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Based on documentation review, interviews and observations of Emergency Department (ED) patients, Immediate Jeopardy was determined because the Hospital failed to ensure that:
1.) items posing potential danger to a suicidal patient were removed from 1 of 8 ED behavioral health patients deemed suicidal in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting" resulting in a drug overdose.
2.) 6 of 8 ED behavioral health patients deemed suicidal were supervised in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting".
3.) a physician or other licensed independent practitioner's order was obtained for the application of 1 of 3 ED behavioral health emergency physical restraint applications.
4.) a patient in simultaneous restraint and seclusion (Patient #1) was continually monitored face-to-face or by both video and audio equipment.

Please refer to Tags A-0144, A-0168 and A-0183 for details.

Based on documentation review, interviews and observations of Emergency Department (ED) patients, it was determined that the Hospital failed to ensure that:
1.) items posing potential danger to a suicidal patient were removed from 1 of 8 ED behavioral health patients deemed suicidal (Patient #2) in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting" resulting in a drug overdose.
2.) 6 of 8 ED behavioral health patients deemed suicidal (Patient's #1, #2, #5, #6, #7 and #8) were not supervised in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting".

Findings include:

The Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting" indicated that patients expressing suicidal ideation are to be placed on constant visual observation, within arm's length of a staff member, at all times (including when the patient is in the bathroom). The physician is to order the observation and a psychiatric consultation. The policy/procedure also indicated that items posing a potential danger to the patient were to be removed from the patient and environment.

PATIENT #1:

An Ambulance Trip Report dated 6/23/12 indicated that Emergency Medical Service (EMS) personnel were summoned at 2:30 A.M. because Patient #1 was found intoxicated and with facial trauma by police. Patient #1 was combative and stated that he/she was going to kill himself/herself. Patient #1 was transported to the Hospital's ED.

ED Triage documentation dated 6/23/12 at 3:14 A.M. indicated that Patient #1 was agitated and anxious. Patient #1 answered no when asked if he/she had tried to hurt himself/herself and denied doing so in the past.

A Confidential Patient Observation/Restraint Form dated 6/23/12 indicated that Patient #1 was placed on Observation at 3:15 A.M. by ED Registered Nurse (RN) #1 because Patient #1 exhibited serious suicidal ideation and/or behavior. Documentation on the Form indicated that the observation was to be provided by Security staff and the security officer was to remain outside the room. Patient #1 could use the bathroom but if he/she attempted to leave the ED, he/she was to be physically restrained and ED staff were to be notified. The documentation also indicated that the room was cleared of all possible hazards, Patient #1 was searched and placed in a hospital gown, and Patient #1's belongings were removed from the room and secured.

ED Physician documentation dated 6/23/12 indicated that Patient #1 was evaluated by ED Physician #1 at 3:20 A.M. Patient #1 was awake and angry and indicated that he/she wanted to die. Patient #1 had bruising on the nose and forehead and a small laceration through the right eyebrow. ED Physician #1 ordered diagnostic and treatment interventions and completed an Application for and Authorization of Temporary Involuntary Hospitalization (commonly known as a Section 12a; a form that when properly completed mandates an involuntary hospitalization until a formal psychiatric evaluation is completed). The Section 12a Form indicated that Patient #1 was at substantial risk of physical harm secondary to suicidal ideation and impaired judgement.

A review of Patient #1's ED Physician Orders did not evidence an order for a specific type or level of Patient Observation.

ED Physician documentation dated 6/23/12 indicated that Patient #1 was diagnosed with alcohol intoxication, facial fractures and suicidal ideation. Patient #1 was medically cleared for a psychiatric evaluation at 7:00 A.M.

ED Nursing documentation dated 6/23/12 indicated that a clinician from the Contracted Psychiatric Service tried to evaluate Patient #1 sometime prior to 10:30 A.M., but Patient #1 was too sleepy. At 10:30 A.M., Patient #1 asked for his/her underwear and a security officer provided his/her belongings bag. Patient #1 put on underwear and a pair of shorts and proceeded to leave the ED. Patient #1 was ordered to stop, but took flight. Patient #1 was apprehended by a security officer and put in 4-point leather restraints. Patient #1 was evaluated by ED Physician #2 and administered intramuscular Ativan (an anti-anxiety/sedative medication).

Patient #1's 6/23/12 Confidential Patient Observation/Restraint Form was not updated to indicate that he/she was a significant flight risk.

ED Nursing documentation dated 6/23/12 indicated that all of Patient #1's restraints were removed by 11:20 A.M.

A Psychiatric Assessment dated 6/23/12 indicated that Patient #1 was evaluated by the Contracted Psychiatric Service at 12:20 P.M. Patient #1 was cooperative and indicated that he/she wanted to go home. The psychiatric clinician assessed Patient #1 to be at a low risk for suicide and discussed discharge planning with an (un-named) ED physician. The ED physician indicated that he wanted Patient #1 admitted for safety and containment. The Section 12a was continued and an inpatient psychiatric bed search was initiated.

ED Nursing documentation dated 6/23/12 indicated that Patient #1 eloped from the ED at 6:24 P.M. The documentation also indicated that security staff were busy with another behavioral health patient at the time of Patient #1's elopement.

ED Nursing documentation dated 6/23/12 indicated that Patient #1 was located by local police and returned to the ED under a Section 12a at 8:43 P.M. Patient #1 was unharmed.

The Hospital's Risk Manager was interviewed in person on 7/17/12 at 8:20 A.M. The Risk Manager said a Hospital Internal Investigation was conducted regarding Patient #1's 6/23/12 ED care/elopement.

A review of the Hospital Internal Investigation revealed it determined that ED security staff/behavioral health patient ratios were often high and that this made effective constant observation impossible. The Investigation also determined that there were hand-off communication issues related to Patient #1's flight risk. A Corrective Action Plan was not developed/implemented.

The Hospital Internal Investigation did not determine that: a.) Patient #1 was not supervised in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting", b.) ED Physician #1 did not order a specific type or level of observation for Patient #1 and c.) the security officer did not consult with Patient #1's nurse regarding giving Patient #1 his/her belongings bag.


PATIENT #2:

ED Triage documentation dated 6/21/12 indicated that Patient #2 was brought to the ED by EMS personnel and police at 10:59 P.M. because he/she had been drinking alcohol and fell sustaining an ankle injury. The police indicated that Patient #2 may have also been using cocaine and that he/she had texted suicidal messages to a family member. Patient #2 answered no when asked if he/she had tried to hurt himself/herself and denied doing so in the past.

An ED Nursing Assessment dated 6/21/12 indicated that Patient #2 had a history of anxiety and depression.

The ED RN assigned to Patient #2 (ED RN #1) was interviewed in person on 7/17/12 at 3:00 P.M. ED RN #1 said that she questioned Patient #2 about being suicidal and Patient #2 denied suicidal ideation. ED RN #1 said that Patient #2 indicated that he/she was having marital problems and following an altercation with his/her spouse, he/she texted a family member and said something like he/she was ready to kill himself/herself. ED RN #1 said that Patient #2 indicated that he/she was not serious about killing himself/herself and that he/she would never do such a thing as he/she had 3 young children.

ED RN #1 reported getting Patient #2 settled and giving a verbal report regarding Patient #2 to ED RN #2.

Documentation completed by ED Physician #3 on 6/21/12 (time not indicated) indicated that Patient #2's spouse and sibling said that Patient #2 had been exhibiting self-injurious behaviors. ED Physician #3 ordered diagnostic procedures and completed a Section 12a. The Section 12a was timed 11:35 P.M. and indicated that Patient #2 was at substantial risk of physical harm secondary to suicidal ideation.

A review of Patient #2's ED Physician Orders did not evidence an order for a specific type or level of Patient Observation.

Laboratory testing dated 6/22/12 indicated Patient #2 tested positive for cocaine (a narcotic) and benzodiazepines (a class of anti-anxiety/sedative medications).

ED RN #2 was interviewed in person on 7/18/12 at 8:00 A.M. ED RN #2 said that she received a verbal report regarding Patient #2 from ED RN #1 around 11:00 P.M. ED RN #2 said that ED RN #1 indicated Patient #2 arrived in the ED under a Section 12a, in police custody with an ankle injury and possible drug overdose.

ED RN #2 said that shortly after getting report from ED RN #1, she observed Patient #2 standing at the end of his/her stretcher in the Behavioral Health Treatment Area (BHTA), looking like he/she might be getting ready to leave. ED RN #2 reported asking the security officer covering the BHTA (Security Officer #1) if he was watching Patient #2. ED RN #2 said that Security Officer #1 indicated that Patient #2 was not on a Security Watch. ED RN #2 reported informing Security Officer #1 that Patient #2 needed to be on a Security Watch and filling out a Confidential Patient Observation/Restraint Form.

A Confidential Patient Observation/Restraint Form dated 6/22/12 indicated that Patient #2 was placed on Observation at 12:45 A.M. by ED RN #2 because Patient #2 was a significant flight risk. Documentation on the Form indicated that the observation was to be provided by Security staff and the security officer was to remain outside the room. Patient #2 could use the bathroom and was not to be restrained if he/she attempted to leave. The documentation also indicated that the room was cleared of all possible hazards, Patient #2 was searched and placed in a hospital gown, and Patient #2's belongings were removed and secured.

ED RN #2 said that Patient #2 was wearing his/her clothes when she filled out the Confidential Patient Observation/Restraint Form. ED RN #2 said that Security Officer #1 told Patient #2 that he/she needed to change into hospital scrubs. ED RN #2 said that Patient #2 indicated that he/she did not want to change into the scrubs and wanted to talk with his/her spouse. ED RN #2 said the Spouse was in the ED Waiting Room and she summoned him/her for Patient #2.

ED RN #2 said that she completed the 6/22/12 Confidential Patient Observation/Restraint Form without verifying that Patient #2's belongings were removed and secured. ED RN #2 said that she did this because she thought Patient #2 had arrived on a Section 12a and ED RN #1 had secured the belongings and forgot to document. ED RN #2 also said that she knew Patient #2 was thought to be suicidal and she should have indicated this on the Confidential Patient Observation/Restraint Form.

ED RN #2 said that Patient #2 spoke with his/her spouse twice and then went into the BHTA bathroom to put on scrubs.

Documentation completed by ED RN #2 on 6/22/12 indicated that at 2:15 A.M., a security officer reported that Patient #2 went into the bathroom with a personal bag and shortly after emerging, had slurred speech.

Documentation completed by ED Physician #3 on 6/22/12 indicated that Patient #2's slurred speech was evaluated and determined to be secondary to the ingestion of multiple tablets of Xanax (a benzodiazepine medication) in the bathroom. Emergency treatment interventions were provided. Patient #2 required intubation (the insertion of a tube into the airway to facilitate breathing) and mechanical ventilation (a breathing machine) for respiratory depression. Patient #2 was transferred to the Intensive Care Unit (ICU).

ICU documentation dated 6/23/12 indicated that Patient #2 was extubated (the breathing tube and mechanical ventilation were discontinued) on 6/22/12 and transferred to a General Medical Unit in stable condition on 6/23/12. A Psychiatric Unit transfer was planned.

The Hospital's Risk Manager said a Hospital Internal Investigation was conducted regarding Patient #2's 6/21/12-6/22/12 ED care/overdose.

A review of the Hospital Internal Investigation revealed that it determined that items posing potential danger to a suicidal patient were not removed from Patient #2 and that there were several hand-off communication issues related to Patient #2's care. A Corrective Action Plan was not developed/implemented.

The Hospital Internal Investigation did not determine that Patient #2 was not supervised in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting" and/or that ED Physician #3 did not order a specific type or level of observation for Patient #2.


PATIENTS #5, #6, #7 and #8:

A Tour of the ED conducted on 7/16/12 at 8:15 A.M. revealed a large Department with 25+ treatment areas including a 4-room BHTA along a hallway off the Main ED. BHTA rooms #2 and #4 and the BHTA bathroom were on the left side of the hallway and BHTA rooms #1 and #3 were on the right side. All of the BHTA rooms had doors and were "safe rooms" (rooms without equipment that could be hazardous to impaired or suicidal patients). BHTA rooms #2 and #4 had observation windows. Security Officer #2 was posted in the BHTA. Security Officer #2 was sitting between BHTA rooms #2 and #4, near the BHTA bathroom, facing the Main ED.

Continued tour of the ED revealed there were 5 patients in the BHTA (Patients #3, #4, #5 and #6) and 1 behavioral health patient in the Main ED (Patient #8). One of the patients in the BHTA was on a stretcher in the hallway and the other 4 patients were in BHTA rooms #1-#4.

During the tour of the BHTA, the ED Nurse Manager asked Security Officer #2 if someone was in the bathroom and Security Officer #2 indicated that he did not know.


PATIENT #5:

A Section 12a Form completed on 7/14/12 (not timed) indicated that Patient #5 was at substantial risk of physical harm secondary to suicidal ideation.

A Psychiatric Assessment dated 7/14/12 at 2:30 P.M. indicated that Patient #5 was at high risk for suicide.

During the 7/16/12 ED tour, Patient #5 was observed to be in BHTA room #1. The door to the room was open approximately 2 inches and the room was dark. Patient #5 was not on constant visual observation within arm's length of a staff member. Security Officer #2 could not see Patient #5 from where he was sitting.


PATIENT #6:

A Section 12a Form completed on 7/15/12 at 1:00 P.M. indicated that Patient #6 was at substantial risk of physical harm secondary to suicidal ideation.

A Psychiatric Assessment dated 7/15/12 at 7:21 P.M. indicated that Patient #6 was at high risk for suicide.

During the 7/16/12 ED tour, Patient #6 was observed to be in BHTA room #4. Patient #5 was not on constant visual observation within arm's length of a staff member.


PATIENT #7:

A Section 12a Form completed on 7/15/12 at 4:15 P.M. indicated that Patient #7 was at substantial risk of physical harm secondary to suicidal ideation.

A Psychiatric Assessment dated 7/15/12 at 5:23 P.M. indicated that Patient #7 was at moderate risk for suicide.

During the 7/16/12 ED tour, Patient #7 was observed to be in BHTA room #3. The door to the room was partially closed. Patient #7 was not on constant visual observation within arm's length of a staff member. Security Officer #2 could not see Patient #7 from where he was sitting.


PATIENT #8:

A Section 12a Form completed on 7/16/12 at 1:25 A.M. indicated that Patient #8 was at substantial risk of physical harm secondary to suicidal ideation.

ED physician documentation dated 7/16/12 indicated that a Psychiatric Assessment was ordered for Patient #8.

During the 7/16/12 ED tour, Patient #8 was observed to be in Main ED treatment room #3. The large glass door to the room was closed and the room was darkened. A mental health counselor was sitting in a chair outside of the room and across the hallway. Patient #8 was not on constant visual observation within arm's length of a staff member.

Following the 7/16/12 ED tour, the Surveyors informed the Hospital System's Regional Director of Quality & Patient Safety and the Hospital's Director of Quality of concerns regarding the Hospital Internal Investigations related to Patients #1 and #2 and the monitoring of suicidal patients in the ED. Within a short period of time, all patients deemed suicidal in all non-psychiatric Hospital settings were placed on one-to-one observation within arm's length of the staff member.

Based on documentation review, it was determined that the Hospital failed to ensure that a physician or other licensed independent practitioner's order was obtained for the application of 1 of 3 Emergency Department (ED) behavioral health emergency physical restraint applications (related to Patient #1).

Findings include:

Please see Tag A-0144 for information regarding Patient #1.

An Application for and Authorization of Temporary Involuntary Hospitalization (commonly known as a Section 12a; a form that when properly completed mandates an involuntary hospitalization until a formal psychiatric evaluation is completed) completed by ED Physician #1 on 6/23/12 at 3:30 A.M. indicated that Patient #1 was at substantial risk of physical harm secondary to suicidal ideation and impaired judgement.

ED Nursing documentation dated 6/23/12 indicated that at 10:30 A.M., Patient #1 asked for his/her underwear and a security officer provided his/her belongings bag. Patient #1 put on underwear and a pair of shorts and proceeded to leave the ED. Patient #1 was ordered to stop, but took flight. Patient #1 was apprehended by a security officer and put in 4-point leather restraints.

A review of Patient #1's ED Physician Orders did not evidence an order for the 4-point leather restraints.

ED Nursing documentation dated 6/23/12 indicated that Patient #1 was evaluated by ED Physician #2 almost immediately after being placed in the 4-point leather restraints.

A review of the Hospital Internal Investigation related to Patient #1's 6/23/12 ED care/elopement revealed that it identified that there was no written physician or other licensed independent practitioner's order for the emergency behavioral health restraints applied to Patient #1 shortly after 10:30 A.M. on 6/23/12. A Corrective Action Plan was not developed/implemented.

Based on documentation review, it was determined that the Hospital failed to ensure that a patient in simultaneous restraint and seclusion (Patient #1) was continually monitored face-to-face or by both video and audio equipment.

Findings include:

Please see Tags A-0144 and A-0168 for information regarding Patient #1.

An Application for and Authorization of Temporary Involuntary Hospitalization (commonly known as a Section 12a; a form that when properly completed mandates an involuntary hospitalization until a formal psychiatric evaluation is completed) completed by ED Physician #1 on 6/23/12 at 3:30 A.M. indicated that Patient #1 was at substantial risk of physical harm secondary to suicidal ideation and impaired judgement.

Emergency Department (ED) Nursing and Physician Notes, ED Physician Orders, a Restraint Documentation Flow Sheet and a Confidential Patient Observation/Restraint Form dated 6/23/12 indicated that Patient #1 was simultaneously restrained and secluded for 3 periods of time on 6/23/12. The restraint episodes commenced at 3:30 A.M., shortly after 10:30 A.M. and at 8:50 P.M.

ED documentation did not indicate that Patient #1 was on face-to-face (one-to-one) monitoring at any time on 6/23/12.