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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13 Patient's Rights, was out of compliance.

A-0144 - The patient has the right to receive care in a safe setting. Based on observations, interviews, and document review, the facility failed to ensure patient safety by failing to prevent suicidal patients from ligature risks and accessing potentially harmful items in two of the three patients observed with suicidal ideation (SI).

Based on observations, interviews, and document review, the facility failed to ensure patient safety by failing to prevent suicidal patients from ligature risks and accessing potentially harmful items in two of the three patients observed with suicidal ideation (SI). (Patients #19 and #21)

Findings include:

Facility policies:

The Assessment and Care of the Suicidal Patient Policy read, this policy supports healthcare professionals to identify and treat individuals with suicidal ideation or behavior. The policy addresses the safety of the healthcare environment and describes evaluation, documentation and discharge for individuals at risk for suicide.

Emergency Department Screening, Assessment and Precautions for Suicide Risk: patients assessed to be at high risk for suicide may have the following precautionary measures: patient observation/monitoring as indicated by clinical presentation (e.g. 1:1, 4:1, etc.), identify and remove potential safety hazards, and notify provider. The healthcare professional documents patient observation and screening in the electronic health record.

Inpatient Setting Screening, Assessment, and Precautions for Suicide Risk: patients assessed to be at moderate or high risk will have the following precautionary measures implemented: 1:1 direct patient observation by qualified personnel with the ability to immediately intervene, identify and remove potential safety hazards, assess the patient and care environment for further restrictions, and notify provider.

Definition(s): 1:1 Direct Observation: Continuous visual observation with the ability to immediately intervene through the use of 1:1 observation with one qualified staff member to one patient. Note: remote/virtual or camera monitoring does not meet this requirement.

References:

The Lippincott Procedures - Suicide precautions procedure, revised 2/19/24 read, a suicide attempt or suicidal ideation - especially those accompanied by a suicide plan - are common reasons for inpatient hospitalization. When assessment determines that a patient is at risk for suicide, standard interventions include increasing the level of supervision and observation, taking suicide precautions, and removing means of suicide. Suffocation or strangulation (hanging) by call lightcord, bandages, sheets, a restraint belt, plastic bags, elastic tubing, or oxygen tubing is a common method of suicide in a health care facility because these objects are readily available.

The facility should also routinely assess clinical areas to determine objects that may contribute to self-harm and (if possible) remove those objects when a patient is identified as being at high risk for suicide.

Evaluate the patient's immediate safety needs. Remove sharp objects and other objects that might pose a risk, such as shoelaces, belts, lighters, matches, pencils, pens, and drawstrings. For a patient in a psychiatric facility, perform or verify the results of a facility-approved environmental risk assessment as directed by your facility. For a patient on a nonpsychiatric unit in a general health care facility, perform a facility-approved environmental risk assessment.

1. The facility failed to identify and mitigate ligature risks for patients with suicidal ideations. Additionally, the facility failed to remove items that the patients could have used for self-harm.

A. Observations

i. On 11/18/24 at 1:20 p.m., observations were conducted in the ED. Observations revealed Patient #19 in a room with their significant other and baby with the door closed and without staff members present. A review of the medical record revealed the patient presented to the ED after a suicide attempt and had a history of intrusive thoughts of harming their baby. Further observations revealed two security guards standing outside the room with the door closed, looking at the floor, and unable to provide line-of-sight monitoring. Further observations revealed the overhead garage door used to limit access to ligature risk items was open. Further observations revealed the patient had access to the call light cord, suction tubing, monitor cords, and nasal cannulas. Registered nurse (RN) #1 stated the patient was medically cleared at 12:30 p.m. and the garage door should have been closed at that time to mitigate ligature risk. This was in contrast to the medical record which revealed Patient #19 was medically cleared at 11:28 a.m. RN #1 stated the patient was at high risk for suicide and should not have had access to ligature-risk items. RN #1 stated the patient could have strangled themself with the cords left in the room. At 1:25 p.m., five minutes after the safety concern was identified, staff failed to intervene and mitigate ligature risks.

ii. On 11/25/24 at 10:47 a.m., observations were conducted in the surgical care unit. Observations revealed Patient #21 in the bathroom with nursing staff and a significant other, with the door closed. Further observations identified ligature risk items readily accessible to the patient, including oxygen tubing, a call light cord, a large trash can with a plastic liner, and removable privacy curtains. During the observation, RN #2 stated the patient was on SI precautions and was considered high risk. RN #2 stated the patient had last used oxygen at 7:00 p.m. the previous evening and acknowledged that the identified ligature risk items should not have been accessible to the patient. RN #2 stated allowing high risk SI patients access to ligature items posed a severe risk of self-harm, such as strangulation.

The observations on 11/18/24 and 11/25/24 were in contrast to the Assessment and Care of the Suicidal Patient Policy which read, staff in the emergency department had implemented precautionary measures for patients assessed as high risk for suicide, including observation and monitoring based on clinical presentation and the identification and removal of potential safety hazards. For patients assessed as moderate or high risk in the inpatient setting, staff had implemented one-on-one direct observation by qualified personnel capable of immediate intervention, identified and removed potential safety hazards, and assessed the patient and care environment for additional restrictions.

The observations on 11/18/24 and 11/25/24 were also in contrast to the Lippincott Procedures - Suicide precautions policy which read, when assessments determined that a patient was at risk for suicide, standard interventions included increasing the level of supervision and observation, taking suicide precautions, and removing means of suicide. Suffocation or strangulation (hanging) using a call light cord, bandages, sheets, a restraint belt, plastic bags, elastic tubing, or oxygen tubing was a common method of suicide in health care facilities because these objects were readily available.

B. Document Review

i. Medical record review revealed Patient #19 presented to the ED on 11/18/24 at 10:44 a.m. for carbon monoxide exposure by attempting suicide from idling their car in the garage with the door closed. Further review of Patient #19's medical record revealed at 11:45 a.m., the Columbia-Suicide Severity Rating Scale (suicide risk assessment to identify someone at risk for suicide) was performed. The patient was deemed at high risk for suicide at that time. Patient #19 was found to be a danger to themself and placed on an M1 hold (an involuntary 72-hour emergency mental health hold placed on a patient determined to be at risk of self-harm, harming others, or gravely disabled). Further review of the medical record revealed a behavioral health evaluation note stating the patient had a history of intrusive thoughts of harming their baby.

ii. Medical record review revealed Patient #21 presented to the ED on 11/20/24 at 9:06 p.m. after a drug overdose from attempting suicide by taking beta blockers (a medication that slows down the heart and relaxes blood vessels) and benzodiazepines (a medication that slows down activity in the brain and nervous system). Further review of the medical record revealed the patient was bradycardic (a condition where the heart beat slower than normal) and unable to maintain their airway. The patient was intubated (insertion of a breathing tube) in the ED for airway management before being admitted to the ICU. Further review of Patient #21's medical record revealed at 9:38 p.m., the Columbia-Suicide Severity Rating Scale was deferred as the patient was not clinically stable. On 11/24/24 at 8:28 a.m., a progress note from psychiatric nurse practitioner (Provider) #3 stated the patient was a high safety risk related to their previous suicide attempt and current SI statements. Provider #3 stated the patient was angry as their suicide attempt was not successful, and the next time they would jump off of a balcony. Provider #3 stated the patient did meet the criteria for an M1 hold but was willing to accept treatment voluntarily. However, if they changed their mind or attempted to leave against medical advice (AMA), an M1 hold would be placed. Further review of Patient #21's medical record revealed on 11/25/24 at 10:59 a.m., a second Columbia-Suicide Severity Rating Scale was performed. The patient was deemed at high risk for suicide at that time.

C. Interviews

i. On 11/20/24 at 3:58 p.m., an interview was conducted with RN #4 who stated staff used the Columbia-Suicide Severity Rating Scale to assess if the patient was at risk for suicide. RN #4 stated if the patient scored moderate or high, the patient would be placed on a one-to-one observation, and a crisis assessment counselor (CAC) would assess the patient and determine any further interventions to keep the patient safe. RN #4 stated patients at risk of suicide should not have had access to ligature risk items. RN #4 stated suicidal patients who had access to ligature risk items could have injured themselves or others, self-strangulated, or killed themselves. RN #4 stated family members visiting the patient could not perform any interventions as they were not trained and could not supplement the care provided by the facility.

ii. On 11/19/24 at 1:22 p.m., an interview was conducted with the ED nurse manager (Manager) #5. Manager #5 stated Patient #19 scored moderate on their suicide risk assessment. Manager #5 verified the two security guards were posted outside the room with the door closed and did not have a direct line of sight of the patient. Manager #5 stated the security guard should have been in the room within arms' reach and to have the ability to intervene immediately. Manager #5 stated the patient had access to ligature risk items such as cords and oxygen tubing. Manager # 5 stated the patient was medically cleared and last on the monitor at 12:30 p.m., and staff should have removed the cords and closed the overhead garage door at that time. Manager #5 stated staff did not follow the facility's policies and should have mitigated the ligature risks to keep the patient safe. Manager #5 stated if SI patients had access to ligature risk items, they could hang themself, potentially leading to anoxic brain or death.

iii. On 11/19/24 at 10:58 a.m., an interview was conducted with the director of regulatory affairs (Director) #6. Director #6 stated Patient #19 should have been on direct observation with the security guard in the room within arms reach. Director #6 stated the security guards were not following the facility's policies. Director #6 stated not following the policies and procedures for patients with SI put the patients at risk for self-harm, including death.