HospitalInspections.org

Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined the facility failed to follow physician's orders for a sitter and failed to follow policy and procedures to establish a safe environment for a high-risk suicidal patient, for one of ten medical records reviewed (MR1).


Findings include:


Review of facility policy "Care of the Patient with Suicide Risk POL-6451697", last approved 8/15/2023, refers to the "Risk Stratified Response Protocols for the Care of the Patient with Suicide Risk" and the "Environmental Safety Precautions for Patient at Risk of Harming Themselves and Others" documents.

Review of "Risk Stratified Response Protocols for the Care of the Patient with Suicide Risk" revealed: " ... High risk for suicide: Constant Observation will be ordered and implemented ... ".

Review of "Environmental Safety Precautions for Patient at Risk of Harming Themselves and Others", last approved 3/12/2024, revealed: " ... A thorough safety search is to be conducted with the intent of locating any items which are deemed to be potentially harmful to the patient or staff. ... Remove unnecessary tubing, bandages, and cords from room. ...".


Review of MR1 revealed the patient presented to the emergency department on April 19, 2024, at 5:12 PM, for a voluntary mental health admission with suicidal ideation and a suicide plan. On April 19, 2024, at 5:15 pm, a physcian order was placed for a Constant Observation sitter. Further review of MR1 revealed that on April 16, 2024, at approximately 7:52 PM, the patient was found with no sitter in their room with a call bell wrapped around their neck.


The above findings were confirmed by EMP1 and EMP4 during medical record review on May 30, 2024 between 1:00 PM and 2:00 PM.