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Based on review of medical records (MR), review of facility documents, and interview with the staff, it was determined the facility failed to: 1.) place a homicidal patient on a one-to-one observation (1:1) in one of two medical records of patients on 1:1 observation who eloped; (A0144) 2.) to provide a STAT psychiatric consultation to a homicidal patient in one of one medical chart reviewed. This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient and others. (A0144)

On 10/31/24, at 12:17 PM, an IJ was identified. On 10/31/24 at 1:09 PM, the IJ template was presented to the administration and an acceptable removal plan was accepted on 10/31/24 at 3:39 PM. On 11/1/24, verification of the IJ removal plan was conducted and included the following: review of staff re-education sign in-sheets and staff interviews regarding the facility's process for placing patients on 1:1 observation and implementing STAT consult orders. The IJ was lifted on 11/1/24 at 11:50 AM.

Cross Reference:
482.13(c)(2) Patient Rights: Care in a Safe Setting

Based on review of medical records (MR), review of facility documents, and staff interviews, it was determined the facility failed to 1.) place a homicidal patient on a one-to-one observation (1:1) in one of two medical records of patients on 1:1 observation who eloped; 2.) provide a STAT psychiatric consultation to a homicidal patient in one of one medical record reviewed.

Findings include:

1. Facility policy titled, "Emergency Department Suicide Risk Assessment" (Reviewed 10/25/2022) stated, "... III. DEFINITIONS: A. TYPES OF OBSERVATION STATUS, commonly referred to colloquially as level of observation, a 'one to one,' or '1:1' status in the ED 1. Constant observation - One designated clinical staff member remains within arm's reach continuously with 1 patient and completes observation documentation every 15 minutes. 2. Close Observation - One designated staff member may monitor patient(s) in an open area with direct line of sight and with unobstructed view of thepatient(s). ... 3. Continuous Observation encompasses both constant and close observation. Patients with SI [suicidal ideation] or HI [homicidal ideation] are designated as Level I. Patients may also be designated for Level I when exhibiting concerning behaviors such as self-injury, elopement attempts, ... or other signs of risk for harming self or others, even if they do not explicitly verbalize SI or HI."

Facility policy titled, "Appendix A: Emergency Department Safe Environment Guidelines' (Reviewed 10/25/22) states, " I. Purpose: A. To provide guidelines to staff observing patients posing a safety risk to themselves or others while in the Emergency Department. ... III., Procedure: A. Safety: 1. Patients shall be placed into hospital paper scrubs. 2. Patient belongings shall be placed in a patient belonging bag, labeled, and stored with security during ED visit. ..."

On 10/29/24 at 12:03 PM, during a review of the medical record (MR) for Patient (P)2, in the presence of Staff (S)1 (Director of Regulatory Affairs), S2 (Interim Clinical Director of the Emergency Department), S3(AVP Regulatory and Patient Safety), S4 (AVP Nursing Operations), S5 (Medical Informatics), and S6 (Medical Informatics) the following was revealed:

On 8/27/24, at 3:45 PM, P2 arrived at the facility's Emergency Department (ED) with complaints of aggressive behavior.

On 8/27/24 at 4:39 PM, P2 was examined by S18, an ED Resident. A review of the ED Provider Notes documented by S18 stated, "... [the patient] tried to cut [his/her] wrists with glass shards ... denying SI [suicidal ideation] now, stating [he/she] wants to hurt someone but does not state who ..."

On 8/27/24 at 4:51 PM, S18 placed an order for STAT continuous 1:1 observation, with an Observation Level 1 indicating "SI/HI precautions or ED behavior risk" and a STAT psychiatric consultation.

MR2 lacked evidence that P2 was placed on a 1:1 observation. MR2 lacked evidence that P2 was changed into paper scrubs and had his/her belongings taken and placed with security.

On 8/27/24 at 5:02 PM, P2 was moved from a hallway bed to a room in the ED at 5:02 PM. MR2 lacked evidence that P2 was on a 1:1 observation at this time.

On 8/27/24 at 5:29 PM, P2's vitals were obtained.

On 8/27/24 at 5:30 PM, ED Notes documentation by S16, a Registered Nurse, stated, "17-25- [5:25 PM] patient brought to ER [Emergency Room] from home, patient became aggressive after talking to [his/her] therapist [outpatient - confirmed with S2], vitals stable [blood pressure, pulse, respirations], A&O x4 [alert and oriented to person, place, time, situation], patient has superficial cuts to [his/her] Lt [left] and Rt [right] forearms, will continue to monitor."

P2's medical record lacked documentation that P2 was placed on a continuous observation prior to P2's elopement.

On 8/27/24 at 6:46 PM, S16's documentation in the "ED Notes" stated, "18:15- patient eloped, walked out the back door by [his/her] mother. 18:35- writer called mom, left a voice message. 18:40- writer called patient. Left a voice message."

On 8/27/24 at 6:55 PM, S19's, a Registered Nurse, documentation in the "ED Notes" stated, "1850-called [city] county police dispatch at this time per physician request to go to patient residence for wellness check, to return to ED for psychiatric evaluation." There was no documented evidence that P2 returned to the Emergency Department.

On 10/29/24 at 12:12 PM, upon interview, S2 confirmed that P2 was not placed on a 1:1 per the physician's order and stated that P2 should have been placed on a 1:1 for homicidal ideation after the physician evaluation since the patient was considered high risk.

On 10/30/24 at 11:41 AM, an interview with S2 was conducted to discuss the process of placing a patient on 1:1 observation. S2 explained that after a physician evaluates the patient and determines the need, the physician would communicate that with the nurse. The nurse then calls the flow manager who calls staffing to send someone to observe the patient. The ED technician will be pulled off the floor to sit with the 1:1 until someone else is available. When asked how long that process should take, S2 stated, "I can't put a time on that, my hope is that it is immediate."

On 10/31/24 at 10:00 AM an interview was conducted with S16, ED Registered Nurse, P2's nurse. When asked about the process for ordering a 1:1, S16 stated, "I am notified of a one-to-one order through the computer tracking system." S16 also stated, "I've had two incidences where I didn't see a 1:1 entered into the system until later." When asked if notification through the computer system is the primary method of notifying the nurse of a one-to-one order, S16 stated, "correct." S16 confirmed that a 1:1 order should be implemented immediately for patient safety.

2. Facility document titled, "Rules and Regulations of the Medical Staff" (Revised 9/9/24, Approved 10/22/2024) stated, " ... J. The attending practitioner is primarily responsible, for requesting consultation when indicated and for calling in a qualified Consultant. EMERGENCY DEPARTMENT AND INPATIENT CONSULTATION: 1. Emergent - ... since patient outcome in emergent cases may be directly related to care provided by the on-call physician, that physician shall respond by telephone within 20 minutes of receiving a call from hospital clinical staff. ..."

A review of P2's medical record on On 10/29/24 at 12:03 PM, revealed that on 8/27/24 at 4:51 PM, a STAT consult to Psychiatry was placed by S18. Upon further review, MR2 lacked evidence that the on-call psychiatrist was notified of the STAT consultation.