HospitalInspections.org

Based on review of hospital policies and procedures, medical record, and interview with staff, it was determined the nurse executive failed to ensure emergency room department nursing personnel implemented 1 on 1 suicide precautions for 1 of 1 patients presenting to the Emergency Department (Pt #1) with suicidal ideation. This failure to observe a suicidal patient could result in harm to a patient.

Findings include:

Facility policy and procedure titled "Patient Bill of Rights", Number 714699, dated 2/2008 revealed: "...You have the right to expect reasonable safety and security in the hospital practices and environment...."

Facility policy and procedure titled "Sitters for Behavioral Health Patients", Number 2364158, dated 4/2016 revealed: "...The sitter will constantly observe the patient to ensure their safety and the safety of those around them...."

Facility policy and procedure titled " ER Safety Precautions", Number 797893, dated 07/2004 revealed: "...Special precautions will be taken to ensure patient, staff, and visitor Safety in the Emergency Room...Do not leave patients alone, in the following categories unattended...Severely Intoxicated Patients...Unstable Psychiatric patient...."

CNO #2 confirmed in an interview conducted on August 11, 2016, that there is no policy or procedure on documentation care and supervision of the suicidal patient in the Emergency Department.

Patient # 1 's Medical record revealed that patient arrived to the emergency department on 8/9/16 at 1635 with suicidal ideation. Patient # 1 has a history of bipolar and paranoid schizophrenia, but has stopped his medications.

RN #22 ' s ED progress notes reveal: " ...Patient is disoriented to place and time ...Describing intermittent suicidal thought and has a specific plan ...In-depth assessment planned ...1 on 1 supervision provided and frequent supervision provided ...Patient has been placed in a safe room and direct sight of the station .... "

Observation on tour on August 10, 2016 at 0945 that Patient # 1 was in room #4. Room # 4 was located down the hall from the nurse ' s station and not in direct view of the nurse ' s station. There was no hospital personnel providing 1 to 1 supervision for patient # 1.

RN #10 and ED Manager # 12 confirmed in individual interviews conducted on August 10, 2016 that there is no one observing Patient # 1 at this time. They also confirmed that there is no documentation that the patient is being observed 1 on 1 supervision. They also confirmed that Room # 4 is around the corner, down the hallway from the nurse ' s station, and not in direct view of the nurse's station.

CNO # 2 confirmed in an interview conducted on August 11, 2016 that there was no one observing Patient # 1 on August 10, 2016. She confirmed that the ER Safety Precautions policy and procedure requires staff to not leave unstable Psychiatric patients alone. She also confirmed that Room # 4 is around the corner, down the hallway from the nurse ' s station, and not in direct view of the nurse's station. She also confirmed that there is no documentation that the patient is being observed 1 on 1 supervision.