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UMASS MEMORIAL HEALTHCARE-MARLBOROUGH HOSPITAL 157 UNION STREET MARLBOROUGH, MA 01752 July 2, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, record review and interviews, immediate jeopardy was determined because Hospital #1 failed to ensure that: 1)one of fourteen patients (Patient #1) received an appropriate suicide risk screening and 2) three of fourteen patients (Patient #10, Patient #11 and Patient #13) were supervised in accordance with the Hospital's Suicide Precaution Policy.

Please refer to F-0144 for details.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, record review and interviews, Hospital #1 failed to ensure that: 1) one of fourteen patients (Patient #1) received an appropriate suicide risk screening and 2) three of fourteen patients (Patient #10, Patient #11 and Patient #13) were supervised in accordance with the Hospital's Suicide Precaution Policy.

Findings include:

PATIENT #1:

The Triage Assessment, dated 5/19/12 at 3:45 P.M., indicated that Patient #1 presented to the Emergency Department (ED) as a walk-in and was found in the Waiting Room Restroom hanging on the back of the restroom door by his/her belt.

Review of video surveillance, dated 5/19/12 at 3:33 P.M, indicated that Patient #1 entered the ED Waiting Area from the Main Entrance and approached the Triage Area.

The Surveyor interviewed Triage Nurse #1 on 6/28/12 at 1:50 P.M. Triage Nurse #1 said that when Patient #1 approached the Triage Area, he was in the process of triaging another patient. Triage Nurse #1 said Patient #1 was calm and told him that he/she was there for a mental health evaluation.

The Suicide Risk Assessment and Management Tool, ED Triage Version, indicated that when a patient presents with a primary behavioral or emotional diagnosis or complaint, the Triage Nurse is required to ask the patient if he/she had any thoughts of hurting him/herself in any way in the last 2 weeks.

Triage Nurse #1 said that he did not ask Patient #1 if he/she had any thoughts of hurting him/herself in any way in the last 2 weeks. Triage Nurse #1 said that he told Patient #1 that he would be finished triaging momentarily, and asked Patient #1 to take a seat in front of the Triage Area. Triage Nurse #1 said Patient #1 requested to go to the restroom and he directed Patient #1 to the Waiting Room Restroom.

Triage Nurse #1 said that when he finished triaging the patient, Patient #1 had not returned from the Waiting Room Restroom. Triage Nurse #1 said that he went back into the Treatment Area to let the staff know they may need a mental health bed and he heard an alarm sound.

The Surveyor interviewed ED Nurse #1 on 6/28/12 at 2:50 P.M. ED Nurse #1 said she was standing at the nursing station in front of the alarm panel when the alarm to the Waiting Room Restroom sounded. ED Nurse #1 said that when she responded to the alarm, she found Patient #1 with a belt around his/her neck, hanging from the door hooks inside the restroom door unconscious.

The Triage and Ongoing Assessment, dated 5/19/12, indicated that Patient #1 was transported back into to ED Treatment Room and was intubated (tube passed through the mouth, down the throat and to the trachea to provide a patent airway).

The Radiology Report, dated 5/19/12, indicated that that Patient #1 suffered from a ligamentous injury of the cervical spine.

The Nursing Continuation Record, dated 5/19/12, indicated that patient #1 was and admitted to the Intensive Care Unit.

The Patient Progress Records and Physician Order, dated 5/20/12, indicated that Patient #1 suffered from neurological deficits and respiratory failure and was transported to Hospital #2 (a tertiary care hospital) for a higher level of care.

Hospital #2's Discharge Summary regarding Patient #1 indicated that Patient #1 recovered from his/her injuries and was discharged to a psychiatric facility. The Discharge Summary indicated that while Patient #1 was recuperating, he/she remained on 1:1 observation.

Hospital #1 failed to ensure that Triage Nurse #1 followed the Suicide Risk Assessment and Management Tool and ask Patient #1 during the initial encounter if he/she had any thoughts of hurting him/herself in any way in the last 2 weeks.

PATIENT #10:

The Triage Assessment, dated 5/26/12 at 4:34 P.M., indicated that Patient #10 presented to the ED as a walk-in accompanied by staff because Patient #10 was suicidal with a plan to jump out of a car window. The Triage Assessment indicated that Patient #10 was triaged immediately as a Emergency Severity Index 2 (ESI, Level 2 is assigned to patients who are in need of urgent care and are high-risk). The Triage Assessment did not not indicate the disposition of Patient #10.

The Policy/Procedure titled Admission (Triage) into the ED indicated that the triage/primary nurse will assess each patient and will communicate with the ED Attending Physician on all patients with emergent (ESI 1) and urgent (ESI 2) conditions.

The ED Nursing Director said that the Triage Nurse was no longer employed at Hospital #1 and was unavailable for an interview.

The ED Nursing Director said that on 5/26/12, the Triage Nurse brought Patient #10 directly back into the ED Treatment Area, placed Patient #10 in Hallway Bed C, located directly in front of the Security Station, and put Patient #10's name on the white board (posting of patients in the ED Treatment Area). The ED Nursing Director said the Triage Nurse did not put the identifier next to Patient #10's name to indicate he/she was suicidal (red magnet with black line). The ED Nursing Director said that the Triage Nurse notified the Security Officer that Patient #10 was there, but did not inform the Security Officer that Patient #10 expressed suicidal ideation. The ED Nursing Director said the Triage Nurse did not inform the Resource or Primary Nurse of Patient #10's presence in the ED.

The Policy/Procedure titled Suicide Precautions: Care of the Suicidal Patient in a Non-Psychiatric Setting indicated that if the patient is considered to be at risk due to potential or actual self-destructive behavior, then a staff member is to be assigned exclusively to the patient at all times and within arms reach. The Policy indicated that suicide precautions can be initiated by a registered nurse. The Policy indicated that the attending physician was to be notified immediately and an order for the suicide precautions and a psychiatric consult was to be obtained.

The Ongoing Assessment, dated 5/26/12 at 7:45 P.M., indicated that Patient #10 was not located in Hall Bed C.

The Triage Assessment, dated 5/26/12 at 7:56 P.M., indicated that Patient #10 was returned to the ED by ambulance after he/she left the ED and darted in front of a car that resulted in an injury to the left elbow.

The ED Physician Record, dated 5/26/12, indicated that Patient #1 left the ED, called his/her group home and informed the group home staff member that he/she was going to jump in front of some cars to kill his/herself. The ED Physician Record indicated that group home staff member called the ED and the local police were notified. The ED Physician Record indicated that when Patient #10 returned to the ED via ambulance, a Section 12 (involuntary hospitalization application) was activated and a psychiatric evaluation was requested. The ED Physician Record indicated that diagnostic testing was performed and determined that Patient #10 had bruised his/her left elbow.

The Ongoing assessment dated [DATE] to 5/27/12, indicated that Patient #10 was placed on 1:1 supervision and then admitted to the inpatient Psychiatric Unit.

Hospital #1 failed to ensure that Patient #10 was placed under 1:1 observation as per the Suicide Precaution Policy which resulted in an injury.

PATIENT #11:

The Triage Assessment, dated 7/2/12 at 9:35 A.M., indicated that Patient #11 presented to the ED with family because he/she felt depressed. The Triage Assessment indicated that Patient #11 was triaged an ESI 3 (non-urgent), brought into the ED and placed in the Trauma Room.

The Ongoing Assessment, dated 7/2/12 at 9:35 A.M., indicated that Patient #11 was suicidal with a plan to drive and hurt his/herself. The Ongoing Assessment indicated that report was given to the Primary Nurse and Patient #11 was being watched by Security.

The Surveyor conducted a tour of the ED on 7/2/12 at 10:15 A.M. with the Patient Safety Officer present. At the time of the tour, the Chief of Security was at the Security Monitoring Station. The Chief of Security said that he had been assigned to observe Patient #11 who was one of 4 patients he was assigned to observe. Observation of the Trauma Room indicated that it was located across from the upper right hand corner of the nursing station and in order for the Chief of Security to observe Patient #11, he had to step away from the Monitoring Station.

Hospital #1 failed to ensure that: 1) Patient #11 was not placed on 1:1 supervision as required per the Suicide Precaution Policy/Procedure and 2) Patient #11 was placed in an area of the ED that could be directly observed by the Chief of Security.

PATIENT #13:

The Triage Assessment, dated 7/1/12, indicated that Patient #13 arrived in the ED at 10:25 P.M. accompanied by family. The Triage Assessment indicated that Patient #13 was crying and reported being depressed with suicidal ideation and was assigned an ESI 2.

The Ongoing Assessment, dated 7/1/12, indicated that Patient #13 was placed in one of the mental health rooms and Security was notified.

The Surveyor conducted a tour of the ED on 7/2/12 at 10:15 A.M. with the Patient Safety Officer present. At the time of the tour, the Chief of Security was at the Security Monitoring Station. The Chief of Security said that he had been assigned to observe Patient #13 who was one of 4 patients he was assigned to observe.

The ED Physician Record, dated 7/1/12 at 11:10 P.M., indicated that Patient #13 suffered from severe depression since having major surgeries a year earlier, was feeling hopeless and had thoughts of driving his/herself off a bridge.

The Section 12(a) Application indicated that it was activated on 7/1/12 at 11:30 P.M.

The Psychiatric Evaluation, dated 7/2/12 at 3:10 A.M., indicated that Patient #13 was tired of the physical pain, saw suicide as his/her only hope and was unable to contract for safety. The Psychiatric Evaluation indicated that inpatient psychiatric placement was being pursued.

Patient #13 was not placed on 1:1 supervision as required per the Suicide Precaution Policy/Procedure.