HospitalInspections.org

Based on observation, document review, and interview, it was determined that the Hospital failed to meet the emergency needs of a patient (Pt. #1), by failing to follow Emergency Department policies to supervise and treat a patient with suicidal ideation. This could potentially affect all current and future patients who present to the ED for treatment. As a result, the Condition of Participation, 42 CFR. 482.55, Emergency Services was not met.

Findings include:

1. The Hospital failed to ensure policies and procedures in assessment, supervision and treatment of a suicidal patient in the Emergency Department (ED) were followed. See deficiency cited at A-1104.

The immediate jeopardy began on 11/13/19, due to the Hospital's failure to ensure policies in assessment, supervision and treatment of a suicidal patient in the Emergency Department (ED) were followed.

As a result, patient (Pt #1) was left unattended in the ED waiting room. Pt. #1 went into the ED waiting room bathroom and attempted suicide by tying a shoelace around his neck. This could potentially affect all current and future patients who come in with allegations of suicidal ideation (desire to kill self), and can potentially result in serious harm.

The IJ was identified and announced on 11/20/19 at 1:41 PM during a meeting with the Chief Executive Officer (E #12), Chief Nursing Officer (E #11), Chief Experience Officer (E #14), Quality Coordinators (E #15 and E #16), Chief Finance Officer (E #10) and Information Technologist (E #13). The IJ was removed by the survey exit date of 11/22/19.

On 11/21/19 the Hospital presented their removal plan for the immediate jeopardy that included:

1. On 11/22/19 from 10:30 AM to 11:15 AM an observational tour was conducted in the Emergency Department. There were no patients in the waiting room. There was a registration clerk in the waiting room. The Triage nurse and a Triage Technician were in the triage room with direct visualization of the ED waiting room. In the main ED, there were 2 patients and these patients were not assessed as suicidal. The ED Staffing consisted of 4 Registered Nurses, 4 Emergency Technicians, one person from Registration and a Unit clerk. Public Safety was observed rounding in the ED. There were 2 bathrooms in the ED waiting room and 2 bathrooms in the main ED. The locks of these bathroom doors have been changed to reflect when the bathroom is in use or vacant and are ligature free. These doors have the capability to be opened in either direction.

2. Random interviews were conducted with the Triage nurse (E #17) and 2 Technicians (E #18 & E #19). They stated that they were recently educated on the Hospital's policies, and the responsibilities of the staff when a patient presents to the Emergency Department with suicidal ideations. The education consisted of notifying the charge nurse immediately, not to leave the patient alone, a sitter assignment and conducting every 15 minutes safety rounds. The assigned nurse will conduct a reassessment every 2 hours or as needed and document in the patient's clinical chart. The patient will be evaluated by the physician. It will be the physician who will determine if the sitter can be discontinued or not.

3. The ED log for 11/21/19 was reviewed. 5 patients presented to the ED for psychiatric evaluation. Two (2) of the 5 patients expressed suicidal ideation and were placed on one to one observation with a sitter (sitter is required to maintain visual contact with the patient while the patient is using bathroom). These 2 patients were admitted to the in-patient Behavioral Health Unit of the Hospital.

4. The Hospital initiated education to their ED staff (nurses, technicians, crisis workers, public safety, registration, physicians and supervisors), on the Hospital's policies that included: Suicide Risk Assessment, Treatment of the Suicidal/Homicidal Patient, Care of the Behavioral Health Patient, Triage and Sitters: For high risk for injury to self and others. As of 11/22/19, 75% of the staff have been educated.

5. On 11/22/19 at approximately at 11:00 AM, the Director of Emergency Services (E #1) was interviewed. E #1stated that staff will not be allowed to work prior to receiving the education. The patients that require a sitter will be monitored at all times, including when a request is made by the patient to go to the bathroom.

6. An audit tool has been created and will be completed by the Director of Emergency Services (E #1) daily to ensure appropriate assessment and treatment of all psychiatric patients that present to the ED. The audit tool will be reviewed monthly at the Hospital's Quality and Patient Safety meetings.

Based on document review, observation, and interview it was determined that for 1 (Pt. #1) of 7 Emergency Department (ED) clinical records reviewed of patients with suicidal ideation (desire to kill self), the Hospital failed to ensure policies and procedures in assessment, supervision and treatment of a suicidal patient in the Emergency Department (ED) were followed. As a result, patient (Pt #1) attempted suicide by tying a shoelace around his neck in the ED bathroom.

Findings include:

1. On 11/19/19, the Hospital's policy titled "Suicide Risk Assessment" (rev 9/15/19) was reviewed an included " ...Patients entering the hospital via emergency department ...will be assessed for suicide risk...III. Interventions listed below are based on risk score (greater than 8): Suicide precautions, psychiatric consult, crisis worker (evaluation)..."

2. On 11/19/19, the Hospital's policy titled "Treatment of the Suicidal/Homicidal Patient" (rev 9/2019) was reviewed and included, " ...All patients will have a Suicide Risk Assessment at the time of triage. Criteria for sitter: I. Patient expresses suicidal ideation...Procedure: Physician/RN (Registered Nurse) 1. Orders suicide precautions including sitter...3. Initiates suicide precautions; including 1:1 sitter ...ED (technician) ... Remove all personal belongings; 11. Maintain constant observation of their patient....16 Accompany patient to bathroom ..."

3. On 11/19/19, the Hospital's policy titled "Triage" (rev 9/2019) was reviewed and included "...II. Triage is a process used to determine the priority of patient's treatment based on the severity of their condition ...Patients should be reassessed every 2 hours ..."

4. On 11/19/19, the clinical record of Pt. #1 was reviewed. Pt.#1 was a 25 year old male that presented to the Emergency Department on 11/13/19 at 4:15 PM for psychiatric evaluation.

- At 4:39 PM, Pt. #1 was triaged and was assessed as actively suicidal. For suicidal risk assessment, Pt. #1 scored 14 (a score above 8 is considered as high risk). Based on the high suicidal risk score, the following interventions were triggered: suicide precautions, a psychiatric consultation, and crisis worker evaluation.

- At 4:47 PM, E #4 completed Pt. #1's triage and without implementing the suicide precautions, sent Pt. #1 to the waiting room.

- On 11/13/19 at 4:44 PM, the "Patient Notes" documented by the Triage Nurse (E #4) included, "(Pt. #1) C/O (complained of) depression, (and) hearing voices telling him to kill himself. (Pt. #1) just discharged from (Hospital's psychiatric inpatient unit) on (11/8/19) ..."

- On 11/13/19 at 7:30 PM, the "Patient Notes" documented by the Nurse (E #2) included "No answer from waiting room, (Pt. #1) left after triage, without being seen by (ED Physician)."

Pt. #1's clinical record lacked a reassessment from 4:39 PM to 6:39 PM (2 hours after triage).

5. On 11/19/19 at 2:23 PM, the video surveillance recording from Pt #1's 11/13/19 Emergency Department (ED) visit, was reviewed. The video indicated the following:

- At 4:27:21 PM: Pt #1 walked into the ED.
- At 4:41:18 PM: Pt #1 walked into the triage area with the ED Triage Nurse (E #4).
- At 4:47:32 PM: Pt #1 walked out of the triage area and returned to the waiting area.
- At 4:53:58 PM: Pt #1 is in the waiting area.
- At 6:57:10 PM: Pt #1 called by admitting clerk and patient walked to the registration desk.
- At 6:59:16 PM: Pt #1 came out of registration area and sat in waiting room hallway.
- At 7:43:10 PM: Pt #1 entered the waiting area's bathroom located near the triage area.
- At 10:20:04 PM: The ED RN (E #5) knocked on the Men's bathroom door located in the waiting area.
- At 10:20:24 PM: E #5 opened the Men's bathroom in the waiting area. Pt # 1 was lying on the floor (with shoelace around his neck).

The Triage room is a designated room located in the ED waiting room. The Triage room has a door that remains closed when patients are being assessed and does not provide direct observation of the ED waiting room.

6. On 11/19/19, Pt. #1's incident report dated 11/13/19 at 10:30 PM, was reviewed and included " ...Event type: Behavioral Incident; Sub event type: Suicide Attempt; Location: ED (Emergency Department ...the facts of the event: (Approximately at 10:18 PM), 911 dispatch called ER informing ...that someone called from the ER bathroom requesting help because he could not get up and no one can hear him ...Triage nurse found (Pt. #1) inside waiting room bathroom floor awake and with ligature (anything that can be used for the purpose of hanging or strangulation) around neck ...(Pt. #1) arrived in ED at (4:15 PM) and triage at (4:39 PM). At (7:30 PM) no one replied /answered from waiting room when we called for his name (Pt. #1) ..."

7. On 11/19/19 at approximately 12:50 PM, a telephone interview was conducted with the Registered Nurse (E #2). E #2 was the assigned ED Charge Nurse on 11/13/19 evening shift (date of Pt. #1's incident in the ED). E #2 stated, "When he received the shift report (at approximately 7:00 PM), there were 4 patients in the waiting room. When (Pt. #1) was called back to the ED he was not in the waiting room and it was documented that (Pt. #1) had left the ED." (Pt. #1 had not left the ED. Pt. #1 was in the waiting room bathroom at the time he was called into the ED).

8. On 11/19/19 at approximately 1:38 PM, the Registered Nurse (E #4) was interviewed. E #4 was the nurse that triaged Pt. #1 when he arrived at the ED on 11/13/19 at 4:15 PM. E #4 stated, "The ED was extremely busy when Pt. #1 presented to the ED. (Pt. #1) had been discharged from (in-patient psychiatric unit) recently. (Pt. #1) was homeless, calm, and was watching TV (television). These types of patients know what to say to be admitted and he was looking for a place to stay." E #4 stated that she assessed Pt. #1 as a high risk for suicide, there were no ED beds available and Pt. #1 was returned to the waiting room. E #4 added that Pt. #1 had no suicidal plan, and did not need a sitter. E #4 stated that she did not notify the charge nurse or physician of the arrival of a patient with suicidal ideation to the ED, to coordinate supervision while awaiting the physician's evaluation.

9. On 11/20/19 at 9:50 AM, an interview was conducted with the ED RN (E #5). E #5 stated, "I came into work that night at 10:00 PM [Pt #1's 11/13/19 ED visit]. I wasn't aware that the patient (Pt #1) was here. I got a call around 10:18 PM from the Charge Nurse (E #2), and (E #2) told me to check the bathrooms because the [local police department] said that a patient (Pt. #1) called them from the bathroom and he (Pt. # 1) needed medical attention. When I opened the bathroom door [in the waiting room area], the patient (Pt. #1) was lying on the floor. The patient had two ligatures around his neck [a lanyard and a shoe lace]. There were a couple of screws missing from the wall. We then took the patient to the back."

10. On 11/20/19 at 11:10 AM, a phone interview was conducted with the ED Technician (E #6). E #6 stated, "When the patient [Pt #1] came in, he told us that he was here to be seen for mental illness. I did Pt #1's vital signs, drew his blood, and then the patient went back to the waiting area. The last time that I saw (Pt #1) was when I drew his blood and did his vital signs. If a patient is in the waiting room for more than two hours, then the Tech[nician] or the nurse is supposed to re-assess the patient and get vital signs again."

11. On 11/20/19 at approximately 12:09 PM, the Director of Emergency Services (E #1) was interviewed. E #1 stated that a patient that presents with suicidal ideation should not remain in the waiting room without supervision.