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Based on observations, facility policy and procedures, ED (Emergency Department) medical records, and staff interviews, it was determined the facility failed to ensure the staff followed the policy and procedures for patients who presented to the ED with Suicidal Risks as follows:

1. Personal belongings were inventoried for possible items that could be used for self-harm per policy.

2, The staff documented removal of ligature risks objects from the patients' treatment area.

3. Patient behaviors were documented every 15 minutes.

4. Suicidal risk re-assessments were completed upon transfer out of the ED.

These deficient practices affected ED Patient Identifier's (PI) # 2, # 3 and # 1, which was 3 of 3 records reviewed for ED patients identified at risk for self-harm and had the potential to negatively affect all at risk patients.

Findings include:

Policy: Suicide Assessment and Preventions
Policy # 9004
Department: Patient Care Services
Reviewed: 05/22/2018

Purpose:

To outline the process for the timely assessment and reassessment of patient's suicide risk and to provide guidelines for safety interventions.

Policy:

It is the policy of Mizell Memorial Hospital to create an environment of care that will foster the accurate identification and successful management of patients who are at increased risk of suicide or self destructive behaviors. Patients at risk for suicide requires intensive support, close observation, and frequent re-assessment and application of protective measures for their emotional and physical well be at all times. The scope for this plan begins with any patient presenting to our hospital for treatment.

Procedures:

A. Assessment of Suicide Risk:

Initial suicide risk assessments must be performed by members of the clinical staff as part of assessment on all patients.

...The initial suicide risk assessment will include specific factors including:

Presence of suicidal ideation at the time of the assessment
Intent to perform self-harm at the time of assessment
Presence of a plan to carry out the self-harm or attempt suicide...How, When, Where
Previous suicide attempts
Date
Methods used to cause self-harm
How often the thoughts of self-harm and/or suicide occur
Any contributing factors. i.e. death of a family member...job loss, financial hardships, etc.

B. Reassessment of Suicide Risk:

A Registered Nurse or Licensed Practical Nurse must reassess the risk of self-harm or suicide at least every 12 hours for any patient...on suicide precautions who exhibits a sudden or significant change in mental status.

The assessment should be documented in the Suicide Risk Re-assessment Form...All patients should be re-assessed for risk of self-harm or suicide prior to discharge. If positive findings, the Attending (physician) should be notified immediately prior to discharging the patient.

If the patient is being discharged to a psychiatric facility, then the ideation of self-harm or suicide may still be present...

Documentation of reassessments:

Nursing: Suicide Risk Re-Assessment Form
Physician: Progress Notes

D. Suicide Precautions:

Suicide Precautions will be ordered by the Attending Physican
Staff will document patient behaviors at minimum of every 15 minutes...notify the charge nurse for...suicidal statements or actions...Attempts to gain access to dangerous items such as sharps, cleaning agents, medications...attempt to gain access to contraband

Staff are to maintain a safe and therapeutic environment for patients at risk for self-harm or suicide by implementing the following...

Perform a thorough search of the patient's clothing, personal articles, room, and belonging to ensure that any times (things) which might be used in a self-harmful way are confiscated...Remove all potential ligatures (shoelaces, belts, oxygen tubing not in use, suction tubing...)...sharps (glass, razors, plastic bags, etc...

E. Safety and Environmental Checks:

Staff are to be continually aware of the environment and immediately correct or report any identified risk, damage, missing linens or any other change in the environment to the Charge Nurse.

Levels of Observation:

Line of Sight: A level of observation wherein the patient remains in staff view at all times. A specific staff member is assigned and the line of sight observation occurs in person not by video monitoring.

1. ED PI # 2 presented to the ED on 6/23/19 and was triaged at 12:23 PM, the chief complaint, Overdose-Intentional and Suicide Attempt.

Review of the 6/23/19 RN Triage Intervention and Suicide Risk Assesment revealed "yes" documented for thoughts of suicide, plan to carry out suicide, previous suicide and frequent thoughts to harm self. The previous suicide attempt was last year and the method used was overdose.

Review of the ED physician history/physical exam (examination) documentation dated 6/23/19 (no time was documented) revealed a history of ADHD (attention deficit hyperactivity disorder) and anger issues. The clinical impression was overdose and attempted suicide.

Review of the physician orders dated 6/23/19 revealed there was no documentation of an order for suicide precautions

Review of the 6/23/19 ED Nurse Note documentation revealed at 12:35 PM, patient to room 2, placed in gown. There was no documentation staff performed a thorough search of personal belongings, inventoried/removed belongings which could be used in a self-harm way and all potential ligatures in the environment were removed.

At 12:50 PM, the ED RN documented "Tech at bedside for one on one care." There were no physician orders for one on one suicide precautions documented in the medical record.

There was no documentation of patient behaviors/monitoring performed on 6/23/19 from 12:50 PM to 1:32 PM, which was 42 minutes, and from 1:35 PM to discharge at 2:11 PM, which was 36 minutes. Staff failed to ensure patient behaviors were documented at a minimum of every 15 minutes.

There was no documentation staff performed a suicide risk re-assessment when the patient was transferred to the Intensive Care Unit.

In an interview on 7/11/19 at 10:14 AM, EI # 2, Director of Senior Behavioral Care, confirmed staff failed to follow the facility policy. There was no documentation staff ensured a safe/therapeutic environment was maintained, no orders for suicide precautions were obtained, behaviors were not documented at least every 15 minutes and no suicide re-assessment was completed at transfer.

2. ED PI # 3 presented to the ED on 7/6/19 with the chief complaint Suicidal Ideation. The ED RN documented the patient was in the trauma bay.

Review of the 7/6/19 1:35 PM ED RN Triage documentation and Suicide Risk Assessment revealed "yes" documented for thoughts of suicide and plan to carry out suicide. Meds (medications) were documented as how to carry out the suicide plan. In addition, the narrative documentation revealed patient reports drinking a fifth of liquor daily.

Review of the ED physician history/physical exam documentation dated 7/6/19 at 2:30 PM revealed a history of Depression and Suicidal Ideation. The clinical impression was Depression and Alcohol Abuse.

Review of the physician orders dated 7/6/19 revealed no documentation of orders for suicide precautions.

Further record review failed to include documentation staff performed a thorough search/inventoried personal belongings, removed belongings which could be used in a self-harm way and all potential ligatures in the environment (trauma bay) were removed.

There was no documentation the patient was placed on suicide precautions while in the ED, no 1:1 care, or line of sight documented.

There was no documentation staff performed a suicide re-assessment when the patient was transferred to the SBCU (Senior Behavioral Care Unit) at 3:47 PM.

In an interview on 7/11/19 at 10:18 AM, EI # 2 confirmed the aforementioned findings.

3. ED PI # 1 presented to the ED on 6/17/19, was triaged at 12:03 PM, with the chief complaint SI (Suicidal Ideation). At triage, the ED RN documented cut R (right) FA (forearm), with a piece of glass, patient states "I want to commit suicide."

Further review of the 6/17/19 ED RN triage documentation revealed Suicide Risk Assessment documentation: thoughts of suicide, plan to carry out suicide were yes, plan how was cut wrist, frequent thoughts to harm self and previous suicide attempt was yes.

In addition, the 6/17/19 ED RN triage documentation revealed the patient was placed in ED room 2 with 1 on 1 care, was agitated and exit seeking. The record included physician orders for restraint use dated 6/17/19 at 12:15 PM.

Review of the 6/17/19 ED physician history and physical exam documentation performed 6/17/19 at 2:10 PM revealed the patient wanted to commit suicide by self-inflicted wounds. Review of the physician orders dated 6/17/19 revealed no documentation of an order for suicide precautions.

In an interview on 7/11/19 at 10:20 AM, EI # 2 verified the above findings.