HospitalInspections.org

Based on policy review, medical record review, and interview in one of one medical record reviewed (Patient #1), the hospital failed to follow the guidance of their policies. Specifically, the hospital did not follow policy for obtaining a provider order for suicide risk level and did not include review of suicide precautions every 24 hours.

Review on 08/06/24 of policy "Suicide Risk Assessment", last reviewed March 2016 revealed, "If a patient is deemed by a registered nurse to be an immediate risk to act out on suicidal thoughts and feelings, threatening to kill or harm [themselves], or has made an overt suicide attempt, the registered nurse will initiate 1:1 observation until the physician orders for level of observation are received. In the emergency department, the emergency department physician will be notified of the results of the suicide risk assessment. Specific suicide precautions will be ordered by the physician at [their] discretion. Every 24 hours the physician will be accountable for reviewing suicide precautions. Types of suicide precautions include: "1:1 observation" which requires one staff member to one patient to continuously observe the patient within arm's length at all times; or "line of sight" which requires the direct view of staff at all times (only in the emergency department and intensive care unit.)" Assessment findings are required to be documented on the observation log every 15 minutes for both types of suicide precautions. "Nursing care for the patient who is considered to have suicidal potential and has been placed on suicide precautions will include: explaining to the patient/family why the precaution is necessary; signage will be placed outside the patient's room; the patient will be placed in a private room to assure safety; a room search will be performed to ensure a safe room; the patient's clothing and belongings will be removed from [them]; the patient will be placed in a cloth gown with no drawstrings (snaps only); only paper or plastic dishes/utensils and no knives on the patient's tray; if a patient who is on suicide precautions attempts to leave the treatment setting call a "doctor gray" to assist in detaining the patient while the attending physician is contacted; and patients on suicide precautions will not be allowed to leave against medical advice. An emergency department patient will be placed in room five, which is considered a "safe room" for suicidal patients. This room is in direct line of sight from the nurse's station. If the patient requires 1:1 observation, the nursing supervisor or nurse manager will arrange for this. If room five is unavailable 1:1 observation is necessary." Physician assessment and documentation are as follows: "The attending physician/designee assesses a suicidal patient at least every 24 hours and records in the progress note [their] findings. Suicide level remains in effect until changed or discontinued by the attending physician/designee providing clinical justification for decreasing the level of observation."

Review on 08/06/24 of policy "Sitter Guidelines", last reviewed 03/26/24 revealed, "a sitter may be used to continuously monitor the patient to prevent the patient from harming [themselves] or others. Sitters must be within arm's length from the patient. Sitters must be between the patient and the door/exit from the room. Sitters observe the patient and maintain a safe environment. Sitters sit in the patient's room with an unobstructed view of the patient. If the patient is suicidal/homicidal, the sitter must document every 15 minutes.

Review on 08/05/24 of Patient #1 emergency department medical record revealed on 06/08/24 at 04:42 PM, Patient #1 arrived ambulatory to the emergency department with the complaint of "mental issues". At 04:47 PM, Staff (K), Registered Nurse documented a triage note indicating Patient #1 presented to the emergency department stating that "the spirits are following me and telling me to leave my body". Patient #1 stated the voices are telling [them] to harm [themselves] or others. At 05:07 PM, Staff (K), Registered Nurse documented a suicide risk assessment as "moderate risk. The charge nurse was notified. Patient #1's risk level was highly changeable." At 04:29 PM, Staff (G), Nurse Practitioner documented Patient #1 had been declined by multiple facilities with inpatient psychiatric care. A repeat psychiatric evaluation was requested to reassess if Patient #1 had a drug-induced psychosis. Patient #1 received another dose of Olanzapine (antipsychotic medication that treats mental health conditions) due to hearing more voices with a verbal response to the voices. Staff (T), Local County Licensed Clinical Social Worker, re-evaluated Patient #1 and felt that Patient #1 would benefit from inpatient psychiatric care. (There was no documentation of the continued need for review of suicide precautions.) On 06/10/24 at 02:30 PM, Staff (J), Registered Nurse documented Patient #1 was discharged in police custody. All belongings were taken by Medina Police Department. Medina Police Department stated Patient #1 was transporting to [another hospital]. There was no evidence that a suicide precaution observation level was ordered by a provider. Further, there was no evidence that a physician/designee reviewed suicide precautions on 06/09/24.

Interview on 08/06/24 at 03:35 PM with Staff (B), Physician revealed it is a protocol for patients that come in with suicidal ideations to have a sitter, and an order is not required for the placement of the sitter. The sitter sits in the doorway of the room and uses a table for their documentation.

Interview on 08/06/24 at 04:09 PM with Staff (A), Risk Manager revealed the "Suicide Risk Assessment" policy is the current policy in use. Medina Memorial Hospital does not provide 1:1 observation, only line of sight observation (within arm's length at all times) for suicide precautions. A patient care technician is three to four feet from the patient when they sit in the doorway of the room. Medina Memorial Hospital stopped providing 1:1 within arm ' s length observation when the behavioral health unit closed eight years ago. Medina Memorial Hospital staff are only trained for line-of-sight observations based off of the "Sitter Guidelines Policy."

Interview on 08/06/24 at 04:18 PM with Staff (A), Risk Manager verified these findings.