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The Hospital failed for two (Patient #3 and Patient #5) of ten sampled patients to ensure investigation and implementation of preventative actions after Patient #3 and Patient #5 were able to attempt suicide while on constant observation while in the hospital's emergency department.

A-0263
The Hospital failed for two (Patient #3 and Patient #5) of ten sampled patients to ensure investigation and implementation of preventative actions after Patient #3 and Patient #5 were able to attempt suicide while on constant observation while in the hospital's emergency department.
A-0286
Based on interviews and records reviewed, the Hospital failed, for two (Patient #3 and Patient #5) of ten sampled patients to ensure investigation and implementation of preventative actions took place after Patient #3 was able to use a razor blade and cut his/her own wrists, require sutures, while on constant observation in the Emergency department and for Patient #5, who was able to use telemetry cords to wrap around his/her neck resulting in lack of respirations and consciousness.
Findings include:
Review of the Hospital's Safety Event Reporting policy, revised in March 2020, indicated that the objectives of safety event reporting are:
1. To systematically identify, evaluate and correct situations which may result in injury to the patients ... 2. To prevent accidents from occurring:
3. To minimize adverse effects of event which do occur to patients, visitors, employees, and healthcare providers; and
4. To provide educational programs designed to improve patient care.

Review of the Hospital's policy Management of the suicidal patient being cared for on the Inpatient Units and in the Emergency Department, dated September 2015 indicated that Patients on suicide precautions all require a patient observer.

1. Patient #3 was brought to the Hospital by an ambulance and admitted to the Hospital in August 2020 following a suicide attempt by cutting him/herself on the neck and forearm with a razor blade. The Patient's Safety Screening, dated 8/26/20 at 10:46 P.M. identified that Patient #3 had thoughts of killing him/herself and the intention of acting on his/her thoughts of killing him/herself. Patient #3 was placed on suicidal/homicidal ideation precautions, including constant observation.
Record review indicated that on 8/26/20 at 10:47 P.M., Patient #3's phone was checked, no objects were found during physical exam and all belongings were secured with the care companion/security. Patient to remain on seclusion/suicidal ideation precautions while awaiting psychiatric consultation.

Record review indicated that two days after admission, on 8/28/20 at 10:00 P.M., Patient #3 was found by the nurse with a small laceration to the right forearm with bleeding. There were 100 ccs of blood noted on bedsheets. A small razor was found in the bedding. Sutures were required as a result of this laceration.
Record review indicated that on 8/28/20 at 10:47 P.M., the patient received sutures and was made a 1:1 observation with ED technician sitting in the doorway to room.
Review of the Hospital's investigation indicated that the Hospital was not able to determine where the razor blade was hidden and the patient refused to tell them. The hospital investigation indicated that they suspect it was hidden in a piece of gum the patient had with him/her.

2. Patient #5 was brought to the Hospital by Emergency Medical Services from home after medication ingestion and waking with a belt around his/her neck.
Record review of Patient #5's Nursing Exam notes dated 8/13/20 at 6:10 P.M., indicated that the patient was aggressive/assaultive and suicidal. Patient #5 was on a section 12 and had thoughts and plans to hurt him/herself.
Record review indicated that on 8/13/20 at 7:37 P.M., Patient #5 was placed on a telemetry monitor due to an elevated heart rate in 130's - 150's.
Record review indicated that on 8/14/20 at 8:30 P.M., Patient #5 was on 1:1 observation for a section 12. Patient #5 was noted to be tachycardic on the telemetry monitor, with heart rate in the 140's. On arrival into the room to obtain electrocardiogram (EKG) the registered nurse noted a telemetry wire wrapped around Patient #5's neck. Patient #5 was found to be unresponsive and cyanotic. The cord was cut with trauma sheers. A "trigger" was called to the room, Patient #5 had positive radial pulses. A bag-valve-mask was used to assist with respirations. A Code Cart was brought to the room. Patient #5 oxygen was maintained on 2 liters of oxygen. A stat order for a computed tomography (CT) scan was placed.
Record review indicated that on 8/14/20 at 6:58 P.M. Patient #5 went to the CT scan and endorsed to the registered nurse that he/she had been "planning it for about an hour. I was tying the cord under the blanket and watching out of the corner of my eye for when the nurse left to help other patients. I've tried over 30 times. I don't know why I can't just die. I want to just die already."
Review of the hospital's investigation indicated that the Vice Chair of Psychiatry was asked to review the case and he questioned how the observation system failed and ways to improve. He further indicated that the Hospital could add to their policy that the face, head and neck must be visible if a patient is on a 1:1 suicide watch.

Review of the Emergency Department staff email dated 9/4/20, indicated that going forward, any patient who presents to the ED due to a suicide attempt will require a 1:1 observation with the observer placed at the room entrance. Patients will be asked to keep their hands visible at all times and blankets must be below their neck. The Hospital could not provide supporting documentation that the nursing staff was aware of this procedure change to reflect this and prevent a like occurrence from happening again.

In an interview on 12/15/20 at 8:21 A.M. with Risk Manager #1, she said that the Management of the suicidal patient being cared for on the Inpatient Units and in the Emergency Department are used house wide.

In an interview on 12/15/20 at 12: 00 P.M. with the Vice President of Psychiatry and Quality Improvement Director for Psychiatry, he said that he remembers raising the question of the constant observer being there but wasn't sure if the hospital had come to a resolution or was still working on this investigation. The Vice President of Psychiatry and Quality Improvement Director of Psychiatry said that his understanding of the observer policy is that the standard constant observation policy can be 1:1 or 1:2 (one observer watching one patient and/or one observer watching two patients at a time) and it is up to the physician ordering the observation.

In an interview on 12/15/20 at 12:30 P.M., the Senior Nurse Director of the Emergency Department said that they do not have a system in place to determine if all staff members received education to be aware of the changes that they are in the process of making.
In an interview on 12/15/20 at 12:30 P.M. with the Clinical Nurse Specialist of the Emergency Department, he said that they are trying to come up with an assessment tool to determine when a patient requires 1:1 observation or 1:2 observation, but they haven't done this yet.
The hospital failed to systematically identify, evaluate and correct situations which may result in injury to the patients after two actively suicidal patients, on 1:1 observation, were able to attempt suicide while in their emergency department. Further, the Hospital failed to identify that patients can be on other inpatient units with suicidal ideation and would also be affected by a lack of identification and implementation of changes made to prevent a like occurrence from happening again.