HospitalInspections.org

Based on the seriousness of the non-compliance and the potential effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.13 Tag A-0144

The information reviewed during the survey provided evidence the facility failed to ensure 1:1 patient monitors remained with high risk suicidal patients and maintained continuous visual observation for six of eight medical records reviewed (MR1, MR2, MR4, MR6, MR7, and MR8).

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP4, and EMP5) regarding the survey team's concerns related to Patient's Rights on October 14, 2021 at approximately 1050.

Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 (a) Organization of Nursing Services
482.23(b)(3) RN Supervision of Nursing Care

Based on review of facility documents, medical records (MR), observations, and staff interview (EMP), it was determined the facility failed to ensure 1:1 patient monitors remained with high risk suicidal patients and maintained continuous visual observation for six of eight medical records reviewed (MR1, MR2, MR4, MR6, MR7, and MR8).
Findings:
Review on October 14, 2021, of facility policy, "Patient's Bill of Rights" revised October 22, 2019, revealed "Purpose: To provide procedures for informing the patients of their rights and responsibilities while receiving services. ...The hospital staff should know and follow all patient rights. ...You have the right to: ....An environment that is safe, preserves dignity and contributes to a positive self-image. ..."
Review on October 14, 2021, of facility policy, "Suicide Precautions" revised August 2020, revealed "Purpose: To outline a mechanism for observation and protection of patients who are assessed to be at risk for suicide, or have expressed suicidal ideations. Policy: 1. A physician's order must be obtained for suicide precautions and a psychiatric consult obtained. 2. Suicide precautions must be re-ordered daily. 3. A patient monitor is assigned until the patient is either transferred to an appropriate facility or is determined to be no longer at risk and discontinued. ...11. The patient monitor must be an employee/contractor of the hospital and must have attended the patient monitoring class provided by the Professional Development Department and have current CPR certification. ...13. The patient monitor is to be located within line of sight, inside the doorway and in direct proximity of the patient. If the patient is in a hallway bed, the patient monitor is to be seated at the foot of the patient's bed (beyond arm's length but in direct proximity of the patient). 14. The patient monitor will report any potentially unsafe behaviors to the assigned nurse. 15. The patient monitor must accompany the patient at all times. 16. While utilizing the bathroom, the door must remain ajar and the patient monitor must keep the patient in sight at all times. 17. The patient monitor is to remain with the patient when visitors are present. 18. The patient monitor may not leave the room of the patient until they are relieved. 20. The patient monitor or other hospital personnel must document patient observation checks every 15 minutes on the Patient Observer Monitoring Checklist Form ...21. The nurse assigned should review the documented observations made by the patient monitor each shift. ..."
Review on October 13, 2021, of video surveillance from October 6, 2021, at 1523 revealed MR1's 1:1 patient monitor walked down the ED hallway away from MR1 leaving MR1 with a family member and did not return. Video surveillance from October 6, 2021, at 1538 revealed a new 1:1 patient monitor arrived at MR1's ED room.
Interview on October 13, 2021, with EMP3, at approximately 1500 confirmed video surveillance from October 6, 2021, revealed MR1 was left with a family member and no 1:1 patient monitor from 1523 to 1538.
Continued review on October 13, 2021, of video surveillance from October 6, 2021, at 1615 revealed MR1 walked to the bathroom with their 1:1 patient monitor. MR1 closed the bathroom door and was not visible to the 1:1 patient monitor.
Interview on October 13, 2021, with EMP3, at approximately 1510 confirmed video surveillance from October 6, 2021, at 1615 revealed MR1 closed the door to the bathroom and was not visible to the 1:1 patient monitor.
Review on October 14, 2021, of MR1 revealed a physician order on October 5, 2021, at 1613 for a 1:1 continuous observation.
Interview on October 14, 2021, with EMP1, at approximately 0830, confirmed MR1 had a physician order dated October 5, 2021, at 1613 for 1:1 continuous observation. EMP1 confirmed a patient monitor is considered a trained facility staff member.
Review on October 13, 2021, of video surveillance from October 6, 2021, at 1526 revealed MR2 with a family member at bedside and 1:1 staff behind the nurses' station.
Interview on October 13, 2021, with EMP3, at approximately 1400 confirmed video surveillance from October 6, 2021, at 1526 revealed MR2 with a family member at bedside and 1:1 staff behind the nurses' station.
Review on October 14, 2021, of MR2, revealed a physician order dated October 6, 2021, at 0120 for 1:1 continuous observation.
Interview on October 14, 2021, with EMP1, at approximately 0835 confirmed MR2 had a physician order dated October 6, 2021, at 0120 for 1:1 continuous observation. EMP1 confirmed a patient monitor is considered a trained facility staff member.
Review on October 13, 2021, of video surveillance from October 6, 2021, at 1527 revealed MR4 in a room and no 1:1 continuous observation sitter.
Interview on October 13, 2021, with EMP3, at approximately 1410 confirmed video surveillance from October 6, 2021, at 1527 revealed MR4 in a room and did not have a continuous 1:1 observation sitter.
Review on October 14, 2021, of MR4, revealed a physician order dated October 6, 2021, at 1315 for 1:1 continuous observation.
Interview on October 14, 2021, with EMP1, at approximately 0840 confirmed MR4 had a physician order dated October 6, 2021, at 1315 for 1:1 continuous observation.
Review on October 13, 2021, of video surveillance from October 6, 2021, at 1528 revealed MR6 in a room and no continuous 1:1 observation sitter.
Interview on October 13, 2021, with EMP3, at approximately 1420 confirmed video surveillance from October 6, 2021, at 1528 revealed MR6 in a room and no continuous 1:1 observation sitter.
Review on October 14, 2021, of MR6 revealed a physician order dated October 6, 2021, at 0945 for 1:1 continuous observation.
Interview on October 14, 2021, with EMP1, at approximately 0845 confirmed MR6 had a physician order dated October 6, 2021, at 0945 for 1:1 continuous observation.
Review on October 13, 2021, of video surveillance from October 6, 2021, at 1529 revealed MR7 in a room and no continuous 1:1 observation sitter.
Interview on October 13, 2021, with EMP3, at approximately 1430 confirmed video surveillance from October 6, 2021, at 1529 revealed MR7 in a room and no continuous 1:1 observation sitter.
Review on October 14, 2021, of MR7 revealed a physician order dated October 6, 2021, at 0515 for 1:1 continuous observation.
Interview on October 14, 2021, with EMP1, at approximately 0845 confirmed MR7 had a physician order dated October 6, 2021, at 0515 for 1:1 continuous observation.
Review on October 13, 2021, of video surveillance from October 6, 2021, at 1530 revealed MR8 in a room with a visitor and no continuous 1:1 observation sitter.
Interview on October 13, 2021, with EMP3, at approximately 1435 confirmed video surveillance from October 6, 2021, at 1530 revealed MR8 in a room with a visitor and no continuous 1:1 observation sitter.
Review on October 14, 2021, of MR8 revealed a physician order dated October 6, 2021, at 1330 for 1:1 continuous observation.
Interview on October 14, 2021, with EMP1, at approximately 0850 confirmed MR8 had a physician order dated October 6, 2021, at 1330 for a 1:1 continuous observation.
Cross reference
482.13 Patient Rights
482.23 (a) Organization of Nursing Services
482.23(b)(3) RN Supervision of Nursing Care

Based on review of facility documents, medical records (MR), and staff interview (EMP) it was determined the facility failed to ensure registered nurses re-assessed suicide risk and need for suicide precautions every shift as ordered for six of eight medical records reviewed (MR1, MR2, MR4, MR6, MR7, and MR8).

Findings:

Review on October 13, 2021, of the facility policy, "Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting," last revised July 22, 2021, revealed ...Policy: All adolescent and adult patients (ages > 11 y.o.) who present for care and services will be screened for suicide ideation and behavior using the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS) excluding patients who present for Obstetrical Services. Screening very young children (ages > 6y.o. - 10y.o.) or if cognitively impaired, only if the chief complaint/primary diagnosis is of an emotional/behavioral disorder including substance abuse or if suicidal ideation, intent or behavior is observed. Based on the severity and immediacy of suicide risk assessed using the Columbia Protocol, patient safety measures and interventions will be implemented as a means to keep patient from inflicting harm to self. This policy is applicable to patients admitted to non-behavioral health settings whether inpatient or outpatient (ED {hospital and free-standing}, OBS, ASC, OR, excluding OB) during the nursing admission assessment, triage, or initial intake. ... Definitions: One to One (1:1) Observation: Intervention for high risk suicide. Continuous observation and staff are able to see the patient in clear view and staff can respond immediately to intervene and assure safety at all times, including while the patient sleeps, uses the toilet, bathes, etc. Video monitoring should only be used when it is unsafe for a staff member to be physically located in the patient's room. ... Procedure ... 6) a. Have you ever done anything, started to do anything, or prepared to do anything to end your life? ... b. If Yes to 6a, ask: How long ago did you do anything, start to do anything or prepare to do anything to end your life?(greater than one year ago, within the past year but greater than 3 month ago or less than 3 months ago) ... If answered Yes to question 6a, asking how long ago will determine risk level. If greater than one year ago determined to be Low risk. If within the past year but greater than 3 months ago determined to be Moderate risk. If within the past 3 months determined to be High risk. ...If patient answered "Yes" to questions #4, #5 or #6 for past 3 months patient is considered High Risk. RN* will notify MD and MD to order Mental Health Professional referral (recommended before leaves the area/unit) to include assessment of suicide risk and protective factors. Continuous observation 1:1, staff (nursing, sitter) are able to see the patient in clear view and staff can respond immediately to intervene and assure safety at all times. [If the patient is High Risk for suicide, the patient may be observed continuously in a dedicated, secured, ligature resistant safe area or room with more than 1:1 (e.g. Secure Hold, Crisis Room, Behavioral Health Hold) as state law allows.] Utilize the Frequent Observation Flow Sheet NS-1606 or EHR for documenting visual surveillance and observations. Assess the environment of care in a patients room and complete the Safe Room Check List (NS-1605 or EHR)[if patient is not located in a dedicated, secured, ligature resistant safe area or room which conducts bi-annual Environmental Risk Assessment including assessing for ligature risk.] ... Table 1: Patient Safety Measures and Interventions Based on Screening Responses... Level of Risk ...Within the past 3 months: High Initiate continuous observation (1:1 or in a dedicated, secured, ligature-resistant area or room) RN* to assess and complete Safe Room Checklist (NS1605) if not in dedicated, secured, ligature-resistant area or room RN* to notify MD and MD to order Mental Health Professional referral (recommended before leaves the area/unit) Use communication/de-escalation techniques If family/significant other with patient: Nurse to provide "Support Person Education" RN* to re-assess suicide risk and need for suicide precautions at least every shift and/or if there is an observed or stated change in behavior ..."

Review on October 14, 2021, of MR1 revealed MR1 presented to the Emergency Department (ED) on October 5, 2021 for suicide attempt. MR1 was assessed as high risk for suicide and ordered 1:1 observation and re-assess suicide risk every shift. There was no documentation a registered nurse completed MR1's suicide risk assessment on October 6 or 7, 2021.

Interview on October 14, 2021, with EMP1, at approximately 0900, confirmed MR1 was ordered re-assess suicide risk every shift. EMP1 confirmed there was no documentation a registered nurse completed MR1's suicide risk assessment on October 6 or 7, 2021.

Review on October 14, 2021, of MR2 revealed MR2 was admitted to the facility on October 6, 2021, for treatment of a mental illness. There was no documentation a registered nurse completed MR2's suicide risk assessment on October 6 or 7, 2021.

Interview on October 14, 2021, with EMP1, at approximately 0900, confirmed MR2 was admitted to the facility on October 6, 2021, for the treatment of a mental illness. EMP1 confirmed there was no documentation a registered nurse completed MR2's suicide risk assessment on October 6 or 7, 2021

Review on October 14, 2021, of MR4 revealed MR4 was admitted to the facility on October 6, 2021, for suicidal ideation. There was no documentation a registered nurse completed MR4's suicidal risk assessment on October 6 or 7, 2021.

Interview on October 14, 2021, with EMP1, at approximately 0910, confirmed MR4 was admitted to the facility on October 6, 2021, for suicidal ideation. EMP1 confirmed there was no documentation a registered nurse completed MR4's suicide risk assessment on October 6 or 7, 2021.

Review on October 14, 2021, of MR6 revealed MR6 was admitted to the facility on October 6, 2021, for suicidal ideation. There was no documentation a registered nurse completed MR6's suicidal risk assessment on October 6 or 7, 2021.

Interview on October 14, 2021, with EMP1, at approximately 0915, confirmed MR6 was admitted to the facility on October 6, 2021, for suicidal ideation. EMP1 confirmed there was no documentation a registered nurse completed MR6's suicide risk assessment on October 6 or 7, 2021.

Review on October 14, 2021, of MR7 revealed MR7 was admitted to the facility on October 6, 2021, for treatment of a mental illness. There was no documentation a registered nurse completed MR7's suicidal risk assessment on October 6 or 7, 2021.

Interview on October 14, 2021, with EMP1, at approximately 0920, confirmed MR7 was admitted to the facility on October 6, 2021, for suicidal ideation. EMP1 confirmed there was no documentation a registered nurse completed MR7's suicide risk assessment on October 6 or 7, 2021.

Review on October 14, 2021, of MR8 revealed MR8 was admitted to the facility on October 6, 2021, for suicidal ideation. There was no documentation a registered nurse completed MR8's suicidal risk assessment on October 6 or 7, 2021.

Interview on October 14, 2021, with EMP1, at approximately 0925, confirmed MR8 was admitted to the facility on October 6, 2021, for suicidal ideation. EMP1 confirmed there was no documentation a registered nurse completed MR8's suicide risk assessment on October 6 or 7, 2021.

Cross reference
482.13 Patient Rights
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23(b)(3) Rn Supervision of Nursing Care

Based on review of facility documents, medical records (MR), observations, and staff interview (EMP) it was determined the facility failed to ensure registered nurses maintained a safe patient care environment for six of eight patients observed (MR1, MR2, MR4, MR6, MR7, and MR8).

Findings:

Review on October 14, 2021, of the facility position description, "Registered Nurse / Graduate Nurse Emergency Services Clinical Services [Facility Name]," last revised April 2018 revealed "... Position Purpose The Emergency Services Registered Nurse/Graduate Nurse consistently performs his/her duties demonstrating an understanding of the essential job functions as reflected in the Emergency Services Registered Nurse/Graduate Nurse job description, department and hospital policies, and regulatory guidelines. Provide direct professional nursing care for assigned patients while maintaining a safe patient care environment. Responsible for directing and coordinating all nursing care based on established clinical nursing practice. Promote the health and well-being of the patient and significant other through the care continuum utilizing the nursing process. ... Experience/Specialized Skills/Aptitudes Managerial skills, clinical expertise, clerical accuracy, communication skills, listening abilities, independent thinking/sound judgment; ability to deal with stress, able to react to emergency and crisis situations. Clinical, managerial, problem-solving and teaching skills. Independent thinker, ability to make sound judgements and commitment to quality care. Pharmacology, aseptic technique, teaching skills, documentation Licenses/Certificate: ... Safe Crisis Management is required and must be completed by end of orientation period. ... General Duties ... 2 Demonstrate responsible decision making in planning, providing and delegating care based upon assessment 3 Communicate effectively with patients, families, peers, staff supervisors, physicians and administrators. ... 5 Utilize the chain of command ... 7 Maintain a safe environment for patients/staff ... 17 Demonstrate leadership skills/charge responsibilities-covers ER techs and NAs, assigns patient care appropriately, assigns patient beds appropriately ... 31 Demonstrate ability to care for the Behavioral Health/Detox patient - management of patient and appropriate referral of Behavioral Health/Detox patient, medical management of overdose (drug/alcohol). Utilized deescalating techniques and proper restraint process that insures [sic] the safety of the patient and staff ..."

Review on October 14, 2021, of facility policy, "Suicide Precautions," revised August 2020, revealed "Purpose: To outline a mechanism for observation and protection of patients who are assessed to be at risk for suicide, or have expressed suicidal ideations. Policy: 1. A physician's order must be obtained for suicide precautions and a psychiatric consult obtained. 2. Suicide precautions must be re-ordered daily. 3. A patient monitor is assigned until the patient is either transferred to an appropriate facility or is determined to be no longer at risk and discontinued. ...11. The patient monitor must be an employee/contractor of the hospital and must have attended the patient monitoring class provided by the Professional Development Department and have current CPR certification. ...13. The patient monitor is to be located within line of sight, inside the doorway and in direct proximity of the patient. If the patient is in a hallway bed, the patient monitor is to be seated at the foot of the patient's bed (beyond arm's length but in direct proximity of the patient). 14. The patient monitor will report any potentially unsafe behaviors to the assigned nurse. 15. The patient monitor must accompany the patient at all times. 16. While utilizing the bathroom, the door must remain ajar and the patient monitor must keep the patient in sight at all times. 17. The patient monitor is to remain with the patient when visitors are present. 18. The patient monitor may not leave the room of the patient until they are relieved. 20. The patient monitor or other hospital personnel must document patient observation checks every 15 minutes on the Patient Observer Monitoring Checklist Form ...21. The nurse assigned should review the documented observations made by the patient monitor each shift. ..."

Review on October 13, 2021, of video surveillance from October 6, 2021, at 1523 revealed MR1's 1:1 patient monitor walked down the ED hallway away from MR1 leaving MR1 with a family member and did not return. Video surveillance from October 6, 2021, at 1538 revealed a new 1:1 patient monitor arrived at MR1's ED room.

Interview on October 13, 2021, with EMP3, at approximately 1500 confirmed video surveillance from October 6, 2021, revealed MR1 was left with a family member and no 1:1 patient monitor from 1523 to 1538.

Interview on October 13, 2021, with EMP1, at approximately 1505 confirmed it was the registered nurse's responsibility to ensure the 1:1 staff remained with the patient.

Review on October 13, 2021, of video surveillance from October 6, 2021, at 1526 revealed MR2 with a family member at bedside, 1:1 staff behind the nurses' station with a registered nurse.

Interview on October 13, 2021, with EMP3, at approximately 1400 confirmed video surveillance from October 6, 2021, at 1526 revealed MR2 with a family member at bedside and 1:1 staff behind the nurses' station. EMP3 confirmed the registered nurse was also behind the nurses' station.

Interview on October 13, 2021, with EMP1, at approximately 1405 confirmed it was the registered nurse's responsibility to ensure the 1:1 staff remained with the patient.

Review on October 13, 2021, of video surveillance from October 6, 2021, at 1527 revealed MR4 in a room and no 1:1 continuous observation sitter.

Interview on October 13, 2021, with EMP3, at approximately 1410 confirmed video surveillance from October 6, 2021, at 1527 revealed MR4 in a room and did not have a continuous 1:1 observation sitter.

Interview on October 13, 2021, with EMP1, at approximately 1415 confirmed it was the registered nurse's responsibility to ensure the 1:1 staff remained with the patient.

Review on October 13, 2021, of video surveillance from October 6, 2021, at 1528 revealed MR6 in a room and no continuous 1:1 observation sitter.

Interview on October 13, 2021, with EMP3, at approximately 1420 confirmed video surveillance from October 6, 2021, at 1528 revealed MR6 in a room and no continuous 1:1 observation sitter.

Interview on October 13, 2021, with EMP1, at approximately 1425 confirmed it was the registered nurse's responsibility to ensure the 1:1 staff remained with the patient.

Review on October 13, 2021, of video surveillance from October 6, 2021, at 1529 revealed MR7 in a room and no continuous 1:1 observation sitter.

Interview on October 13, 2021, with EMP3, at approximately 1430 confirmed video surveillance from October 6, 2021, at 1529 revealed MR7 in a room and no continuous 1:1 observation sitter.

Interview on October 13, 2021, with EMP1, at approximately 1435 confirmed it was the registered nurse's responsibility to ensure the 1:1 staff remained with the patient.

Review on October 13, 2021, of video surveillance from October 6, 2021, at 1530 revealed MR8 in a room with a visitor and no continuous 1:1 observation sitter.

Interview on October 13, 2021, with EMP3, at approximately 1435 confirmed video surveillance from October 6, 2021, at 1530 revealed MR8 in a room with a visitor and no continuous 1:1 observation sitter.

Interview on October 13, 2021, with EMP1, at approximately 1425 confirmed it was the registered nurse's responsibility to ensure the 1:1 staff remained with the patient.

Review on October 13, 2021, of video surveillance from October 6, 2021, at approximately 15:30 revealed three 1:1 patient monitor staff standing and talking to a registered nurse at the nurses' stations in the locked crisis unit within the Emergency Department.

Review on October 13, 2021, of the facility document, "[Facility Name] Sitter Log," dated October 6, 2021, revealed PF1, PF2, and PF3, were assigned to 1:1 observations in the locked crisis unit at 15:30.

Interview on October 13, 2021, with EMP2, at approximately 1500, confirmed PF1, PF2, and PF3 were assigned to 1:1 patient observations on October 6, 2021. EMP2 confirmed PF1, PF2, and PF3 were observed on video surveillance standing at the nurses' station talking to a registered nurse. EMP2 confirmed PF1, PF2, and PF3 were observed not continuously monitoring their assigned patients.

Cross reference
482.13 Patient Rights
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 (a) Organization of Nursing Services