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Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) for behavioral health patients and patients at risk for suicide or self-harm were implemented for two patients (Patient 9 and 11), when:

1. For Patient 9, a suicide risk assessment was not performed appropriately (Refer to A 0395);

This failure resulted in Patient 9 eloping (an unauthorized departure of a patient from a hospital) from the Emergency Department (ED) with an intravenous (IV, catheter inserted through the vein for the administration of medications and fluids) catheter (plastic tube inserted into a vein) in place. Patient 9 was found deceased one hour after; and

2. For Patient 11, a one-to-one observation was not conducted timely as ordered by a physician (Refer to A 0395). This failure had the potential to result in self-harm and death to Patient 11.

The cumulative effects of these systemic failures resulted in Patient's 9 and 11 to not be provided safe and quality care to meet their needs and had the potential to result in harm to other patients while in the ED and may lead to patient elopement which may cause harm, injury, or death to the patient.

Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) for behavioral health patients and patients at risk for suicide or self-harm were implemented for two patients (Patient 9 and 11), when:

1. For Patient 9, a suicide risk assessment was not performed appropriately.

This failure resulted in Patient 9 eloping (an unauthorized departure of a patient from a hospital) from the Emergency Department (ED) with an intravenous (IV, catheter inserted through the vein for the administration of medications and fluids) catheter (plastic tube inserted into a vein) in place. Patient 9 was found deceased one hour after; and

2. For Patient 11, a one-to-one observation was not conducted timely as ordered by a physician.

This failure had the potential to result in self-harm and death to Patient 11 and other patients while in the ED, as well as may lead to elopement which can lead to harm, injury, or death..

Findings:

An unannounced visit was conducted at the facility on May 11, 2023, at 9:54 a.m., for a complaint validation survey.

1. On May 11, 2023, at 10:30 a.m., Patient 9's record was reviewed. The ambulance report titled, "Patient Care Report," dated May 6, 2023, indicated, "...PT (Patient 9) FOUND LAYING SUPINE ON GRASS NEAR PARKING SPACE. PT IS PALE AND UNRESPONSIVE...PT GIVEN 1 (one) MG (milligram, unit of measurement) NARCAN (medication for opiod overdose)...RESPIRATORY STATUS STARTED TO IMPROVE...PT STATES "LET ME DIE" "SHOOT ME IN THE HEAD" (sic)..."

Review of the facility document titled, "ED Triage Part 1," dated May 6, 2023, at 11:53 a.m., was conducted. The document indicated, "...Chief Complaint: biba (brought in by ambulance) - drug overdose; SI (suicidal ideation, thoughts of suicide or killing one self) "Pls kill me"..."

Review of the facility document titled, "ED Screenings/History Adult," dated May 6, 2023, at 12:07 p.m., was conducted. The document indicated, "CSSRS (Columbia Suicide Severity Rating Scale, a suicide risk screening tool) Pre-Screener...Suicide Presents Sign and /or Symptoms: No...Suicide Present BH (Behavioral Health) Complaint: No...CSSRS Screener Section Interpretation: Do not open (the CSSRS screening was not performed)..."

Review of the facility document titled, "Results Details," dated May 6, 2023, at 12:12 p.m., was conducted. The document indicated, "...Patient Rounding Comment: Infromed cxharge (sic) nurse thwat (sic) pt said "pls kill me :(sic)"..."

Review of the facility document titled, "Results Details," dated May 6, 2023, at 2:18 p.m., was conducted. The document indicated, "...Patient Rounding Comment: pt (Patient 9) became aggressive (sic) and ran out of the ER (Emergency Room, ED), pt punched the security 4 (four) times while getting out of ER; pt had a IV (intravenous line used to administered medications or fluids into a vein); PD (Police Department) was called..."

The facility document titled, "ED Note- Report," dated May 6, 2023, at 3:39 p.m., indicated Patient 9 was admitted to the facility with diagnoses which included acetaminophen (medication for pain and fever) and opiate (narcotic) overdose. The document indicated, "...Patient stated that he would like to die...Patient will need case manager/social work evaluation for suicidal ideation (SI)..."

Review of the facility document titled, "ED Supervision/Handoff EMR," dated May 6, 2023, at 3:58 p.m., was conducted. The document indicated, "...plan is to start N-acetylcysteine (medication for acetaminophen overdose) for acetaminophen overdose and admit patient per recommendations from poison control as the ingestion time of the Tylenol (acetaminophen, a pain reliever) is unknown and there is mild transaminitis. I was informed by staff that patient became combative and agitated. Plan was to have one-to-one (1:1, one staff to one patient monitoring) sitter...PD was immediately called by nursing staff as the patient still had his IVN (sic, IV catheter) at the time of his elopement from the emergency room..."

There was no documented evidence a 1:1 constant observer and social work consult to evaluate for 5150 (a 72-hour involuntary hold for treatment) were ordered for Patient 9. There was no documented evidence Patient 9 was monitored by a 1:1 constant observer.

An interview was conducted with Registered Nurse (RN) 1 on May 11, 2023, at 2:27 p.m. RN 1 stated, "I was covering the primary nurse's lunch, I was not told that patient had stated, "Please kill me." RN 1 stated if a patient came in with suspected overdose, she would keep her eyes on the patient, notify the clinical manager, social worker, and the physician, put the patient on a 1:1 observation. RN 1 stated, "There was no sitter at bedside."

An interview was conducted with RN 2 on May 11, 2023, at 2:40 p.m. RN 2 stated Patient 9 was brought in by paramedics after he was found unresponsive at a gas station, was given Narcan (medication for opiod overdose), and became alert after. RN 2 stated Patient 9 told him, "Please kill me" and he notified the charge nurse about it. RN 2 stated Patient 9 was to be transferred to the behavioral section of the ED but it did not happen. RN 2 stated he notified the ED physician and the ED resident physician at that time about Patient 9 stating "Please kill me." RN 2 stated she came back to assess Patient 9 and Patient 9 woke up, stood up, and sprinted out of the room. RN 2 further stated, "...The police arrived an hour later and informed the hospital that the patient was found deceased..." RN 2 stated, if a patient was having SI, "The expectation would be to tell the physician, the charge nurse, transfer to a safe room, one on one sitter, and a social worker."

An interview was conducted with the Charge RN (CRN) on May 11, 2023, at 3:20 p.m. The CRN stated she was aware Patient 9 came in due to overdose and had told the primary nurse, "Please kill me." The CRN stated patients with SI should be placed on a constant observation (1:1) for safety right away and this never happened. The CRN stated, "This was our fallout we did not have the patient with a 1:1 for constant observation." The CRN stated there was no evidence of documentation anyone reached out to the social worker to assess Patient 9 for a 5150 hold.

An interview was conducted with the Interim ED Director (IEDD), on May 12, 2023, at 8:43 a.m. The IEDD stated Patient 9's Suicidal Risk Assessment was not done correctly. The IEDD stated if the nurse had done the screening correctly, this would have opened more interventions for suicide, like a social worker consult, 1:1, and more safety measures.

2. A concurrent interview and record review was conducted with the Performance Improvement Specialist (PIS) on May 12, 2023, at 9:15 a.m.

Review of the facility document titled, "ED Note-Physician," dated May 3, 2023, was conducted and indicated Patient 11 was seen by the physician on May 2, 2023, at 10:11 p.m. The document indicated Patient 11 was brought into the ED by law enforcement on a 5150 hold for SI.

Review of the facility document titled, "ED Triage Form-Text," dated May 2, 2023, at 11:12 p.m., indicated an RN performed the CSSRS Pre-Screener on May 2, 2023, at 11:02 p.m. The CSSRS Pre-Screener assessment indicated, "...Suicide Presents Sign and/or Symptoms: Yes...CSSRS Wish to be Dead: Lifetime, yes...In past month, have you actually had thoughts about killing yourself?...Yes...Interventions: Self harm observation, Suicide precautions initiated..."

An untitled facility document," indicated an order for "BH Constant Observer Self Harm" was ordered to start on May 2, 2023, at 11:12 p.m. The order further indicated, "...Priority Stat (Immediately)...Level of Constant Observation One to One Observation..."

Review of facility document titled, "Constant Observer Flow Sheet," dated May 3, 2023, indicated constant observation of Patient 11 was documented every 15 minutes on May 3, 2023, from 7 a.m. to 7:30 p.m.

There was no documented evidence a one to one constant observation was immediately implemented as ordered by the physician from May 2, 2023, at 11:12 p.m. through May 3, 2023, at 7 a.m.

The PIS stated he was unable to find a "Constant Observer Flow Sheet" completed for Patient 11 on May 2, 2023, at 11:12 p.m., after the one-to-one constant observation was ordered.

During an interview on May 15, 2023, at 9:05 a.m., conducted with the Certified Nurse Assistant (CNA) 1, CNA 1 stated when a patient is ordered to be on one-to-one observation, it should be started immediately once the order is put in. CNA 1 stated the one-to-one observation is documented on the patient's constant observer flow sheet every 15 minutes.

During an interview on May 15, 2023, at 9:10 a.m., conducted with the RN 3, RN 3 stated an order for one-to-one observation of a patient should be started immediately and she would ensure the patient is in a safe environment. RN 3 further stated if a one-to-one constant observer/sitter is not immediately available for her patient, she would be the patient's one to one observer.

During an interview with the Regulatory Manager (RM), the RM reviewed Patient 11's record. The RM stated Patient 11's 1:1 constant observation was ordered by a physician. The RM stated the suicide screening would trigger the order for a 1:1 observation.

Review of the facility's P&P titled, "DES ETS 1301 CARE OF THE BEHAVIORAL HEALTH PATIENT IN THE EMERGENCY/TRAUMA CENTER," dated April 27, 2021, was conducted. The P&P indicated, "...The purpose of this policy is to ensure proper evaluation and safety measures for the care of the behavioral health patient at risk of elopement or harm to self or others while in the Emergency/Trauma Center...Patients who present to the ED verbalizing suicidal ideation will be immediately placed in high risk suicide precautions (includes 1:1 continuous observation...)...For those patients placed on suicide/homicide precautions, the sitter/observer documents patient observations on the Constant Observer Flowsheet...If patient is a danger to self, others or a flight risk, a qualified competent employee will be requested to continually observe the patient..."

Review of the facility's P&P titled, "DES ADM 855 SUICIDE RISK ASSESSMENT," dated September 22, 2022, was conducted. The P&P indicated, "...(Hospital Name) will provide for the proper assessment and plan of care for patients with suicidal/self harm ideation in accordance with this policy...(Hospital Name) will use a multidisciplinary approach for the care of the suicidal patient...will provide, at a minimum, an initial suicide screening for all patients aged 12 years and older who are being evaluated or treated for behavioral health conditions to determine further care and treatment...A registered nurse will pre-screen all patients, >= 12 years of age (12 years old or older) upon admission...A registered nurse will complete the Columbia Suicide Severity Rating Scale (C-SSRS) screening tool for patients requiring suicide risk screening...If the patient screens positive using C-SSRS, which is defined as providing a "Yes" response to questions three (3), four (4), five (5), or seven (7), the nursing staff will complete the following...Send an order request for one-to-one observation to the attending physician...Send a referral for consult to case management, social services, and a BHP...Immediately place the patient on a one-to-one observation by a CHP and obtains a physician's order as soon as possible...Implement at a minimum the flowing precautions...The nursing staff will use the Constant Observation Flowsheet to document observation following the hospital protocol for a patient at risk of suicide...Using the Environment Patient Safety Checklist, the Constant Observer will maintain visualization of identified risks which are not able to be removed..."

A review of the facility's P&P titled, "DES NAD 37 CONSTANT OBSERVER USAGE ASSESSMENT, IMPLEMENTATION, AND DISCONTINUATION," dated December 20, 2019, was conducted. The P&P indicated, "...This policy applies to all clinical patient care areas of (Hospital Name) that utilize constant observers for patient care and safety...If an assessment reveals that a patient is a danger to self and/or others a constant observer will be implemented immediately. A constant observer at the bedside takes priority...One to one observation - one competent Constant Observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area. Close proximity is determined by the physician, mid- level provider, registered nurse or qualified mental health professional...The Constant Observer will document patient observations every 15 minutes on the Constant Observer Flow Sheet as indicated and as instructed by the nurse..."

Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) for behavioral health patients and patients at risk for suicide or self-harm were implemented for two patients (Patient 9 and 11), when:

1. For Patient 9, a suicide risk assessment was not performed appropriately (Refer to A 0395);

This failure resulted in Patient 9 eloping (an unauthorized departure of a patient from a hospital) from the Emergency Department (ED) with an intravenous (IV, catheter inserted through the vein for the administration of medications and fluids) catheter (plastic tube inserted into a vein) in place. Patient 9 was found deceased one hour after; and

2. For Patient 11, a one-to-one observation was not conducted timely as ordered by a physician (Refer to A 1101).

This failure had the potential to result in self-harm and death to Patient 11.

The cumulative effects of these systemic failures resulted in Patient's 9 and 11 to not be provided safe and quality care to meet their needs and had the potential to result in harm to other patients while in the ED and may lead to patient elopement which may cause harm, injury, or death to the patient.

Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) for behavioral health patients and patients at risk for suicide or self-harm were implemented for two patients (Patient 9 and 11), when:

1. For Patient 9, a suicide risk assessment was not performed appropriately.

This failure resulted in Patient 9 eloping (an unauthorized departure of a patient from a hospital) from the Emergency Department (ED) with an intravenous (IV, catheter inserted through the vein for the administration of medications and fluids) catheter (plastic tube inserted into a vein) in place. Patient 9 was found deceased one hour after; and

2. For Patient 11, a one-to-one observation was not conducted timely as ordered by a physician.

This failure had the potential to result in harm to Patient 11 and other patients while in the ED, as well as may lead to elopement which can lead to harm, injury, or death.

Findings:

An unannounced visit was conducted at the facility on May 11, 2023, at 9:54 a.m., for a complaint validation survey.

1. On May 11, 2023, at 10:30 a.m., Patient 9's record was reviewed. The ambulance report titled, "Patient Care Report," dated May 6, 2023, indicated, "...PT (Patient 9) FOUND LAYING SUPINE ON GRASS NEAR PARKING SPACE. PT IS PALE AND UNRESPONSIVE...PT GIVEN 1 (one) MG (milligram, unit of measurement) NARCAN (medication for opiod overdose)...RESPIRATORY STATUS STARTED TO IMPROVE...PT STATES "LET ME DIE" "SHOOT ME IN THE HEAD" (sic)..."

Review of the facility document titled, "ED Triage Part 1," dated May 6, 2023, at 11:53 a.m., was conducted. The document indicated, "...Chief Complaint: biba (brought in by ambulance) - drug overdose; SI (suicidal ideation, thoughts of suicide or killing one self) "Pls kill me"..."

Review of the facility document titled, "ED Screenings/History Adult," dated May 6, 2023, at 12:07 p.m., was conducted. The document indicated, "CSSRS (Columbia Suicide Severity Rating Scale, a suicide risk screening tool) Pre-Screener...Suicide Presents Sign and /or Symptoms: No...Suicide Present BH (Behavioral Health) Complaint: No...CSSRS Screener Section Interpretation: Do not open (the CSSRS screening was not performed)..."

Review of the facility document titled, "Results Details," dated May 6, 2023, at 12:12 p.m., was conducted. The document indicated, "...Patient Rounding Comment: Infromed cxharge (sic) nurse thwat (sic) pt said "pls kill me :(sic)"..."

Review of the facility document titled, "Results Details," dated May 6, 2023, at 2:18 p.m., was conducted. The document indicated, "...Patient Rounding Comment: pt (Patient 9) became aggressive (sic) and ran out of the ER (Emergency Room, ED), pt punched the security 4 (four) times while getting out of ER; pt had a IV (intravenous line used to administered medications or fluids into a vein); PD (Police Department) was called..."

The facility document titled, "ED Note- Report," dated May 6, 2023, at 3:39 p.m., indicated Patient 9 was admitted to the facility with diagnoses which included acetaminophen (medication for pain and fever) and opiate (narcotic) overdose. The document indicated, "...Patient stated that he would like to die...Patient will need case manager/social work evaluation for suicidal ideation (SI)..."

Review of the facility document titled, "ED Supervision/Handoff EMR," dated May 6, 2023, at 3:58 p.m., was conducted. The document indicated, "...plan is to start N-acetylcysteine (medication for acetaminophen overdose) for acetaminophen overdose and admit patient per recommendations from poison control as the ingestion time of the Tylenol (acetaminophen, a pain reliever) is unknown and there is mild transaminitis. I was informed by staff that patient became combative and agitated. Plan was to have one-to-one (1:1, one staff to one patient monitoring) sitter...PD was immediately called by nursing staff as the patient still had his IVN (sic, IV catheter) at the time of his elopement from the emergency room..."

There was no documented evidence Patient 9 was monitored by a 1:1 constant observer and social work consult to evaluate for 5150 (a 72-hour involuntary hold for treatment) were ordered for Patient 9.

An interview was conducted with the Interim Emergency Department Director (IEDD) on May 11, 2023, at 2:15 p.m. The IEDD stated the expectation would be to notify the clinical manager, place the patient on 1:1 constant observation, inform the provider, call the social worker to assist, and the patient would be given a green gown to indicate this is a behavioral health patient.

An interview was conducted with Registered Nurse (RN) 1 on May 11, 2023, at 2:27 p.m. RN 1 stated, "I was covering the primary nurse's lunch, I was not told that patient had stated, "Please kill me." RN 1 stated if a patient came in with suspected overdose, she would keep her eyes on the patient, notify the clinical manager, social worker, and the physician, put the patient on a 1:1 observation. RN 1 stated, "There was no sitter at bedside."

An interview was conducted with Physician 1 on May 11, 2023, at 2:34 p.m. Physician 1 stated she saw Patient 9 at the ED when Patient 9 was brought in with possible overdose. Physician 1 stated she was aware Patient 9 was experiencing SI. Physician 1 stated she was not aware of the entry on the H&P, authored by her on May 6, 2023, at 3:55 p.m., signed by her on May 6, 2023, at 4:08 p.m., which indicated, " ...Patient states that he would like to die ..." Physician 1 stated, "I electronically signed Resident 1's note on May 6, 2023, at 4:08 p.m., I was not aware that the patient stated suicidal ideations."

An interview was conducted with RN 2 on May 11, 2023, at 2:40 p.m. RN 2 stated Patient 9 was brought in by paramedics after he was found unresponsive at a gas station, was given Narcan (medication for opiod overdose), and became alert after. RN 2 stated Patient 9 told him, "Please kill me" and he notified the charge nurse about it. RN 2 stated Patient 9 was to be transferred to the behavioral section of the ED but it did not happen. RN 2 stated he notified the ED physician and the ED resident physician at that time about Patient 9 stating "Please kill me." RN 2 stated she came back to assess Patient 9 and Patient 9 woke up, stood up, and sprinted out of the room. RN 2 further stated, "...The police arrived an hour later and informed the hospital that the patient was found deceased..." RN 2 stated, if a patient was having SI, "The expectation would be to tell the physician, the charge nurse, transfer to a safe room, one on one sitter, and a social worker."

An interview was conducted with the Charge RN (CRN) on May 11, 2023, at 3:20 p.m. The CRN stated she was aware Patient 9 came in due to overdose and had told the primary nurse, "Please kill me." The CRN stated patients with SI should be placed on a constant observation (1:1) for safety right away and this never happened. The CRN stated, "This was our fallout we did not have the patient with a 1:1 for constant observation." The CRN stated there was no evidence of documentation anyone reached out to the social worker to assess Patient 9 for a 5150 hold.

An interview was conducted with Physician 2, on May 11, 2023, at 4:08 p.m. Physician 2 stated he was not notified of Patient 9's SI and patients with SI should be placed with a constant observer and a social worker consult to consider a 5150 hold.

An interview was conducted with the Interim ED Director (IEDD), on May 12, 2023, at 8:43 a.m. The IEDD stated Patient 9's Suicidal Risk Assessment was not done correctly. The IEDD stated if the nurse had done the screening correctly, this would have opened more interventions for suicide, like a social worker consult, 1:1, and more safety measures.

An interview was conducted with Resident 1 (a physician in training), on May 12, 2023, at 9:53 a.m. Resident 1 stated she was told by Patient 9's primary nurse Patient 9 had stated, "Please kill me." Resident 1 stated, if a patient expressed he wanted to die or have suicide ideation, she would assess the patient, would get a social worker involved to assess for possible 5150 hold, watch patient closely, and put the patient on a 1:1 observation with a sitter. Resident 1 stated she did not place orders for a constant observer or social worker consult. Resident 1 stated, "My intention was to have all of this in place but it did not happen."

2. A concurrent interview and record review was conducted with the Performance Improvement Specialist (PIS) on May 12, 2023, at 9:15 a.m.

Review of the facility document titled, "ED Note-Physician," dated May 3, 2023, was conducted and indicated Patient 11 was seen by the physician on May 2, 2023, at 10:11 p.m. The document indicated Patient 11 was brought into the ED by law enforcement on a 5150 hold for SI.

Review of the facility document titled, "ED Triage Form-Text," dated May 2, 2023, at 11:12 p.m., indicated an RN performed the CSSRS Pre-Screener on May 2, 2023, at 11:02 p.m. The CSSRS Pre-Screener assessment indicated, "...Suicide Presents Sign and/or Symptoms: Yes...CSSRS Wish to be Dead: Lifetime, yes...In past month, have you actually had thoughts about killing yourself?...Yes...Interventions: Self harm observation, Suicide precautions initiated..."

An untitled facility document," indicated an order for "BH Constant Observer Self Harm" was ordered to start on May 2, 2023, at 11:12 p.m. The order further indicated, "...Priority Stat (Immediately)...Level of Constant Observation One to One Observation..."

Review of facility document titled, "Constant Observer Flow Sheet," dated May 3, 2023, indicated constant observation of Patient 11 was documented every 15 minutes on May 3, 2023, from 7 a.m. to 7:30 p.m.

There was no documented evidence a one to one constant observation was immediately implemented as ordered by the physician from May 2, 2023, at 11:12 p.m. through May 3, 2023, at 7 a.m.

The PIS stated he was unable to find a "Constant Observer Flow Sheet" on May 2, 2023, at 11:12 p.m., after the one-to-one constant observation was ordered.

During an interview on May 15, 2023, at 9:05 a.m., conducted with the Certified Nurse Assistant (CNA) 1, CNA 1 stated when a patient is ordered to be on one-to-one observation, it should be started immediately once the order is put in. CNA 1 stated the one-to-one observation is documented on the patient's constant observer flow sheet every 15 minutes.

During an interview on May 15, 2023, at 9:10 a.m., conducted with the RN 3, RN 3 stated an order for one-to-one observation of a patient should be started immediately and she would ensure the patient is in a safe environment. RN 3 further stated if a one-to-one constant observer/sitter is not immediately available for her patient, she would be the patient's one to one observer.

During an interview with the Regulatory Manager (RM), the RM reviewed Patient 11's record. The RM sated Patient 11's 1:1 constant observation was ordered by a physician. The RM stated the suicide screening would trigger the order for a 1:1 observation.

Review of the facility's P&P titled, "DES ETS 1301 CARE OF THE BEHAVIORAL HEALTH PATIENT IN THE EMERGENCY/TRAUMA CENTER," dated April 27, 2021, was conducted. The P&P indicated, "...The purpose of this policy is to ensure proper evaluation and safety measures for the care of the behavioral health patient at risk of elopement or harm to self or others while in the Emergency/Trauma Center...Patients who present to the ED verbalizing suicidal ideation will be immediately placed in high risk suicide precautions (includes 1:1 continuous observation...)...
patient is a danger to self, others or a flight risk, a qualified competent employee will be requested to continually observe the patient..."

Review of the facility's P&P titled, "DES ETS 1301 CARE OF THE BEHAVIORAL HEALTH PATIENT IN THE EMERGENCY/TRAUMA CENTER," dated April 27, 2021, was conducted. The P&P indicated, "...The purpose of this policy is to ensure proper evaluation and safety measures for the care of the behavioral health patient at risk of elopement or harm to self or others while in the Emergency/Trauma Center...Patients who present to the ED verbalizing suicidal ideation will be immediately placed in high risk suicide precautions (includes 1:1 continuous observation...)...For those patients placed on suicide/homicide precautions, the sitter/observer documents patient observations on the Constant Observer Flowsheet...If patient is a danger to self, others or a flight risk, a qualified competent employee will be requested to continually observe the patient..."

Review of the facility's P&P titled, "DES ADM 855 SUICIDE RISK ASSESSMENT," dated September 22, 2022, was conducted. The P&P indicated, "...(Hospital Name) will provide for the proper assessment and plan of care for patients with suicidal/self harm ideation in accordance with this policy...(Hospital Name) will use a multidisciplinary approach for the care of the suicidal patient...will provide, at a minimum, an initial suicide screening for all patients aged 12 years and older who are being evaluated or treated for behavioral health conditions to determine further care and treatment...A registered nurse will pre-screen all patients, >= 12 years of age (12 years old or older) upon admission...A registered nurse will complete the Columbia Suicide Severity Rating Scale (C-SSRS) screening tool for patients requiring suicide risk screening...If the patient screens positive using C-SSRS, which is defined as providing a "Yes" response to questions three (3), four (4), five (5), or seven (7), the nursing staff will complete the following...Send an order request for one-to-one observation to the attending physician...Send a referral for consult to case management, social services, and a BHP...Immediately place the patient on a one-to-one observation by a CHP and obtains a physician's order as soon as possible...Implement at a minimum the flowing precautions...The nursing staff will use the Constant Observation Flowsheet to document observation following the hospital protocol for a patient at risk of suicide...Using the Environment Patient Safety Checklist, the Constant Observer will maintain visualization of identified risks which are not able to be removed..."

A review of the facility's P&P titled, "DES NAD 37 CONSTANT OBSERVER USAGE ASSESSMENT, IMPLEMENTATION, AND DISCONTINUATION," dated December 20, 2019, was conducted. The P&P indicated, "...This policy applies to all clinical patient care areas of (Hospital Name) that utilize constant observers for patient care and safety...If an assessment reveals that a patient is a danger to self and/or others a constant observer will be implemented immediately. A constant observer at the bedside takes priority...One to one observation - one competent Constant Observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area. Close proximity is determined by the physician, mid- level provider, registered nurse or qualified mental health professional...The Constant Observer will document patient observations every 15 minutes on the Constant Observer Flow Sheet as indicated and as instructed by the nurse..."