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Based on document review, observation, and interview, the facility failed to provide care in a safe setting for 2 of 10 patients (Patient #4 and Patient #9). See tag 144


The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review, observation, and interview, the facility failed to provide care in a safe setting for 2 of 10 patients (Patient #4 and Patient #9).

Findings Include:

1. Facility policy titled "Patient Rights and Responsibilities" no policy number, last revised 06/2022, indicated when you are a patient, you have the right to: retain your personal dignity and privacy, receive care sensitive to your personal feelings and need for bodily privacy, receive care in a safe setting, and to be free from abuse and harassment.

2. Facility policy titled "Suicide Risk Assessment and Precautions", no policy number, last revised 3/2022, indicated patients at risk for suicide require an initial assessment, intensive support, high levels of visual observation, frequent reassessment, and application of protective interventions for their overall emotional and physical well-being; patients with an affirmative response to ANY C-SSRS (Columbia-Suicide Severity Rating Scale) question are considered a suicide risk and suicide precautions should be implemented immediately. Staff roles: Nurse notifies the House Supervisor/bed control to assign a sitter for the patient; places patient in appropriately prepared room; supervises or assigns staff to supervise patient until sitter arrives; assists sitter or delegates to the sitter to assist patient. Sitter maintains 1:1 constant observation of the patient; reports any changes to the nurse.

3. Medical record (MR) review on 09/13/2023 of patient #4 indicated the following:
a. Emergency Department provider note dated 08/16/2023 indicated patient was a high risk for suicide.
b. MR lacked documentation of suicide precautions/close observation implemented.
c. Medical record lacked documentation of personal items list removed from patient.
d. Medical record lacked documentation of nurse notifying house supervisor/bed control of sitter request.
e. Medical record lacked documentation of nurse giving report to sitter.
f. Medical record lacked documentation of 15 (fifteen) minute checks.

4. Medical Record review on 09/13/2023 of patient #9 indicated the following:
a. Triage note dated 08/30/2023 indicated patient was a high risk for suicide.
b. Legal Status 24 Hour Hold Order was placed by medical provider on 08/30/2023.
c. MR lacked documentation of suicide precautions/close observation implemented.
d. Emergency department nurse note dated 08/31/2023 indicated patient walked out of room and was on his/her way outside. Nurse attempted to stop patient before he/she walked out. Nurse was unable to remove IV, blood pressure cuff, oxygen sensor, and stop patient. Nurse and Charge nurse were unaware patient was on 24 (twenty-four) hour hold. Patient did not have security sitting with him/her.
e. Medical record lacked documentation of personal items list removed from patient.
f. Medical record lacked documentation of nurse notifying house supervisor/bed control of sitter request.
g. Medical record lacked documentation of nurse giving report to sitter.
h. Medical record lacked documentation of 15 (fifteen) minute checks.
i. Patient eloped from facility emergency department on 08/31/2023 at approximately 0815 hours.

5. Review of F1 Safe Report Log on 09/13/2023 indicated security/sitter was not assigned to patient #4 or patient #9.

6. On 09/13/2023 this writer, accompanied by A1, A2, and A3 (Accreditation Coordinator), toured the Emergency Department. During the tour of patient #4 and patient #9 ED rooms, an observation was made of ligature risks such as overhead lamps, cords and instruments attached to the wall of the room; facility lacked specific rooms for seclusion or close monitoring, all rooms are set up with the same equipment.

7. In interview on 09/13/2023 with A1, he/she acknowledged patient #4 and patient #9 required a sitter for their safety. A1 confirmed MR #4 and #9 lacked documentation of suicide precautions/close observation implemented.

8. In interview on 09/13/2023 with A2 (Emergency Department Director), he/she indicated nursing must have overlooked the provider order of 24 hour hold for patient #9. A2 also indicated all rooms in the ED are the same layout, there is no specific room for observations, holds, or 1:1. Those patients that need 1:1 care are placed in a room close to the nurses station and a sitter is provided. If security/sitter is provided, it is entered into the Safe Report Log.

9. In interview on 09/13/2023 with N1 (Registered Nurse-RN), he/she indicated when he/she received report from the previous nurse, nothing was reported of a 24 hour hold for patient #9, patient was to be transferred that morning to F4 (Behavioral Health Facility), food and drink had been offered but patient declined, personal items were checked with security. N1 indicated previous RN may have not implemented suicide precautions due to patient being agreeable to plan of care. Patient was seen by N1 leaving room, when N1 made attempt to stop patient to keep from leaving and removing IV, he/she bumped staff on shoulder with his shoulder and left F1 driving his personal vehicle. Nurse called charge nurse, A1, and security to inform of patient elopement; staff looked for patient but did not find, authorities were called.