HospitalInspections.org

Based on document review and interview, the facility failed to provide for patient safety for 1 of 10 patients (patient #P1).

Findings Include:

1. Review of patient P1's medical record indicated on 5/29/2019, Medical Staff A4, conducted a psychiatric evaluation that states the "patient was placed under suicidal guard." No orders were placed for suicide precautions on 5/29/2019 or 5/30/2019. On 5/31/2019 on or about 1345 hours, the patient attempted to strangle himself, and the patient was then placed on suicide precautions, and 1:1 supervision.

2. Review of facility Policy 702.10 Attachment A, "Levels of Observations and Precautions," states that "all patients will be continually monitored for safety by the use of patient observation rounds." As required the physician will order a "specific precaution" for the following with sub-categories noted:
a. Suicide (verbal, gesture/attempt, lethality)
b. Self Harm (gesture, attempt, lethality)
c. Homicide (verbal, gesture/attempt, lethality)
d. Assault (verbal, physical)
e. Sexual Acting Out (boundaries, victim, aggressor)
f. Elopement
g. Seizure
h. Fall
The policy also states that "all levels of observation or change in precautions level requires a Physician order."

3. In interview with staff A1, CNO (Chief Nursing Officer), on 6/5/2019 at 1335 hours confirmed that Medical Staff A4 states in the psychiatric evaluation (5/29/2019) the patient is on "suicidal guard" but no orders were placed for suicide precautions until 5/31/2019. Staff A1 also confirms "heightened observation" should take place when a patient is placed on some type of precaution order.