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Based on interview, record review, policy review and video review, the hospital failed to properly observe one patient (#10) who was ordered to be on one to one (1:1, continuous visual contact with close physical proximity) observation status, was protected from self-harm, when he was able to remove the drawstring from his pants and tie it around his neck. (A-0144) The hospital also failed to complete a thorough investigation and recognize failures to prevent future reoccurrences, following incidents of self-harm. (A-0145)

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights. The hospital census was 26.

The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 11/30/23, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included all current and oncoming nursing staff were educated on the suicide (to cause one's own death) precaution procedures, physical assessment after a self-harm event, and the behavioral assessment and care of psychiatric (relating to mental illness) patients. All remaining staff were educated prior to the start of their next shift.

Please refer to A-0144 and A-0145

Based on observation, interview, record review, policy review and video review, the hospital failed to ensure staff properly observed and protected from harm one patient (#10) who was ordered to be on one to one (1:1, continuous visual contact with close physical proximity) observation status, when they were able to remove the drawstring from their pants and tie it around their neck.

Findings included:

Review of the hospital's policy titled, "Behavioral Assessment and Care of Psychiatric (relating to mental illness) Patients in the Emergency Department (ED)", reviewed 09/2023, showed that a suicide risk screening will be completed with initial screening in triage utilizing the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life). Suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) were implemented as outlined. Level I Suicide/Behavior Precautions requires constant observation (sitter) and should be considered when the patient has scored High Risk on the C-SSRS screening. If physician orders Level I SP, a sitter is placed at bedside. If a sitter is not immediately available, evaluate staffing options and consider modifying assignments to provide direct observation of patient. Public safety is notified of patient arrival and, if available, Public Safety to assist with monitoring the cameras of psychiatric preferred rooms. If a patient attempts suicide, remove hazard, assess patient, provide appropriate care, and notify the ED provider. Nursing responsibilities are to provide appropriate level of observation for the suicidal patient in accordance to the physician's order.

Review of Patient #10's medical record showed they were a 50-year-old brought to the ED by a law enforcement officer (LEO) on 11/03/23 at 8:25 PM. The ED provider note showed the patient was brought to the hospital for a fit for confinement (patient is medically and psychiatrically stable to go to jail) evaluation after they reported chest pain. A triage (process of determining the priority of a patient's treatment based on the severity of their condition) assessment was completed at 8:31 PM with a C-SSRS result of High Risk. The patient reported suicidal ideation (SI, thoughts of causing one's own death) with a plan to overdose on fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use). An order for suicide and behavior precautions every 15 minutes with a SP Level I was entered at 8:57 PM. The ED provider note showed that at 9:32 PM, Patient #10 wrapped the draw string from their hospital pants around their neck and the string was immediately removed by nursing staff. The provider note showed the patient did not have any pressure markings on their neck after the event and x-rays were not indicated. Late entry suicide and behavior precaution observations were documented by nursing on 11/04/23 at 2:37 AM, for 11/03/23 at 9:00 PM, 9:15 PM and 9:30 PM and showed observation status as SP 1:1, continuous and Level I. Hand-written constant 1:1 observation documentation began at 9:45 PM.

Review of the video recording of ED Room #6 dated 11/03/23 showed:
- At 9:28 PM, hospital staff stand in the hallway and appear to talk with the patient. Hospital staff exit doorway.
- At 9:30 PM, the patient moves to the floor in front of doorway, removes the mattress from bed and covers body from view of the camera. Then lays on top of mattress on floor with head at doorway.
- At 9:31 PM, Patient #10 on floor with head at doorway. Pulls and breaks a portion of the drawstring from paper scrub pants, holds it to their neck (appears to be checking length).
- At 9:32 PM, pulls and breaks another portion of drawstring from the paper scrubs and ties it in several knots to the previous portion of string. Continues to lay on mattress on floor with head in doorway. Changes position in room so head is no longer at doorway. Lays on back on mattress and wraps knotted drawstring around their neck.
- At 9:33 PM, Patient #10 cinches the string around neck and pulls on opposite ends to tighten. An end portion of the string breaks away. Patient #10 fidgets and inspects paper scrubs.
- At 9:34 PM, Patient #10 pulls and tears at paper scrubs, then pulls more drawstring from paper scrub pants and ties it to the string remaining around neck.
- At 9:35 PM, Patient #10 wraps the additional string around neck and continues to pull and tighten the string around neck.
- At 9:36 PM, Patient #10 continues to pull on the string around neck and kick legs. Patient appears to be coughing and removes grip from string. Staff J, ED Charge Registered Nurse (RN), walks into the room and Patient #10 re-grabs the string around neck. Staff J walks towards Patient #10's head, places hand under the string wrapped around patient's neck. The patient released the string, pulled their head away from Staff J and begins to kick legs. Staff J removes scissors from pants pocket and cuts the string away from Patient #10's neck and holds it up while the patient kicks legs. Patient Care Technician (PCT) and Staff K, Security Officer, viewed in doorway.
- At 9:37 PM, all staff exit ED Room #6. The patient lays on the floor thrashing and appears to be coughing.

Although requested, video surveillance from the hallway outside of ED Room #6 during Patient #10's ED visit on 11/03/23 was not provided by the hospital.

Observation in the ED on 11/27/23 at 11:33 AM, showed the monitor utilized for video observation of ED patients in the psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) was in the nursing station on a swing-out mount about four feet above the desk area utilized by the ED charge nurse. When the monitor mount was pushed flat against the wall, the chair at the desk area was directly underneath the monitor. The monitor could not be visualized while seated at the charge nurse area unless the chair was moved away from the desk and the observer looked straight up. The windows for the ED nursing station were tinted to prevent visualization of staff within the nursing station and hindered clear observation to areas outside of the nursing station.

Observation in the ED on 11/29/23 at 12:05 PM, showed the area marked "Hall Bed D" was located in the hall directly in front of the window of the ED nursing station and between the nursing station and rooms utilized as psychiatric safe rooms (ED rooms #6 and #7). When the privacy curtain for Hall Bed D was pulled closed, visualization of the psychiatric safe rooms from inside the nursing station was blocked.

During an interview on 11/28/23 at 3:15 PM, Staff J, ED Charge RN, stated that at the time Patient #10 came to the ED, the technician assigned as a 1:1 sitter in the ED was already observing two other patients who had SI and homicidal ideation (HI, thoughts or attempts to cause another's death). Staff J called the house supervisor and told them there were three psychiatric patients in the ED and no one "extra" to perform 1:1 duties. SI and HI patients in the ED were assigned Level I or Level II observation precautions based on their assessed risk. Patient #10 had orders for Level I observation, which involved a 1:1 sitter. Because the patient had voiced a plan to overdose on fentanyl and did not have access to the drug immediately, Staff J felt that observation through the window of the nurses' station and video surveillance were adequate until a sitter became available.

During an interview on 11/28/23 at 8:30 AM, Staff K, Security Officer, stated that he was working with another security officer and they were monitoring all of the video surveillance in the hospital. They noticed on the camera for ED Room #6 that Patient #10 was trying to tie something around their neck and attempted to call the nursing station in the ED and notify them. No one in the ED answered the phone, so Staff K went to the ED while the other security officer continued to attempt to contact ED staff. Staff K walked into the ED and yelled "He's trying to tie something around his neck." Staff J, ED Charge RN, was walking out of the nurses' station just as Staff K walked into the ED and they both went to ED Room #6 and the charge nurse cut the string away from the patient's neck.

During an interview on 11/27/23 at 11:30 AM, Staff E, ED Director, stated that the hospital's policy regarding SP showed that Level I SI patients expressed a plan, were at higher risk of suicide and had 1:1 observation. Patient #10 was not placed on 1:1 observation immediately, but the charge nurse requested a sitter be sent to the ED. Nursing staff were unable to sit with the patient. The LEO left and patient was under camera observation. Security was watching from their department and the charge nurse was observing from monitor in the nursing station. The charge nurse was quick to arrive to the patient's room and cut the string. Patient #10's circulation and breathing were assessed, the charge nurse insured the patient was stable and increased surveillance.

During an interview on 11/29/23 at 12:33 PM, Staff T, ED Physician, stated that they performed an assessment of Patient #10 after the drawstring was removed from their neck and the patient had no identified airway or vascular concerns. Staff T ordered Level 1 SP and expected that Patient #10 had a 1:1 sitter for constant observation. They were not aware that the patient did not have a constant observer until they were told the patient had tied the drawstring from the paper scrubs around their neck.

Based on interview, record review, policy review and video review, the hospital failed to recognize failures and conduct a complete and thorough investigation to prevent future reoccurrences following incidents of self-harm when one patient (#10) removed the drawstring from their pants and wrapped it around their neck while ordered to be on one to one (1:1, continuous visual contact with close physical proximity) observation status.

Findings included:

Review of the hospital's policy titled, "Event Reporting", reviewed 08/2021, showed the Incident Reporting System will be used to report possible errors, untoward events, and near misses to management and administration. The purpose is to promptly document information to investigate causes and develop appropriate measures to minimize risk of injury and adverse occurrences. A sentinel event (actual events that could or did cause patient harm) was outlined as an unexpected occurrence which involved death or physical injury, or the risk thereof. Staff were directed that the supervisor, charge nurse, or their designee will assess the event. The supervisor will review the report to determine the need for follow-up or corrective action and add investigative actions that have been completed. The risk manager will review, investigate further if need, and provide follow-up as indicated. In addition to the completion of an Incident Report, a root cause analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) may be conducted involving the employees involved in the event and a member of the Quality Service and Innovation Department. RCA will focus primarily on systems and processes, not individual performance and will be utilized to identify potential improvement in processes that would tend to decrease the likelihood of such events in the future or determine after analysis that no such improvement opportunities exist. When an action plan is indicated it will be based on the RCA and will identify changes to be made in systems and processes. Changes may be through redesign or development of new systems of processes to reduce the risk of such event occurring in the future. The plan will be implemented and evaluated for effectiveness.

Although requested, the hospital did not provide a policy which guided staff on how to conduct an investigation following a serious patient event.

Review of the hospital's policy titled, "Behavioral Assessment and Care of Psychiatric (relating to mental illness) Patients in the Emergency Department (ED)", reviewed 09/2023, showed Level I Suicide/Behavior Precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) requires constant observation (1:1 sitter) and should be considered when the patient has scored High Risk on the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life). If physician orders Level I SP, a sitter is placed at bedside. If a sitter is not immediately available, evaluate staffing options and consider modifying assignments to provide direct observation of patient. If a patient attempts suicide (to cause one's own death), remove hazards, assess patient, provide appropriate care, and notify the ED provider. Nursing responsibilities are to provide appropriate level of observation for the suicidal (SI, thoughts of causing one's own death) patient in accordance to the physician's order.

Review of Patient #10's medical record showed they were a 50-year-old brought to the ED by a law enforcement officer (LEO) on 11/03/23 at 8:25 PM. A triage (process of determining the priority of a patient's treatment based on the severity of their condition) assessment was completed at 8:31 PM with a C-SSRS result of High Risk. The patient reported SI with a plan to overdose on fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use). An order for SP Level I was entered at 8:57 PM. The ED provider note showed that at 9:32 PM, Patient #10 wrapped the draw string from their hospital pants around their neck and the string was immediately removed by nursing staff. Nursing documented assessment of the patient at 9:40 PM. Late entry suicide and behavior precaution observations were documented by nursing on 11/04/23 at 2:37 AM for 11/03/23 at 9:00 PM, 9:15 PM and 9:30 PM and showed observation status as SP 1:1, continuous and Level I. Hand-written constant 1:1 observation documentation began 9:45 PM.

Review of the video recording of ED Room #6 dated 11/03/23 showed:
- At 9:30 PM, the patient moves to the floor in front of doorway, removes the mattress from bed and covers body from view of the camera. Then lays on top of mattress on floor with head at doorway.
- At 9:31 PM, Patient #10 on floor with head at doorway. Pulls and breaks a portion of the drawstring from paper scrub pants, holds it to their neck (appears to be checking length).
- At 9:32 PM, Patient #10 pulls and breaks another portion of drawstring from the paper scrubs and ties it in several knots to the previous portion of string. Continues to lay on mattress on floor with head in doorway. Changes position in room so head no longer at doorway. Lays on back on mattress and wraps knotted drawstring around their neck.
- At 9:33 PM, Patient #10 cinches the string around neck and pulls on opposite ends to tighten. An end portion of the string breaks away. Patient #10 fidgets and inspects paper scrubs.
- At 9:34 PM, Patient #10 pulls and tears at paper scrubs, then pulls more drawstring from paper scrub pants and ties it to the string remaining around neck.
- At 9:35 PM, Patient #10 wraps the additional string around neck and continues to pull and tighten the string around neck.
- At 9:36 PM, Patient #10 continues to pull on the string around neck and kick legs. Patient appears to be coughing and removes grip from string. Staff J, ED Charge Registered Nurse (RN), walks into the room and Patient #10 grabs the string around neck. Staff J walks towards Patient #10's head, places hand under the string wrapped around patient's neck. The patient released the string, pulled their head away from Staff J and begins to kick legs. Staff J removes scissors from pants pocket and cuts the string away from Patient #10's neck and holds it up while the patient kicks legs. Patient Care Technician (PCT) and Staff K, Security Officer, viewed in doorway.

Review of the hospital's undated document titled, "RCA Framework," showed review of an event which occurred on 11/03/23 at approximately 9:35 PM in the ED where a patient attempted self-harm by removing the drawstring from their paper scrubs and pulled it tightly around their neck. The RCA showed policies were followed and absence of a 1:1 sitter was not identified as a root cause with no opportunity for improvement. Opportunities for improvement with action plans identified were moving the video surveillance monitor in the ED nurses' station, reviewing the placement and use of the privacy curtain for Hall Bed D, the psychiatric safe paper scrubs did not perform as expected, enlisting security assistance with camera monitoring when a 1:1 sitter cannot be allocated, notification of security when psychiatric or patient with LEO arrived in ED, potentially placing additional cameras for monitoring rooms from a different angle and removal of the tint from the nurses' station windows.

Review of the hospital's document titled, "ED/Intensive Care Unit (ICU, a unit where critically ill patients are cared for) Staff Meeting Minutes," dated 11/17/23, showed that staff were informed that the hospital's investigation of Patient #10's event identified that staff acted in accordance to policy based on the patient's initial chief complaint. Due to their swift actions to intervene, the patient did not harm himself.

During an interview on 11/28/23 at 12:35 PM, Staff L, Chief Nursing Officer (CNO) stated that the hospital had not implemented changes in their 1:1 policy as a result of the incident with Patient #10 on 11/03/23. The hospital had identified potential areas of improvement as a result of the RCA, and the challenges were being addressed, but other hospital projects involving their maintenance team held higher priority. Staff L did not view the video surveillance of the event, but knew that other staff had reviewed it as a part of the investigation of the event and the development of a RCA. They were unaware that the patient exhibited intent of self-harm by removing the drawstring from their paper scrub pants and wrapping it around their neck the first time, approximately five minutes prior to the charge nurse and security officer responding to Patient #10's room. Had they been aware of that time lapse in the sequence of events, the action plan involved with the RCA would have been addressed differently.

During an interview on 11/29/23 at 10:10 AM, Staff P, Risk Manager, stated that because this incident was not identified as a sentinel event, their role involved coordinating with the staff performing the investigation, ensuring that someone involved in the investigation took the lead and providing guidance to the RCA process. She asked the department manager to advise who was involved and who they wanted to invite to the RCA meeting. They recognized issues with the paper scrubs, lack of sitter, hall bed curtains, and monitor location during their investigation. It was expected that any education needed or any action plan items were started very soon after they were identified. They viewed the video of Patient #10's incident in the ED on 11/06/23 and "other than needing a sitter" for the patient, there were no concerns. The RCA was initiated on 11/14/23 and sent to involved parties for suggested action plans on 11/16/23. Staff P stated they believed the hospital's process in the investigation and RCA was good and the staff did everything they could for the patient involved.

During an interview on 11/27/23 at 11:30 AM and follow-up on 11/28/23 at 12:30 PM, Staff E, ED Director, stated that a staff meeting was held for ED staff on 11/17/23 where staff were educated regarding the event investigation results, the importance of every 15 minute documentation for psychiatric patients and that documentation would be carried out on a written form, rather than in the electronic health record (EHR).

During a follow-up interview on 11/30/23 at 8:15 AM, Staff E, ED Director, stated an investigation into the events of Patient #10 on 11/03/23 was started immediately after they were notified of the incident. They instantly gathered statements from all staff involved. The video surveillance was viewed on 11/06/23. They received guidance from Staff N, Hospital Nursing Director, on what to include in reviewing the incident and conducting the investigation, but Staff E completed the bulk of the investigation. They were then contacted by Staff P in Risk Management about gathering individuals to meet and complete the RCA.

During an interview on 11/28/23 at 3:15 PM, Staff J, ED Charge RN, stated that they were present in the meeting with hospital administrative staff and the other ED and security personnel involved in Patient #10's 11/03/23 event. They understood it was determined through the investigation of the incident that there was nothing identified for improvement other than staffing support within the ED and challenges identified with direct visualization of the psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) from the nursing station due to privacy curtains, tinted windows and the placement of the video surveillance monitor.

During an interview on 11/28/23 at 8:30 AM, Staff K, Security Officer, stated they attended a "debriefing" meeting a few days after the incident where administration and the hospital staff involved in the incident reviewed the events of that evening. The only change in hospital procedure since the incident involving Patient #10 was that ED registration staff now informed security that a psychiatric patient had presented to the ED, in case ED staff did not have time to contact security.