HospitalInspections.org

Based on document review, policy review, record review, and interview, the hospital failed to adhere to the policies of the hospital when 1 of 4 (Patient #3) left the facility after a medical hold was ordered.

Findings included:

Review of the facility's "Suicide Prevention Policy & Guidelines," last revised 8/31/2022, revealed "...In any care setting, once the patient is identified as high suicide risk*immediate 1:1 observation is required. This means that the individual obtaining the high suicide risk/positive screen must remain with the patient until hand-off can be made to another trained associate..."

Medical record review revealed Patient #3 was admitted to the ED [Emergency Department] on 12/1/2022 with diagnoses of Resuscitated Opiate Overdose, Cardiac Arrest, Acute Hypoxic Respiratory Failure, Hyperkalemia, Obtunded, and Polysubstance Abuse.

Review of the ED [Emergency Department] Records dated 9/20/2022, revealed "...Per EMS, he was found unresponsive outside in front of his mother's apartment complex. He was hypopneic and hypoxic to the 70's when he was found ...I was able to get in touch with his aunt...She states that the patient has a long history of psychiatric issues and polysubstance abuse. He has been in multiple inpatient and outpatient psychiatric programs over the years. He has a strained relationship with both of his parents..."

Review of the Progress Note dated 9/22/2022, revealed "...Follow-up requested by MD [Medical Doctor] due to concern for pt making suicidal statement. The patient reports he is "not suicidal", however he provides conflicting statements to provider regarding suicidally..."

Review of the Assessment/Plan dated 9/22/2022, revealed "...On follow-up examination this afternoon, the patient discloses suicidal ideation...He will require further evaluation and treatment in the inpatient psychiatry setting. I completed 6404 [medical hold] form at approx. 4:20 PM and returned to pt's [patient] room to discuss disposition of inpatient psych...I then verbally notified pt's RN [Registered Nurse] of his 6404 status due to SI [suicidal ideations], and spoke with MD to relay plan; MD ordered suicide precautions/sitter...At 6:02 PM I received phone call from floor supervisor to discuss pt, was notified that pt had unfortunately eloped the premises..."

Review of the SBAR [Situation, Background, Assessment, and Recommendation] for this event reviewed the hospital's policy and recommended "...Patient attendants and those acting in that role must maintain constant visual observation of their assigned patient regardless of patient location (ie: in the patient room, in the hallway, on the toilet, in the shower, etc...) at all times throughout their shift. Observation should begin as soon as the high risk or moderated risk score is identified by the RN performing the screening. The patient cannot be left alone at any point after the threat is identified. By acting expeditiously in these types of high-risk situations, we are putting forth a good faith effort to mitigate further risk and potential harm. Patient attendance compliance should be completed through direct observation of the patient attendant by department charge RN...If the MD at any times feels the patient is a threat to himself or others and this has not been identified by the nursing staff, he/she will alert the charge RN so that appropriate precautions will be placed..."
During an interview with Hospitalist [Physician #1] on 12/5/2022 at 11:28 AM, he stated "...We reviewed the Suicide Prevention Policy and SBAR with the physician's during the Hospitalist meetings held on September 29, 2022, and October 6, 2022..."

During an interview with the Risk Manager on 12/5/2022 at 10:15 AM, she stated "...He [Patient #3] was evaluated 9/21/2022 by psych Nurse Practitioner. He denied OD [over dose] was intentional and was felt to not require involuntary hold. On 9/22/2022, he was having mild symptoms of opiate withdrawals and shared with the medical doctor that he had experienced chronic suicidal ideation since he was 16 years old. Psych was asked to re-evaluate the patient and placed an involuntary hold. This was communicated to the RN who had just received a post op amputation in the room next door. While the physician was communicating with the RN, the patient slipped out of the room and left. The patient was left unattended for a maximum of 10 minutes ...The sitter had just gotten to the unit. The patient was not found on the property so metro police was notified and the patient remained unfound. The following day, the mother called because the patient was in her home in the shower. She told us that he was unwilling to be committed and left her home prior to the police arriving ...I have spoken with the mother and his sister on numerous occasions, and they are not surprised by anything he does and allows him to come to eat and shower in the home but that is it because he has taken advantage of them and stolen things to pay for his addiction..."

During an interview with the Risk Manager on 12/5/2022 at 11:45 AM, she stated "...we review every event that takes place during staff huddles. It's our practice to review the event at each unit shift changes every two weeks...The travel nurse received education for 2 weeks over the 6440 policy and the sitter policy...The sitter policy was reviewed at the quarterly meeting on the units..."

During a telephone interview with Registered Nurse (RN) #1 on 12/9/2022 at 2:10 PM, he stated "...He [Patient #3] was not initially placed on a 6404 for the first few hours that I had him...I received a patient from the PACU [Post-Anesthesia Care Unit] in the room next door and was trying to get him settled in. I was having trouble getting his oxygen saturation...I stepped out in the hallway and the Nurse Practitioner stopped me and informed me that she was going to place him [Patient #3] on medical hold ...I stepped back into the room with the patient to finish getting him settled and then went into his [Patient #3]'s room and he was not there. It was maybe 5-10 minutes getting the PACU patient settled...One contributing factor I think was we were short 2 techs and he would have normally had one with him..."