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The Hospital failed to ensure for one (Patient #1) patient of 10 sampled patients that the Hospital provided care in a safe setting.

Refer to Tag A-0144

Based on interviews and records reviewed, the Hospital failed to ensure for one (Patient #1) patient of 10 patients sampled to provide care in a safe setting to prevent an attempted suicide and multiple attempts at self injurious behaviors while admitted on the Medical Surgical Unit.

Findings include:

It was reported that Patient #1 was admitted to the Hospital's Medical Surgical Unit from the Emergency Department on 1/11/20, after an attempted suicide by overdosing on dextromethorphan/chlorpheniramine (a cough suppressant) and extra strength Tylenol, for medical clearance prior to transfer to an acute psychiatric hospital. Patient #1's diagnoses included depression with multiple suicide attempts, factitious disorder and polysubstance use disorder. The admission orders included 1:1 constant observation due to active suicidal thoughts with intent to harm him/herself as well as a psychiatry consult. The Admission Suicide Risk Assessment, dated 1/11/20, indicated that the patient was currently suicidal. The Admission History and Physical, dated 1/11/20 at 2:00 A.M., indicated that Patient #1 had evidence of current and past cutting on the right forearm. He/She is at high risk of self-harm right now.

On 1/12/20, while on the Medical Surgical Unit, Patient #1 requested to use the Hospital's telephone at the nurse's station. When Patient #1 hung up the phone, he/she grabbed a pair of scissors that were on the nurse's station desk and proceeded to cut his/her wrists. A "code gray" was called to intervene and aid in the de-escalation of the situation. Patient #1 threatened to cut deeper if anyone attempted to come near him/her. When the Patient Safety Officers arrived, Patient #1 ran to the unlocked stairwell and cut his/her wrist deeper into the artery and tendon, requiring an orthopedic consult and exploratory surgery.

Review of the Hospital's Psychiatric Consultation in the Emergency Department, dated 7/2017, indicated that psychiatric patients in the Emergency Department will receive timely and active consultation of the management of the psychiatric presentation.

Review of the Hospital's Suicide/Self Injury Risk or Behavior Policy, dated 10/2019, indicated that risk assessments for objects that pose a risk for self-harm will be routinely removed from the immediate vicinity of patients with suicidal ideation. The Policy further indicated that: The patient may not leave the room while on precautions unless an environmental safety check is completed in the adjoining areas. Food must be sent with plastic or paper plates or cups, no utensils, no metal can and no trays.

Review of Patient #1's medical record, dated 1/11/20 at 11:24 A.M., indicated another order for a psychiatric consult was placed due to suicide attempt and depression.

Review of the Case Manager Progress Note, dated 1/11/20 at 11:41 A.M., indicated that Patient #1 was admitted for suicidal/homicidal ideation and was on a 1:1, awaiting a psychiatric evaluation.

Review of a Psychiatric Consult Note, dated 1/12/20 at 12: 16 P.M., (over 40 hours after the initial psychiatric consult was ordered) indicated that medicine paged him with a concern that Patient #1 was getting more agitated and trying to leave against medical advice. The Psychiatrist indicated that, when he was on his way to evaluate the patient, he heard a code gray called for the Patient who grabbed a pair of scissors and and was observed to be cutting his/her wrists. The Psychiatrist indicated that Patient #1 was visibly anxious and distressed. Patient #1 told the Psychiatrist that he/she had been feeling "really suicidal" and hopeless.

Review of a Registered Nurse Progress Note, dated 1/12/20 at 5:35 P.M., indicated that Patient #1 woke up that morning and requested to see psychiatry and then fell back to sleep until 11:30 A.M. When Patient #1 woke up for the second time, he/she started cutting his/her forearms with a pull top of a soda can. The physician was notified and saw the patient. After Patient #1 finished talking with the physician, he/she asked to use the phone at the nurse's station because his/her cell phone battery was dead and due to the suicide protocol, the phones had been removed from the bedroom. The nurse documented that Patient #1 used the phone and grabbed a pair of scissors from the nurse's station and made a threat to harm him/herself by placing a blade of the scissors onto his/her right wrist. The 1:1 constant observer and a physician attempted to get the scissors from the patient but were unsuccessful. The code gray was activated to aid in de-escalation. When Public Safety Officers arrived, Patient #1 became more agitated and attempted to elope via the emergency exit and was able to cut his/her wrists deeper. The Public Safety Officers were then able to obtain the scissors and get the Patient to his/her room to be evaluated. After the Public Safety Officers left, the Patient took another pull top of a soda can out of his/her sock and started cutting him/herself again.

Review of a General Medicine Progress Note, dated 1/13/20 at 4:26 P.M., indicated that Patient #1 was given a metal knife with his/her food tray.

Review of a Registered Nurse Event Note, dated 1/14/20 at 12:28 A.M., indicated that while on 1:1 observation, the Patient was able to pull an unidentified object off of the wall and intended on harming him/herself with it. The Physician was notified and shown the object. Patient #1 said he/she didn't have any other objects and was too tired to hurt him/herself. A safety reassessment was completed. Patient #1 continued on 1:1.

Review of a Registered Nurse Event Note, dated 1/14/20 at 2:26 A.M., indicated that Patient #1 was able to obtain a paperclip while on 1:1 observation. The 1:1 observer did not see the paperclip. The Patient said that he/she got it off of a folder but flushed it in the toilet. A body search was performed and the RN did find a pin inside Patient #1's sock. Additional removal of items were taken off walls in his/her room for safety measures.

Review of the Discharge Summary, dated 1/14/20, indicated that Patient #1 sustained a significant self-inflicted wrist laceration on 1/12/20 and also had several superficial lacerations on both forearms. The Discharge Summary indicated that many of these were self-inflicted on this admission with a soda can top as well as with scissors. Patient #1 continued to obtain and hide sharp objects while admitted including a paperclip, a pin, a knife from a food tray and some sort of socket equipment from the hospital room many of these were hidden in his/her socks and hair. Further attempts at self-injurious behavior included an attempt to wrap a bathroom call cord around his/her neck and striking his/her head on the TV in the bedroom.

During an interview on 2/6/20 at 9:38 A.M., Nurse #1 said that, on 1/11/20, Nurse #2 told her that Patient #1 was actively suicidal. Nurse #1 cared for Patient #1 again on 1/12/20 and that morning Patient #1 requested to see a psychiatrist because he/she really wanted to hurt him/herself. She said that Patient #1 had gotten soda can pull tops and cut his/her forearms. The 1:1 observer told the nurse and the nurse notified the physician. They did a room safety search and found nothing. Patient #1 then took a pull tab out of his/her sock that he/she was hiding. Nurse #1 said that the nurses need more education on patients who are on suicide watch.

During an interview on 2/6/20 at 9:50 A.M., Nurse #2 said that, when Patient #1 was admitted, there was an order for 1:1 constant observation due to suicidal ideation. Nurse #2 said that when the suicide assessment indicates suicide risk, a psychiatry consult is automatically put in the order set.

The Hospital failed to identify the potential for self injurious behavior with intention of suicide by not having a psychiatric consult performed in a timely manner and by not following their own policy titled Suicide/Self-Injury Risk or Behavior which resulted in multiple attempts of self injurious behavior and a suicide attempt while admitted to the Medical Surgical Unit.

The Hospital failed to identify and implement immediate and long term corrective actions to prevent the reoccurrence of self harm in patients with suicidal ideation/self injurious behaviors on the medical surgical units of the Hospital.

Refer to TAG A-0286

Based on interviews and records reviewed, the Hospital failed to identify and implement immediate and long term corrective actions to prevent the reoccurrence of self harm in patients with suicidal ideation/self injurious behaviors on the Medical Surgical Units of the Hospital.

Findings include:

It was reported that Patient #1 was admitted to the Hospital's Medical Surgical Unit from the Emergency Department, after an attempted suicide by overdosing on dextromethorphan/chlorpheniramine (a cough suppressant) and extra strength Tylenol, for medical clearance prior to transfer to an acute psychiatric hospital. Patient #1 had an order for 1:1 constant observation due to active suicidal thoughts with intent to harm him/herself. While admitted on the Medical Surgical Unit, Patient #1 requested to use the Hospital's telephone at the nurse's station. When Patient #1 hung up the phone, he/she grabbed a pair of scissors that were on the nurse's station desk and proceeded to cut his/her wrists. A "code gray" was called to intervene and aid in the de-escalation of the situation. Patient #1 threatened to cut deeper if anyone attempted to come near him/her. When the Patient Safety Officers arrived, the patient ran to the unlocked stairwell and cut his/her wrist deeper into the artery and tendon, requiring an orthopedic consult and exploratory surgery including irrigation and debridement of the right wrist.

Review of the Hospital's Patient Safety and Performance Improvement Plan, effective calendar years 2019-2023, indicated that adverse events and process failures resulting in significant patient harm may be reviewed through the mechanism of root cause analysis. Appropriate measures to improve patient care, safety and patient satisfaction as well as reduce the likelihood of recurrence are recommended through the root cause analysis. All reported incidents are analyzed to identify systems issues that need improvement.

Review of the Hospital's Safety Event Reporting/Good Catch Policy, dated 7/1/18, indicated that it is the responsibility of the Manager/Supervisor to conduct an investigation into adverse events and address any identified issues and report finding and recommendations to the appropriate individuals.

Review of the Hospital's Psychiatric Consultation in the Emergency Department, dated 7/2017, indicated that psychiatric patients in the Emergency Department will receive a timely consultation for the management of their psychiatric condition.

Review of the Hospital's Suicide/Self Injury Risk or Behavior policy, dated 10/2019, indicated that risk assessments for objects that pose a risk for self-harm will be routinely removed from the immediate vicinity of patients with suicidal ideation. The Policy further indicated that: The patient may not leave the room while on precautions unless an environmental safety check is completed in the adjoining areas. Food must be sent with plastic or paper plates or cups, no utensils, no metal can and no trays.

Review of Patient #1's admission orders, dated 1/10/2020 at 8:03 P.M., indicated that Patient #1 required a psychiatry consult.

Review of Patient #1's record indicated that, on 1/11/20 at 11:24 A.M., another order for a psychiatric consult was placed due to suicide attempt and depression.

Review of a Case Manager Progress Note, dated 1/11/20 at 11:41 A.M., indicated that Patient #1 was admitted for suicidal/homicidal ideation and was on a 1:1, awaiting a psychiatric evaluation.

Review of a Psychiatric Consult Note, dated 1/12/20 at 12: 16 P.M., (over 40 hours after the initial psychiatric consult was ordered) indicated that medicine paged him with a concern that the Patient #1 was getting more agitated and trying to leave against medical advice. The Psychiatrist indicated that, when he was on his way to evaluate Patient #1, he heard a code gray called for Patient #1 because he/she grabbed a pair of scissors and was observed to be cutting his/her wrists. The Psychiatrist indicated that Patient #1 was visibly anxious and distressed and told the Psychiatrist that he/she had been feeling "really suicidal" and hopeless.

Review of a Registered Nurse Progress Note, dated 1/12/20 at 5:35 P.M., indicated that Patient #1 woke up that morning and requested to see psychiatry and then fell back to sleep until 11:30 A.M. When Patient #1 woke up for the second time, he/she started cutting his/her forearms with a pull top of a soda can. The physician was notified and saw the patient. After Patient #1 finished talking with the physician, he/she asked to use the phone at the nurse's station because his/her cell phone battery was dead and due to the suicide protocol, the phones had been removed from the bedroom. The nurse documented that the patient used the phone and grabbed a pair of scissors from the nurse's station and made a threat to harm him/herself by placing a blade of the scissors onto his/her right wrist. The 1:1 constant observer and a physician attempted to get the scissors from the patient but were unsuccessful. The code gray was activated to aid in de-escalation. When Public Safety arrived, Patient #1 became more agitated and attempted to elope from the emergency exit and was able to cut his/her wrists deeper. The Public Safety Officers were then able to obtain the scissors and get Patient #1 to his/her room to be evaluated. After the Public Safety Officers left, Patient #1 took another pull top of a soda can out of his/her sock and started cutting him/herself again.

Review of a General Medicine Progress Note, dated 1/13/20 at 4:26 P.M., indicated that Patient #1 was given a metal knife with his/her food tray.

Review of a Registered Nurse Event Note, dated 1/14/20 at 12:28 A.M., indicated that while on 1:1 observation, the Patient was able to pull an unidentified object off of the wall and intended on harming him/herself with it. The Physician was notified and shown the object. Patient #1 said he/she didn't have any other objects and was too tired to hurt him/herself. A safety reassessment was completed and Patient #1 continued on 1:1.

Review of a Registered Nurse Event Note, dated 1/14/20 at 2:26 A.M., indicated that Patient #1 was able to obtain a paperclip while on 1:1 observation. The 1:1 observer did not see the paperclip. The Patient said that he/she got it off of a folder but flushed it in the toilet. A body search was performed and the RN did find a pin inside Patient #1's sock. Additional removal of items were taken off the walls in Patient #1's room for safety measures.

Review of the Discharge Summary, dated 1/14/20, indicated that Patient #1 sustained a significant self-inflicted wrist laceration on 1/12/20 and also had several superficial lacerations on both forearms. The Discharge Summary indicated that many of these were self-inflicted on this admission with a soda can top as well as with scissors. Patient #1 continued to obtain and hide sharp objects while admitted, including a paperclip, a pin, a knife from a food tray and some sort of socket equipment from the hospital room many of which were hidden in his/her socks and hair. Further attempts at self-injurious behavior included an attempt to wrap a bathroom call cord around his/her neck and striking his/her head on the TV in the bedroom.

Review of the Root Cause Analysis, dated 2/4/20, does not identify any immediate corrective actions or education provided to the Hospital nursing/medical staff to prevent a like occurrence from taking place in the future. It did identify some potential action that had not been implemented as of 2/7/20.

During an interview on 2/6/20 at 9:38 A.M., Nurse #1 said that there has been no re-education regarding caring for patients with suicidal ideation or self injurious behaviors since Patient #1 attempted to commit suicide and engaged in multiple self injurious behaviors on the unit.

During an interview on 2/6/20 at 9:50 A.M., Nurse #2 said that since Patient #1 attempted suicide and engaged in self injurious behaviors they have removed sharps from the nurse's station, but there have been no policy changes or re-education provided to the evening staff.

During an interview on 2/6/20 at 11:55 A.M., the Nurse Manager said that the Hospital had done online training with staff in October 2019 regarding suicidal patients on the unit. The Nurse Manager said that there have been no updates or re-education to staff on the unit since the attempted suicide and multiple self-injurious behaviors of Patient #1. The Nurse Manager said that they have rearranged the desk so that the scissors are no longer attainable by patients, but there was no organized policy change or education in effect.

During an interview on 2/5/20 at 1:28 P.M., the Risk Manager said that the Hospital educated staff in October of 2019 on the Suicide/Self-Injury Risk or Behavior Policy. This training included a check list for patients identified as at Risk for Suicide and/or Self Injury, as well as Room Readiness and Post Discharge Checklist. The Risk Manager said that no further education has been provided to the staff since 10/2019 and after this attempted suicide and multiple self injurious behaviors which took place in 1/2020. The Risk Manager said that the only changes on the unit are an increased awareness on the Medical Surgical Unit and that there have been no global changes to prevent a like occurrence from happening at this time.

During an interview on 2/6/20 at 8:30 A.M., the Senior Director of Quality and Patient Safety said that the Hospital is developing a Consultation Policy that is not in effect at this time.

The Hospital failed to identify corrective actions to prevent patients with the identified intention of suicide and/or self harm from obtaining objects to self injure or attempt suicide while admitted to the Medical Surgical Unit.