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Based on record review, Medical Staff Rules and Regulations and interview with staff the government body failed to ensure the medical staff was accountable to the governing body for the quality of care provided to patients by not 1) reassessing 1 of 1 patients (patient #1) in a total sample of 6 for injuries upon return to the Emergency Department after eloping, 2) providing psychiatric consults for 2 of 2 patients (patient #1 and patient #2) as indicated in the Emergency Department policy and procedures and 3) referring 2 of 2 patients with psychiatric diagnoses to the Mental Health Clinic or rehabilitation facility as indicated in the Medical Staff Rules and Regulations.
Findings:

1. Review of the ED (Emergency Department) log revealed patient #1 was a 74 year-old who presented by ambulance on 6/15/2011 at 8:20 PM (this reveals the patient was triaged before being admitted to the hospital) from Nursing Home A with chief complaint of "overdose". The nurse documented that patient #1 ingested 8 Vistaril 50 mg capsules. Further review revealed the triage nurse asked the patient "why she took them" and she stated "to commit suicide, what else. The triage nurse also documented patient #1 was an "Alzheimer's" patient with a history of heart disease, hypertension, diabetes, anxiety and high cholesterol. Review of the 6/15/2011 at 8:12 PM initial assessment revealed patient #1 needed assistance with activities of daily living and was oriented to person, place and time.

Documentation by S4 LPN on 6/15/2011 at 9:30 PM revealed patient #1 "came to the nurses' station and said she was ready to go back to (Nursing Home A). Documentation revealed at that time the nurse asked patient #1 to return to her room and they (staff) would check on the results of her lab (psych panel was ordered and the results were in within normal limits).

Further documentation revealed on 6/15/2011 at 9:35 PM (5 minutes after patient #1 was talking with staff at the nurses' station) the patient was not in her room and security was notified. According to the ED record patient #1 was found at 10:20 PM (45 minutes after staff noticed that the patient was not in her room)" on a street near the hospital. Pt. is returned to hosp. (hospital) pt. removed sl (saline lock) from (left) FA (forearm)" . The patient's ED record revealed S1 MD wrote orders to send patient #1 back to the local nursing where she was transported from due to possible drug overdose. Review of the ED record revealed S1 MD failed to examined patient #1 for injuries upon return to the hospital. There failed to be documented evidence that the physician (S1 MD) notified the receiving facility (local nursing home) and also failed to write an order for a psychiatric consult as indicated in the ED policy. There also failed to be documented evidence that the physician referred the patient to a Mental Health Clinic as addressed in the Medical Staff Rules and Regulations.

2. Review of the medical record revealed patient #2 was a 22 year-old who presented to the ED on 4/11/2011 at 1:10 PM with chief complaint of suicidal ideation, anxiety, depression, suicide thoughts and unable to sleep. Review of the ED nurses' notes revealed the patient was triaged at 1:35 PM and his blood pressure was 153/96, heart rate 56 beats per minute, respirations 16 breaths per minute and temperature 98.7 degrees F. The ED (Emergency Department) record revealed that the triage nurse assigned patient #2 to the orthopedic room.

Further review of the ED form revealed patient #2 was in the Orthopedic room and was not seen by the physician until 2 hours and 10 minutes later. There was no documentation of physician orders, interventions or change in the patient's condition during that time. There also failed to be documentation that the patient was observed continuously due to his chief complaint of suicidal thoughts.

Review of the 4/11/2011 at 3:20 PM physician's Emergency Physician Record for patients who present to the hospital with psych disorder, suicide attempt and overdose revealed patient #2's chief complaint was depression and has threaten to kill himself. Further review revealed S10 MD documented that the onset was "pretty good while ago" and the behavior is "continuing in the ED". Further documentation revealed the patient had symptoms of "depressed, angry, frustrated and hostile".

S10 MD documented that he explained the results of his (patient 2's) examination to him at 3:45 PM and gave the patient a prescription for Klonopin 0.5 mg (milligrams) 3 times a day. Further review revealed S10 MD discharge the patient home at 4:20 PM in stable condition.
Review of documentation in the ED records for patient #2 revealed the physician ((S10 MD) failed to write an order for a psychiatric consult as indicated in the ED policy. In an interview on 6/27/2011 at 10:20 AM S8, ED Manager confirmed the above findings. According to documentation in the ED record for patient #2 the physician (S10 MD) failed to refer the patient to the Mental Health Clinic or rehabilitation facility as indicated in the Medical Staff Rules and Regulations.

Review of the Medical Staff Rules and Regulations revealed "There shall be appropriate referral of patients who are emotionally ill to the area Mental Health Clinic or area rehabilitation facility as determined by the attending Physician".

Review of the "Emergency Department Psychiatric Assessment" policy approved 3/02/2011 revealed "all patients presenting with possible psychiatric emergencies will be appropriately evaluated" Further review revealed the purpose of the policy was to "provide a standard of care for all patients treated in the ED for psychiatric emergencies "including" overdose, suicide threats/attempts, self inflicted gunshot wounds, cut wrists, self mutilation, overdose " and "homicidal" . The procedure section indicated that the "ED physician will arrange for transfer of the patient to appropriate facility as soon as possible" and "the physician is responsible for notifying the receiving facility and arranging for psychiatric consult".

Based on record review and interviews the hospital failed to meet the requirement for the Condition of Participation for Patient Rights by failing to ensure patient #1, who was transported from the Alzheimer's unit at Nursing Home A and presented to the ED of Morehouse General Hospital was placed in a safe setting. Patient #1 had a chief complaint of intentional drug overdose, suicidal thoughts. S1 MD's clinical impression of her was drug overdose intentional and attention seeking. Staff placed the patient in trauma room 4 at the distal end of the hall away from the ED's nurses' station. This room was observed on 6/23/2011 at 2:00 PM to have an unlocked cabinet containing Betadine, Peroxide (chemicals), 2 sharp containers with dirty needles, blood pressure tubing, electrical cords that were greater than 2 feet in length, non break-away curtains hanging from the ceiling, plastic trash can liners and electric fan with metal blades. Staff failed to continuously observe patient #1 on 6/15/2011 which resulted in the patient eloping.

An Immediate Jeopardy situation was identified by the survey team on 6/23/2011 at 4:14 PM and was reported to the Chief Nursing Officer and the Administrator. It was determined that the hospital failed to 1) ensure a policy and procedure was developed and implemented to ensure the safety of patients presenting to the emergency department with a diagnosis of suicide attempt, suicide ideations, and drug overdose, 2) ensure a safe environment was provided for patient #1 who was sent to the Emergency Department from a secure unit in a nursing home with a diagnosis of Alzheimer's, suicide attempt, suicidal ideations, and drug overdose. The hospital further failed to monitor patient #1 after being assessed by S1MD as being currently suicidal and placing patient #1 in a room located at the distal end of the hall away from the Emergency Department nursing station. The hospital further failed to ensure staff was assigned to continuously observe patient #1, resulting in the patient eloping from the Emergency Department on 06/15/11 at 9:35pm. The hospital further failed to remove dangerous items from the exam room in the Emergency Department that posed a risk to patients with suicidal ideations prior to assigning patient #1 who had suicide ideations to the exam room as evidenced by sharps containers with dirty needles, blood pressure tubings, electrical cords 2 feet in length, and chemicals (Betadine and Peroxide) stored in an unlocked cabinet available in the exam room.

The hospital's corrective plan of action was submitted on 6/24/2011 at 3:40 PM by the Chief Nursing Officer and Administrator to address the Immediate Jeopardy situation which revealed the hospital implemented the following:
1) Ensure the safety of patients presenting to the Morehouse General Hospital Emergency Department with a diagnosis of suicide attempt, suicidal ideations and drug overdose by implementation of policy #ER 03.01.01 Care of Patients in the ER with Psychotic Symptoms, Suicidal or Homicidal Ideation, and Violent Behavior.

2) Educate staff concerning Care of Patients in the ER with Psychotic Symptoms, Suicidal or Homicidal Ideation, and Violent Behavior policy #ER 03.01.01.

3) Educate staff concerning care and observation of the suicidal patient.

4) Implementation of security involvement as noted in the policy #ER
03.01.01 Care of Patients in the ER with psychotic symptoms, suicidal or homicidal ideations, and violent behavior.

5) Ensure the safety of patients presenting to the Morehouse General Hospital Emergency Department by installing an alarm installed on Endoscopy door leading from the Emergency Room.

6) The Emergency Department will monitor the suicide attempt, suicidal ideation and drug overdose patient by reassessing patients at clinically significant points as noted in the policy # ER03.01.01 care of patients in the ER with psychotic symptoms, suicidal or homicidal ideations, and violent behavior. Observations will be documented every 15 minutes on the suicidal patient on the "Observation Flow Sheet." However , the need may occur to document more frequent due to patient's stability.

7) The Emergency Department will ensure patient safety by placing the patient in the closest room available to the nurses' station and will be free of any harmful materials/items such as sharp containers with needles, blood pressure tubing, electrical cords and chemicals such as (Betadine and Peroxide) that is not in a locked cabinet.

8) Reassessment of the patient will be documented on the newly developed physician's T-Sheet.

9) The patient's disposition will be determined by the ED physician. If the physician determines the environment is unsafe for the patient to return, the social worker will be contacted to work on a discharge plan.

10) Reeducate staff regarding occurrence reporting policy #AS15.03.00

11) Monitor the care provided to the patient with suicide attempt, suicide ideations and overdose to prevent the likelihood of the practice reoccurring consistent with current QA/PI Plan. A patient with a diagnosis of suicide, suicide ideations and overdose will be incorporated in the ED Quality Improvement Plan. A critical indicator log will be completed by the employee providing care to the patient. The Department Head, Chief Nursing Officer and/or Risk Manager will be notified as soon as possible but no later than 24 hours after the admission to the ER.

12) Educate staff concerning the policy ER09.14.17 "Initial Management of Overdose, Accidental Ingestion of Medication or Poisoning".

As a result of the hospital's plan of removal the Immediate Jeopardy was removed on 6/24/2011 at 3:40 PM and remains cited at condition level. See findings cited at A0144.

I. Based on observation, record review and interview with staff the hospital failed to ensure 2 of 2 patients (#1, #2) in a total sample of 6 patient received care in a safe setting who presented to the Emergency Department with psychiatric diagnoses by failing 1) to ensure a safe environment was provided for patient #1 who was sent to the emergency department from a secure unit in the nursing home with a diagnosis of Alzheimer's suicide attempt suicidal ideations and drug overdose, 2) monitor patient #1 after being assessed by S1 MD as being currently suicidal and by placing patient #1 in a room located on the distal end of the hall away from the Emergency Department nurses' station and 3) to remove dangerous items from the exam rooms in the Emergency Department that posed a risk to patients with suicidal ideations prior to assigning patient #1 who had suicide ideations in the exam room as evidenced by sharp containers with dirty needles, blood pressure tubings, electrical cords 2 feet in length, and chemicals (Betadine and Peroxide) stored in an unlocked cabinet available in the exam room; 4) assign staff to provide continuous observation for patient #2 who had diagnoses of suicidal ideations and 5) remove dangerous items from the exam rooms in the ED that posed a threat prior to making room assignments. Findings:

Patient #1

Review of the ED (Emergency Department) log revealed patient #1 was a 74 year-old who presented by ambulance on 6/15/2011 at 8:20 PM (this reveals the patient was triaged before being admitted to the hospital) from Nursing Home A with chief complaint of " overdose". The nurse documented that patient #1 ingested 8 Vistaril 50 mg capsules. Further review revealed the triage nurse asked the patient "why she took them" and she stated "to commit suicide, what else. Pt. (patient #1) found meds (medications) in her purse and (bottle) was dated 8/14/09". The triage nurse also documented patient #1 was an
"Alzheimer's" patient with a history of heart disease, hypertension, diabetes, anxiety and high cholesterol. The triage nurse assessed patient #1's condition as non-urgent.

Review of the ED physician Record revealed at 8:20 PM S1MD, (the ED physician who examined patient #1 on 6/15/2011) documented that patient #1 was the " historian " (she gave an account of what happen to her before being transferred from Nursing Home A to Morehouse General Hospital). Documentation by S1 MD revealed the patient ' s chief complaint was "intentional drug overdose" her intent was suicide and she had thoughts of suicide.

Documentation by S4 LPN on 6/15/2011 at 9:30 PM revealed patient #1 "came to the nurses' station and said she was ready to go back to (Nursing Home A). pt. (Patient #1) said she was not going to drink anymore charcoal because she has heart stents and she didn't take any pills. Pt. stated that she was not waiting anymore" . Documentation revealed at that time the nurse asked patient #1 to return to her room and they (staff) would check on the results of her lab (psych panel was ordered and the results were in within normal limits).

Further documentation revealed on 6/15/2011 at 9:35 PM (5 minutes after patient #1 was talking with staff at the nurses' station) the patient was not in her room and security was notified. The ED record revealed the entire hospital was searched, at 9:45 PM the local police department was notified of "a missing pt (patient)" and Nursing Home A where the patient resides was informed at 9:50 PM that the patient had left the hospital and to be on the lookout for her.

Review of the local police report revealed the dispatcher received a call on 6/15/2011 at 10:07 PM from S2 RN regarding a "missing patient with Alzheimer's". Further review revealed the police arrived at 10:10 PM and "made contact with ER R. N. nurse, (S2RN). The local police "dispatch notes" revealed S2 RN at Morehouse General Hospital "advised officer (police officer) help was needed ref (reference) to locating a wf (white female) wearing green PJs (pajamas) a PC (psych) patient from (a local nursing home) was missing from the ER. The report also indicated that S2 RN advised them that patient #1 "left out of the side door south end of the hospital" and she left "with out being discharged .

Further review revealed the "officer patrolled the area and was unable to locate (patient #1). A short time later ER contacted the police department and advised that (patient #1) had been located and returned to the hospital" .

According to the ED record patient #1 was found at 10:20 PM (45 minutes after staff noticed that the patient was not in her room) "on a street near the hospital. Pt. is returned to hosp. (hospital) pt. removed sl (saline lock) from (left) FA (forearm)".

On 6/22/2011 at 8:30 AM a telephone interview with S4 LPN who stated on 6/15/2011 patient #1 crawled out of the end of the stretcher with siderails up x 2 walked to the nurses ' station and asked the nurses to call her ride. S4 stated patient #1 told her "I am ready to go back to the nursing home". S4 LPN stated that she informed the patient that she was waiting on her lab work before she could leave the hospital. The patient was instructed to go back to her ED exam room. S4 LPN stated a family member of another patient who was in the ED came to the nurses' station and informed her (LPN S4) that patient #1 walked out the door to the Endoscopy room (this door was attached to the ED). S4 LPN stated she and 2 other employees searched outside the building for the patient. S4 LPN said the security guard notified the local police department, the emergency department notified Nursing Home A that the patient was missing, and 2 CNAs from the nursing home helped look for the patient. A CNA from the nursing home found the patient by the church near the hospital.

S4 LPN stated when patient #1 initially arrived at the ED she was placed in a room that was not visible from the nurses' station and she did not feel the patient needed 1:1 supervision. Further interview with S4 LPN stated after the elopement the patient was placed in a room closer to the nurses' station for supervision and monitoring. S4 LPN stated when a psychiatric patient comes into the emergency department they try to place them close to the nurses' station but it is impossible to continuously monitor the patients because they do not have the staff.

Observation on 6/22/2011 at 2:00 PM of ED trauma room 4 where patient #1 was assigned on 6/15/2011 revealed an unlocked cabinet that contained Betadine and Peroxide (chemicals) that were available to the patient. Further observation revealed 2 sharp containers with dirty needles, blood pressure tubing and electrical cords that were greater than 2 feet in length. There were also non break-away curtains hanging from the ceiling, plastic trash can liners and electric fan with metal blades.

Patient #2

Review of the medical record revealed patient #2 was a 22 year-old who presented to the ED on 4/11/2011 at 1:10 PM with chief complaint of suicidal ideation, anxiety, depression, suicide thoughts and unable to sleep. Review of the ED nurses' notes revealed the patient was triaged at 1:35 PM and his blood pressure was 153/96, heart rate 56 beats per minute, respirations 16 breaths per minute and temperature 98.7 degrees F. The ED record revealed that the triage nurse assigned patient #2 to the orthopedic room. Observation of this room on 6/22/2011 at 2:00 PM revealed the orthopedic room contained blood pressure cuff with tubing, electrical equipment with cords greater than 2 feet in length that would pose a threat to patients with complains of suicide.

Further review of the nurse documentation revealed the only time the nurse saw patient #2 was at 2:30 PM (55 minutes after the patient was triaged) and 3:00 PM (30 minutes after the last documented assessment). Documentation at 2:30 PM revealed "(no) distress noted" and at 3:00 PM "no distress noted family at bedside". There also failed to be documentation that staff monitored the patient continuously for suicide attempts and ideations. Documentation revealed that the patient was discharged home at 4:07 PM and his condition was "unchanged" and he was "stable".

In an interview on 6/27/2011 at 10:20 AM S8, ED Manager confirmed the above findings. S8 stated that patient #2 presents to the ED on a regular basis with the same psychiatric complaint. Further interview revealed the patient often presents to ED at another acute care hospital about 25 miles from Morehouse General for complaints of psychiatric symptoms. He said the nurses in the ED at that hospital always administers "Haldol (anti-psychotic), Benadryl (antihistamine) and Ativan (antianxiety)" to patient #2 and the physician discharges him home.

Based on record review and interview the registered nurse failed to evaluate the nursing care for 2 of 2 patients in a total sample of 6 patients (patient #1 and patient #2) by not: 1) assessing 1 of 1 patients (patient #1) for injuries after crawling off of the stretcher and walking to the nurses' station and upon return to the hospital after eloping from the hospital, 2) reassessing patient #1 for signs and symptoms of overdose, 3)assessing patient #1's temperature and respirations prior to discharging her from the hospital and 4) reassessing patient #1 and patient #2 for suicide. Findings:

1. Review of the ED (Emergency Department) log revealed patient #1 was a 74 year-old who presented by ambulance on 6/15/2011 at 8:20 PM (this reveals the patient was triaged before being admitted to the hospital) from Nursing Home A with chief complaint of " overdose". Review of the ED Record revealed the nurse assessed patient #1 at 8:12 PM as having a blood pressure of 148/75, heart rate 87 beats per minute, respirations 18 breaths per minute and temperature 98 degrees F. The nurse documented that patient #1 ingested 8 Vistaril 50 mg capsules. Further review revealed the triage nurse asked the patient "why she took the" and she stated "to commit suicide, what else. Pt. (patient #1) found meds (medications) in her purse and (bottle) was dated 8/14/09 " . The triage nurse also documented patient #1 was an " Alzheimer's" patient with a history of heart disease, hypertension, diabetes, anxiety and high cholesterol. The triage nurse assessed patient #1's condition as non-urgent.

Review of the 6/15/2011 at 8:12 PM initial assessment revealed patient #1 needed assistance with activities of daily living and was oriented to person, place and time. The assessments also revealed the triage nurse (S2 RN) notified poison control at 8:35 PM and documented that the control center "advised" staff "to watch for sedation and agitation, tachycardia and poss (possible) seizures, and advised the use of activated charcoal". After talking to the poison control center the nurse was instructed to monitor for signs and symptoms of drug over dose for Vistaril. Review of the ED record revealed the nurse failed to document that she assessed patient #1 for signs and symptoms of Vistaril overdose (decreased respirations, bradycardia and agitation) as instructed by the poison control center.

S4 LPN stated patient #1 crawled out of the end of the stretcher with siderails up x 2 walked to the nurses' station and asked the nurses to call her ride. Documentation in the ED record failed to reveal that S4 LPN or S2 RN assessed patient #1 for injuries after crawling out the foot of the stretcher. S4 stated patient #1 told her "I am ready to go back to the nursing home" . S4 LPN stated that she informed the patient that she was waiting on her lab work before she could leave the hospital. The patient was instructed to go back to her ED exam room. S4 LPN stated a family member of another patient who was in the ED came to the nurses' station and informed her (LPN S4) that patient #1 walked out the door to the Endoscopy room (this door was attached to the ED).

Further documentation revealed on 6/15/2011 at 9:35 PM (5 minutes after patient #1 was talking with staff at the nurses' station) the patient was not in her room and security was notified. The ED record revealed the entire hospital was searched, at 9:45 PM the local police department was notified of "a missing pt (patient) "and Nursing Home A where the patient resides was informed at 9:50 PM that the patient had left the hospital and to be on the lookout for her.

Further review revealed the "officer patrolled the area and was unable to locate (patient #1). A short time later ER contacted the police department and advised that (patient #1) had been located and returned to the hospital".

According to the ED record patient #1 was found at 10:20 PM (45 minutes after staff noticed that the patient was not in her room) "on a street near the hospital. Pt. is returned to hosp. (hospital) pt. removed sl (saline lock) from (left) FA (forearm)". There failed to be documented evidence that the nurse assessed the patient for injuries or signs and symptoms of Vistaril overdose upon return to the ED at Morehouse General Hospital.

2. Review of the medical record revealed patient #2 was a 22 year-old who presented to the ED on 4/11/2011 at 1:10 PM with chief complaint of "reports suicidal ideation, anxiety, depression", and "can't sleep". Review of the ED nurses' notes revealed the patient was triaged at 2:00 PM and his blood pressure was 153/96, heart rate 56 beats per minute, respirations 16 breaths per minute and temperature 98.7 degrees F. There failed to be documentation that the nurse assessed and reassessed patient #2 throughout his stay in the ED for signs and symptoms related to his chief complaint. The nurse also failed to obtain vital signs on discharge.

Based on record review and interviews the hospital failed to meet the requirements of the Condition of Participation for Emergency Services by failing to ensure a patient (#1) with the diagnoses of Alzheimer, intentional suicide attempt, suicidal ideation and drug overdose was continuously monitored by hospital staff resulting in the patient eloping from the Emergency department on 6/15/2011 at 9:35 PM. The Local police was contacted by the hospital on 6/15/2011 at 9:45 PM by the security at Morehouse General Hospital to report the patient eloping. The hospital further failed to ensure a physician assessed the patient for injuries after being located and returned to the emergency department for 1 of 1 patients in a total sample of 6 patients (#1).
Findings:

An Immediate Jeopardy situation was identified by the survey team on 6/23/2011 at 4:14 PM and was reported to the Chief Nursing Officer and the Administrator. It was determined that the hospital failed to 1) ensure a policy and procedure was developed and implemented to ensure the safety of patients presenting to the emergency department with a diagnosis of suicide attempt, suicide ideations, and drug overdose, 2) ensure a safe environment was provided for patient #1 who was sent to the Emergency Department from a secure unit in a nursing home with a diagnosis of Alzheimer's, suicide attempt, suicidal ideations, and drug overdose. The hospital further failed to monitor patient #1 after being assessed by S1MD as being currently suicidal and placing patient #1 in a room located at the distal end of the hall away from the Emergency Department nursing station. The hospital further failed to ensure staff was assigned to continuously observe patient #1, resulting in the patient eloping from the Emergency Department on 06/15/11 at 9:35pm. The hospital further failed to remove dangerous items from the exam room in the Emergency Department that posed a risk to patients with suicidal ideations prior to assigning patient #1 who had suicide ideations to the exam room as evidenced by sharps containers with dirty needles, blood pressure tubings, electrical cords 2 feet in length, and chemicals (Betadine and Peroxide) stored in an unlocked cabinet available in the exam room.

The hospital's corrective plan of action was submitted on 6/24/2011 at 3:40 PM by the Chief Nursing Officer and Administrator to address the Immediate Jeopardy situation which revealed the hospital implemented the following:
1) Ensure the safety of patients presenting to the Morehouse General Hospital Emergency Department with a diagnosis of suicide attempt, suicidal ideations and drug overdose by implementation of policy #ER 03.01.01 Care of Patients in the ER with Psychotic Symptoms, Suicidal or Homicidal Ideation, and Violent Behavior.

2) Educate staff concerning Care of Patients in the ER with Psychotic Symptoms, Suicidal or Homicidal Ideation, and Violent Behavior policy #ER 03.01.01.

3) Educate staff concerning care and observation of the suicidal patient.

4) Implementation of security involvement as noted in the policy #ER
03.01.01 Care of Patients in the ER with psychotic symptoms, suicidal or homicidal ideations, and violent behavior.

5) Ensure the safety of patients presenting to the Morehouse General Hospital Emergency Department by installing an alarm installed on Endoscopy door leading from the Emergency Room.

6) The Emergency Department will monitor the suicide attempt, suicidal ideation and drug overdose patient by reassessing patients at clinically significant points as noted in the policy # ER03.01.01 care of patients in the ER with psychotic symptoms, suicidal or homicidal ideations, and violent behavior. Observations will be documented every 15 minutes on the suicidal patient on the "Observation Flow Sheet." However , the need may occur to document more frequent due to patient's stability.

7) The Emergency Department will ensure patient safety by placing the patient in the closest room available to the nurses' station and will be free of any harmful materials/items such as sharp containers with needles, blood pressure tubing, electrical cords and chemicals such as (Betadine and Peroxide) that is not in a locked cabinet.

8) Reassessment of the patient will be documented on the newly developed physician's T-Sheet.

9) The patient's disposition will be determined by the ED physician. If the physician determines the environment is unsafe for the patient to return, the social worker will be contacted to work on a discharge plan.

10) Reeducate staff regarding occurrence reporting policy #AS15.03.00

11) Monitor the care provided to the patient with suicide attempt, suicide ideations and overdose to prevent the likelihood of the practice reoccurring consistent with current QA/PI Plan. A patient with a diagnosis of suicide, suicide ideations and overdose will be incorporated in the ED Quality Improvement Plan. A critical indicator log will be completed by the employee providing care to the patient. The Department Head, Chief Nursing Officer and/or Risk Manager will be notified as soon as possible but no later than 24 hours after the admission to the ER.

12) Educate staff concerning the policy ER09.14.17 "Initial Management of Overdose, Accidental Ingestion of Medication or Poisoning".

As a result of the hospital's plan of removal the Immediate Jeopardy was removed on 6/24/2011 at 3:40 PM and the deficiency remains at a condition level.