HospitalInspections.org

Based on observation, interview and record review the facility failed to protect the patient rights for 1 of 4 patients (#1) requiring a safe environment placing all 56 current inpatient and future patients at risk for the loss of their rights.

Findings include:

1. The facility failed to provide adequate supervision for 1 of 4 patients (#1) requiring safety observations resulting in a suicidal patient
(#1) covering their head with a plastic trash bag when left alone inside a bathroom placing Patient #1 at risk for serious harm, injury and poor treatment outcomes. (See A-144).

Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 4 patients (#1) requiring safety observations resulting in a suicidal patient (#1) covering their head with a plastic trash bag when left alone inside a bathroom placing Patient #1 at risk for serious harm, injury and poor treatment outcomes. Findings include:

Review of the medical record and other documentation revealed Patient (Pt) #1 was a 17 year-old female with a history of bulimia arrived at the emergency department (ED) on 01/25/20 at 1118. The ED triage acuity flowsheet dated 01/25/20 at 1131 was signed with the initials of registered nurse (RN) G and indicated Pt #1's acuity was emergent and that triage was complete.

The pediatric suicide risk screening (RSQ-4) flowsheet dated 01/25/20 at 1132 also signed with the initials of RN G indicated Pt #1 answered yes to having thoughts of killing self in the past week and having something very stressful happening in the past few weeks. The results of the RSQ-4 questionnaire were documented as "Positive".

The ED triage note dated 01/25/20 at 1138 was signed with the initials of RN G and indicated, Pt #1 "states she is currently suicidal, reports she was going to take a bunch of pills and alcohol and drown herself in the river ...It doesn't really matter, I'll just shoot myself when I get out ...". This note also indicated Pt #1 was tearful and stated, "anytime I'm alone I'm going to try to kill myself, I'm looking for stuff here to do it, but I'm not smart enough".

The ED notes dated 01/25/20 with a date of service time of 1144 indicated Pt #1 used the restroom with care assistant (PCT F) and while Pt #1 was in the bathroom, PCT F heard "what sounded like a bag rustling". The note indicated PCT F found Pt #1 "attempting to place garbage bag over head.".

Review of video recording of the event was initiated on 02/05/20 at 1525 with Security Officer I, Vice President of Nursing (RN B) and ED Manager (RN C) present. Note the camera angles did not show the interior of the bathroom. Results as follows, in date/military time/seconds format:

01/25/20 at 1136:49, PCT F is escorting Pt #1 from ED room to ED bathroom across hall. Pt #1 is dressed in ED gown, appears cooperative and ambulates without assistance.

01/25/20 at 1136:55, PCT F and Pt #1 enter inside bathroom together.

01/25/20 at 1137:19, PCT F departs bathroom leaving Pt #1 inside alone and unassisted. When departing bathroom, PCT F appears to completely shut bathroom door, however due to video quality this cannot be conclusively determined. Despite the video quality the door is at least 95-100% closed making any direct observation of Pt #1 extremely limited. PCT F then walks away from the bathroom toward another room and begins talking to another staff member. At this time there is no evidence that PCT F was providing any reasonable degree of observation or safety monitoring for Pt #1.

01/25/20 at 1138:10, PCT F is pacing in hall outside bathroom. The bathroom door remains at least 95-100% closed. At this time there is no evidence that PCT F was providing any reasonable degree of observation of Pt #1.

01/25/20 at 1139:06, PCT F is facing bathroom door, places head toward the door, appears to be engaging in conversation with Pt #1 through the bathroom door which remains 95-100% closed.

01/25/20 at 1139:12, PCT F opens door and enters into bathroom.

01/25/20 at 1139:28, PCT F and Pt #1 depart bathroom. Pt #1 is ambulating alone and unassisted without resistance though she appears to be crying. PCT F escorts Pt #1 back into ED room.

Summary of video review: PCT F did not provide a reasonable degree of observation of Pt #1 from 1137:19 to 1139:12 (1 minute and 53 seconds).

During tour of the ED on 02/05/20 starting at 1255, the bathroom in which the event occurred was observed having multiple ligature points, including fixed sink with protruding handles, fixed handicapped rails protruding from walls, fixed swinging wall hook to accommodate intravenous bags, fixed storage shelf on wall, as well as a trash can with a plastic bag. During an interview with the ED Manager (RN C) on 02/05/20 at 1305, RN C said the bathroom was used by all ED patients as needed.

During an interview with the ED Patient Care Technician (PCT F) on 02/05/20 at 1240, PCT F said she escorted Pt #1 to the ED bathroom because she was informed Pt #1 had expressed suicidal ideation while in the ED. PCT F said she did not maintain visualization of Pt #1 while Pt #1 used the bathroom however she stood outside the bathroom door with the door slightly cracked. PCT F said she heard Pt #1 flush the toilet, wash hands in the sink, and then heard a plastic bag rattle. PCT F said approximately 30 seconds from the time she heard the bag rattle, she asked Pt #1 if they were okay from outside the door. PCT F said she eventually opened the door because Pt #1 did not respond. PCT F said when she opened the door she visualized Pt #1 with a plastic trash bag encased over the head holding the bag down securely with both hands. PCT F said she tore the plastic trash bag open in the middle to release it from Pt #1's head and escorted Pt #1 back to her room.

During an interview with the ED registered nurse (RN G) on 02/05/20 at 1410, RN G said Pt #1 voiced suicidal ideation however Pt #1 was not on a 1:1 (one to one) observation status at the time Pt #1 used the bathroom. RN G said Pt #1 had family members sitting with her in the ED room. RN G said not all patients having suicidal ideation were automatically placed on 1:1 status and the safety status was determined by a variety of factors including the results of the suicide assessment screening, history and the patient's presentation. RN G could not recall what the results of Pt #1's suicide assessment (RSQ-4) were. RN G acknowledged Pt #1 placed a plastic trash bag on her head while using the bathroom. RN G said Pt #1 was immediately assessed post-event and did not have any signs of physical injury.

During an interview with the Vice President of Nursing (RN B) and ED Manager (RN C) on 02/05/20 at 1500, neither RN B or RN C could provide a definition or policy/procedure regarding the pediatric suicide risk screening (RSQ-4) assessment, specifically a definition of the result "positive" as well as what level of safety would be implemented in regards to a "positive" finding. Note the facility did not provide any further information regarding this matter as of the survey exit date.

Review of facility policy/procedure titled, "Suicide Policy and Procedure" last revised November 2019, indicated, under section IV, Care of Emergency Department Patients A, "iii. Emergency Department patients are screened during triage, using the C-SSRS or the Pediatric (17 years or less) Risk Suicide Questionnaire (RSQ-4).", and, under C, "iv. Patients will be monitored 1:1 by an appropriately trained staff member following the Close Observation/Constant Attendance (COCA) policy. This includes 1:1 monitoring during the patient's use of the bathroom.".

Review of facility policy/procedure titled, "General Nursing-Close Observation and Constant Attendance Policy with Procedure" last revised November 2017 indicated, under policy statement section, "When patients are assessed and found to be at a greater risk for falls, harm to self, or harm to others, consideration should be taken to place the patient in Close Observation or Constant Attendance (CO/CA)." and, under procedure section, "2. Constant Attendance: a. potential harm to self or others. B. A staff member will be within close proximity of the patient at all times so that they are able to observe the patient, interact with the patient and physically intervene if necessary.".