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Based on observation, interview and record review, Hospital A and B failed to ensure that an action plan (product of root cause analysis- identification and resolution of fundamental reason/s for a failure or insufficiency of a process intended for implementation to reduce the risk of similar future adverse events), which was developed following a patient's (1) attempted suicide in the Emergency Department (ED), was completely implemented. The Hospital did not ensure that all staff who cared for high risk suicidal (plan to kill oneself), homicidal (plan to kill others) and psychiatric patients in the ED, were trained to the new ED process and procedure (memorandum - memo) in accordance with their action plan.

In addition, the Hospital failed to identify through its own auditing and tracking process that, ED Clinical Care Partners and Registry Clinical Care Partners (provide constant observation of patients under the supervision of Registered Nurses-CCP) were trained per the action plan. Therefore, the hospital had not implemented it's own Performance Improvement and Patient Safety Plan (PIPS) and Sentinel Event and Significant Adverse Events Policy (SESA).

Findings:

On 4/26/16 at 1:30 P.M., an entrance conference was conducted with with the Assistant Director Accreditation and Regulatory Compliance (ADARC), the Quality Compliance Specialist (QCS)1, an Assistant Nurse Manager (AN) 2 and the ED Manager (EDM). During the conference, the EDM stated that part of the action plan implemented on 3/16/16, after Patient 1's incident of attempted suicide, included mandatory education and audits of the ED memo which contained guidelines in the care of suicidal, homicidal and 5150 (involuntary hold) patients. Per the EDM, the ED memo was sent to all ED staff and was made effective on 3/16/16. The ED memo instructed and educated ED staff to use safe gowns and bottoms, policy for removing belongings, keeping patients in sight at all times, utilization of chain of command, and removal of tubing,wires, and other items that could be used as a means to hurt oneself or others. The ED memo indicated the following:

"Dear ED Staff,

In order to keep your psychiatric patients and yourselves safe from harm, effective immediately, the following guidelines need to be followed with our high risk, suicidal and/or homicidal patients:

As per policy, all belongings must be removed from the bedside; valuables placed in the safe.

Suicidal, homicidal and patients on a 5150 need to be placed in a paper gown.

Suicidal, homicidal and patients on a 5150 should not be given pants with a drawstring or gowns with long tie strings.

Remove all monitor wires, oxygen tubing and any other item that can be used as a weapon from the patient room.

Do not let patient out of sight... unfortunately, this means even when they use the bathroom.

If there is an event with a psych patient such as legitimate attempt of self-harm or physical harm to staff...you must utilize chain of command. Notify Charge Registered Nurse (RN), Notify the on-duty Assistant Nurse manager (ANII), Notify Department Manager of Director (call any time of the night), Notify the house supervisor, Notify the Attending MD on duty."

On 4/26/16 at 3:00 P.M., a tour of Hospital A's ED was conducted with QCS 1 and AN 2. CCP 1 was seated in a chair outside of the doorway which led to Patient 12 and 13's shared room, and Patient 20 in an adjacent hallway bed.

On 4/26/16 at 3:30 P.M., an interview was conducted with CCP 1, QCS 1 and AN 2. CCP 1 stated that she worked for a registry (contracted employee) and did not receive education related to recent changes in the ED when providing care of suicidal, homicidal and psychiatric patients. CCP 1 stated that she had heard about an incident (Patient 1) in the ED restroom. In addition, CCP 1 stated that when staff cared for suicidal, homicidal and psychiatric patients; patient care cords, tubing and lines remained in the patient's room environment. CCP 1 stated that CCP's and ED technicians were assigned as sitters (1:3 ratio; 1 sitter in direct line of sight of 3 patients) for suicide, homicide and psychiatric patients.

On 4/26/16 at 3:40 P.M., an interview was conducted with AN 2. AN 2 acknowledged that CCP 1's knowledge of suicidal, homicidal and psychiatric patients' room environment was not consistent with the recent education presented to the ED staff.

On 4/26/16 at 4:40 P.M., an interview was conducted with the EDM, AN 2, QCS 1 and the ADARC. The EDM stated that on 3/16/16, the ED memo was sent out to all ED staff. The ED memo contained guidelines for the care of high risk suicidal, homicidal and psychiatric patients in the ED. The EDM acknowledged that the memo read "Remove all monitor wires, oxygen tubing and any other item that can be used as a weapon from the patient room," and this was inconsistent with CCP 1's interview response. In addition, the EDM stated that the Hospital staff CCP's and Registry CCP's did not receive the ED education related to the ED memo. The EDM, AN 2, QCS 1 and ADARC acknowledged that CCP's provided care for suicidal, homicidal and psychiatric patient's in the ED and should have received the mandatory education found in the ED memo.

On 4/27/16 at 7:30 A.M., Patient 12, 13 and 20's medical records were reviewed with QCS 1.

Patient 12 was admitted to Hospital A on 4/26/16 at 10:56 A.M. on a 5150 (involuntary hold) for homicidal ideation (thoughts of killing others) and placed on 1:3 sitter per the ED record, dated 4/27/16.

Patient 13 was admitted to Hospital A on 4/26/16 at 3:21 P.M., on a 5150 for suicide and placed on 1:3 sitter per the ED record dated 4/27/16.

Patient 20 was admitted to Hospital A on 4/26/16 at 7:32 A.M., for suicide and placed on 1:3 sitter per the ED face sheet, dated 4/26/16.

On 4/28/16 at 11:30 A.M., an untitled document which contained a list of Hospital A and B's employed CCP's and Registry CCP's was reviewed. The list indicated that 50 Hospital and Registry CCP's worked in both Hospital A and Hospital B's ED from 3/17/16 to 4/28/16, and had not received the ED memo with the mandatory training.

On 4/28/16 at 11:45 A.M., the Hospital's audit related to the memo titled "Psychiatric Patient Education: Staff knowledge assessment", dated 3/20/16 through 4/27/16, was reviewed. One of the audit monitoring components included "Knowledge of surroundings: Patient room and/or area is free of monitor wires, oxygen tubing, and any other item that could be used as a weapon as patient condition allows? Y/N (yes/no)." CCP 1's name was documented on 3/26/16, as compliant with verbalization of "knowledge of surroundings," however; this was inconsistent with CCP 1's interview which showed a lack of knowledge regarding the current process.

On 4/28/16 at 2:00 P.M., a meeting with the Hospital's leadership was conducted. The EDM acknowledged that the ED and Registry CCP's had not been educated and signed off in attendance of the mandatory ED education related to the care of suicidal, homicidal and psychiatric patients. The Chief Medical Officer (CMO) acknowledged that CCP 1 was unable to verbalize the current process for the care of suicidal, homicidal and psychiatric patients in the ED. The CMO also acknowledged that there was no documented evidence that 50 of the Hospital and Registry CCP's who worked in the ED as sitters, received the mandatory education (ED memo) as indicated in the hospital's action plan that specified all ED staff must receive the training.

The Hospital's SESA Policy, dated 6/2/15, indicated that Root Cause Analysis- (Process for identifying factors that underlie variation in performance, focusing on systems and processes-RCA) and Action Plans were developed and monitored to improve the safety of patients, identify causal issues and actions to reduce the risk of reoccurrence.

The Hospital's RCA related to the care of suicidal, homicidal, and psychiatric patients in the ED, did not identify that the ED CCP's and Registry CCP's did not receive mandatory training to ensure the safety of high risk, suicidal homicidal and psychiatric patients. The Action Plan was implemented for 39 days, without ensuring that the ED and Registry CCP staff were included in the mandatory training via the ED memo.

The Hospital's PIPS Plan Fiscal Year 2015/2016, indicated, "The purpose of this plan is to ensure that the health system plans and provides high quality, safe, patient-focused care. The plan provides the framework, structure and methodology to support performance improvement and patient safety activities related to the provision of care, in addition to the accountability for achieving objectives and communicating results."

The Hospital failed to ensure that their SESA policy was implemented when, the implemented action plans were not completely monitored for effectiveness. In addition, the PIPS plan was not fully implemented when, the current ED processes in place for the care of suicide, homicide and psychiatric patients, were inconsistently measured. As a result, the outcomes of the audit were inconsistent with CCP 1's verbalization of the process.

Based on interview, record, and document review, Hospital A failed to ensure that suicide protocol checklist (performed and documented by a Registered Nurse-RN, upon admission to identify suicide risk) and Q2 (every two hours) suicide reassessments were performed and documented by RN's for 7 of 32 sampled patients (1, 2, 10, 12, 13, 15, 16). There was no documented evidence of suicide protocol checklists and suicide reassessments to demonstrate that RN's implemented the Hospital's Suicide Risk Management policy and procedure.

The lack of completion and documentation, did not ensure that staff consistently identified patients at risk for suicide, to ensure safety precautions and to plan disposition (discharge plan) for suicidal (plan to kill oneself), homicidal (plan to kill others) and psychiatric (relating to mental illness or its treatment) patients who presented in the Emergency Department (ED) and inpatient units.

Findings:

1. On 4/18/16 at 2:40 P.M., Patient 1's ED record was reviewed with the Assistant Director Accreditation and Regulatory Compliance (ADARC).

Patient 1 was admitted to Hospital A on 3/15/16 at 10:22 P.M., and placed on 1:3 sitter observation (1 staff assigned to observe 3 patients within direct line of sight) for suicide precautions, per the ED record, dated 4/18/16.

Patient 1's ED record entry documented by an Emergency Department Technician (EDT) 2 on 3/16/16 at 3:18 A.M., indicated, that Patient 1 was found in the ED restroom with threading from scrub pants around his neck.

A suicide protocol checklist for Patient 1 was documented on 3/15/16 at 10:30 P.M. and a Q2 suicide reassessment was documented at 12:10 A.M. There was no documented evidence of a Q2 suicide reassessment for Patient 1 until 3/16/16 at 10:55 P.M., and then on 3/17/16 at 12:50 A.M. There was no further documented evidence of a Q2 suicide reassessment for Patient 1 until 3/17/16 at 2:10 P.M. In addition, there was no Q2 suicide reassessment documented thereafter, and Patient 1 was discharged to another unit of the Hospital on 3/17/16 at 8:15 P.M. There was no documented evidence that Patient 1 was reassessed every two hours by an RN, in accordance with the Suicide Risk Management Policy.

Per the Hospital's policy and procedure titled Suicide Risk Management, dated 4/18/13, the RN will assist with initiating appropriate suicide precaution measures and to ensure the patient's safety measures and behaviors, will be documented every two hours.

Part of the electronic medical record (EMR) document titled "Checklist For Patient Presenting to ED with Suicidal Ideation", contained documentation completed every 2 hours in the ED medical record by the RN.

The electronic medical record (EMR) document titled "Q2 hour suicide precautions-RN to complete" included the documentation of the following: suicide precaution status, direct observation in place, room clear of potentially harmful objects, and behavioral mood observation.

On 4/25/16 at 8:45 A.M., an interview was conducted with the Emergency Department Manager (EDM) and RN 3. RN 3 stated that the suicide protocol checklist was documented every two hours by the RN. RN 3 and the EDM acknowledged that there was no documented evidence that RN 3 reassessed Patient 1 for suicide risk and precautions in accordance with their policy which, indicated the RN will document every two hours to ensure the patient's safety measures and behaviors.

2. Patient 2 was admitted to Hospital A on 11/2/15 at 4:41 P.M. and placed on 1:3 sitter observation (1 staff assigned to observe 3 patients within direct line of sight) for suicide precautions, per the ED record, dated 4/27/16.

A suicide protocol checklist for Patient 2 was documented on 11/2/16 at 5:05 P.M. and a Q2 suicide reassessment was documented at 7:40 P.M. There was no Q2 suicide reassessment documented thereafter and Patient 2 was discharged to another unit of the Hospital on 11/3/15 at 12:19 A.M. There was no documented evidence that Patient 2 was reassessed every two hours by an RN, in accordance with the Suicide Risk Management Policy.

Per the Hospital's policy and procedure titled Suicide Risk Management, dated 4/18/13, the RN will assist with initiating appropriate suicide precaution measures and to ensure the patient's safety measures and behaviors, will be documented every two hours.

Part of the electronic medical record (EMR) document titled "Checklist For Patient Presenting to ED with Suicidal Ideation", contained documentation completed every 2 hours in the ED medical record by the RN.

The electronic medical record (EMR) document titled "Q2 hour suicide precautions-RN to complete" included the documentation of the following: suicide precaution status, direct observation in place, room clear of potentially harmful objects, and behavioral mood observation.

3. Patient 10 was admitted to Hospital A on 3/2/16 at 7:57 P.M. and placed on 1:3 sitter observation (1 staff assigned to observe 3 patients within direct line of sight) for suicide precautions, per the ED record, dated 4/27/16.

A suicide protocol checklist for Patient 10 was documented on 3/2/16 at 8:01 P.M. There was no Q2 suicide reassessment documented thereafter and Patient 10 was discharged from the hospital on 3/3/16 at 8:00 A.M. There was no documented evidence that Patient 10 was reassessed every two hours by an RN, in accordance with the Suicide Risk Management Policy.

Per the Hospital's policy and procedure titled Suicide Risk Management, dated 4/18/13, the RN will assist with initiating appropriate suicide precaution measures and to ensure the patient's safety measures and behaviors, will be documented every two hours.

Part of the electronic medical record (EMR) document titled "Checklist For Patient Presenting to ED with Suicidal Ideation", contained documentation completed every 2 hours in the ED medical record by the RN.

The electronic medical record (EMR) document titled "Q2 hour suicide precautions-RN to complete" included the documentation of the following: suicide precaution status, direct observation in place, room clear of potentially harmful objects, and behavioral mood observation.

4. Patient 12 was admitted to Hospital A on 4/26/16 and placed on 1:3 sitter observation (1 staff assigned to observe 3 patients within direct line of sight) for suicide precautions, per the ED record dated 4/27/16.

A suicide protocol checklist for Patient 12 was documented on 4/27/16 at 12:04 P.M. There was no Q2 suicide reassessment documented thereafter. There was no documented evidence that Patient 12 was reassessed every two hours by an RN, in accordance with the Suicide Risk Management Policy.

Per the Hospital's policy and procedure titled Suicide Risk Management, dated 4/18/13, the RN will assist with initiating appropriate suicide precaution measures and to ensure the patient's safety measures and behaviors, will be documented every two hours.

Part of the electronic medical record (EMR) document titled "Checklist For Patient Presenting to ED with Suicidal Ideation", contained documentation completed every 2 hours in the ED medical record by the RN.

The electronic medical record (EMR) document titled "Q2 hour suicide precautions-RN to complete" included the documentation of the following: suicide precaution status, direct observation in place, room clear of potentially harmful objects, and behavioral mood observation.

5. Patient 13 was admitted to Hospital A on 4/25/16 and placed on 1:3 sitter observation (1 staff assigned to observe 3 patients within direct line of sight) for suicide precautions, per the ED record, dated 4/27/16.

A suicide protocol checklist for Patient 13 was documented on 4/25/16 at 3:23 P.M. There was no documented evidence of a Q2 suicide reassessment for Patient 13 until 4/25/16 at 10:36 P.M. There was no documented evidence that Patient 13 was reassessed every two hours by an RN, in accordance with the Suicide Risk Management Policy.

Per the Hospital's policy and procedure titled Suicide Risk Management, dated 4/18/13, the RN will assist with initiating appropriate suicide precaution measures and to ensure the patient's safety measures and behaviors, will be documented every two hours.

Part of the electronic medical record (EMR) document titled "Checklist For Patient Presenting to ED with Suicidal Ideation", contained documentation completed every 2 hours in the ED medical record by the RN.

The electronic medical record (EMR) document titled "Q2 hour suicide precautions-RN to complete" included the documentation of the following: suicide precaution status, direct observation in place, room clear of potentially harmful objects, and behavioral mood observation.

6. Patient 15 was admitted to Hospital A on 10/1/15 and placed on 1:3 sitter observation (1 staff assigned to observe 3 patients within direct line of sight) for suicide precautions, per the ED record, dated 4/27/16.

A suicide protocol checklist for Patient 15 was documented on 10/1/15 at 4:30 A.M. and a Q2 suicide reassessment was documented on 10/1/15 at 5:16 A.M. There was no Q2 suicide reassessment documented thereafter, and Patient 15 was discharged to another unit of the hospital on 10/1/16 at 11:16 A.M. There was no documented evidence that Patient 15 was reassessed every two hours by an RN, in accordance with the Suicide Risk Management Policy.

Per the Hospital's policy and procedure titled Suicide Risk Management, dated 4/18/13, the RN will assist with initiating appropriate suicide precaution measures and to ensure the patient's safety measures and behaviors, will be documented every two hours.

Part of the electronic medical record (EMR) document titled "Checklist For Patient Presenting to ED with Suicidal Ideation", contained documentation completed every 2 hours in the ED medical record by the RN.

The electronic medical record (EMR) document titled "Q2 hour suicide precautions-RN to complete" included the documentation of the following: suicide precaution status, direct observation in place, room clear of potentially harmful objects, and behavioral mood observation.

7. Patient 16 was admitted to Hospital A on 10/2/15 at 10:17 A.M. and placed on 1:3 sitter observation (1 staff assigned to observe 3 patients within direct line of sight) for suicide precautions, per the ED record, dated 4/27/16.

A suicide protocol checklist for Patient 16 was documented on 10/2/15 at 3:24 P.M. after the patient received orders for discharge from the hospital on 10/2/15 at 3:21 P.M. There was no documented evidence that Patient 16 was reassessed every two hours by an RN, in accordance with the Suicide Risk Management Policy.

Per the Hospital's policy and procedure titled Suicide Risk Management, dated 4/18/13, the RN will assist with initiating appropriate suicide precaution measures and to ensure the patient's safety measures and behaviors, will be documented every two hours.

Part of the electronic medical record (EMR) document titled "Checklist For Patient Presenting to ED with Suicidal Ideation", contained documentation completed every 2 hours in the ED medical record by the RN.

The electronic medical record (EMR) document titled "Q2 hour suicide precautions-RN to complete" included the documentation of the following: suicide precaution status, direct observation in place, room clear of potentially harmful objects, and behavioral mood observation.

On 4/28/16 at 2:00 P.M., a meeting with the hospital's leadership was conducted. The Chief Medical Officer (CMO) and the Nursing Director of Emergency Department (NDED) both stated that the hospital had been monitoring the completion of the protocol checklist in the past; however, compliance was sustained and periodic monitoring had not been continued. The CMO and the NDED acknowledged that during the survey, 7 sampled records were randomly selected over a six month period. The records indicated that documentation of the suicide protocol checklist and Q2 suicide reassessments were not fully implemented in 10/2015, 11/2015, 3/2016 and 4/2016, in accordance with their Suicide Risk Management Policy.

Based on observation, interview and document review, Hospital A and B failed to ensure that all Emergency Department (ED) staff received mandatory education related to the care of suicidal (plan to kill self), homicidal (plan to kill others) and psychiatric (relating to a mental illness or its treatment) patients. A clinical care partner (Hospital Clinical Care Partners and Registry Clinical Care Partners who provide constant observation of patients under the supervision of Registered Nurses-CCP) 1, was unable to verbalize current Emergency Department (ED) processes and procedures (ED memorandum - memo). The lack of implementation of mandatory education related to the ED memo to include Hospital and Registry CCP's, did not ensure that all staff were aware of measures in place in an effort to provide safe care and monitoring for suicidal, homicidal and psychiatric patients.

Findings:

On 4/26/16 at 1:30 P.M., an entrance conference was conducted with the Assistant Director Accreditation and Regulatory Compliance (ADARC), the Quality Compliance Specialist (QCS) 1, the Assistant Nurse Manager (AN) 2 and the ED Manager (EDM). The EDM stated, on 3/16/16, after Patient 1's incident (an attempted suicide by hanging in an ED restroom), mandatory education in an ED memo was implemented and signed by all ED staff on 3/17/16.

The ED memo indicated the following:

"Dear ED Staff,

In order to keep your psychiatric patients and yourselves safe from harm, effective immediately, the following guidelines need to be followed with our high risk, suicidal and/or homicidal patients:

As per policy, all belongings must be removed from the bedside; valuables placed in the safe.

Suicidal, homicidal and patients on a 5150 (involuntary hold) need to be placed in a paper gown.

Suicidal, homicidal and patients on a 5150 should not be given pants with a drawstring or gowns with long tie strings.

Remove all monitor wires, oxygen tubing and any other item that can be used as a weapon from the patient room.

Do not let patient out of sight... unfortunately, this means even when they use the bathroom.

If there is an event with a psych patient such as legitimate attempt of self-harm or physical harm to staff...you must utilize chain of command. Notify Charge Registered Nurse (RN), Notify the on-duty Assistant Nurse manager (ANII), Notify Department Manager of Director (call any time of the night), Notify the house supervisor, Notify the Attending MD on duty."

On 4/26/16 at 3:00 P.M., a tour of Hospital A's ED was conducted with QCS 1 and AN 2. CCP 1 was seated in a chair outside of the doorway which led to Patient 12 and 13's shared room, and Patient 20 in an adjacent hallway bed.

On 4/26/16 at 3:30 P.M., an interview was conducted with CCP 1, QCS 1 and AN 2. CCP 1 stated that she worked for a registry (contracted employee) and that she did not receive education related to recent changes in the ED when providing care of suicidal, homicidal and psychiatric patients. In addition, she stated that she heard about an incident that occurred with a patient, who attempted suicide (Patient 1) in the ED restroom. In addition, CCP 1 stated that when staff cared for suicidal, homicidal and psychiatric patients; cords, tubing and lines remained in the patient's room environment. CCP 1 stated that CCP's and ED technicians were assigned as sitters (1:3 ratio; 1 sitter in direct line of sight of 3 patients) for suicidal, homicidal and psychiatric patients.

On 4/26/16 at 4:40 P.M., an interview was conducted with the EDM, AN 2, QCS 1 and the ADARC. The EDM stated that the hospital staff CCP's and registry CCP's did not receive the mandatory ED education because they were not part of the ED staff however; the EDM, AN 2, QCS 1 and the ADARC acknowledged that CCP's were assigned to care for suicidal, homicidal and psychiatric patients in the ED and should have received the education as indicated in the memo.

On 4/28/16 at 11:30 A.M., an untitled document contained a list of Hospital A and B's employed CCP's and registry CCP's. The list contained a total of 50 CCP's who did not receive the mandatory education (ED memo) related to the care of suicidal, homicidal and psychiatric patients in the ED, that was made effective 3/16/16.

This failure impeded the Hospital from ensuring that all ED staff were aware of safety measures implemented in an effort to provide safe care and monitoring for suicidal, homicidal and psychiatric patients.