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Based on document review, observation and interview, it was determined the Hospital failed to follow Emergency Department (ED) policies to protect a patient with suicidal/homicidal ideations. As a result, the Condition of Participation (42 CFR 482.55) Emergency Services was not met. This potentially affects approximately 2200 patients per month who present for treatment, staff and visitors.

Findings include:

1. The Hospital failed to ensure suicide precautions were implemented per policy. (A-1104)

2. The Hospital failed to ensure the emergency department was appropriately supervised. (A-1111)

The immediate jeopardy (IJ) began on 3/18/17 with the presentation of Pt #1 to the Emergency Department (ED) via ambulance, handcuffed and escorted by a police officer with a diagnosis of Suicidal Ideation with a plan. The Hospital failed to ensure continuous monitoring of Pt #1, subsequently Pt #1 obtained a scalpel from an unlocked cart and lacerated both wrist which required surgical repair.

The IJ was announced on 3/24/17 at 2:00 PM, during a meeting with the Chief Executive Officer (E#7), Vice President Professional Services (E#5), Quality Manager (E#1), Director of Emergency Department (E#2) and the Quality Management Specialist (E#10). The IJ was not removed by the survey exit date of 3/24/17.

Based on document review and interview, it was determined in 4 of 10 (Pt #1, #6, #7, #9) records reviewed, the Hospital failed to ensure suicide precautions were implemented per policy. This has the potential to affect all patients placed on suicide precaution.

Findings include:

1. The policy titled "Suicide-Homicide Assessment- Precautions" (revised 11/16) was reviewed on 3/23/17. The policy required "C ... The suicidal/homicidal patient will be evaluated by the Emergency department (ED) physician. The admitting registered nurse (RN) or House Supervisor evaluates for the most appropriate care area ... placed on suicidal/homicidal precautions ... H. The patient must be observed continually by a staff member while on suicide/homicide precautions ...K. Precautions should be taken to keep the patient safe at all times ...1. The patient should be dressed in hospital gown at initial point of care. 2. All patient belongings should be removed from the room ... 3. Remove all sharp objects from the room. 4. Remove all potential hazards from room (tubing, cords ... gloves ... 5. Remove all non-essential, non-medical electrical appliances ..."

2. The policy titled "Sitters for Patient Safety" (revised 3/16) was reviewed on 3/23/17. The policy required "I. Purpose to provide sitters for patients who require close, visual monitoring for safety reasons. II. Policy 1. Sitter will be given a report on patient status from the Registered Nurse (RN) ... 5. The RN, Charge Nurse or House Supervisor may initiate a sitter for a patient at any time .... B. Patients at Risk for Harming Self/Others When sitting with patients at risk for harming self, the sitter needs to comply with the following: 1. Room must be made safe by removing ... cords, sharp objects ... gloves ... 2. A patient belongings must be removed from the patient's room ... 3. Never leave the patient alone ..."

3. The clinical record of Pt #1 was reviewed on 3/23/17 at approximately 11:45 AM. Pt #1 was admitted to the Emergency Department, room 2, on 3/18 17 at 12:06 AM via ambulance, handcuffed and escorted by a police officer with a diagnosis of Suicidal Ideation with a plan. The record noted "Suicide Assessment: Suicide risk, actively suicidal or Homicidal Ideation, charge nurse notified, suicide precautions initiated... Patient in view of the nursing station, Suicide precautions maintained, Belongings removed... States plan to stab him/her self...security notified... patient placed on cardiac monitor... blood pressure monitor... continuous pulse oximetry... The patient is on a police hold with a police officer just outside of his/her room and security however the patient was able to find a scalpel and managed to cut both of his/her wrist while in the emergency department..." The clinical record lacked documentation of a sitter or continual observation.

4. The "Quality/Patient Safety Summary" was reviewed on 3/23/17 at approximately 3:00 PM. The Summary report dated 3/18/17 at 11:08 PM by Security Guard (E#9) noted the police officer removed Pt #1's handcuffs at approximately 1:00 AM then sat in a chair outside of room 2 and monitored Pt #1 with the overhead mirror. The Summary report dated 3/18/17 at 3:30 AM by Pt #1's assigned nurse noted "... Police Department sitting outside the doorway at the time of the event with hospital security staff standing outside the room as well."

5. During an observational tour of the Emergency Department on 3/23/17 at approximately 11:00 AM with E#2 (Emergency Department Director), the patient area of room 2 was unable to be visualized from the nurses station. Room 2 was observed to have a "Trauma Cart", approximately 6 foot tall and 3 foot wide, and a privacy curtain behind the trauma cart, across half of doorway which obscured any visual access of the patient area. E#2 demonstrated how the sliding door of the Trauma Cart was opened and the scalpel was accessed by Pt #1. E#2 stated the police officer and the security guard were stationed outside of the room with their backs to the room and did not hear the sliding door being lifted.

6. During an interview on 3/24/17 at approximately 8:30 AM, E#1 (Quality Manager) stated "The House Supervisors showed me their spreadsheet for tracking when a request for a sitter is requested." The spreadsheet was reviewed and noted a request for a sitter wasn't made for Pt #1 until 3/18/17 at 9:48 AM (greater than 9 hours after admission). E#1 verbally agreed suicidal precautions were not implemented per policy and should have been.

7. The closed clinical record for Pt #6 was reviewed on 3/23/17 at 12:30 PM. Pt #6 was admitted to the ED on 3/17/17 with a Diagnosis of Major Depression with Suicidal Ideation. A Triage suicide assessment on 3/17/17 at 6:01 AM noted Pt #6 was a suicide risk, actively suicidal and suicide precautions were initiated. The record lacked documentation a sitter was present, for continual observation.

8. The closed clinical record for Pt #7 was reviewed on 3/23/17 at 3:00 PM. Pt #7 was admitted to the ED on 2/24/17 with a Diagnosis of Suicidal Ideation. The record noted in the triage assessment dated 2/24/17 at 2:30 PM, Pt #7's chief complaint was documented as ..."I want to die". The record lacked documentation a sitter was present, for continual observation.

10. The closed clinical record for Pt #9 was reviewed on 3/24/17 at 12:00 PM. Pt #9 was admitted to the ED on 2/9/17 with a Diagnosis of Depression with Suicidal Ideation. A nurses note on 2/9/17 at 6:58 AM noted that suicide precautions were maintained. The record lacked any documentation a sitter was present, for continual observation.

11. During an interview with E#2 (Emergency Department Director) on 3/24/17 at approximately 12:30 PM, E#2 stated it was unable to be determined if Pt #6, #7 and #9 had a sitter.










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Based on document review and interview, it was determined in 1 of 1 (Pt #1) record reviewed with an adverse event, the Hospital failed to ensure the emergency department was appropriately supervised. This has the potential to affect staff, visitors and patients who receive care by the hospital with a current census of approximately 2200 patients per months.

Findings include:

1. The policy titled "Adverse Events" (revised 7/16) was reviewed on 3/23/17. The policy required "II. Definitions: An Adverse Event is an unexpected occurrence ... any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. These events signal the need for immediate investigation and response .... III. Policy: A. ... A Root Cause Analysis for each event will be initiated ... C. Following are the Adverse Events identified .... 3. Patient Protection Events ... c. Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting ... IV. Procedure: ... D ...will facilitate the RCA (Root Cause Analysis) ... E ... the appropriate personnel will take the necessary steps to develop action items that will prevent reoccurrence of the event ...."

2. The policy titled "Variance/Event Reporting" (revised 6/14) was reviewed on 3/23/17. The policy required "Variance/Event report must be completed as soon as possible following any event involving a patient ... Reporting events provides an opportunity to evaluate and a database for further investigation in an attempt to determine deviations from standards of care, corrective measures needed to prevent recurrence and improve quality of care .... Procedure 1. An employee with the most knowledge of the incident or who discovers an event, shall complete a report ... as soon as possible following the incident ... 7. Incidents involving serious injury ...shall be immediately brought to the attention of the appropriate Manager/Director ..."

3. The closed clinical record of Pt #1 was reviewed on 3/23/17 at approximately 11:45 AM. Pt #1 was admitted to the Emergency Department, room 2, on 3/18 17 at 12:06 AM via ambulance, handcuffed and escorted by a police officer with a diagnosis of Suicidal Ideation with a plan. The record noted "Suicide Assessment: Suicide risk, actively suicidal or Homicidal Ideation, charge nurse notified, suicide precautions initiated... Patient in view of the nursing station, Suicide precautions maintained, Belongings removed... States plan to stab him/her self...security notified... patient placed on cardiac monitor... blood pressure monitor... continuous pulse oximetry... The patient is on a police hold with a police officer just outside of his/her room and security however the patient was able to find a scalpel and managed to cut both of his/her wrist while in the emergency department..." The clinical record lacked documentation of a sitter or continual observation.

4. During an interview on 3/23/17 at approximately 10:30 AM, E#1 (Quality Manager) stated "I was told the House Supervisor was notified (Pt #1's adverse event) but it wasn't reported on the shift sheet or passed on to the Administrator on-call... The House Supervisor told me "It was no big deal. The patient was fine."

5. During an interview on 3/23/17 with E#1 and E#2, it was stated that education about suicide precautions was provided to the ED staff upon notification of the incident on 3/20/17. E#2 stated education was not provided to the Physician, Security Guard or the House Supervisor.

6. During an interview on 3/24/17 at approximately 10:00 AM, E#7 (President and Chief Executive Officer) stated "It's always the last person in the room who is responsible for the patient no matter who you are." E#7 verbally agreed Pt #1 attempted suicide, Administration should have been immediately notified and an investigation for root causes and steps to prevent reoccurrence were not developed and should have been.