HospitalInspections.org

Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that patients receive care in a safe setting.

Findings include:

The facility failed to ensure suicidal patients on 1:1 (one-to-one) observation are continuously observed and supervised when toileting. (Cross refer to Tag A-144)

Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to ensure that patients on 1:1 (one-to-one) observation for a risk for self-harm, are continuously observed and supervised when toileting.

Findings include:

Reference #1: Facility policy titled, "Care of the Patient Assessed to be at Risk for Suicide" dated 02/02/23, states, " ... Procedure ... 13. The 1:1 sitter cannot leave the patient until he/she is relieved or 1:1 sitter is discontinued ... In addition, closed doors or curtains are not permitted; patient may not be left unsupervised even while toileting."

Reference 2: Facility document titled, "Environmental Risks for Suicide Assessment Checklist for the Emergency Department [Except for Rooms 4-7]," dated 09/21/21 and 10/13/21, states, "... sinks (including faucets, valves, and plumbing fixtures) ... grab bars ... towel bars ... toilets (including tanks and plumbing fixtures) [are all] ... mitigated with 1:1 sitter."

A tour of the Emergency Department (ED) was conducted in the presence of Staff #2 (ED Nurse Manager) and Staff #3 (Director of Nursing) on 03/06/23 at 11:13 AM. At 11:30 AM, Staff #2 identified two bathrooms, (bathroom across from Room 9 and Hallway 5 bathroom) that are used for patients on 1:1 observation. Staff #2 and Staff #3 indicated the Hallway 5 bathroom was a ligature free bathroom and the ideal bathroom for 1:1 patients to use. At 11:30 AM, a tour of the bathroom across from Room 9 revealed the bathroom contained the following ligature risks: one grab bar, one hanging basket on the wall with five urinals hanging from it, a towel hook, a toilet with a loose toilet seat, a loose stabilizing square bar approximately one foot long located from the bottom of the toilet to the floor, and a sink with turning hooked handles and exposed pipe underneath.

During a tour of the ED at 11:26 AM, Staff #6 (Patient Safety Technician) was seen observing Patient #3 (P3) from the doorway of Room 5. Upon interview, Staff #6 stated he/she was observing the patient because "[he/she] cut [him/herself] trying to commit suicide and [he/she] is on a 1:1." Staff #6 stated that he/she "needed to be at arm's length from the patient." Staff #6 stated, "That bathroom [bathroom across from Room 9] is the bathroom I would take the patient to. I close the door most of the time and if they are taking too long, I knock on the door. I can look through the crack and see them." Staff #6 stated that he/she had already taken P3 to the bathroom across from Room 9 "earlier today" and kept the door shut while P3 was inside.

A review of P3's medical record revealed a physician's order entered on 03/06/23 at 2:55 AM that states, "Sitter at Bedside Suicide/High Risk."

At 11:36 AM, an interview was conducted with Staff #8 (Patient Transport/Safety Sitter) in Hallway 5. Staff #8 stated that he/she was performing 1:1 observation for Patient #1 (P1), a patient determined to be at risk for self-harm. Staff #8 stated that when a patient on 1:1 observation uses the restroom, he/she will "stand outside and keep an eye through the crack of the door to make sure the patient doesn't do anything." A review of P1's medical record revealed a physician's order entered on 03/05/23 at 9:46 PM that states, "sitter at bedside suicide/high risk."

On 03/06/23 at 12:00 PM, Staff #3 and Staff #4 (Director of Risk Management), confirmed that the facility's policy on performing 1:1 observation should be followed by all staff.

Due to the above findings, an Immediate Jeopardy (IJ) was identified for the facility's failure to ensure suicidal patients on 1:1 observation are continuously observed and supervised when toileting, due to a risk for self harm.

On 03/06/23 at 11:30 AM, the IJ was identified and at 1:20 PM, the IJ template was provided to the facility's administrative staff. On 03/06/23 at 4:36 PM, an acceptable IJ removal plan was received.

On 03/07/23 at 11:30 AM, on-site verification of the implementation of the IJ removal plan was conducted and included the following: review of staff education and sign in sheets regarding the facility's policy for one-to-one (1:1) observation, a tour of the Emergency Department (ED), interviews with staff actively performing 1:1 observation, and staff interviews verifying re-education and facility policy regarding 1:1 observation. The IJ was lifted on 03/07/23 at 11:30 AM.