 5/31/21 with SI and plan, putting his/her face in a pillow. Problems identified, depression with SI and plan, monitored in ICU, and discharge to inpatient psychiatric facility, suicide precautions. PI # 5 transferred on 6/1/23 at 3:35 PM to an inpatient psychiatric facility.

There was no MR documentation that staff performed a safety inspection of PI # 5's ED and ICU room per policy.

In an interview conducted on 7/25/23 at 2:23 PM, EI # 2 confirmed there was no reason/rationale documented after the C-SSRS high risk screening was conducted why the patient was not placed on 1:1, or that safety inspections in the patient's environment was conducted.

4. PI # 3 presented to the ED on 3/26/23 at 8:56 PM with family, cc psychiatric problem, "pt reports being actively suicidal right now".

MR review revealed on 3/26/23 at 9:01 PM, the ED nurse documented the C-SSRS, high-risk for suicide, pt placed in gown, family at bedside, environmental/safety risk checklist completed, room door and curtain open. At 9:14 PM, the nurse documented pt reports being in control but could snap anytime, pt reports looking around for a way to hurt self.

Review of the ED documentation revealed at 9:37 PM physician states pt does not have to be 1:1, mother may remain in room with patient. There was no documentation staff discussed and/or educated the family to remain with the patient to ensure patient safety and notify the staff when leaving the patient room.

Record review revealed at 3/26/23 at 10:02 PM MH consultation via phone with patient was conducted. There was no MR documentation of the BH providers assessment/recommendations following the MH phone consultation.

Review of the ED physician documentation dated 3/27/23 at 12:50 AM, revealed orders to admit to ICU, Observation; consult: Psychiatry (done) in ED; Consultation reason: Suicidal; 1:1 in ICU.

MR review revealed on 3/27/23 at 1:17 AM PI # 3 was admitted to ICU, 1 to 1 observation, Patient Care Technician sitting with patient. There was no documentation staff re-assessed PI # 3's suicide risk when admitted to the ICU.

Review of a Care Companion check sheet (no date) revealed a total of three every 15-minute patient observations documented at 11:00 PM, 11:15 PM, and 11:30 PM. There was no date and no department documented where the three 15-minute care checks were conducted.

Review of the Care Companion check sheet dated 7/23/23 from 7:00 AM to 6:45 PM, revealed EI # 9, RN, performed and documented every 15-minute observations.

Review of staff annual training during 2022 and 2023 for Suicide Risk Assessment and 1:1 observation monitoring failed to reveal documentation that EI # 9 completed an initial or annual training for suicide risk assessment and 1:1 observation.

An interview was conducted on 7/25/23 at 12:31 PM, with EI # 2, who confirmed staff failed to re-assess the patients' suicide risk while in the ICU, failed to ensure MH consultation was available within 24 hours of the assessment, failed to document the Care Companion check sheet monitoring date, location/department, and ensure all staff were trained to provide 1:1 observation.

5. PI # 1 presented to the ED on 7/22/23 at 5:07 PM by EMS, triage and assessment time was 5:07 PM, cc suicide attempt, ingestion of unknown amount of Geodon, Depakote, and Wellbutrin.

Review of the ED Nurse C-SSRS revealed suicide risk high, placed in room with line of site visibility, provider notified, 1:1 observation, belongings/clothing cleared.

MR review revealed an ED physician order dated 7/22/23 at 5:07 PM for 1:1 observation.

Record review revealed physician orders dated 7/22/23 at 6:35 PM, Adult General Admission, Observation in ICU, diagnosis suicide attempt, Consultation: MH...other orders 1:1 Observation.

Further record review revealed on 7/22/23 at 6:47 PM, pt on the phone with the MH Therapist, and on 7/22/23 at 8:25 PM, PI # 1 was transferred to ICU.

MR review revealed a document titled, "Care Companion Behavioral Observation Flowsheet" 1900-0645 (7:00 PM-6:45 AM) that failed to include the date 15-minute observations conducted from 12:45 AM to 6:45 AM.

Further review revealed documents titled, Care Companion Check Sheet 0700-1845 (7:00 AM to 6:45 PM) with no date 15-minute observations were conducted from 7:00 AM to 12:15 PM, and from 5:15 PM to 6:45 PM.

Record review revealed Care Companion Check Sheets 1900-0645 (7:00 PM-6:45 AM) with no dates documented for 15-minute observations from 7:00 PM to 8:15 PM, from 12:45 AM to 6:45 AM, from 7:00 PM to 11:00 PM, and from 7:00 PM to 12:30 AM.

MR review was completed on 7/24/23 at 3:30 PM by the surveyor and revealed no documentation of the MH consultation. There was no documentation staff re-assessed PI # 1's suicide risk while in the ICU.

An interview was conducted on 7/25/23 at 1:35 PM with EI # 2 who confirmed there was no MH consult documentation, staff failed to re-assess PI # 1's suicide risk while in the ICU, and failed to ensure the Care Companion Behavioral Observation Flowsheet and the Care Companion Check Sheets were dated.

6. PI # 6 presented to the ED on 7/24/23 at 9:57 PM, cc suicide attempt, took 12 Benadryl.

Review of the ED Nurse Record documentation revealed C-SSRS, high-risk suicide.

Review of the Care Companion Check Sheet documentation dated 7/24/23 1900-0645 (7:00 PM-6:45 AM) revealed on 7/25/23 from 12:30 AM to 1:00 AM and from 2:00 AM to 2:30 AM, EI # 8, Ward Clerk, documented 1:1 observation every 15-minutes.

Review of EI # 8's staff training documentation for 2022 and 2023 revealed no initial and no annual training for 1:1 observation.

Further MR review revealed ED physician orders dated 7/25/23 at 1:55 AM, Adult General Admission, Observation ICU, diagnoses SI/Attempt. Consultation MH, reason Suicide Attempt, other orders Suicide Precautions, 1:1 observation.

Further record review revealed PI # 6 was transferred to ICU on 7/25/23 at 2:32 AM. There was no suicide risk re-assessment performed during the ICU stay from 2:32 AM until discharge on 7/25/23 at 5:10 PM.

In an interview conducted on 7/25/23 at 2:31 PM, EI # 2 confirmed staff failed to re-assess PI # 6's suicide risk after ICU admit, and there was no documentation EI # 8 was trained to provide 1:1 observation for patients at high-risk for suicide.