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Based on document review, observation, and interview, it was determined, the Hospital failed to follow Emergency Department (ED) policies to protect patients with emergency psychiatric conditions. As a result, the Condition of Participation (42 CFR 482.55) Emergency Services was not met. This potentially affects approximately 4 psychiatric patients presenting to the ED each day.

Findings include:

1. The Facility failed to ensure a psychiatric patient, who ignited his clothes on fire, was triaged and monitored in accordance with Hospital policy (A-1104).

The immediate jeopardy (IJ) began on 9/15/16 with the presentation of Pt. #1 to the Emergency Department (ED), his notification to the registration clerk that he was suicidal, followed by instructions from the staff, for Pt. #1 to go and sit in the waiting room. The patient's status was not reported by the clerk to the triage RN or ED physician, and Pt. #1's person and belongings were not searched. Pt. #1 subsequently set himself on fire, suffering "first degree burns to the chest ...singed hair to his legs and abdomen ..blistering to his left wrist, slight blistering on abdomen, small blister on right groin."

The IJ was announced on 09/21/2016 at 4:20 PM, during a meeting, to the Director of Quality (E #1), Chief Operating Officer, Chief Medical Officer, Chief Executive Officer, and 5 additional Hospital Leaders. The immediate jeopardy was not removed by the survey exit date of 09/22/16.

A. Based on document review, observation, and interview, it was determined for 1 of 1 Patient (Pt #1) who presented to the Hospital's Emergency Department (ED) on 9/15/16 with suicidal ideation, the Hospital failed to ensure the Patient was triaged and monitored in accordance with Hospital policy. This resulted in the patient setting his clothes on fire and sustaining first degree burns to the chest, scattered blisters, and singed hair on his body.

Findings included:

1. The Hospital policy entitled "Emergency Department Triage Policy" (reviewed 07/2016) was reviewed on 9/20/16 at approximately 2:00 PM and required, "...The Triage RN will evaluate all patients upon arrival to Emergency Department and determine the urgency of their problem and the appropriate care needed. All patients are assessed and categorized using the Emergency Severity Index Triage Scale. Patients may bypass the triage assessment based on their presenting complaints and at the decision of the Triage nurse. Immediate triage assessment will then be done at the bedside. The Triage RN designates the priority needed into the following categories: 1. ESI I--A patient is at risk of imminent death or could die without immediate intervention... G. All patients will be taken directly back to an open room/bed if one is available. ESI I, II, and III patients take priority when beds are limited... J. The Triage RN maintains awareness of the patient flow in patient access, triage, and waiting room..."

2. The Hospital's policy entitled "Management of Psychiatric Patients" (revised 01/2016) was reviewed on 9/20/16 at approximately 2:15 PM and required, "...It is the purpose of [the Hospital's] Emergency Department to establish guidelines for the management of patients presenting with acute psychiatric illness... C. Any patient with psychiatric disturbances that is being evaluated will be brought to a room and assisted in undressing (REMOVING ALL CLOTHING) immediately... placed in a yellow patient gown... All clothing and belongings will be placed in patient belonging bags, and removed from room, but placed in a secure area..."

3. The Hospital's policy entitled "Management of Suicidal Patients" (revised 05/2015) was reviewed on 9/20/16 at approximately 2:30 PM and required, "...A. All Suicidal Patients...B. The following safety precautions are taken:..one to one suicidal observation. 2. Remove items from patient room to prevent self-harm upon identification of suicidal ideation... Disposition of contraband will be as follows: Alcohol will be sent home or disposed of by the department... Items that must be restricted from the patient's room:... Lighters and matches... Emergency Department: Suicidal patient will be closely monitored by a Registered Nurse (RN)/ Technician assigned or designee..."


4. Pt. #1's clinical record was reviewed on 9/20/16 at 11:00 AM. Pt. #1 was a 39 year old male, seen in the Emergency Department (ED) on 9/15/16 at 10:00 PM, with a complaint of suicidal ideation. Pt. #1's clinical record included, Pt. #1 was seen by a Registration Clerk (E #2) at 10:00 PM.

5. On 9/20/16 at 3:40 PM, an interview was conducted with E #2. E #2 stated she encountered Pt. #1 at the registration desk at 10:00 PM. E #2 stated she asked Pt. #1 why he came to the ED, and Pt. #1 stated, he wanted to kill himself. E #2 affixed an ID wrist band on Pt. #1 and told Pt. #1 to wait in the waiting room. Pt. #1's name and reason for the ED visit were posted on the computer display in the ED treatment area and at the triage desk. However, E #2 stated she did not verbally inform the Triage Nurse (E #3), about Pt. 1. Pt. #1 went and sat in a chair next to the ED treatment area entrance.

6. On 9/21/16 at 7:20 AM, an interview was conducted with the Triage Nurse (E #3). E #3 stated the triage nurse also functions as the charge nurse in the ED. E #3 stated on 9/15/16 when Pt. #1 arrived, E #3 was in ED room 16 triaging and assisting in the care of a deaf and mute female, whose blood pressure could not be obtained and who appeared to be septic. E #3 was not verbally informed of Pt. #1's arrival or presenting complaint. Pt. #1's name and complaint were entered in the computer and displayed on the tracking board.

7. On 9/20/16 at approximately 11:15 AM, a surveillance video of Pt. #1's incident on 9/15/16 was viewed in the Director of Security's Office. At 10:11 PM, Pt. #1 walked into the ED treatment area and up to the nurses' station. E #3 was standing approximately 10 feet away and looked toward Pt. #1 as he waived papers in the air. E #3 was not in the triage area and did not speak to Pt. #1 at this time. An ED Physician (MD #2) appeared to speak to Pt. #1 and pointed in the direction of the waiting room.

At 10:12 PM, a Security Officer (E #5) entered the ED and walked Pt. #1 back to the chair in the waiting area.

At 10:15 PM, Pt. #1 was sitting in the chair, leaned forward and down, reached into his bag. (Due to camera and patient positioning, Pt. #1's actions were not visible while fumbling with the contents of his bag.) Pt. #1 left the waiting room and walked into the ED treatment area with the front of Pt. #1's tank top in a blue blaze of fire. Pt. #1 stopped just inside the doorway to the ED and removed the tank top and pants.

8. Pt. #1's medical screening exam dated 9/15/16 at 10:21 PM, included burn injuries: "first degree burns to the chest ... singed hair to his legs and abdomen ... [at 10:45 PM] blistering to his left wrist, slight blistering on abdomen, small blister on right groin. "

Pt. #1's triage notes, dated 9/15/16 at 11:34 PM, included Pt. #1 was transferred to another Hospital, with a burn unit, on 9/15/16 at 11:39 PM.