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Based on staff interview and record review, the Critical Access Hospital (CAH) failed to provide care and services in accordance with established polices for 1 of 8 applicable patients. (Patient #1) Findings include:
Per record review, Emergency Department (ED) staff failed on 8/10/13 to conduct a complete triage assessment for Patient #1, failed to appropriately reassess and initiate safety interventions when the patient demonstrated a change in condition and failed to complete and submit an adverse event report associated with the provision of care provided to Patient #1 as required per hospital policy.
On 8/10/13 Patient #1, who was 7 weeks pregnant, was referred by a local clinic to the ED for treatment of Hyperemesis Gravidarum (abnormal condition in pregnancy characterized by protracted vomiting) requiring intravenous hydration. Patient #1 was triaged at 12:25 with an Acuity level of 3 (Emergency Severity Index rating 1-5, determining extent of emergency presentation and resources required). Per CAH policy Emergency Department Plan of Care, last approved 06/13/2013, states " ...the urgency of patient ' s presenting problem/complaint is determined on arrival by a qualified Registered Nurse " . However, at the time of Triage, the nurse failed to complete the Social History component of the triage assessment, specifically the " self harm assessment " which questions patients regarding thoughts of self harm, whether the patient experienced feelings of depression or hopelessness.
Patient #1 was checked into an ED room and briefly seen by a Physician Assistant (PA) who prescribed intravenous fluids and medication for Patient #1. At 13:30 a nursing note states Patient #1 was " ...very upset ... " regarding the breakup of a relationship and future plans regarding the pregnancy. ED nursing note states at 14:10 " Pt. continues to cry. Told PA ' life wasn ' t worth living' " . The PA note further states Patient #1 crying during treatment and when questioned Patient #1 stated " ...felt so badly that she wanted to die " .
Per Initial Nursing Assessment and Reassessment: Emergency Department last approved 05/09/2013 " Assessment of nursing care needs will include appropriate considerations of biophysical, psychosocial, environmental ....factors " and " in order to identify and prioritize patient care needs, problems or nursing diagnosis, information related to the assessment will be obtained as appropriate through input from the patient .... " . Despite the patient demonstrating and acknowledging feelings of hopelessness and noting their life was not worth living and with the determination Patient #1 should be screened for possible psychiatric hospitalization, neither the PA or the RN assigned to Patient #1 reassessed the need for further safety precautions to be initiated for Patient #1. Patient #1 was left alone in an ED room where hospital equipment and supplies had not been removed. At approximately 14:30 the Crisis Screener arrived to evaluate Patient #1. Upon entering the patient ' s room for interview, the Screener found Patient #1 with oxygen tubing wrapped tightly multiple times around their neck and was pulling on the tubing. Per the Screener ' s note, red marks were noted still present around the patient ' s neck 2 hours after removal of the oxygen tubing. It was not until this event occurred, Patient #1 was placed on Suicide precautions which included the stripping of the patient ' s room of any supplies and equipment that could be used for further self-harm and 1:1 supervision was begun.
Per interview on 9/3/13 at 4:30 PM both the ED Nurse Manager and the Director of Patient Care Services confirmed staff failed to follow hospital policy when conducting the Triage assessment, acknowledging specific social history questions may have provided the opportunity to identify Patient #1 ' s potential risk for self harm. In addition, it was confirmed staff failed to reassess the patient ' s environment and potential safety concerns until after the suicide attempt had occurred.
In addition, despite the significant event, nursing staff and PA involved with Patient #1 ' s care on 8/10/13 failed to complete an Event Report of the suicide attempt. Per Event Reporting Procedure dated 02/02/2005 states " The person who discovers, witnesses, or to whom the event if reported should complete an electronic event report using the Safety Risk Management " . The scope of reporting includes all employees and medical staff. Per interview on 9/4/13 at 12:10 Nurse #1 involved in Patient #1 ' s ED care confirmed there was a " ..Presumption another nurse involved was going to complete a report " . Per interview on 9/4/13 at 12:38, the PA who provided the clinical evaluation/diagnosis for Patient #1 confirmed s/he has seldom completed an event report and in this specific case although aware of the reporting process s/he did not complete an event report.
Per interview on the afternoon of 9/3/13, the Chief of Quality and Systems Improvement was not aware of the event that had occurred on 8/10/13, but confirmed the attempted strangulation by Patient #1 was a definite reportable event as per hospital policy.

Based on staff interview and record review, the CAH failed to asssure staff consistently completed assessment documentation during the Triage process in the ED for 1 of 8 applicable patients. (Patient #1) Findings include:

Per record review, Emergency Department (ED) staff failed on 8/10/13 to conduct a complete triage assessment for Patient #1. Patient #1, who was 7 weeks pregnant, was referred by a local clinic to the ED for treatment of Hyperemesis Gravidarum (abnormal condition in pregnancy characterized by protracted vomiting) requiring intravenous hydration. Patient #1 was triaged at 12:25 with an Acuity level of 3 (Emergency Severity Index rating 1-5, determining extent of emergency presentation and resources required). Per CAH policy Emergency Department Plan of Care last approved 06/13/2013 states " ...the urgency of patient ' s presenting problem/complaint is determined on arrival by a qualified Registered Nurse " . However, at the time of Triage, the nurse failed to complete the Social History component of the triage assessment, specifically the " self harm assessment " which questions patients regarding thoughts of self harm, whether the patient experienced feelings of depression or hopelessness.
Patient #1 was checked into an ED room and briefly seen by a Physician Assistant (PA) who prescribed intravenous fluids and medication for Patient #1. At 13:30 a nursing note states Patient #1 was " ...very upset ... " regarding the breakup of a relationship and future plans regarding the pregnancy. Per ED nursing note states at 14:10 " Pt. continues to cry. Told PA ' life wasn ' t worth living' " . The PA note further states Patient #1 crying during treatment and when questioned Patient #1 stated they " ...felt so badly that she wanted to die " . Patient #1 was left alone in an ED room where hospital equipment and supplies had not been removed. At approximately 14:30 the Crisis Screener arrived to evaluate Patient #1. Upon entering the patient ' s room for interview, the Screener found Patient #1 with oxygen tubing wrapped tightly multiple times around their neck and was pulling on the tubing. Per the Screener ' s note, red marks were noted still present around the patient ' s neck 2 hours after removal of the oxygen tubing. It was not until this event occurred, Patient #1 was placed on Suicide precautions which included the stripping of the patient ' s room of any supplies and equipment that could be used for further self-harm and 1:1 supervision was begun.
Per interview on 9/3/13 at 4:30 PM both the ED Nurse Manager and the Director of Patient Care Services confirmed staff failed to follow hospital policy when conducting the Triage assessment, acknowledging specific social history questions may have provided the opportunity to identify Patient #1 ' s potential risk for self harm. In addition, it was confirmed staff failed to reassess the patient ' s environment and potential safety concerns until after the suicide attempt had occurred.

Based on record review and confirmed through staff interviews the CAH Quality Performance failed to consistently implement corrective actions developed as the result of a recognized deficient practice and staff failed to follow CAH policy by failing to complete a Adverse Event Report involving 1 of 8 applicable patients. (Patient #1) Findings include:

On 8/10/13 Patient #1, who was 7 weeks pregnant, was referred by a local clinic to the ED for treatment of Hyperemesis Gravid arum (abnormal condition in pregnancy characterized by protracted vomiting) requiring intravenous hydration. Patient #1 was triaged at 12:25 with an Acuity level of 3 (Emergency Severity Index rating 1-5, determining extent of emergency presentation and resources required). Per CAH policy Emergency Department Plan of Care last approved 06/13/2013 states " ...the urgency of patient ' s presenting problem/complaint is determined on arrival by a qualified Registered Nurse " . However, at the time of Triage, the nurse failed to complete the Social History component of the triage assessment, specifically the " self harm assessment " which questions patients regarding thoughts of self harm, whether the patient experienced feelings of depression or hopelessness.
Patient #1 was checked into an ED room and briefly seen by a Physician Assistant (PA) who prescribed intravenous fluids and medication for Patient #1. At 13:30 a nursing note states Patient #1 was " ...very upset ... " regarding the breakup of a relationship and future plans regarding their pregnancy. Per ED nursing note states at 14:10 " Pt. continues to cry. Told PA ' life wasn ' t worth living' " . The PA note further states Patient #1 crying during treatment and when questioned Patient #1 stated they " ...felt so badly that she wanted to die " .
Despite the patient demonstrating and acknowledging feelings of hopelessness and noting their life was not worth living and with the determination Patient #1 should be screened for possible psychiatric hospitalization, neither the PA or the RN assigned to Patient #1 reassessed the need for further safety precautions to be initiated for Patient #1. Patient #1 was left alone in an ED room where hospital equipment and supplies had not been removed. At approximately 14:30 the Crisis Screener arrived to evaluate Patient #1. Upon entering the patient ' s room for interview, the Screener found Patient #1 with oxygen tubing wrapped tightly multiple times around their neck and was pulling on the tubing. Per the Screener ' s note, red marks were noted still present around the patient ' s neck 2 hours after removal of the oxygen tubing. It was not until this event occurred, Patient #1 was placed on Suicide precautions which included the stripping of the patient ' s room of any supplies and equipment that could be used for further self-harm and 1:1 supervision was begun.
Despite the significant event, nursing staff and PA involved with Patient #1 ' s care on 8/10/13 failed to complete an Adverse Event Report of the suicide attempt. Per Event Reporting Procedure dated 02/02/2005 states " The person who discovers, witnesses, or to whom the event if reported should complete an electronic event report using the Safety Risk Management " . The scope of reporting includes all employees and medical staff. Per interview on 9/4/13 at 12:10 Nurse #1 involved in Patient #1 ' s ED care confirmed there was a " ..Presumption another nurse involved was going to complete a report " . Per interview on 9/4/13 at 12:38, the PA who provided the clinical evaluation/diagnosis for Patient #1 confirmed s/he has seldom completed an event report and in this specific case although aware of the reporting process s/he did not choose to complete an adverse event report.
Per interview on the afternoon of 9/3/13, the Chief of Quality and the Director of Patient Care Services confirmed although recent corrective actions for previous deficient practice included a daily review of restraint use, although in this case Patient #1 was placed in restraints for a brief period, the Performance Improvement process failed to capture either the use of restraints which would have led to the adverse event involving Patient #1's attempted strangulation. As a result of not following corrective processes, and the failure of staff to file the Adverse Event Report, the Chief of Quality was not aware of the event that had occurred on 8/10/13 until made aware by the surveyor, confirmed the attempted strangulation by Patient #1 was a definite reportable event as per hospital policy.