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Based on medical record review, document review, and interview, in one (1) of nine (9) medical records reviewed, the facility failed to ensure a patient admitted to a non-psychiatric unit for medical and psychiatric diagnoses, received care in a safe setting. Specifically, the facility failed to:

(a) Continue to implement mitigating strategies and patient safety measures when 1:1 special observation for suicidality was discontinued.

(b) Monitor and conduct patient hourly rounding after 1:1 special observation was discontinued to ensure a safe patient environment.

These failures may have caused the death by suicide of Patient #1 and may result in serious adverse outcome to other patients.


See Findings - TAG A 144.

Based on medical record review, document review, and interview, in one (1) of nine (9) medical records reviewed, the facility failed to ensure a patient admitted to a non-psychiatric unit for medical and psychiatric diagnoses, received care in a safe setting. Specifically, the facility failed to:

(a) Continue to implement mitigating strategies and patient safety measures when 1:1 special observation for suicidality was discontinued.

(b) Monitor and conduct patient hourly rounding after 1:1 special observation was discontinued to ensure a safe patient environment.

Findings include:

Review of Patient #1's Medical Record (MR) identified: A 72-year-old male brought into the Emergency Department (ED) by Emergency Medical Services (EMS) from home on 11/30/2022 at 5:11 PM, for chief complaints of not eating and drinking for 3 days and wanting to die.
One to one 1:1 special observation was initiated.

At 5:27 PM, a Columbia Suicide Screening Rating Scale, CSSR (a tool used to assess the severity and immediacy of suicide risk), was completed. The patient was identified High Risk for Suicide.

The patient was evaluated by medical and psychiatry services. He was admitted to the Medical Floor B4 with diagnoses of Major Depressive Disorder, and Acute Kidney Injury (AKI), and received medical and psychiatric management. Psychiatry follow-up continued.

Review of the Special Observation Forms for Psychiatry 1:1 Suicidal Ideation, noted, patient received special observation hourly from 11/30/2022 to 12/12/2022, with mitigation approaches and patient safety measures implemented.

On 12/12/2022 at 12:12 PM, Psychiatry evaluation documented:
"On 12/12/2022 at 12:12 PM, Psychiatry attestation documented patient continued to report wish for death but simultaneously stated enjoying the food and company, pleased with his physical environment, and hopeful for his physical recovery. When this contradiction was pointed out to the patient, patient stated "Maybe I'm crazy" while laughing. Denied Suicidal Ideation (SI), denied plan or intent for suicide. okay to discontinue suicide 1:1.
Cognitive impairment remained evident but was improving. Patient on this day displayed deficits in attention, language (word-finding difficulties), remote memory, and processing speed. Also, significant bilateral intention tremor.
Possibly improving with B12 repletion.
- Ok to discontinue suicide 1:1; Deferred to nursing assessment for need for additional observation level.
- Continue mirtazapine (antidepressant) 7.5 mg at bedtime.
- No psych contraindication to discharge to SAR (Sub-Acute Rehabilitation) care at this time; Patient should have psychiatric follow-up while there."

Special Observation Forms for Nursing 1:1, from 12/12/2022 to 1/4/2023, documented the patient was continued on hourly special observation every shift with environmental checks completed including, but not limited to, removal of potentially harmful objects from bedside, locker/closet, and bathroom.

From 1/4/2023 to 1/28/2023, the medical record did not have documented evidence staff continued Special Observation including hourly monitoring and implemented mitigating approaches and patient safety measures to ensure a safe patient environment.

On 1/28/2023 at 7:15 AM, the patient was found in bed by the Patient Care Assistant (PCA) with plastic bag over the head and unresponsive. Resuscitation was initiated and a Code was called. Resuscitation was unsuccessful. The patient was pronounced dead on 1/28/2023 at 7:40 AM.

The facility's Administrative Policy and Procedure titiled, "Suicide Screening and Assessment in General Hospitals Settings," Date revised 7/21, documented the following:

"Purpose:
To provide guidelines for the performance of suicide screening and assessments in emergency, inpatient care, and ambulatory settings (this policy does not apply to inpatient and emergency behavioral health settings), and institute mitigation strategies and patient safety precautions on those case identified at risk.

The Joint Commission's National Patient Safety Goal (15.01.01) mandates that health care organizations identify and care for patients who are potentially at risk for suicide. Non-psychiatric units are not expected to be ligature resistant; however, the units should minimize the risks in the environment for patients identified at risk for suicide ...

Definitions: (includes)
Environmental Risk Assessment - a systemic process whereby environmental features that may increase the risk of suicide is identified. It includes undertaking a review of the area(s) to identify:
-Structures or fittings which could be in a suicide attempt by hanging, strangulation, or asphyxiation.
-Obstruction to observing high risk patients.
-Identifying potential ligatures/ligature points.
-Identifying other risks for self-Harm or suicide in the physical environment. Mitigation of identified risks are a component of the overall risk assessment.

Procedure:...
- In General Care hospitalization units and Emergency Departments, the Special Observation form (MS ELM 309, Pink color) will serve as documentation for a patient on 1:1 observation assessed at risk for suicide. Included on this form are environmental risk mitigation strategies and patient safety precautions.

- For Hospitalized patients on General Care Floors, the need to continue appropriate mitigation strategies and patient safety precautions for suicidality will be reassessed by the Consultation Liaison Psychiatrist collaborating with the treatment team.

-The decision to continue appropriate mitigation strategies and patient safety precautions for suicidality will only be made by the Consultation Liaison Psychiatrist. The Psychiatrist's face to face evaluation and recommendation are required to discontinue the mitigation strategies and patient safety precautions.

In addition, in all cases, staff must implement mitigation strategies and patient safety precautions geared to remove, when possible, and without interfering with medical care, any high-risk items from the immediate vicinity of the patient.

Mitigation strategies and patient safety precautions may include but not limited to:

-Mitigation strategies/modification to the patient's environment to provide a safe environment. Staff conducts environmental checks and are aware of potential risks.

-1:1 Observation-a special observation level where 1 staff is assigned to 1 patient.
Staff must maintain direct observation and be within arm's length of the patient at all times ...

-Sharp objects/ plastic wrappings on meal trays will be removed by the staff member prior to reaching the patient.

-Plastic bags are removed from the immediate surroundings of the patient....

The facility's Nursing policy and procedure titled, "Observation of Patients in General Care Units (Special Observation)," dated 11/30/2021 includes:...

Policy:
Nurse Initiated Special Observation
-Nurse may request or initiate special observation
-Nurse initiated special observation does not need a physician order....

a. Special observation if indicated: document on Page 2 of the Special Observation record/EMR (Electronic Medical Record).
b. Special observation if not indicated: document on the EMR indicating reasons and interventions implemented to keep patient safe. NM will communicate decision to the referring health care professional.
-NM/Supervisors can adjust or discontinue patient special observation level at any time based on their assessment of the patient behavior and response to intervention.

There was no documented evidence a nursing assessment was completed to justify the discontinuation of Nursing 1:1 Special Observation on 1/4/2023.

During interview with Staff C, Charge Nurse RN, on 2/9/2023 at 12:20 PM, Staff C stated, Medical unit takes care of suicidal patients with medical problems. Suicidal assessment using the CSSR tool is completed on admission. If patient has Suicidal Ideation, the doctor, psychiatry, and the nursing supervisor are notified. The patient is placed on 1:1 hourly watch, a PCA is assigned...
Staff C stated a safe environment is maintained for the patient. Two (2) nurse environment check is done. Make sure bathroom is checked. Belongings are removed and secured. The PINK form is completed. Make sure garbage is paper bag and not plastic and speak with housekeeping. Tray with no plastic knife.
Visitors and families are checked.
Staff C was asked what happens to the PINK form if Suicide 1:1 is discontinued? What happens to patient monitoring and environmental checks? Staff C stated Psychiatry comes to do a face-to-face evaluation and writes the order to discontinue the watch, no more hourly checks, and environment checks are done.

Per interview with Staff D, RN Supervisor on 2/10/2023 at 10:16 AM, the following information were obtained: Staff D stated an incoming PCA found Patient #1 with clear plastic bag over head, with plastic bag similar to the garbage bag. Staff explained they use the regular transparent bag in the patient's room, unless the patient is on 1:1, then, paper bags are utilized. Garbage in the room and bathroom were checked and found with plastic bags in.

-Staff D indicated Patient #1 had psychiatric and medical issues so was admitted to the medical floor. Patient was identified on CSSR assessment with Suicidal Ideation. Suicide 1:1 Observation was implemented. Staff D explained CSSR is done on admission and on any change in patient's condition.

-Staff D explained, Patient #1 was getting better, no more on 1:1 Suicidal precautions, including checks, and no more PCA at bedside.


As per interview with Staff J, RN Chief Nurse Officer (CNO) on 2/13/2023 at 1:50 PM, Staff J validated the mechanism of monitoring suicidal patients in the medical floor.
Staff J explained for patient safety watch, the nursing supervisor can initiate or take- off safety watch......
-Staff J was asked what the expectations are for patient monitoring and mitigation approaches to implement, if 1:1 suicide is discontinued for a Psychiatric patient in a Medical Unit? Staff J stated if psychiatry decides the patient is no longer suicidal 1:1 observation, an order is made to discontinue Suicide 1:1 Special Observation and mitigating risks approaches are discontinued.
One-to-one watch is off unless another patient safety reason like 1:1 for fall is identified.

-Staff J was asked to explain the facility's Administrative Policy and Procedure on "Suicide Screening and Assessment in General Hospitals Settings" which indicated: "In addition, in all cases, staff must implement mitigation strategies and patient safety precautions geared to remove, when possible, and without interfering with medical care, any high-risk items from the immediate vicinity of the patient." Staff J stated the statement is meant for patients identified at high risk for suicide.

During interview with Staff G, Attending Psychiatrist on 2/13/2023 at 10:49 AM, the following information were obtained:
Staff G verbalized recollection of patient during end of November and early December. A consult to Psychiatry was made for the patient starving himself and not eating.
Staff G stated the first few times the patient had cognitive impairment, difficulty with comprehension, and indicated suicidal attempts. Staff G stated diagnoses were possibly delirium and underlying dementia. Patient had also history of being alcoholic. Attempted to obtain collateral but was not successful.
Staff G explained the patient was placed on Suicide 1:1 Special Observation. The patient was assessed to have elevated risk for suicide with suicidal attempts, with intent and plan. Psychiatry team followed-up the patient. This was communicated to medical and nursing team.
Staff G explained the patient later improved, did not have acutely elevated suicide risks. At times the patient reported SI of which he was inconsistent and later says it was a joke. The patient demonstrated behavior of which he was no longer suicidal. Patient communicated he had gained strength, liked, and ate the good food, and enjoyed team interaction. Patient did not endorse symptoms of suicidal ideation. His mental function improved and denied wanting to take away his life.

-Staff G explained intermittently, the patient mentioned thoughts of suicide but no intent and plan to do it. It was determined because of no plan and no intent; patient did not need the 1:1 watch...

-Staff G stated he spoke with the medical team who communicated the patient was doing well, walked around the unit, and was anticipating placement to an assisted living. Team got in touch with the family and determined patient would best be discharged to an assisted living because of some cognitive impairment and for emotional support from a supportive environment.

-Staff G stated he was made aware of the event by the Director of Psychiatry several hours after the patient expired.

During interview with Staff H, Director of Psychiatry on 2/13/2023 at 11:40 AM, the following information were obtained. Staff H stated he received an alert notification that day of event, and subsequent communication followed. Staff H explained he volunteered to Risk Management to review the case.
Staff H stated standard of psychiatric care was met.
Staff H explained the patient was assessed and identified suicidal. Patient was placed on 1:1 observation. Based on clinical assessment, 1:1 was removed when patient showed improvement. Once the Suicide 1:1 observation is discontinued, the expectation was for nursing to assess and continue the 1:1.

The facility's policy on 1:1, was reviewed with Staff H. Staff H explained, once the patient is on a 1:1 observation, or a 2:1 observation, the form should be filled up and completed including hourly watch and mitigation measures. After the doctor discontinues the 1:1 observation, it becomes a routine nursing care.

Staff H stated Joint Commission had a requirement on Suicidal Ideation. Staff was asked to provide a printed copy. Joint Commission requirement National Patient Safety Goal (NPSG 15.01.01, EP) was reviewed with Staff H. Staff H stated requirement mentioned the use of validated screening tools for suicide.


Review of the facility's Video recording of B4 Medical Unit, dated 1/28/2023, for the timeframe 12:00 AM to 8:00 AM, revealed Patient #1 was not monitored, and patient rounding was not conducted from 12:31 AM to 7:13 AM. There was a 6 hours and 42 minutes gap.

During interview with Staff L, RN on 2/13/2023 at 3:47 PM, Staff L stated when he was giving report, heard the PCA reporting patient had a bag over his head. Plastic bag was transparent, bag taken off, pulled over his face. Cardio-Pulmonary Resuscitation (CPR) was started and a Code was called. Resuscitation was unsuccessful. Patient was found pale. Both hands were straight upward and was placed down.
Staff L stated the last time he saw the patient was,"can't remember exactly, but was between 4:00 AM or 6 AM."
Staff L explained if a patient is discontinued for Suicide 1:1 by psychiatry, no more 1:1 monitoring and no more environment checks.

As per interview with Staff J, RN Chief Nurse Officer (CNO) on 2/13/2023 at 1:50 PM, Staff J stated there is a Nurse Rounding practice tool when nurses make rounds and check on the regular patients on a medical floor. Hourly rounding is done to check on patients for pain, position, and others. The nurses are not required to document the rounding. The facility had no written policy and procedure for same.

Based on medical record review, document review and staff interview, in one (1) of five (5) medical records reviewed, the hospital did not ensure that its process for investigation and management of a sexual assault incident was fully implemented.

Findings include:

Review of the Medical Record for Patient #2 identified: On 11/23/22 at approximately 1:37 PM, a Spanish speaking patient arrived at her scheduled appointment at the Orthopedic Out-patient clinic, with a complaint of hip pain. The patient medical record noted a need for an interpreter. The patient arrived at the enclosed examination room and the physician, Staff T, proceeded with the examination. There was no documentation an interpreter was provided.
Patient #2 left the examination room and informed Staff V, Head Nurse, that she was sexually assaulted. The patient stated Staff T, physician, asked her to walk forward, he was behind the patient. Then Staff T, physician, went on to rub his penis against her buttocks. Staff V, Head Nurse informed Staff W, Nurse Manager. Staff W Informed Patient Relations of the incident. The hospital was aware of the allegation of sexual abuse on 11/23/22.
Hospital Patient Relations Department investigated on 11/29/22. Patient Relations then referred their investigation to the Department of Risk Management. Risk management then met with their team regarding this abuse on 12/1/22. The facility's investigation of the abuse was determined unsubstantiated.

The hospital policy titled "Abuse, Mistreatment and Neglect," section titled "Procedure Inpatient and Outpatient Allegation of Abuse," states, "The Department Supervisor who receives the notice will immediately separate the patient and identified involved staff member. If the allegation is deemed seriously egregious and the perpetrator is a staff member, the individual will immediately be relieved of duty for the remainder of the tour and referred to Human Resources/Labor Relations.

Staff T was not removed from the clinic despite the facility knowledge of the sexual assault. Review of staffing plans for the month of November 22,2022 the physician remained working at the clinic for an additional 6 days. Staff T received a suspension from work on 11/29/2022 by medical staff contractor.

During interview and document review with Elmhurst regarding staff not removed, Staff A stated that removing staff from the facility does not fall under the Risk Management Department, that responsibility falls under Labor Relations. Risk management conducts the investigation and meets with their team on the incident but does not remove staff from the facility, only the Labor Relations Department can do that.
During interview and document review with Elmhurst staff, it was identified the facility did not inform the medical staff contractor of the sexual assault until 11/28/23- six days after the assault.

At interview with Staff Z, Elmhurst Contractor Administrator for Medical Staff on 2/10/23, he informed the surveyor that Elmhurst Medical Staff contractor only provides medical staff to the hospital. The medical staff follows Elmhurst hospital's policies not the contractors' policies. The contractor proceeded to suspend Staff T, physician, the next day on 11/29/23.