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Based on review of the Hospital Complaint File, the Administrative Policy regarding Patient Complaints and interviews, the Hospital failed to ensure that in its resolution of the grievance, the hospital failed to provide the complainant with written notice of its decision that contained the name of the hospital contact person, steps taken on behalf of the complainant to investigate the grievance, the results of the grievance process and the date of completion.

Findings included:


1) Review of the Hospital file on the complaint indicated that a verbal complaint was filed in person on 7/1/10 at 11:35 am and by telephone on 7/9/10. Although documentation indicated that the ED Nurse Manager updated the Complainant on 7/15/2010 with changes made in response to the complaints, as of 8/16/10, the Complainant had received no written response from the Hospital regarding the multiple complaints filed.


2) Review of the Administrative Hospital Policy titled: Patient Complaint Grievance, Section C Documentation of Findings, point 5. indicated that the patient or the patient's representative will receive written communication from the organization within 7 days of the receipt of the grievance. This letter is prepared by the department director of the vice president. Point 6. indicated that when a grievance will not be resolved or the investigation is not or will not be completed within the 7 day time frame, the patient/patient's representative will be informed within those 7 days that followup will be provided in the form of a written response within 21 days.

3) The Nurse Manager of the ED was interviewed in person on 8/23/10 at 9:20 am. The ED Nurse Manager confirmed that several telephone discussions were held with the Complainant as documented in the complaint file as well as several face to face contacts during the Patient's multiple ED visits and inpatient admissions. The ED Nurse Manager confirmed that no written response was provided because it was her impression during the phone call on 7/15/10 that the Complainant said she was pleased with the investigation and changes made, that the complaint was resolved.

The ED Nurse Manager acknowledged that a written response should have been provided as required by hospital policy.

Based on review of documentation, ED Policies regarding Risk Assessment and Seclusion, interviews and observations of the ED, the Hospital failed to ensure the Patient received care in a safe setting.

Findings included:

Background information: Review of the Patient's medical record indicated the Patient had a history of Bipolar Disorder, major depression, history of multiple suicide attempts, personality disorder NOS, post traumatic stress disorder and substance abuse. Review of the medical record indicated the Patient had a history of attempted hangings and a near successful attempt was made in 2007 in an inpatient psychiatric facility. Documentation indicated the Patient made a prior suicide attempt by overdosing with medications at a Family member's home.

Review of the medical record indicated the Patient had presented to the Hospital Emergency Department [ED] three times over a short period of time for expression of suicidality:

1) 6/30/10 through 7/5/10: The Patient presented to the ED after being discharged from an inpatient facility. The Patient had spoken to her Psychiatrist and spoke of intent to commit suicide by hanging. The Patient was brought to the ED on a Section 12 [involuntary commitment for care based on threat or attempt to cause self harm] and admitted for inpatient psychiatric care.

2) 7/7/10 through 7/15/10: The Patient presented to the ED after being pulled over by the Police for driving under the influence. The Patient told the Police she was suicidal, but denied having said that during Triage assessment. The Patient escaped from the ED a short time (24 minutes) after being assessed in Triage, but was brought back by the Police. The Patient was again placed on a Section 12. The Patient was in the ED for two days, waiting for an inpatient psychiatric bed and attempted to hang herself on 7/8/10 in the bathroom. The Patient was admitted to the Hospital's inpatient psychiatric unit.

3) 8/4/10 through 8/6/10: The Patient again presented to the ED for expression of suicidality by hanging. The Patient was admitted to the Hospital's inpatient psychiatric unit.


1.A) Please refer to Tag A 1104 regarding ED staff not following Policy regarding Risk Assessment and Seclusion, Points 2 and 3 that address the Patient wearing a necklace while under seclusion, hospital pants with a draw string and underwear which were all used by the Patient as a rope in an attempted hanging. Review of the medical record had documentation regarding the Patient's prior, near successful attempt to hang herself at another inpatient Hospital. Medical record documentation indicated several prior expressions of intent to hang herself with detailed plans.

Based on review of documentation, Hospital incident reports, interviews and observations, the Hospital failed to ensure that a registered nurse supervised and evaluate the nursing care for each patient.

Findings included:

1) Please refer to Tag A 1104 regarding ED staff not following Policy regarding Risk Assessment and Seclusion, Points 2 and 3 that address the Patient wearing items of jewelry and clothing that were used in an attempt to hang herself. In addition, the Security Guards expressed concerns and sought consultation from the Nurse assigned to the Patient in regards to the Patient wearing a necklace and using the bathroom alone with the door closed and locked. In situations in which the Registered Nurse assigns care to a non-professional staff member, the Registered Nurse is responsible for the oversight of care provided to the Patient to ensure the well being and safety of the patients.

Based on review of documentation, interviews, the ED Policies regarding Risk Assessment and Seclusion and observations of the ED, the hospital failed to ensure that policies and procedures governing medical care in the ED were established by and were a continuing responsibility of the medical staff.

Findings included:

1) Review of the Emergency Department [ED] Clinical Policy titled, " Observation Risk Assessment " indicated that a risk assessment will be completed on patients determined by a registered nurse to be at risk for harming themselves or others. The policy indicated that the Seclusion Protocol will be initiated based on an assessment risk score of greater than 25 points.

Review of the Patient's ED admission medical record dated 7/7/10 at 6:44 pm indicated the Patient's Observation/Risk Assessment score was 55 and that Seclusion was indicated. The Patient was placed on a Section 12 hold [involuntary hold for treatment based intention or action to harm self] and placed in Seclusion with 1:1 close observation and documentation of every 15 minute checks.

Review of the ED Admission Triage documentation 7/7/10 indicated that the Patient was apprehended by the Police Department for a motor vehicle moving violation. According to documentation, the Patient informed the Arresting Officer that she intended to harm herself. The Arresting Officer initiated the Section 12 paperwork and arranged for transport of the Patient to the ED for an evaluation. Documentation indicated the Patient had eloped shortly after being transported to the ED. The Patient was returned to the ED by the Police after a search that lasted approximately 24 minutes.

2) Review of the ED Policy titled " Seclusion in the Acute Care Setting "; section on Process, part V, C, point 1. Indicated that all harmful and or personal objects, i.e. shoes, jewelry, scarves, belts, portable radio headsets, etc, must be removed before the patient is placed in the seclusion room.

Review of the Patient's medical record indicated that there was no documentation that a check for harmful objects was done and what, if any, items were removed from the Patient for personal safety.

Review of Security Guard #1 Incident Narrative of the event dated 7/7/10 at 6:30 pm indicated that at 12:15 am, the ED Nurse waited for the Patient who was inside the bathroom. The Security Guard who was assigned to observe the Patient documented that he informed the ED Nurse that the Patient was in the bathroom for 15 minutes playing with the towel machine and has something around her neck - the Security Guard informed the ED Nurse the Patient had a necklace on and the ED Nurse said OK. Documentation at 2:25 am indicated the Patient was in the bathroom again for a long period of time and did not respond to knocking or calling out the Patient's name. The Security Guard was called and the key to the bathroom was used to enter the bathroom. Documentation indicated the Patient had tried to hang herself with the string from the hospital pants, the necklace and her underwear, which was torn to create a rope with the elastic bands.

Documentation in the Incident Report written by Security Guard #2, who opened the door, indicated that he had called Security Guard #1 at about 2 am to ask if the Patient had a necklace on earlier. Security Guard #1 confirmed that the Patient had the necklace on earlier and the ED Nurse said it was OK for the Patient to have it on. Documentation indicated the Security Guard notified the Nursing Supervisor to know what was going on.

Security Guard #1 was not available for interview. Security Guard #2 was interviewed by telephone on 8/16/10 by telephone on 11:55 am. Security Guard #2 confirmed that the Security Guards were concerned about the Patient wearing a necklace, the frequency of going to the bathroom and of being in the bathroom for long periods of time. Security Guard #2 said that he did phone Security Guard #1 after he relieved him of observing the Patient to confirm that the Patient was allowed to wear a necklace and use the bathroom with no direct observation and to lock the bathroom door.

The Nurse Manager of the ED was interviewed in person on 8/23/at 9:20 am. The Nurse Manager confirmed that the ED Policy was not followed in regards to conducting a safety assessment of the Patient prior to placing the Patient in Seclusion, documenting the check was done and the items removed and documenting a potential risk item: necklace, and the fact it was allowed to be worn.

3) Section V. Point E of the Seclusion Policy indicated that: Attention shall be paid during these observations to the patient ' s need for regular meals, bathing, toileting and fluids.

Review of the frequent observation checks which were conducted every 15 minutes indicated the Patient was allowed to use the bathroom, however, there was no documentation by the ED Nurse that indicated the Patient was assessed for safety in using the bathroom.

Interview with the ED Nurse on duty during the Patient's attempted suicide on 8/17/10 indicated that the Security Guards [who were male] would walk the Patient to the bathroom and stay outside the closed and locked bathroom door. The ED Nurse said that sometimes she walked the Patient to the bathroom and also remained outside the door. Review of the frequent safety checks dated 7/8/10 at 2 am indicated the Patient used the bathroom at 2 am; 2:15 am and 2:30 am and the ED Nurse was notified of the second and third time the bathroom was used. The suicide attempt occurred during the third use of the bathroom, around 2:30 am.

4) The policy and the ED clinical practice reflected the lack of specificity of the observation policy during personal hygiene activities. The Patient had a long history of elopement, attempted suicide attempts, verbal and physical assault against clinicians in hospital settings. The Patient ' s clinical history was also relevant in that the Patient was hospitalized three times from June through August at the Facility and presented as very high psychiatric risk. In fact, the Patient had eloped on a bathroom trip event shortly after being brought to the ED; yet, there was no documentation to indicate a risk assessment for use of the bathroom

Observations made during the tour of the ED on 8/17/10 indicated that Security Guards did not automatically walk the Patient to the bathroom and stand outside the door. It was observed that one Patient on one to one observation got up from the room, announced she was going to the bathroom and walked to the bathroom independently. The Security Guard and the ED Patient Care Technician were interviewed and they said they were told the Patients could go to the bathroom alone. However, another Security Guard came to the bathroom area and asked an ED Nurse in another room to stand outside the bathroom door while the patient was inside with the door closed.