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ASCENSION RIVER DISTRICT HOSPITAL 4100 RIVER RD EAST CHINA, MI 48054 April 7, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview the facility failed to protect a suicidal patient from self harm for 1 of 17 patients (patient #1) reviewed resulting in the potential for patient harm for any new patients with the diagnosis of "Suicidal Ideation" who enter the Emergency Department (ED). An Immediate Jeopardy (IJ) was determined to exist on 01/08/16 at 1630 hours, regarding the facility's failure to protect 1 of 17 patients (#1) from neglect by failure to monitor the patient who had been identified to be at risk for suicide, and failure to follow policies and procedures for suicide prevention. One of seventeen (17) patients (patient #1) died as a result of self injury while she was a patient in the Emergency Department (ED). Findings include:

A0144- The facility failed to maintain a safe environment, monitor a patient who had been identified to be at risk for suicide, and follow policies and procedures for suicide prevention for 1 of 17 patients (patient #1) resulting in the death of one patient (patient #1).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review the facility failed to: maintain a safe environment, monitor a patient who had been identified to be at risk for suicide, and follow policies and procedures for suicide prevention for 1 of 17 patients (patient #1), resulting in the death of patient #1 while receiving care in the Emergency Department. Findings include:

On 04/07/16 at approximately 1000 review of the medical record for patient #1 revealed that she was a [AGE] year old female brought to the Emergency Department (ED) on 01/07/16 via local law enforcement. Patient #1 was admitted to the ED at 2058 with a chief complaint of Suicidal Ideation. The physician placed a continuous order for "Suicide Precautions" on 01/07/16 at 2111. Patient #1 was Petitioned and Certified (involuntary admission to a psychiatric facility) by Staff H on 01/7/16 at 2146 with a diagnosis of "Acute Suicidal Ideation with a Plan." An accepting facility was found and a transfer order was written at 0428 on 01/8/16.

On 04/07/16 at approximately 1345 review of Patient#1's medical record, on a document titled "Admit/Progress" note, dated 01/08/16 at 1400, revealed the following: "1220: Upon entering the pts (patient's) room, observed pt sitting on the floor under cardiac monitor. Pt (patient) had strip of blanket material tied around her neck, the other end tied to cardiac monitor mount. Pt immediately cut down and assistance summoned. Pt was mottled in extremities and pulseless. Code initiated. No cords were available in room as they had been removed as part of suicide precautions. Pt was in observation room with window easily visible to staff, however, pt continually pulled curtains shut. Pt belongings had been removed upon her arrival and were stored in nurse's station." At the time of review, Staff F (Emergency Department Registered Nurse assigned to patient #1 on 1/8/16) confirmed she was the author.

On 04/07/16 at approximately 1445 during an interview with Staff F, she stated she worked the day shift (7am-7pm) on 01/08/16 and she recalled the incident that occurred to patient #1. Staff F when queried stated, "When I started my shift that morning I remember the midnight shift reported she (patient #1) was on suicide precautions and there was not a sitter available for the day shift. She (patient #1) was in the room across from the nurse's station. That room has windows. I observed her all through my shift. It was a busy day. There were 3 of us working, we all tried to keep our eyes on her because of the situation. When asked if patient #1 had been tearful, agitated or expressed that she was suicidal Staff F stated, "No. She was asleep during my shift." When asked if she had assessed patient #1, she stated, "No, she wanted to be left alone." When asked to explain what "Suicide Precautions" measures were required to prevent an actual suicide attempt, Staff F stated, "The patient has to be observed at all times. There should be sitter present. The room should have been made safe. Anything that was moveable should have been removed. When asked to provide any documentation of her assessment for patient #1, she stated, "I only charted on her once and that was when I observed her on the floor non-responsive with the strips of blanket around her neck."

Staff F was unable to explain why she documented on 1/8/16 at 1400 "(Patient #1) continually pulled the curtains shut in the room" and did not document any interventions to decrease occurrence(s) or increase supervision for the behavior.
Staff F when asked if she had received any further training related to " Suicide Precautions", after 1/8/16, stated, "No."

On 04/07/16 at approximately 1515 during review of the policy titled, "Self-Harm/Harm to Others (Suicide/Homicide) Precautions, Continuous Patient Monitoring" policy # 8, last reviewed on 07/15, stated under "A. ... obtain an order for the appropriate precautions and put a safety attendant with the patient." and "F. The RN assigns a staff member to monitor the patient who will be under constant visual observation by a competency validated staff member."