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Based on review of the facility policy, medical records (MR), and staff interviews, it was determined the facility failed to ensure all patients identified with suicidal ideation were provided care in a safe setting which affected patients presenting to the ED (Emergency Department) and patients admitted to the inpatient medical unit.

Findings include:

Please refer to tag A-0144 for findings.

Based on facility policy, medical record (MR) reviews and staff interviews, it was determined the facility failed to ensure staff followed the facility policy for patients identified at risk for suicide, documented provision of a safe environment of care, provided continual patient observations and performed patient assessments/re-assessments per policy for 2 of 2 ED (Emergency Department) record reviewed with suicidal ideations (SI) which affected PI (Patient Identifier) # 10, PI # 3 and with 1 of 1 inpatient records reviewed with SI which also was PI # 3.

This had the potential to affect all patients at risk for self harm who present to the hospital.

Findings include:

Facility Policy Reference 1178
Subject: The Psychiatric Patient
Department: Emergency Department
Reviewed: 12/21

POLICY:

Hill Hospital is a non-psychiatric receiving hospital. Any patient accessing care at this facility who requires psychiatric treatment (emotional illness, alcoholism or drug abuse) shall be managed through referral and transfer to a behavioral health facility and /or management through consultative psychiatric services on a temporary basis, until the patient's clinical condition has stabilized to allow for psychiatric facility transfer.

Patients Awaiting Care (Transfer) for Emotional Illness and/or Alcoholism or Drug Abuse:

Shall be provided with a location that is safe and is monitored while boarded.
...Patient assessments and reassessments shall be performed every one or two hours.
Care consistent with the patients' needs shall be provided.

...For Patients Accessing the Hospital Through the ED:

The ED physician shall evaluate the patient and determine the need for a psychiatric evaluation. If the patient is deemed in need of psychiatric treatment, the following criteria shall be assessed and documented:

All medical complaints are stabilized...medically cleared prior to transfer...
If the patient is a danger to self, staff or others, a security officer or staff member shall be requested to continually observe the patient.
Call West Alabama Mental Health Services.
Maintain patient safety.

...Assessment and documentation shall include:Patient history
History from family...others...involved in the patient's care
Patient complaint
Observation of signs and symptoms of mental, behavioral or suspected substance abuse
Vital signs
Documentation of potential danger to self, staff, or others
Patient/family education...

For Inpatients Demonstrating Psychiatric Conditions during Hospitalization:

A psychiatric evaluation shall be obtained from a psychiatrist or qualified practitioner...
If the patient is a danger to self, staff or others, a security officer or staff member shall be requested to continually observe patient until the acute psychiatric episode has subsided, and the patient is no longer considered a danger to self, staff, or others...or discharged...
Maintain patient safety. Clear room of any dangerous or potentially dangerous items...

...Assessment and documentation shall include:
Patient history
Patient complaint
Observation of signs and symptoms of mental, behavioral, or suspected substance abuse
Vital signs
Documentation of potential danger to self, staff, or others...

1. PI # 10 presented to the ED 3/2/22 at 10:24 AM per private vehicle with spouse, and chief complaint (cc) was suicidal thoughts.

Record review revealed ED physician record documentation dated 3/2/22 (no time was documented) for Psychiatric Disorder, Suicide Attempt, Overdose evaluation which revealed onset was 2-3 days ago for suicidal thoughts, with no plan, the severity was moderate and continues in the ED. The ED Physician documented PI # 10's clinical impression, Depression, manic and Suicidal Ideation.

Further record review revealed on 3/2/22 at 11:44 AM West Alabama Mental Health Services (WAMH) was notified, and PI # 10 was interviewed via phone and at 1:15 PM, the nurse documented the spouse left the hospital.

MR review revealed on 3/2/22 at 1:45 PM and again at 2:00 PM the nurse documented the patient was resting on a stretcher, eyes closed, and vital signs were monitored. There was no documentation PI # 10 was observed/monitored by ED staff from 2:00 PM till 7:30 PM, which was 5 hours 30 minutes until ED staff documented resting on stretcher at 7:30 PM and "no suicidal attempts or thoughts shared this PM."

Record review revealed on 3/2/22 at 8:10 PM the ED nurse documented CNA (certified nurse assistant) observing 1:1 (1 patient, 1 staff). There was no documentation staff, or a security officer was requested, and PI # 10 was continually observed from 10:24 AM until 8:10 PM which was 9 hours 46 minutes. There was no physician order for security or patient observation, and no documentation the ED environment/location and patient belongings were determined to be clear of potentially dangerous items.

MR review revealed on 3/3/22 at 12:35 AM PI # 10 was transferred via ambulance to an adult psychiatric unit.

In an interview on 3/9/22 at 8:10 AM, Employee Identifier (EI) #16 , ED Physician was asked how the ED staff ensure patients at risk for self-harm are kept safe while in the ED? EI # 16 stated it starts with the physician history and the mental status evaluation. EI # 16 was asked how the staff ensured the ED environment was safe and what was the procedure for patient monitoring? EI # 16 stated this was a small facility with few resources, ED had no safe room but ED staff monitored the patient every 2-3 minutes in between care of other patients.

During an interview on 3/9/22 at 2:17 PM, EI # 1, Director of Nursing reported when an at risk patient presents the ED staff get a history, do triage, and put in room 2 across from nurse desk, then bring the doctor in. EI # 1 stated we clear the room from dangerous objects, tell the patient staff will sit here, we try and have staff observe the patient and when ordered we call WAMH. Staff know to do this and EI # 1 reported we usually have a note pad and the nurse documents what the sitter says. EI # 1 confirmed ED staff should document all safety interventions in place until West Alabama Mental Health examines the patient. EI # 1 verified there was no documentation of how PI # 10''s safety was ensured for over 9 hours while in the ED.

2. PI # 3 presented to the ED 2/25/22 at 6:00 AM per emergency transport, cc was trying to step in front of a truck, multiple attempts of trying to kill himself.

Record review revealed on 2/25/22 at 5:50 AM (time verified) the ED physician documented hx (history) of bipolar/schizo (schizoid/schizophrenia)" ...says likes people and wouldn't hurt self" and the physician's clinical impression documentation was Schizophrenia/Affect and History of Suicide attempts or gestures. The ED nurse documented at triage at 6:00 AM, depressed thinking about killing self and history of bipolar.

Review of the MR documentation dated 2/25/22 revealed at 6:00 AM PI # 3 was triaged and at 7:45 AM the ED nurse documented WAMH called, message left. At 8:05 AM the nurse administered medications which was 2 hours 5 minutes after arrival to the ED, with no documentation of patient observations. The next observation with vital signs was documented at 9:12 AM, which was 1 hour 7 minutes later. At 9:30 AM phone contact with WAMH informed of patient's suicidal thoughts. At 10:15 AM, 11:35 AM and 12:55 PM patient observations were documented which was greater than 1 hour with no observations documented. There were no patient observations documented from 12:55 PM until 3:00 PM which was 2 hours 5 minutes. A urine specimen was collected at 3:26 PM, a patient observation was documented at 4:45 PM and the next patient observation was documented at 7:15 PM, which was 3 hours 15 minutes later. At 9:00 PM, 10:00 PM, 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM patient observations were documented. On 2/26/22 at 6:40 AM, the ED nurse documented does not voice any thoughts of suicide and at 7:00 AM documented "I feel much better about my self and do not want to harm myself today."

Further record review revealed patient observations on 2/25/22 at 8:00 AM, and not again for 2 hours 10 minutes at 10:10 AM. The next observation was 11:30 AM, which was 1 hour 20 minutes. The next observation was at 1:45 PM which was 2 hours 15 minutes. Staff documented the next observation at 5:00 PM which was 3 hours 45 minutes later.

There was no physician order while in the ED for security or patient observation when PI # 3 was identified a danger to self and no documentation the ED environment/location and patient belongings were determined to be clear of potentially dangerous items.

MR review revealed ED Physician discharge instructions on 2/26/22 at 4:20 PM to admit to the hospital. The Physician Orders for Adult General Inpatient Admission Orders included one on one observation signed by the physician on 2/26/22 at 4:30 PM.

MR review revealed no documentation PI # 3 was continually observed while in the ED per facility policy on 2/25/22 from 6:00 AM until inpatient admit on 2/26/22 at 5:08 PM when ED nursing staff documented PI # 3 was admitted to room with CNA 1:1 until relief arrives.

Review of the initial inpatient history and physical completed by the physician 2/6/22 at 4:30 PM revealed the patient with ambivalence states would hurt self. The inpatient nursing initial interview dated 2/26/22 at 4:20 PM revealed cc, suicidal thoughts with past/current substance use. The nurse note documentation dated 2/26/22 at 4: 46 PM revealed the patient was received from ER with CNA-room previously cleared of any objects that could cause harm-informed a sitter would be present as all times for safety, sitter instructed not to leave patient alone.

Further review revealed Patient Progress Note dated 2/26/22 at 8:07 PM with the following nurse documentation: "...while in talking with the patient writer notice a black object on his/her table and writer asked what it was because it appear to be a razor which the patient confirmed that it was a razor and staff reported that he/she got it out of his/her pocket and placed it on the table...". There was no documentation the patient belongings were evaluated and no dangerous objects/items were identified.

In an interview on 3/9/22 at 2:17 PM, EI # 1 reported he/she was not aware the razor was found in PI # 3's room. EI # 1 stated I know what my staff do, they take care of the patients. EI # 1 confirmed staff failed to follow the facility policy for care of a psychiatric patient.