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Based on observation, document review and interview, the Hospital failed to ensure that a patient with suicidal ideation was assessed, supervised and was provided care, timely and appropriately. This has the potential to affect all patients who presents to the Emergency Department with suicidal ideation. As a result, the Condition of Participation for Patient Rights, 42 CFR 482.13, was not in compliance.

Findings include:

1. The Hospital failed to ensure that the Patient Flow Coordinator/Charge Nurse (E #11), supervised the suicidal ideation patient appropriately. See deficiency cited at A-0144 -A.

2. The Hospital failed to ensure that the Pivot Nurse (E #8) removed all the personal belongings from the suicidal ideation patient. See deficiency cited at A-0144- B.

3. The Hospital failed to ensure that the Triage Nurse (E #7) immediately notified the ER Physician about the suicide attempt of the patient. See deficiency cited at A-0144- C.

A. Based on observation, document review and interview, it was determined that for 1 of 7 (Pt. #1) clinical records reviewed for suicidal ideation, the Hospital failed to ensure that the Patient was immediately placed on one-to-one supervision in the Emergency Department. This has the potential to affect all patients who presents to the Emergency Department with suicidal ideation.

Findings include:

1. On 10/31/19 from approximately 2:45 PM through 03:10 PM, a video recording dated 10/02/19, of Pt #1 was reviewed. The video included:

- Pt. #1 brought in to the ED by EMS crew on 10/02/19 at 9:49 AM. The EMS crew stopped by the PFC (E #11) at 9:52 AM, wheeled Pt. #1 to Pivot Nurse (E #8), leaving Pt. #1 with a ziploc (clear plastic) bag of medications and personal belongings. Pt. #1 was left unsupervised between 9:52 AM to 10:14 AM. At 9:58 AM, Pt. #1 was observed going to the bathroom along with the Ziploc bag of medications. The personal belongings and Ziploc bag of medications were not taken by the security until 10:14 AM. Additionally, Pt. #1 was not seen by the Triage Nurse (E #7) until 10:38 AM.

2. On 10/31/19 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt.#1 was transported from a local Rehabilitation Facility by ambulance to the Hospital's Emergency Room (ER) on 10/02/19 at 9:55 AM, with a chief complaint of suicidal ideation. On 10/02/19 at 12:16 PM, Pt. #1 was admitted to the Medical Intensive Care Unit (MICU). On 10/03/19 at 12:42 PM, Pt. #1 was transferred from MICU to General Medical Unit (16 West) and was discharged to the local psychiatric Hospital on 10/12/19 at 12:35 PM.

3. The Hospital's policy titled, "Care of the Suicidal Patient in the Emergency Department" (effective date 06/05/19) was reviewed. The policy included, "B. Patients in the general ED area, presenting as actively suicidal, as determined by medical or nursing staff, are placed on constant visual monitoring with a safety aide immediately ..."

4. On 10/31/19 at approximately 10:45 AM, the Patient Care Manager/ ED (E #4) was interviewed. E #4 stated, "When the EMS crew brought the patient (Pt. #1), they first saw the PFC (Patient Flow Coordinator) (E #11). She (E #11), arranges the Security Standby Unit (SSU) room. The EMS crew explained to the PFC about the suicidal ideation of the patient (Pt. #1). This patient (Pt. #1) should have been immediately placed on monitoring. They wheeled the patient to the Pivot Nurse (E #8) who was able to watch the patient. Unfortunately, he (E #8) got busy and did not notice her (Pt. #1) going to the bathroom with the bag of medications. The expectation is, for any suicidal ideation patient, we must immediately provide one-to-one staff with patient within arms-reach watch."

5. On 11/01/19 at approximately 11:15 AM, the Director of Nursing -ED (E #13) was interviewed. E #13 stated, "We could have done a better job. The fact that the SI patient was left unsupervised."

B. Based on document review and interview, it was determined that for 1 of 7 (Pt. #1) clinical records reviewed for suicidal ideation, the Hospital failed to ensure that all personal belongings including medications were immediately removed from the patient. This has the potential to affect all patients who presents to the Emergency Department with suicidal ideation.

Findings include:

1. The Hospital's policy titled, "Care of the Suicidal Patient in the Emergency Department" (effective date 06/05/19) was reviewed. The policy included, "B. Patients in the general ED area, presenting as actively suicidal, as determined by medical or nursing staff ... D. All belongings of patients on suicide precautions are immediately searched by security. Searched by security ...Contraband, medications, and any items considered to be harmful to the patient are removed from the patient environment."

2. The Hospital's policy titled, "Patient Rights and Responsibilities" effective date 07/27/18 was reviewed. The policy included, "Responsibilities or [Procedural Responsibilities]: A Patient Rights and Responsibilities ...as appropriate, staff works with patients and visitors to ensure that they understand and adhere to the terms of their responsibilities ...Physical Comfort ...Be cared for in an environment that is healing, clean and safe ..."

3. On 10/31/19 at approximately 2:00 PM, the Pivot Nurse (E #8) was interviewed. E #8 stated, "Patient (Pt. #1) was seen by the PFC and then they wheeled her to the triage area. I was the Pivot Nurse, (Pt. #1) looked calm and was sitting on a wheel chair right in front of me. I did not notice when she walked to the bathroom with the bag of medications. The PFC had called for the security check. I received the petition from the EMS crew and the chief complaint was suicidal ideation. It was a busy morning, they did not have any psychiatric beds at the back, that day. Normally, the suicidal ideation patients are taken to the back straight away. I did not do the acuity assessment on the (Pt. #1)."

4. On 10/31/19 at approximately 3:00 PM, the Patient Care Manager/ ED (E #4) was interviewed. E #4 stated, "When the EMS crew brought the patient (Pt. #1), they first saw the PFC (Patient Flow Coordinator) (E #11). The EMS crew explained to the PFC about the suicidal ideation of the patient (Pt. #1). This patient's (Pt. #1's) personal belongings should have been removed immediately."

C. Based on document review and interview, it was determined that for 1 of 7 (Pt. #1) clinical records reviewed for suicidal ideation, the Hospital failed to ensure that the Triage Nurse immediately notified the physician about the suicide attempt. This has the potential to affect all patients who presents to the Emergency Department with suicidal ideation.

Findings include:

1. The Hospital's policy titled, "ED Triage" (effective date 05/20/16) was reviewed. The policy included, "C. Process: 1. A 2-tiered process will be used for patients when beds are not open. The 1st triage nurse who will determine if the patient can wait for the remainder of the assessment or needs immediate care will do the initial sorting. The 2nd phase will involve a more detailed assessment by the 2nd Triage RN ...4. If it is determined that the chief complaint warrants immediate treatment, Category 1, the 1st triage nurse bring the patient immediately to the back ...4. The triage nurse will notify security for any patient who requires 1:1 (one-to-one) monitoring for the safety of the patient or staff ..."

2. On 11/01/19 at approximately 11:30 AM, the Hospital's document titled, "Job Description- Position Specification of Clinical Nurse - ED" dated 07/06/14 was reviewed. The document included, "Clinical Expert: Identifies priorities ... and implements nursing interventions in a safe and timely manner."

3. On 10/31/19 at approximately 1:45 PM, the Triage Nurse (E #7) was interviewed. E #7 stated, "I did not see the patient (Pt. #1) until after the security search was completed. I started asking her questions and she stated, 'I took 30 (thirty) 200 mg (milligram) Seroquel (antidepressant) pills 30 minutes ago'. Since she was drowsy and answering my questions, the Emergency Severity Index (ESI) score of 2 (two)- emergent (not life-threatening), was given to the patient. Later, I came to find out that, she (Pt. #1) had taken the pills while she was in the waiting area and had attempted suicide. I should have changed the ESI score to 1 (one) since it was life-threatening at that time. The expectation is that, when we have a suicidal patient we must immediately remove all the personal belongings and place the patient on one-to-one supervision for SI (suicidal ideation) precautions."

4. On 11/01/19 at approximately 11:15 AM, the Director of Nursing -ED (E #13) was interviewed. E #13 stated, "We could have done a better job." Upon asking about the patient (Pt. #1) came to ED at 9:55 AM and Triage Nurse did not see Pt. #1 until 10:24 AM and finally the ER Physician (MD #1) saw the Pt. #1 at 12:14 AM, E #13 responded, "The Triage Nurse completed her initial assessment and gave the patient an ESI of 2- emergent (not life-threatening). Later, when she was made aware that Pt. #1 took 30 (thirty) pills while she was in the ED and there was a suicide attempt, she (E #7) should have notified the physician immediately."

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #12) clinical records reviewed for, restraints for violent or self destructive behavior in the ED (Emergency Department), the Hospital failed to ensure that use of restraint was in accordance with the order of a physician.

Findings include:

1. On 11/1/19 at approximately 9:30 AM, the clinical record of Pt. #12 was reviewed. Pt. #12 came to the ED on 10/5/19 due to combative and bizarre behavior. The clinical record indicated that Pt. #12 was placed in four-point locked restraints (a type of restraint that's used to restrict the movement of both upper arms and both legs) on 10/5/19 from 10:33 PM to 11:36 PM (1 hour and 3 minutes). However, the clinical record lacked a physician's order regarding the use of restraints.

2. On 11/1/19 at approximately 10:00 AM, the Hospital's policy titled, "Use of Restraints" (effective 6/2018) was reviewed and included, "...To guide the safe, appropriate, and clinically justified use of restraints... XII... Appendix A: Procedure for Caring for the Patients in Restraints... Violent or self destructive behavior Restraint Application. An order from a physician... must be obtained immediately... The order is to be documented on the appropriate restraint order form and include the reason for the restraint..."

3. On 11/1/19 at approximately 10:00 AM, findings were discussed with E #12 (ED Patient Care Manager). E #12 stated that the chart did not include an appropriate physician's order regarding the use of restraint. E #12 stated, "The order should have been written."