HospitalInspections.org

Based on observation, interviews for 3 of 3 staff members, and reviews of 1 of 4 sampled patient records, and the Patient Observation for Prevention of Harm and Suicide Risk Assessment and Management policies, the Hospital failed to provide a safe patient environment in its emergency department. On 4/14/17, staff failed to provide continuous observation and during this time Patient #1 obtained a razor and lacerated himself/herself in 8 locations and required 58 sutures.

Please see tag A-0144.

Based on record review, interview and observation, the Hospital failed to take preventable steps to ensure Emergency Department (ED) psychiatric patients did not harm themselves. On 4/14/17, Patient #1 arrived to the ED expressing suicidal ideation. Patient #1 required constant staff observation, however, he/she obtained a pencil sharpener containing a razor blade from a visitor and self-inflicted eight lacerations to his/her arm while inside a bathroom with the door closed and unsupervised by staff. Patient #1 required 53 sutures. On the date of survey, three of three staff responsible for patient observation were still unaware of the Hospital ED continuous observation and contraband policy required to prevent such occurrences.

Findings include:

Patient #1's Physician ED report, dated 4/14/17, indicated he/she told staff he/she wanted to "shed blood" and was suicidal. The ED report indicated Patient #1 was diagnosed with acute bipolar disorder and had a history of self-cutting behavior. The Physician ED report indicated that Patient #1 went to the restroom and cut him/herself with a razor blade. Patient #1 sustained eight lacerations over the left forearm, requiring 53 sutures, and 2 superficial abrasions. The Physician ED note indicated Patient #1 told staff, "I was attacked by a ghost."

The Hospital's incident report to the Department of Public Health, dated 5/01/17, indicated Patient #1 was not directly observed while in the bathroom. The incident report indicated Patient #1 later told staff that a family member, who had visited him/her earlier in the ED, gave him/her a pencil sharpener and that he/she removed the blade and used this to cut in the bathroom. The incident report indicated corrective measures included a staff review of the Patient Observation for Prevention of Harm policy and procedures.

The Patient Observation for Prevention of Harm (non-behavioral health units) policy and procedure, dated 7/8/16, indicated "continuous observation" is defined as: observation of the patient at all times to prevent harm to the patient or others. The observer cannot leave the patient unattended at any time.

The Suicide Risk Assessment and Management policy and procedure, dated 9/10/13, indicated that all items brought in by visitors for patients on suicide precautions must be searched by staff.

The Surveyor interviewed the ED Director on 6/27/17 at 10:30 A.M. The ED Director said it was Hospital policy for staff to maintain constant observation of all ED psychiatric patients while they changed from their personal clothing into a hospital gown. The ED Director said that this procedure ensured that the patient did not transfer potentially unsafe contraband and have it in their possession in the ED. The ED Director said it was Hospital Policy for ED staff to constantly observe patients in the bathroom who are assessed as needing continuous observation. The ED Director said that staff were required to keep the bathroom door sufficiently open to enable a continuous view of the patient. The ED Director said that visitors to the psychiatric ED were not allowed to bring bags of any type into patient rooms and were required to leave them at the nursing station. The ED Director said that due to the fast-paced nature of the ED and the risk of missing a contraband item, staff did not conduct visitor bag searches.

The Surveyor interviewed the ED Clinical Leader on 6/28/17 at 3:00 P.M. The ED Clinical Leader said it was the Hospital's procedure for staff to maintain a constant view of ED psychiatric patients while they changed into a hospital gown and while they were in the bathroom, regardless of observation status. The ED Clinical Leader said that visitors were not allowed to bring bags of any type into psychiatric patient rooms.

The Surveyor interviewed the Mental Health Counselor on 6/27/17 and 6/28/17, during the morning. The Mental Health Counselor said that he was frequently assigned the role of the Constant Observer in the ED. The Mental Health Counselor said that while ED psychiatric patients were in the admission process, they were required to remove their clothing and dress into hospital gowns. The Mental Health Counselor said he used his safety judgement as to whether he allowed a patient to dress under constant observation, or in privacy behind a screen, or in the bathroom with a closed door. The Mental Health Counselor said that he also used his safety judgement as to whether to keep the bathroom door open to enable continuous observation, or allow the patient to shut the door closed for privacy. The Mental Health Counselor said he would knock on the door if after approximately 3 minutes the patient had not exited.

The Surveyor interviewed the ED Support Aide on 6/28/17 at 10:30 A.M. The ED Support Aide said that he often was assigned the role of Constant Observer in the ED. The ED Support Aide said that he and other staff used their discretion as to whether they maintained continuous observation or allowed privacy when ED psychiatric patients with continuous observation status changed from their personal clothing into hospital gowns. The ED Support Aide said that when psychiatric patients have visitors with bags, he would either keep the bag at the nursing station or check it for contraband and then allow the visitor to bring the bag into the patient's room. The ED Support Aide said that if a visitor's bag is a pocketbook, he usually did not check the pocketbook for contraband and allowed it in the patient's room because he had not received guidance from management on how to address bags of a personal nature. The ED Support Aide said that a nurse sometimes instructed him as to whether to allow a bag into the patient's room or not.

The Surveyor interviewed the Certified Nurse Aide (CNA) on 6/28/17 at 3:25 P.M. The CNA said that she was a Constant Observer in the ED approximately once per week. The CNA said that when a psychiatric patient had a visitor with a bag she would search the bag for contraband. The CNA said that if the bag is free of contraband she will allow it into the patient's room.

The Surveyor toured the Hospital's Campus A ED on 6/27/17 and 6/28/17, at multiple times, and Campus B's ED on 6/28/17 at 3:00 P.M. The Surveyor observed that there were no apparent hazards or visitor bags in any of the EDs psychiatric patient rooms.