HospitalInspections.org

Based on document review and staff interview, the hospital's administrative staff failed to ensure 3 of 3 reviewed patients (Patient #1, Patient #2, and Patient #3) received care in a safe setting when the nursing staff failed followed the hospital's policies for performing visual safety checks on the patients in the Emergency Room and prevented patients from attempting to cause harm to self, others, or attempt to commit suicide. Please refer to A-0144 for additional information.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure staff provided patient care occurred in a safe setting.

Based on document review, staff interviews, and review of video footage, the hospital's administrative staff failed to ensure the hospital staff provided adequate supervision to 3 of 3 patients in the Emergency Department (ED) that were deemed as low risk on the Initial Suicide Assessment, unstable behavioral health patients (Patient #1, Patient #2, and Patient #3). Failure to provide adequate supervision for the patients could potentially result in patient attempting to harm themselves or others, while in the ER. The hospital's administrative staff identified a census of 1,787 ED patients in the fiscal year 2021 and 189 ED behavioral health patient in the fiscal year of 2021.

Findings include:

1. Review of the policy "Suicide screening, risk assessment, and interventions," revised 06/2020, revealed in part, "Upon arrival to the ED or admission ...if the patient makes suicidal comments after being screened on admission ...If the patient (ages 10 and up) answers "yes" to any of the screening questions ...have someone remain with the patient until Risk Level and appropriate interventions are determined." "Document the interventions that are implemented. Document 15-minute visual checks on the appropriate Rounding Flowsheet for patient who score low, moderate, or high risk."

"Once the patients are identified as an 'at risk' patient for suicide the ED staff will: ... Establish therapeutic relationships, ... Inventory patient belongings, ... Remove any prohibited items from room, ... Place patient in burgundy scrubs/gown, ... Door to room should be open, ... Obtain psychiatric consult ..."

Appendix A of the "Suicide screening, risk assessment, and interventions," policy revealed in part, "High Suicide Risk Required Interventions ... 1 on 1 observation. Video monitoring may be used as a secondary safety measure but CANNOT be used as the only means to observe the patient." "Moderate Suicide Risk Required Interventions ...Direct or video observation ... initiate every 15-minute visual checks." "Low Suicide Risk Required Interventions ... every 15-minute visual checks."


2. Review of the policy "Care of Patients Presenting with Psychiatric Complaints in the Emergency Department" revealed in part, " ... If Security or safety tech needs to leave the Emergency Department to respond to an urgent situation, the Emergency Department Charge Nurse will assign an Emergency Department associate to perform the Direction Observation of the patient until the Security personnel returns. Direct observation may occur via video at the Nursing Station or with personnel positioned immediately outside the patient room. Staff performing direct observation will keep the patient within his or her view at all times."


3. Review of the policy "Safety Companions" revealed in part, "To provide constant observation, visualization, and companionship to assigned high risk patients ... RNs, LPNs, Paramedics, PCAs/Techs, Security Officers or any other trained colleague may serve as safety companions."



4. Review of Patient #1's medical record revealed the following:

a. Patient #1 presented to the hospital's emergency department on 4/9/22 at 11:51 PM, complaining of trying to kill themselves. Patient #1 indicated they wanted to kill themselves by overdosing on an excess of pills and attempting to cut wrists with a knife.

b. at 12:00 AM, ED RN F requested Security Guard I perform every 15 minute observations on Patient #1.

c. at 12:05 AM on 4/10/22, ED RN F performed the C-SSRS (Columbia-Suicide Severity Rating Scale is a questionnaire used for suicide assessment) on Patient #1, which revealed Patient #1 was at low risk for committing suicide.

d. at 2:00 AM on 4/10/22, Security Guard I asked Security Guard H assume the responsibility to perform every 15 minute observations on Patient #1.

e. the flow sheet, titled Security Department Patient Watch Log, lacked evidence the hospital staff performed 15 minute/continuous checks between 2:00 AM and 5:00 AM on 4/10/22 on Patient #1.

f. the hospital staff resumed performing 15 minute checks at 5:09 AM on 4/10/22 (resulting in Patient #1 going 3 hours and 9 minutes without the hospital staff providing Patient #1 the required 15 minute observations, potentially allowing Patient #1 to harm themselves without the ED staff's knowledge).



5. Review of Patient #2's medical record revealed the following:

a. Patient #2 presented to the hospital's emergency department on 4/9/22 at 11:30 PM, complaining of trying to kill themselves. Patient #2 indicated they wanted to kill themselves by using a toothbrush to cut their wrist and attempting to cut their throat.

b. on 4/9/22 at 11:00 PM, ED RN F performed the C-SSRS (Columbia-Suicide Severity Rating Scale is a questionnaire used for suicide assessment) on Patient #2, which revealed Patient #2 was at low risk for committing suicide.

c. at 11:40 PM, ED RN F requested Security Guard I to perform every 15 minute observations on Patient #2.

d. at 2:00 AM on 4/10/22, Security Guard I asked Security Guard H assume the responsibility to perform every 15 minute observations on Patient #2.

e. the flow sheet, titled Security Department Patient Watch Log, lacked evidence the hospital staff performed 15 minute/continuous checks between 2:00 AM and 5:00 AM on 4/10/22 on Patient #2.

f. the hospital staff resumed performing 15 minute checks at 5:09 AM on 4/10/22 (resulting in Patient #2 going 3 hours and 9 minutes without the hospital staff providing Patient #2 the required 15 minute observations, potentially allowing Patient #2 to harm themselves without the ED staff's knowledge).



6. Review of Patient #3's medical record revealed the following:

a. Patient #3 presented to the hospital's emergency department on 2/23/22 at 3:22 PM, complaining of trying to hurt themselves. Patient #3 indicated they wanted to hurt themselves by cutting their right forearm 7 times with a pocket knife.

b. at 6:00 PM, ED RN K performed the C-SSRS (Columbia-Suicide Severity Rating Scale is a questionnaire used for suicide assessment) on Patient #3, which revealed Patient #3 was at low risk for committing suicide.

c. at 3:52 PM, ED RN K requested Security Guard A to perform every 15 minute observations on Patient #3.

d. at 4:47 PM, Security Guard A asked Security Guard D assume the responsibility to perform every 15 minute observations on Patient #3.

e. the flow sheet, titled Security Department Patient Watch Log, lacked evidence the hospital staff performed 15 minute checks between 6:37 PM and 6:55 PM on 2/23/22 on Patient #3.

f. the hospital staff resumed performing 15 minute checks at 6:55 PM on 2/23/22 (resulting in Patient #3 going 18 minutes without the hospital staff providing Patient #3 the required 15 minute observations, potentially allowing Patient #3 to harm themselves without the ED staff's knowledge).



7. During an interview on 4/13/22 at 7:54 AM, RN G revealed the security guards sat with behavioral health patients at risk for self-harm and provided monitoring to the behavioral health patients. The ED staff had placed a table outside the rooms used for behavioral health patients, so the security guards could monitor the patients. If a Security Guard had to stop monitoring a behavioral health patient and leave the ED, the nursing staff are responsible for finding someone to continue monitoring the behavioral health patient.


8. During an interview on 4/12/22 at 2:49 PM, RN C revealed the ED staff normally placed behavioral health patients in rooms designed specifically to help keep behavioral health patients safe. If the behavioral health dedicated rooms were not available, the ED staff would place a behavioral health patient in a regular ED room and attempt to remove items from the regular ED room that a behavioral health patient could use to harm themselves. However, RN C acknowledged that the ED staff could not provide the required monitoring to behavioral health patients, especially patients in non-dedicated behavioral health rooms, due to a lack of staff available to monitor the patients.


9. During an interview on 4/12/22 at 12:51 PM, the Security Manager revealed that the security staff perform the monitoring of behavioral health patients requiring monitoring (video monitoring, 1 to 1 continuous observation, or every 15 minute visual checks) in the Emergency Department. In the prior 3 weeks, due to staffing issues, the security staff only had 1 Security Guard on-duty from midnight to noon. The Security Manager had notified the hospital's Safety Officer and the Director of Facilities they only had 1 Security Guard on-duty from midnight to noon.


10. During an interview on 4/12/22 at 1:17 PM, Security Guard A revealed that if a security guard was assigned to monitor a patient in the ED, and the security guard had to leave the ED to address a security issue in the hospital, the security guard informs the ED nursing staff that the security guard has to leave the ED due to them needing to respond to the security issue in the hospital. The security guards reminded the nursing staff that the ED nursing staff needed to find someone to take over monitoring the behavioral health patient in the ED.

When the security guard returns to the ED, after addressing the hospital's security issue, the security guards normally find that the ED staff did not complete the Rounding Flowsheet to document if the ED staff monitored the behavioral health patients to ensure the behavioral health patient did not attempt to harm themselves while the security guard was not in the ED. Security Guard A had informed the Emergency Department Manager about the issue and the Emergency Department Manager acknowledged the ED staff had failed to provide the required monitoring to behavioral health patients.



11. Review of video footage on 4/10/22 at 2:00 AM in the core area of the ED an emergency call was paged overhead in which Security Guard I and Security Guard H attended. Security Guard I was performing video monitoring on behavioral health Patient #1 and Patient #2. Security Guard I informed Security Guard H that Security Guard I was leaving the video monitoring of Patient #1 and Patient #2. RN F was in charge of Patient #1 and Patient #2. From approximately 2:00 AM until 4:47 AM, neither RN F nor RN G physically checked on either Patient #1 or Patient #2, nor looked at the video monitor. The door to both Patient #1's and Patient #2's ED room door was closed the entire time Security Guard I and Security Guard H had left the ED.

Additional observations of the video footage revealed:

a. at 2:05 AM Environmental Service staff walked through the ED.

b. between 2:06 AM until 3:09 AM ED staff randomly walked through the department, entering information into a computer, pulling medication out of Pyxis machine (an automated medication dispensing system), and making phone calls.

c. at approximately 3:25 AM, Security H walks through ED and held a conversation with RN G until 3:32 AM, approximately 12-15 feet from Patient #1 room.

d. at 3:33 AM, Security H walked through the ED without visually monitoring Patient #1 or Patient #2.

d. at 4:51 AM, Security Guard H picked up a patient's belongings that were placed at a desk in the center of the ED.

e. at 5:00 AM, Patient #1 and Patient #2 had no observable monitoring or assessment by RN F or RN G.

f. at 5:09 AM, Security Guard H resumed monitoring Patient #1 and Patient #2 and performing the required checks every 15 minutes.