HospitalInspections.org

Based on clinical record review, document review and staff interviews it was determined the facility failed to ensure Registered Nurse #1 provide patient care in a safe setting following facility policy and in accordance with applicable State law and failed to provide care to meet the needs of the patient. This failure was identified in one (1) out of twenty (20) patient record reviews (patient #10). These findings have the potential to place all patients at risk for serious injury. (See tags C 1006 and C 1046).

Based on clinical record review, document review and staff interviews, it was determined the facility failed to ensure Registered Nurse (RN) #1 provide patient care in a safe setting following facility policy and in accordance with applicable state law. This failure was identified in one (1) out of twenty (20) patient record reviews (patient #10). These findings have the potential to place all patients at risk for serious injury.

Findings include:

1. A review of patient #10's emergency department (ED) clinical record revealed a nursing note by RN #1 dated 04/19/21 at 7:52 p.m. states in part: "Suicide Screening: Have you wished you were dead or wished you could go to sleep and not wake up? Yes. Have you actually had any thoughts of killing yourself? Yes. Have you been thinking about how you might do this? Yes. Have you had these thoughts and had some intention of acting on them? Yes: Physician notified, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Yes, Physician notified, have you ever done anything, started to do anything, or prepared to do anything to end your life? Within the past 3 (three) months? Yes;" RN #1's documented nursing notes at 7:54 p.m. states in part: "Presentation: ... Patient states that she wishes that she was dead and that she tries to kill herself every day. Patient reports today she was wanting to go to a remote location in the woods and drive off a cliff. ... ." A documented nursing assessment at 8:22 p.m. stating in part: "Patient has become combative and unapproachable. Patient has pulled out her IV (intravenous access tube) and is screaming at hospital staff. ...."

2. A review of patient #10's ED clinical record revealed "Physician Documentation" by physician #1 dated 04/19/21 at 7:56 p.m. states in part: "Patient ... suicidal, not cooperative with history or with exam, will check labs, consult with psych." Physician #1 documented on 04/19/21 at 8:45 p.m., states in part: "Patient eloped from the ED, she was aggressive, verbally and physically toward staff, police contacted." A physician note documented on 04/20/21 at 6:45 a.m. states in part: "8:55 p.m. Patient return to the emergency department, patient initially was cooperative and then she became belligerent and verbally abusive and agitated again. ..."

3. A review of patient #10's ED clinical record revealed a "Nursing Note" by RN #2 dated 04/20/21 at 12:29 p.m. states in part: "Social work contacted, Social worker #1, and she will be coming up at 3 (three) to evaluate patient and write a safety contract with the patient."

4. A review of patient #10's ED clinical record from 04/19/21 through 04/20/21 revealed there were no orders documented for one (1) to one (1) (1:1) monitoring and no nursing documentation of the patient having continuous monitoring for suicide prevention.

5. A review of hospital policy, "Suicide Risk Assessment and Suicide Prevention in the Outpatient Behavioral Health Setting," revised 02/2020, states in part: "In the event a patient reports feeling suicidal with a reasonable plan, intention, access and means, the therapist or a designated staff person will stay with the patient. The medical director or responsible physician will be notified/consulted for guidance ... In the event a patient is assessed to have developed acute safety risks or determined to be at risk for suicide, the patient is not left alone by staff. The physician is notified for direction or additional interventions which may include hospitalization. All staff members are trained to recognize the risk factors for suicide, protective factors for suicide, and the behaviors that may signal an impending suicide attempt."

6. A review of the "Position Description" of the "Registered Nurse (Emergency Department)," undated, states in part: "Emergency Department nurses are responsible for the care of patients that suffer from traumatic, medical and mental illnesses that span the health continuum. They work closely with physicians, emergency medical services and ancillary departments to ensure that safe, timely, and compassionate care are provided to the patients served. ... Scope of Responsibilities: ... Update all patient information in EMR (electronic medical records)."

7. An interview was conducted with the Chief Nursing Officer on 04/21/21 at approximately 1:14 p.m. When notified of a lack of documentation for 1:1 monitoring of patient #10 with suicidal thoughts with a plan and having eloped from the ED, she stated in part: "Someone should have stayed with the patient and it should have been documented."

8. An interview was conducted with Physician #1 on 04/21/21 at approximately 2:25 p.m. When asked if patient #10 was ordered a 1:1 he stated in part: "When she came in, she did express suicide ideations, but she was intoxicated. The patient was loud, insisted on leaving. She left out of the door. A few minutes later then she came in. The police were called. She didn't go to town. She came back before the police came. She left through the door; staff tried to talk with her. I don't know what happened outside. ... The emergency medical service and registration went with her outside the door." When notified there were no orders or documentation of 1:1 monitoring he stated in part: "The chart doesn't reflect what we did. ... The documented order did not come through. It is not reflected in the documentation. Normally when I am there, patients with suicide are ordered a 1:1 and we put someone with them."

Based on clinical record review, document review and staff interviews it was determined the facility failed to ensure Registered Nurse (RN) #1 provide nursing care in accordance with the needs of the patient following facility policy. This failure was identified in one (1) out of twenty (20) patient record reviews (patient #10). These findings have the potential to place all patients at risk for serious injury.

Findings include:

1. A review of patient #10's emergency department (ED) clinical record revealed a nursing note by RN #1 dated 04/19/21 at 7:52 p.m. states in part: "Suicide Screening: Have you wished you were dead or wished you could go to sleep and not wake up? Yes. Have you actually had any thoughts of killing yourself? Yes. Have you been thinking about how you might do this? Yes. Have you had these thoughts and had some intention of acting on them? Yes: Physician notified, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Yes, Physician notified, have you ever done anything, started to do anything, or prepared to do anything to end your life? Within the past 3 (three) months? Yes;" RN #1's documented nursing notes at 7:54 p.m. states in part: "Presentation: ... Patient states that she wishes that she was dead and that she tries to kill herself every day. Patient reports today she was wanting to go to a remote location in the woods and drive off a cliff. ... ." A documented nursing assessment at 8:22 p.m. stating in part: "Patient has become combative and unapproachable. Patient has pulled out her IV (intravenous access tube) and is screaming at hospital staff. ...."

2. A review of patient #10's ED clinical record revealed "Physician Documentation" by physician #1 dated 04/19/21 at 7:56 p.m. states in part: "Patient ... suicidal, not cooperative with history or with exam, will check labs, consult with psych." Physician #1 documented on 04/19/21 at 8:45 p.m., states in part: "Patient eloped from the ED, she was aggressive, verbally and physically toward staff, police contacted." A physician note documented on 04/20/21 at 6:45 a.m. states in part: "8:55 p.m. Patient return to the emergency department, patient initially was cooperative and then she became belligerent and verbally abusive and agitated again. ..."

3. A review of patient #10's ED clinical record revealed a "Nursing Note" by RN #2 dated 04/20/21 at 12:29 p.m. states in part: "Social work contacted, Social worker #1, and she will be coming up at 3 (three) to evaluate patient and write a safety contract with the patient."

4. A review of patient #10's ED clinical record from 04/19/21 through 04/20/21 revealed there were no orders documented for one (1) to one (1) (1:1) monitoring and no nursing documentation of the patient having continuous monitoring for suicide prevention.

5. A review of hospital policy, "Suicide Risk Assessment and Suicide Prevention in the Outpatient Behavioral Health Setting," revised 02/2020, states in part: "In the event a patient reports feeling suicidal with a reasonable plan, intention, access and means, the therapist or a designated staff person will stay with the patient. The medical director or responsible physician will be notified/consulted for guidance ... In the event a patient is assessed to have developed acute safety risks or determined to be at risk for suicide, the patient is not left alone by staff. The physician is notified for direction or additional interventions which may include hospitalization. All staff members are trained to recognize the risk factors for suicide, protective factors for suicide, and the behaviors that may signal an impending suicide attempt."

6. A review of the "Position Description" of the "Registered Nurse (Emergency Department)," undated, states in part: "Emergency Department nurses are responsible for the care of patients that suffer from traumatic, medical and mental illnesses that span the health continuum. They work closely with physicians, emergency medical services and ancillary departments to ensure that safe, timely, and compassionate care are provided to the patients served. ... Scope of Responsibilities: ... Update all patient information in EMR (electronic medical records)."

7. An interview was conducted with the Chief Nursing Officer on 04/21/21 at approximately 1:14 p.m. When notified of a lack of documentation for 1:1 monitoring of patient #10 with suicidal thoughts with a plan and having eloped from the ED, she stated in part: "Someone should have stayed with the patient and it should have been documented."

8. An interview was conducted with Physician #1 on 04/21/21 at approximately 2:25 p.m. When asked if patient #10 was ordered a 1:1 he stated in part: "When she came in, she did express suicide ideations, but she was intoxicated. The patient was loud, insisted on leaving. She left out of the door. A few minutes later then she came in. The police were called. She didn't go to town. She came back before the police came. She left through the door; staff tried to talk with her. I don't know what happened outside. ... The emergency medical service and registration went with her outside the door." When notified there were no orders or documentation of 1:1 monitoring he stated in part: "The chart doesn't reflect what we did. ... The documented order did not come through. It is not reflected in the documentation. Normally when I am there, patients with suicide are ordered a 1:1 and we put someone with them."

Based on clinical record review, document review and staff interviews it was determined the facility failed to ensure Registered Nurse (RN) #1 maintain and document a complete and accurate clinical record. This failure was identified in one (1) out of twenty (20) patient record reviews (patient #10). These findings have the potential to place all patients at risk for serious injury.

Findings include:

1. A review of patient #10's emergency department (ED) clinical record revealed a nursing note by RN #1 dated 04/19/21 at 7:52 p.m. states in part: "Suicide Screening: Have you wished you were dead or wished you could go to sleep and not wake up? Yes. Have you actually had any thoughts of killing yourself? Yes. Have you been thinking about how you might do this? Yes. Have you had these thoughts and had some intention of acting on them? Yes: Physician notified, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Yes, Physician notified, have you ever done anything, started to do anything, or prepared to do anything to end your life? Within the past 3 (three) months? Yes;" RN #1's documented nursing notes at 7:54 p.m. states in part: "Presentation: ... Patient states that she wishes that she was dead and that she tries to kill herself every day. Patient reports today she was wanting to go to a remote location in the woods and drive off a cliff. ... ." A documented nursing assessment at 8:22 p.m. stating in part: "Patient has become combative and unapproachable. Patient has pulled out her IV (intravenous access tube) and is screaming at hospital staff. ...."

2. A review of patient #10's ED clinical record revealed "Physician Documentation" by physician #1 dated 04/19/21 at 7:56 p.m. states in part: "Patient ... suicidal, not cooperative with history or with exam, will check labs, consult with psych." Physician #1 documented on 04/19/21 at 8:45 p.m., states in part: "Patient eloped from the ED, she was aggressive, verbally and physically toward staff, police contacted." A physician note documented on 04/20/21 at 6:45 a.m. states in part: "8:55 p.m. Patient return to the emergency department, patient initially was cooperative and then she became belligerent and verbally abusive and agitated again. ..."

3. A review of patient #10's ED clinical record revealed a "Nursing Note" by RN #2 dated 04/20/21 at 12:29 p.m. states in part: "Social work contacted, Social worker #1, and she will be coming up at 3 (three) to evaluate patient and write a safety contract with the patient."

4. A review of patient #10's ED clinical record from 04/19/21 through 04/20/21 revealed there were no orders documented for one (1) to one (1) (1:1) monitoring and no nursing documentation of the patient having continuous monitoring for suicide prevention.

5. A review of hospital policy, "Suicide Risk Assessment and Suicide Prevention in the Outpatient Behavioral Health Setting," revised 02/2020, states in part: "In the event a patient reports feeling suicidal with a reasonable plan, intention, access and means, the therapist or a designated staff person will stay with the patient. The medical director or responsible physician will be notified/consulted for guidance ... In the event a patient is assessed to have developed acute safety risks or determined to be at risk for suicide, the patient is not left alone by staff. The physician is notified for direction or additional interventions which may include hospitalization. All staff members are trained to recognize the risk factors for suicide, protective factors for suicide, and the behaviors that may signal an impending suicide attempt."

6. A review of the "Position Description" of the "Registered Nurse (Emergency Department)," undated, states in part: "Emergency Department nurses are responsible for the care of patients that suffer from traumatic, medical and mental illnesses that span the health continuum. They work closely with physicians, emergency medical services and ancillary departments to ensure that safe, timely, and compassionate care are provided to the patients served. ... Scope of Responsibilities: ... Update all patient information in EMR (electronic medical records)."

7. An interview was conducted with the Chief Nursing Officer on 04/21/21 at approximately 1:14 p.m. When notified of a lack of documentation for 1:1 monitoring of patient #10 with suicidal thoughts with a plan and having eloped from the ED, she stated in part: "Someone should have stayed with the patient and it should have been documented."

8. An interview was conducted with Physician #1 on 04/21/21 at approximately 2:25 p.m. When asked if patient #10 was ordered a 1:1 he stated in part: "When she came in, she did express suicide ideations, but she was intoxicated. The patient was loud, insisted on leaving. She left out of the door. A few minutes later then she came in. The police were called. She didn't go to town. She came back before the police came. She left through the door; staff tried to talk with her. I don't know what happened outside. ... The emergency medical service and registration went with her outside the door." When notified there were no orders or documentation of 1:1 monitoring he stated in part: "The chart doesn't reflect what we did. ... The documented order did not come through. It is not reflected in the documentation. Normally when I am there, patients with suicide are ordered a 1:1 and we put someone with them."