HospitalInspections.org

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure staff had a direct and unobstructed view of a suicidal patient while the patient was showering (MR1).

Findings include:

Review of the facility's "Rights & Responsibilities Patient Rights and Responsibilities" policy, last revised September 2018, revealed "... 41. A patient has the right to receive care in a safe setting. ..."

Review of the facility's "10.0 Provision of Care, Treatment and Services Suicide/Self-harm Precautions" policy, last approved May 8, 2019, revealed "Purpose: To provide guidelines for staff caring for patients when there is a reasonable risk the patient may endanger themselves and/or others. Patients presenting with acute medical care needs may also be assessed for exhibiting acute psychiatric conditions, chronic mental disturbances, substance abuse and be at risk of self-harm. ... 1:1 Direct Visual Observation: The provision of a hospital member of the hospital's staff to be in constant attendance and in close proximity to the patient, even during bathroom use (patient will be accompanied by appropriate clinical staff). The staff member must have a clear and unobstructed view of the patient at all times. ... Inpatient Admission Procedure ... 5. Provide 1:1 direct visual observation to observe patient throughout hospitalization while suicide precautions are in effect or patient is medically cleared and transferred to the psychiatric unit. ... When a patient is in the bathroom, the staff member must have a clear and unobstructed view of the patient...."

Review of MR1 on June 10, 2020, revealed physician documentation dated June 4, 2020, at 9:55 AM this patient verbalized thought of killing self and was ordered a one-to-one suicide sitter.

Review of MR1's nursing documentation dated June 4, 2020, at 2:30 PM, revealed MR1 was accompanied to the shower by EMP6. At 2:39 PM, EMP6 saw MR1 slumped over in the shower.

Review of MR1's nursing documentation dated June 4, 2020, at 2:40 revealed EMP6 activated the shower nurse call bell. Facility staff responded. CPR (Cardio Pulmonary Resuscitation) was started. MR1 was intubated (insertion of a breathing tube to assist a patient who is not breathing) and 1 milligram (mg) of Narcan (a drug used to reverse the effects or revive a person following an opioid overdose) was administered intravenously (IV). Nursing documentation revealed the end cap of an intravenous was found in the back of the patient's throat when intubated.

Interview with EMP1, EMPMP2, EMP3 and EMP4 on June 11, 2020, at approximately 1:30 PM confirmed MR1's physician documentation this patient verbalized thought of killing self and was ordered a one-to-one suicide sitter.

Interview with EMP1, EMPMP2, EMP3 and EMP4 on June 11, 2020, at approximately 1:45 PM confirmed MR1's nursing documentation this patient was accompanied to the shower by EMP6 and at 2:39 PM EMP6 saw MR1 slumped over in the shower. EMP6 activated the shower nurse call bell and facility staff responded. CPR was started. MR1 was intubated and 1 mg of Narcan was administered IV. EMP1, EMPMP2, EMP3 and EMP4 confirmed the end cap of an intravenous was found in the back of MR1's throat when they were intubated.

Interview with EMP1, EMPMP2, EMP3 and EMP4 on June 11, 2020, at approximately 2:00 PM revealed EMP6 did not have a clear and unobstructed view of MR1 while this patient was in the shower.