HospitalInspections.org

Based on interview, record review and policy review, the facility failed to:
- Protect one discharged suicidal patient (#11) of one discharged patient in the Emergency Department (ED) from attempted suicide, when appropriate staff oversight was not provided.
- Protect one discharged suicidal patient (#11) of one discharged patient in the ED, when she was left alone in the treatment room after she attempted suicide while she was a patient within the ED.
- Provide an immediate physical assessment of one discharged suicidal patient (#11) of one discharged patient in the ED after she attempted suicide while she was a patient within the ED. These failures could potentially place all suicidal patients at risk of harm when inadequate supervision was provided. The facility census was 24.

On 10/18/18, at the time of the survey exit, the facility provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Developed a case study on evaluation and documentation of suicidal/homicidal patients in the ED. Case study included notification of Registered Nurse (RN) and physician of any suicidal attempt in the ED, documentation of reassessment by the RN and physician of any significant event to include suicidal attempts and completion of event report of any suicidal attempt that occurs.
- Education Manager and ED Manager met with ED staff and physicians to provide in-person education of the case study.
- Provided education on observation levels for one to one (1:1, continuous visual contact with close physical proximity) line of sight and continuous 1:1 as defined within policy.
- Implemented a behavioral health observation form (paper copy) to document 15 minute observations and other key information for patients designated for this level of observation.
- ED RN consistently completed the Patient Safety Associate "Suicidal Assessment and Precautions" flowsheet by ED staff and documented observations and handoff.
- Trained and educated ED staff and ED physicians on Suicidal Prevention in the Emergency Department, Suicidal Screening Assessment and Reassessment policies and observation documentation requirements.
- Beginning October 18, 2018, the ED medical records of 100% of suicidal patients will be audited weekly to validate appropriate level of observation, including use of the Patient Safety Associate Suicidal Assessment flowsheet, until 100% compliance is achieved for three consecutive months; then medical records of 50% of suicidal patients will be audited weekly until 100% compliance is achieved for three consecutive months.
- Sustained compliance to include: monthly audit of 10 medical records of suicidal patient in the ED to ensure appropriate level of observation is maintained.
- Educated 100% of staff who performed phlebotomy in the ED and ED staff on the elimination of Coban (a thin, lightweight, breathable support bandage) use for ED patients who are suicidal.

Based on interview, record review and policy review, the facility failed to:
- Protect one discharged suicidal patient (#11) of one discharged patient reviewed in the Emergency Department (ED), from attempted suicide when appropriate staff oversight was not provided.
- Protect one discharged suicidal patient (#11) of one discharged patient reviewed in the ED, when she was left alone in the treatment room after she attempted suicide, while she was a patient in the ED.
- Provide an immediate physical assessment of one discharged suicidal patient (#11) of one discharged patient reviewed in the ED, after she attempted suicide while she was a patient within the ED. These failures could potentially place all suicidal patients at risk of harm when inadequate supervision was provided. The facility census was 24.

Findings included:

Review of the facility policy titled, "Suicide Prevention for Patients in the Emergency Department," showed:
- Provide guiding principles to decrease the risk of suicide for patients who present to the emergency departments when managing patients at risk of harming themselves or others due to behavioral health issues.
- High Risk indicates continuous one-to-one (1:1, continuous visual contact with close physical proximity) if not in a dedicated "Behavioral Health Ligature resistant Locked Area" area (an area specifically outfitted to prevent harm for behavioral health patients).
- Patients with serious suicidal risk must be placed under reliable monitoring, such as 1:1 continuous monitoring, continuous visual observation within line of sight, allowing for 360 degree viewing.
- Patients will be placed into an ED medical room, and all objects that pose a risk for self-harm that can be easily removed with adversely affecting the ability to deliver medical care will be removed utilizing a Suicide Safety Checklist in the Electronic Health Record (EHR).

Review of the facility policy titled, "Suicide Screening and Assessment," dated 09/12/18 showed:
- Patients are assessed for risk of suicide using the Columbia Suicide Severity Rating Scale (C-SSRS) which is a validated screening tool used when presenting to the Emergency Department (ED) or admitted to the hospital.
- The C-SSRS answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs.
- A suicidal patient is someone who has recently made an attempt, or has expressed the desire, compulsion and has disclosed a plan to end his or her own life or is intending to end his or her own life.
- A seriously suicidal patient is someone who is a high risk for suicide and has an imminent plan with means to act on it at present time.
- If a patient was placed on Suicide Precaution (SP) they should be monitored continuously 1:1.
- To obtain a sitter to provide continuous observation when indicated.
- Patients identified to be at risk for suicide are placed on appropriate suicide precautions.
- A patient identified as high risk for suicide will have interventions implemented immediately to ensure patient safety.
- A Suicide Safety Checklist Assessment (SSCA) will be completed and documented in EHR, which includes but not limited to removal of any items not essential for care.
- All patients on SP will be checked and documented on at a minimum of every 15 minutes not to exceed 20 minutes by designated sitter/staff.

Review of the facility policy titled, "Required Elements of Daily Assessment (REDA)," dated 11/2017 showed:
- Clinical staff will obtain subjective and objective assessment data which promotes a holistic approach to the provision of care and provide written communication reflecting the patient's plan of care and to provide a current reference to all members of the heath care team.
-The reassessment is defined as review of all patient information that has changed since the previous assessment and further analysis of data about the patient .
- Assessment of patients is the responsibility of the registered professional nurse.
- Reassessment is based on the patient's diagnosis, the care setting, the patient' desire for care, change in condition, previous abnormal findings and the response to previous care.

Review of Patient #11 medical record showed that:
- She presented to the ED on 09/12/18 at 5:30 PM for Suicidal Ideation (SI, thoughts to harm self) as an Acuity 2 (High risk situation which may include SI).
- Her past medical history included diagnosis of Bipolar (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day to day tasks), borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships), depressive disorder (sadness severe enough or persistent enough to interfere with function), generalized anxiety disorder (persistent and excessive worry) and post traumatic stress disorder (a psychiatric condition that can occur in people who have experienced or witnessed a traumatic event).
- She had previously attempted suicide and had been discharged from the facility on 09/07/18.
- An order for 1:1 continuous observation (visual observation allowing for 360 degree viewing) was placed.
- The SSCA showed that the room safety check was completed and the sitter/direct observation was initiated.
- No physical assessment documentation by the physician or Registered Nurse (RN) was found.
- The patient was in a non psych safe room (#4) until approximately 8:00 PM when she was placed in a psych safe room (#3).

By interview, there was no equipment removed from the non psych safe room (#4) and a sitter was not present until approximately 9:00 PM on 09/12/18.

Review of the nursing assessment dated 09/12/18, showed that she answered "yes" to thoughts of suicide, tried to hurt yourself, her affect/mood was flat/hopeless and her behavior was withdrawn.

Review of the suicidal screen by Staff GG, Qualified Mental Health Professional (QMHP) dated 09/12/18, showed:
- The patient reported chronic suicidal thoughts.
- She had numerous past attempts, and significant history of self- harm, mostly cutting.
- She reported Monday that she took a handful of pills with the intent to fall asleep and never wake up.
- She continued to have thoughts of overdosing and had medications at home (that could be used to overdose).
- She took a bandage from her arm while in the ED and wrapped it around her neck, in an attempt to restrict her airway.

Review of Patient #11's C-SSRS dated 09/12/18, showed she was at high risk for suicide

During a telephone interview on 10/23/18 at 3:28 PM, Staff GG, QMHP, stated that:
- She brought the patient into the ED for assessment because of her SI.
- The patient was placed in a non psych safe room.
- No equipment was removed from the room.
- No facility sitter was assigned to the room until she prepared to leave, which was around 8:00 PM.
- Staff II, ED Manager, notified her that the patient had something around her neck and was choking herself.
- Staff II asked "Do you want me to stop her?"
- She and Staff II entered the room and the patient had a bandage wrapped around her neck.
- The patient gave the bandage to her.
- The patients neck was red.

Review of the nursing documentation by Staff HH, RN, dated 09/12/18 showed:
- At 7:01 PM, the patient used both thumbs to press on her carotid artery (major blood vessels that take blood to the brain, neck and face) on each side of her neck.
- At 7:07 PM, the physician was notified that the patient attempted to strangle herself with a thin, lightweight, breathable support bandage from a previous lab draw.
- At 8:51 PM, the patient had a dirty roll of gauze in her hand, and when the RN stated that she would throw the gauze away since it wasn't being used, the patient responded, "that's because you're in the room." (The patient was hinting that she would use the roll of gauze to attempt suicide again).
- At 8:52 PM, security was notified to come sit 1:1 with the patient.

An interview could not be obtained with Staff HH.

An interview could not be obtained with the patient.

Review of the medical record showed no 15 minute documentation of the patient's 1:1 observation by security was found.

During an interview on 10/17/18 at 3:03 PM, Staff EE, Security, stated that:
- He sat 1:1 with the patient on 09/12/18, from around 9:00 PM and continued for approximately one and half hours.
- He sat in a chair against the wall of the nursing station across from the patient's room.
- He did not have 360 degree observation of the patient's room.
- He did not document his observations of the patient.
- No one relieved him as a sitter when he left.

During an interview on 10/17/18 at 6:10 PM, Staff JJ, ED Physician, stated that:
- He remembered the patient's face/appearance and that she had a superficial scratch on her thigh.
- He did not recall being told the patient had something around her neck.
- If this was brought to his attention, he would have examined the patient for injuries.

During an interview on 10/17/18 at 10:00 AM, Staff Z, ED Medical Director, stated that:
- He would expect a physical assessment by the physician of any patient after an incident, such as attempted strangulation.
- If ordered, a suicidal patient should have continuous observation until the order was discontinued.
- He was not aware of this incident until 10/16/18.
- An incident report should have been initiated.

Review of the facility incident reports did not reveal an incident report for this event.





















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