HospitalInspections.org

Based on observation, interview, record review, and policy review, the hospital failed to to ensure patients were monitored for safety when they failed to:
- Ensure that one patient (#1) of one patient reviewed with a diagnosis of suicidal ideation (SI, thoughts to harm self), was placed in a psychiatric safe room (an exam room that was free of medical equipment or dangerous objects that the patient could use to harm himself or others).
- Provide adequate oversight to prevent self-injury or self-harm, for one patient (#1) of one patient reviewed, who was left unattended with access to dangerous objects that could be used to inflict harm to himself or others.
- Ensure that nursing staff had a clear understanding of implementing suicide precautions and placement of suicidal patients on one-to-one (1:1, continuous visual contact with close physical proximity) observation.

The cumulative effects of these failures resulted in non-compliance with 42 CFR 486.635 Condition of Participation: Provision of Services.

Refer to C-1046 for further information.

Based on observation, interview, record review, and policy review, the hospital failed to ensure patients were monitored for safety when they failed to:
- Ensure that one patient (#1) of one patient reviewed with a diagnosis of suicidal ideation (SI, thoughts to harm self), was placed in a psychiatric safe exam room (an exam room that was free of medical equipment or dangerous objects that the patient could use to harm himself or others).
- Provide adequate oversight to prevent self-injury or self-harm, for one patient (#1) of one patient reviewed, who was left unattended with access to dangerous objects that could be used to inflict harm to himself or others.
- Ensure that nursing staff had a clear understanding of implementing suicide precautions and placement of suicidal patients on one-to-one (1:1, continuous visual contact with close physical proximity) observation.
These failures had the potential to place all patients seeking psychiatric treatment from this hospital at risk of significant harm or death. The hospital census was six.

Findings included:

1. Review of the hospital's Emergency Department (ED) policy titled, "Special Cases Psychiatric Patients - Suicide Prevention," revised 01/15/14, showed that staff are directed to:
- Inquire about current, and any prior, suicidal behaviors and/or specific details to include method, place, and motivation.
- Keep patient room doors open.
- Ensure the patient is in line of sight of the nurses' desk.
- Initiate 1:1 monitoring for acutely suicidal patients.
- Remove any and all articles from the room that may be used in self-harm, including belts, suspenders, clothing, shoes, shoe laces, glass objects, pocket knives, nail files, and nail clippers (any sharp objects or items that can be used as ligatures [anything that can be used for the purpose of hanging or strangulation]).
- Complete a Psychiatric Observation Flowsheet, for the patient, which monitors the patient's behavior, location, any restraint in use, and the initials of the person making that observation, every 15 minutes.

Although requested, the hospital failed to provide a policy specific to 1:1 monitoring.

Review of the hospital's ED policy titled, "Special Cases Psychiatric Patients-Patient Requiring Psychiatric Evaluation," revised 01/13/2014, showed that:
- Patients with high risk for self-harm, harm to others, or elopement, require close observation.
- The patient must remain within view of a health care team member at all times.
- High risk indicators include an attempt at self-harm, expression of desire or clear intent to harm self, hallucinating (seeing or hearing things that are not there), delusional (having false ideas about what is taking place or who one is), exhibition of signs of depression (extreme sadness that doesn't go away), acute psychosis (a disorder characterized by false ideas about what is taking place or who one is), or chemically impaired.
- If the patient is at high risk of self-harm, a 1:1 staff member should be assigned to continually observe the patient.

Review of Patient #1's ED Nurse's Notes, dated 01/26/20, showed that:
- At 10:40 PM, he arrived at the ED in custody of law enforcement.
- At 11:36 PM, he was triaged (process of determining the priority of a patient's treatment based on the severity of their condition).
- At 11:43 PM, he presented with SI.
- He had threatened suicide by hanging, and then told law enforcement that he would follow through on his threat to commit suicide upon his release.
- At 11:51 PM, the Psychiatric Observation Flowsheet was initiated.
- At 11:59 PM, his Suicidal/Homicidal (thoughts to harm another person) Screening (evaluation used to determine suspected suicide risk) was positive for active suicidal/homicidal thoughts.

Review of an affidavit (a written statement confirmed by oath it is true) dated 01/26/20, showed that Law Enforcement Officer T, documented that:
- He had made contact with Patient #1 at his residence when he responded to a law enforcement call regarding a suicidal male.
- Patient #1 was visibly upset, verbalized that he had been having a hard time dealing with separation from his wife.
- Patient #1 told him that he had thoughts of suicide, and had sent a suicide note via text to his wife.
- Patient #1's plan for suicide was to hang himself in the garage.
- When Patient #1 was told he was being detained for a mental health evaluation, he voiced that he would kill himself upon being discharged.
- Two loaded handguns were removed from Patient #1's residence.

Review of an affidavit dated 01/26/20, showed that Law Enforcement Officer T, transcribed a text message/suicide note, which documented that:
- Patient #1 had left written messages for his wife and kids, in a yellow notebook on a cart in his kitchen.
- Patient #1 directed his wife to tell whomever responded that he would be in the garage.
- Patient #1 had a rope on the main garage door.

Review of Patient #1's Physician Documentation, dated 01/26/20, showed that:
- At 11:53 PM, Suicide Precautions (SP, interventions put into place to prevent self harm or death) were ordered.
- Patient #1 had reported anxiety (excessive fear or worry), depression, and SI, that started with an altercation with his spouse earlier that day.
- He reported that his plan had been to shoot himself with his pistol.
- At 3:31 AM, Patient #1 was given a diagnosis of Acute Psychotic Break (a sudden onset of losing touch with reality, such as having false beliefs or seeing/hearing/smelling/feeling things that are not there in the absence of insight into their nature).

2. Observation on 01/27/20 at 2:55 PM, in the ED, showed Patient #1 was in exam room #3, directly across from the nurses' desk, wearing green scrubs, without staff supervision. Patient #1 had easy access to the following dangerous objects that posed a safety risk:
- Unsupervised use of person cell phone (screen easily shatters for access to sharp object for cutting).
- Unsupervised use of a call light/cord, approximately five feet in length (ligature hazard), attached to the side rail of the stretcher he was lying on.
- Clear trash bag liner (asphyxiation hazard), within a trash can, directly outside of exam room.
- Unlocked exit door within 30 feet of his open exam room door.
- Easy access to any number of items throughout the main corridor of the ED.

Review of an affidavit dated 01/27/20, Staff S, ED Doctor of Medicine (MD), documented that:
- Patient #1 had voiced to his wife, Staff S, and others that he was deeply depressed and suicidal.
- Patient #1's plan was to go home, get a pistol, and take his own life.
- Law enforcement removed guns that they could find, from Patient #1's residence.
- Patient #1 wrote a detailed suicide not to his wife, which included motives and ability to commit suicide.
- Patient #1's behavior presents the likelihood of committing serious harm to himself.

Review of court documents dated 01/27/20, showed a signed circuit court order that placed Patient #1 on a 96 hour Detention, Evaluation, and Treatment Hold (court ordered evaluation by a behavioral specialist to determine if a person is safe to themselves and others).

3. During an interview on 01/27/20 at 3:00 PM, Staff G, ED Registered Nurse (RN), stated that:
- Psychiatric patients were evaluated individually, and if they contracted for safety, they did not require constant supervision.
- Psychiatric patients were left alone, unsupervised, but they were checked on every 15 minutes.
- The hospital did not have security, or video surveillance for psychiatric patients.
- Patient #1 had been calm and cooperative during his time in the ED.
- She admitted that Patient #1 would have access to exit by the ambulance door, or to any number of cords, sharp objects, or plastic bags to inflict self-harm, in the main ED corridor.
- The ED had access to 1:1 supervision by another staff member if a patient was truly suicidal.

During an interview on 01/27/20 at 3:10 PM, Staff H, ED RN, stated that:
- The only patients transported by local law enforcement to a psychiatric hospital were those who were placed on a 96 hour hold.
- 15 minute rounds were to ensure the safety of the patient.
- The ED physician filled out an affidavit to petition a judge for the 96 hour hold.
- It was not common practice to leave a psychiatric patient unattended, but there were other staff members around to help watch him.
- Patient #1 had been sent to the ED several times for the same issue, and he did not really want to hurt himself.

During an interview on 01/28/20 at 1:45 PM, Staff P, RN, ED Director, stated that:
- Patients would be placed on 15 minute rounds if they were cooperative and forthcoming with information.
- 1:1 observation would only be used if a patient was determined to be a flight risk, combative, aggressive, or non-compliant.
- Psychiatric patients should not have a call light.
- Patient #1 was calm and cooperative, not acutely suicidal.

During a concurrent interview on 01/29/20 at 9:38 AM, with Staff C, RN, Chief Nursing Officer (CNO), and Staff B, RN, Acute Care Director, stated that a patient placed on suicide precautions, should be observed by staff at all times, and that there were always staff members available to provide 1:1 observation. Staff could be pulled from the acute care area, or the ED based paramedics/emergency medical technicians could assist.