The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TRISTAR SOUTHERN HILLS MEDICAL CENTER 391 WALLACE RD NASHVILLE, TN 37211 July 11, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of facility policy, medical record review, review of a facility video recording, and interview, the facility failed to ensure care was provided in a safe manner for 1 patient (#1) of 4 patients reviewed for Suicide and Homicidal Ideations.

The findings included:

During the survey it was found one patient (#1) was admitted to the facility's Emergency Department (ED) on 6/26/18 with complaints of Depression, Suicidal and Homicidal Ideation, and a Previous Suicide Attempt. The patient was placed in a room in the ED, triaged by the nursing staff and evaluated by the Physician's Assistant (PA). On arrival to the ED, the patient had a cell phone, his clothing, and his home medications. Continued review revealed the medications were Latuda (used to treat bipolar disorder) 40 mg (milligrams) tablets and Trazodone (antidepressant) 150 mg tablets. Further review revealed the number of tablets in each bottle was not counted prior to being placed on a tray in the patient's room. Continued review revealed the medications were left on a tray in the patient's room and the patient was left unattended while he was to undress and change into paper clothing. Further review revealed the patient called his mother and told her he had took all of the pills in the medication bottles and the patient's mother then called the nursing staff and told the charge nurse the patient had taken the medications. Continued review revealed the patient confirmed he took the medications while he was left alone in the ED room. Further review revealed the patient required admission to the CCU (Critical Care Unit) for telemetry observation.

During a conference on 7/11/18 at 4:05 PM, in the conference room, with the Administrator, the Chief Operations Officer, the Chief Financial Officer, and the Vice President of Quality and Risk Management, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at 42 CFR PART 482.13, Conditions of Participation, Patient Rights.

Review of an Immediate Action Plan, which removed the Immediate Jeopardy on 7/11/18 revealed the following actions were implemented:

Failure to follow facility Behavioral Health Policies; failure to follow suicide prevention plan and failure to utilize facility tools and checklist.

1. The facility provided the following education to all ED staff members, Physicians and Licensed Individual Practitioners (LIP) who provide patient care which included:

All patients should be screened for suicidal ideation upon admission with any change in status and prior to discharge. Patients on suicide precautions should be reassessed at least once per shift by a Registered Nurse and at least daily by a physician or LIP. Any patient who responds to yes to any screening questions should be placed on suicide precautions and begin monitoring immediately.
* Do not leave patient alone. Call for help.
* Notify physician or LIP so they may assess patient to determine need for suicide precautions and place order.
* Notify Nursing Supervisor of suicide precaution orders and need for continuous monitoring.
* Implement Behavioral Observation Log
* Implement Suicide Safe Environment emergency room (ER)/Intensive Care Unit (ICU) Readiness Checklist.
* Secure all patient clothing, shoes, jewelry and belongings, including medications.
* Suicide precautions should be clearly communicated to staff members verbally (handoff or handover) and in writing (report/round sheets).
* Review of facility education revealed 47/48 (98%) of the ED staff received education on 7/11/18
* Review of 2 patient medical records that were currently admitted to the ED and remained on 1:1 observations, revealed the safe environment form was completed and no home medications were in the patients rooms.

2. Huddle message with Connect to Purpose (facility's education) distributed to Leadership and to be shared in Daily Huddles. Huddle message content includes screening requirements and safe environment expectations. (90% of staff will complete Huddle Message education).
* Individual Responsible for Actions: Chief Nursing Officer (CNO), Vice President of Quality and Risk Management, Unit Leaders
* Huddle message created 7/5/18.
* 7/11/18: Education and training related to the Huddle message was implemented to all ED staff which included the Physicians, LIP's and Security Staff.
* Review of facility educational training revealed 98% of the ED staff received education on 7/11/18 from 4:05 PM-7:45 PM.

3. Staff member who failed to follow policy and utilize safe environment checklist was suspended during the investigation; termination of staff member for failure to protect the patient.
Individual responsible for Actions: Director of Emergency Services and Vice President of Quality and Risk Management.
Suspension 6/27/18 and termination 7/2/18.
Review of the Suicide Safe Environment Readiness Checklist dated 7/2018 revealed the facility revised the checklist to include the following:
"...Warning!!! This patient had been identified as an imminent or high risk for suicide and/or violence directed at others. The Registered Nurse must be responsible to implement the following precautions immediately and the Nursing Supervisor will perform a second review of these precautions:
a. Remove all patient belongings, including medications from the patient's room and secure. Do not leave patient alone with belongings
b. place patient in paper scrubs or a gown with snaps
c. 2 staff members will accompany the patient to the bathroom and must have visual contact with the patient during all activities
d. patient has camera observation
e. document reason(s) why any intervention could not be implemented. Nursing Supervisor must approve..."

The form was placed on for online access for the staff to use on 7/9/18 and will be sent to the Medical Executive Committee (MEC) and the Governing Body (GB) for final approval.

100% of ER staff will attest to content of Huddle Message and the expectation of utilization of all behavioral health checklists and second level signature with completion of environmental safety checklist. Completion date 7/11/18.
* Review of facility documentation revealed 98% of the ED staff completed the required training on 7/11/18.

ED staff was also educated relative to the inventory, removal and storage of patient's home medications. The inventory will occur during validation of Safe Environmental Checklist. Education done 7/11/18, 47/48 (98%) of ED staff completed the education.


New Policy for monitoring of ED cameras and providing appropriate staff education.
1. Revise camera observation policy and define new process for ER patients on continuous camera observation. Medical Executive Committee (MEC) and Governing Body (GB) approve prior to implementation. Projected completion date: MEC 7/12/18 and GB 7/17/18.

2. 7/11/18: revised Sitter and Virtual Sitter staff competencies. 5/5/ have completed education
* Review of the competencies revealed the education was completed 7/11/18 and attestation forms were signed.

3. 7/11/18: educational process for staff members who will monitor Behavioral Health patients via camera have been initiated at the beginning of the shift and will be completed one on one by the House Supervisor. No staff member will be allowed to monitor camera without completed education.
* Review of educational training and educational sign-in sheets were reviewed.

4. Initiate algorithm to identify patients requiring a sitter/safety attendant. Algorithm will be sent for approval to the MEC on 7/12/18 and GB 7/17/18.
* Review of the algorithm revealed criteria for placing patient's on camera observation.
* Observation in the ED during the investigation revealed 2 patients who were placed on 1:1 observation. Both patients were on continuous camera monitoring and the cameras were in constant observation by the monitoring staff.

Facility does not have defined policy for Involuntary Commitment of patients experiencing psychiatric emergencies.
1. 7/10/18: drafted new policy defining specific expectations for the care, maintenance and treatment of all patients who have a Certificate of Need and are awaiting transfer to higher level of care.
* Individual Responsible for Actions: Vice President of Quality and Risk Management.
* Policy in draft. MEC 7/12/18 and GB 7/17/18.
* Review of facility documentation revealed the staff was given education regarding direct observation of patients and continuous monitoring. 98% of the ED staff received education on 7/11/18.

Staff failed to inventory and store patient's "home" medications securely.
1. House supervisors will assist with inventory, removal and storage of patient home medications. The inventory will occur during validation of Safe Environment Readiness Checklist.
2. ED staff was educated relative to inventory, removal, and storage of patient's home medications. The inventory will occur during validation of Safe Environment Readiness Checklist. Education done 7/11/18, 47/48 (98%) of staff have completed the education. Staff members currently on leave will complete the referenced education prior to returning to work. Director of ED Services will ensure education is completed with these staff members.
3. Individual Responsible for Actions: Director of Nursing, Director of ED Services, and Directors and Leaders. Completion date 7/11/18 and is ongoing.
* Review of facility documentation on 7/11/18 revealed 47 ED staff signed the education sign-in sheet or an attestation form.
* Observations in the ED during the investigation revealed no patient belongings or home medications in the rooms of those patients who were on 1:1 observation.

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

Based on review of facility policy, review of facility checklists, medical record review, review of the facility's video, and interview, the facility failed to provide care in a safe setting for 1 patient (#1) of 4 patients reviewed for Suicide and Homicidal Ideations.

The findings included:

Review of facility policy, Care of Personal Property/Belongings, last revised 3/1/12 revealed "...medications should be sent back home after medication reconciliation form completed. If this is not possible medication will be listed by nurse, placed in bag, sent to Pharmacy, and documented in patient valuables record...for psychiatric patients, a full inventory of belongings may be included in the patient record as part of the assessment process..."

Review of facility policy, Home Medications/Self Administration, last reviewed 5/18/16 revealed "...medications brought into the hospital by a patient should be sent home with the patient...or surrendered to the nursing supervisor who will place them in the pharmacy night cabinet/room...the nurse caring for the patient will list the drugs the patient has brought into hospital. They will count the contents of each bottle...the nurse will document each medicine...on the Record of Patient's Own Medications Storage sheet..."

Review of facility policy, Continuous Camera Observation/Virtual Sitter, last revised 5/25/17 revealed "...the camera monitoring system is for visual observation and assessment [no taping is involved] of patients who require closer observation to maintain patient safety. The monitor technician maintains twenty-four hour observation in the monitor room...a physician order is not required for a patient to receive camera observation..." Further review revealed "...patients with one or more of the criteria within the guidelines will be placed on camera observation which may be initiated by the Primary Nurse, Charge Nurse, or Nursing Supervisor..."

Review of facility policy, Suicide Prevention Plan, last revised 7/26/17 revealed "...patients at risk for suicide, homicide, and/or self-destructive behavior require intensive support, close observation and frequent re-assessment for their emotional and physical well-being at all times..." Further review revealed "...suicide precautions: utilize the following safe environment guideline...ER [emergency room ] or CCU [critical care unit] Suicide Safe Readiness Checklist will be completed in its entirety..."

Review of the Suicide Safe Environment Readiness Checklist, last revised 6/19/17, revealed "...this patient has been identified as at imminent or high risk for suicide and/or violence...the Registered Nurse must be responsible to implement the following precautions immediately and the Nursing Supervisor will perform a 2nd Tier [2nd level] review of these precautions...the list below includes interventions...guide you to implement an improved safe environment...patient is placed in paper scrubs...all patient clothing, shoes, jewelry and belongings are secured...patient is searched for any metal/sharps in their possession...staff must have visual contact with the patient during all activities...room has camera observation..."

Medical record review revealed Patient #1 was admitted to the facility's Emergency Department (ED) on 6/26/18 at 12:47 PM with complaints of Depression, Suicidal and Homicidal Ideation, and a Previous Suicide Attempt. Further review revealed the patient was discharged to an Inpatient Psychiatric facility on 6/29/18.

Medical record review of an ED Nursing Triage record dated 6/26/18 at 12:47 PM revealed "...states he was cutting himself last night, was planning on jumping off a bridge or building today...states he was going to hurt his mother, but had no plan...hx [history] of depression and bipolar..." Continued review revealed no documentation the facility completed the Suicide Safe Readiness Checklist for Patient #1.


Medical record review of an ED Physician's record dated 6/26/18 at 12:47 PM revealed the patient presented to the ED related to suicidal ideations and a suicide attempt while at home and had with thoughts of harming his mother...developed a plan today to walk to the bridge over [Interstate] 65 and states he wanted to jump off it and land in traffic in hopes of ending his life...states he has been abrading his skin over his left wrist...thoughts about hurting his mother however states he did not develop a plan...has history of previous psychiatric evaluation for suicidal attempt...has a large laceration to his left forearm from the previous attempt...is currently being treated for bipolar disorder and severe depression...takes Xanax [antianxiety medication] recreationally which he is not prescribed...patient has been admitted under 6404 [emergency commitment] as he has suicidal ideations with a plan and homicidal ideations without a plan..." Continued review revealed "...shortly after interview when I left the room patient grabbed his medications that he had on hand and took all of them. He had a bottle of Latuda 40 mg tablets and Trazodone 150 mg tablets which were both approximately half full...Poison Control was called at 1:35 PM...stated Latuda may cause hypotension...respiratory depression and prolonged QT interval [cardiac arrhythmia]...Trazodone this may cause respiratory depression, CNS [central nervous system] depression, hypotension, and possible seizure..."

Medical record review of a Certificate of Need (CON) for Emergency Involuntary Admission form dated 6/26/18 at 1:15 PM revealed the form was signed by the Physician Assistant (PA) and the ED attending physician. Further review revealed "...bipolar disorder and depression...Suicidal Ideations with plan to jump off bridge. Expresses that he wants to hurt his mother..."

Medical record review of an Admission History and Physical dated 6/26/18 at 5:13 PM revealed "...[AGE] year old male who was placed under [involuntary emergency commitment] for suicidal ideations with a plan and homicidal ideations without a plan...took unknown number of Latuda and Trazodone. Patient was in the ED...he was left alone. Both bottles were half way fall [full]. He grabbed a bunch of these medications in his hand and swallowed them while in the ED. Poison Control was notified. Patient was recommended for observation...[medications] may cause hypotension which responds to fluids so will continue with fluid hydration. Trazodone causes respiratory depression, CNS depression, hypotension, and possible seizure-like activity. He is to be monitored for cardiac arrhythmias...assessment and plan: admitted for active suicidal attempt..."

Medical record review of a Cardiology Consult dated 6/27/18 at 9:34 AM revealed "...consulted...no prior history of cardiac problems. Apparently...in our ED yesterday, the patient took several Trazodone and Latuda tablets. He is now awaiting inpatient psychiatric transfer...both medicines can cause prolonged QT interval...QT interval was slightly prolonged...this morning showed decrease...was mildly short of breath overnight but blames his asthma and felt better after breathing treatment. No sense of arrhythmia..."

Medical record review of a Pulmonary Critical Care Consult dated 6/27/18 at 6:23 PM revealed "...[Patient #1] history of depression, Attention Deficit Disorder, Bipolar Disorder admitted with drug overdose and suicidal ideations. He presented to ED with depressive symptoms and while in the ED took unknown quantity of Latuda and Trazodone. He thinks it was about 20 pills..."

Medical record review of a Discharge Summary dated 6/28/18 at 1:20 PM revealed "...suicidal attempt with drug overdose...QT stable, cardiology cleared for d/c [discharge]...medically cleared for psychiatric...due to suicidal ideations and homicidal ideations will be transferred to inpatient psychiatry..."

Review of a facility video recording dated 6/26/18 revealed the following:
12:45 PM: the patient presented to the ED by EMS (Emergency Medical Services). The patient was ambulatory. The patient had his cell phone in his hands.
12:48 PM: the patient was taken to ED room #11 by the EMS and the charge nurse.
12:50 PM: the charge nurse and the secretary removed items from Room #11.
12:54 PM: the charge nurse and the Physician's Assistant (PA) were in the room with the patient.
1:07 PM: the charge nurse and the staff nurse were in the room with the patient.
1:16 PM: security guard was in the room with the patient.
1:18 PM: the security guard pulled the curtain and turned his back to the patient's room, leaving the patient alone. Metro police officer comes to the patient's room, but was standing outside the room. The staff nurse was outside the patient's room. The curtains were pulled and the patient could not be visualized by the staff.
1:21 PM: security officer pulled the curtain back and entered the patient's room. (the patient was left alone for 3 minutes and 36 seconds).
1:23 PM: the staff nurse returned to the patient's room with socks for the patient.
1:24 PM: security exited the patient's room with a patient's belongings bag.
1:28 PM: the charge nurse and the PA entered the patient's room (approximate time the patient's mother called the charge nurse).
1:30 PM: the patient was moved to room #8.

Interview with the ED Director on 7/10/18 at 11:15 AM, in the conference room, revealed the patient presented to the ED for a suicidal attempt and homicidal ideations. The patient came to the ED via Emergency Medical Services (EMS) and was ambulatory on arrival at the ED. Further interview revealed "...the patient had his home medications with him and was taken into room #11 by the charge nurse and EMS...the Physician's Assistant saw the patient upon his arrival and after his assessment he decided the patient needed to be a 6404 patient [involuntary emergency commitment]...the charge nurse did the initial intake in the room and then handed the patient off to the primary ED nurse...the patient's medication bottles were on the [stainless steel tray], which was left in the patient's room...the patient started getting loud, abusive, and yelling when they told him he had to change into paper scrubs and give up his phone and clothes...security was called...the contracted security officer responded and called for the Metro Police officer who was also stationed in the ED...the primary nurse was in the room also and after a discussion with the patient, the nurse and security officer told the patient they would step out of the room while the patient changed into the paper scrubs...they pulled the curtain and left the patient in the room unattended with the medications still on the [stainless steel tray]...he had his cell phone in the room with him also..." Further interview revealed "...a few minutes later, the nurse and the security officer went back into the room, got the patient's clothes and cell phone, and took them out of the room...right after that, the patient's mother called the Charge Nurse...and told her they better go check on her son because he had called her and told her that he had taken all of his medications which were left at the patient's bedside...the charge nurse and the PA went to the patient's room immediately...they told the patient's primary nurse about the phone call...they asked the patient if he had taken the medications...he said that he had taken all of the pills in the bottles...the patient was immediately moved to a room closer to the nurses station and placed on a 1:1 observation...Poison Control was called immediately and they told the PA that a prolonged QT interval is the main side effect for the Latuda which could result in cardiac arrhythmias and for the Trazodone the patient could develop hypotension...he was medically screened and then admitted to the ICU...he remained in the unit until 6/29/18 and was discharged to an inpatient psychiatric facility..."

Interview with the Vice President of Quality and Risk Management on 7/10/18 at 12:05 PM, in the conference room, confirmed "...there were several things missed during this patient's admission...never took custody of the medications and the staff was not in constant observation of the patient. If they had removed the medications from the room, the patient would not have had the opportunity to ingest the medications...they did not reconcile the medications so they were not sure how much he took...the charge nurse reported the bottles were half full...that is not our policy, our policy is to reconcile the medications, remove them from the room, and store the medications in a secured storage cabinet...the charge nurse called...told them to activate the camera in the room. The technician told her she would activate the camera but she needed an order to do it. The camera did not get turned on...it was a system error and a communication error...the Suicide Readiness Checklist was not initiated or performed for the patient. Our policy states the checklist will be started by the admission nurse in the ED or the CCU...the house supervisor should have been notified to complete the 2nd tier of the checklist to ensure medications were removed, the camera was activated, and the patient's belongings were secured...the staff and security did not ensure the scrubs were placed on the patient upon admission. When the patient changed into the scrubs the nurse and security guard did not stay in the room with the patient, they left the patient unattended and pulled the curtain, and the patient took the medications...the facility's policy was not followed related to the patient left unattended or in direct observation..."

Interview with the ED Nurse Manager, on 7/10/18 at 1:40 PM, in the conference room, revealed "...the charge nurse called me and notified me of what had happened with the patient...the nurse stated she and the security guard left the patients room briefly to allow him to change into the paper scrubs...they stood right outside the room with the curtains closed and did not have direct sight of the patient...the patient took the medications during that time...the charge nurse was called by the patient's mother who told her the patient had taken the medications...there were multiple facility policies that were not followed during the care of this patient..."

Interview with Registered Nurse (RN) #1 on 7/10/18 at 3:30 PM, in the conference room, revealed "...the patient was brought in by the EMS with suicidal and homicidal ideations...the patient had his home medication bottles with him...the medications were Latuda and Trazodone and they appeared to half full...I did not count the pills in the bottle...we should have counted them and removed the bottles from the room...he had his cell phone with him and he did not want to give his phone up...he was talking with his mother on the phone and wanted me to talk to her...I gave the patient our direct line to the ED to give to his mother...he was becoming very upset and I was trying to calm him down...he had expressed thoughts of wanting to kill his mother and I was trying to de-escalate that situation by getting him off the phone with her...I know security was called to the room because the patient was getting aggressive with the staff...a few minutes after that, the secretary told me that the patient's mother was on the phone. When I picked up the phone, his mother told me that the patient had just called her and told her that he had taken all of his home medications while in the ED room...she said you better go check on him...I hung the phone up...myself and the PA went to the patient's room...the primary nurse was outside the room and security was in the room with him. I asked the patient if he had taken the medications and he said he had taken all of the pills...the bottles appeared to be half full when the patient arrived in the room..." Further interview confirmed the staff failed to reconcile and remove the patient's medications from the room of a psychiatric patient.

Interview with ED Medical Director on 7/11/18 at 9:00 AM, in the ED Hallway, revealed "...the patient came into the ED with Suicidal and Homicidal Ideations with a previous suicidal attempt...he was placed under an involuntary emergency commitment...there were medications identified as Latuda and Trazodone that were in the patient's room and they never were removed from the room..." Further interview revealed "...the patient was very insistent for privacy when undressing and there were some accommodations made by security and the nurse for the staff to step outside of the room and to pull the curtains for the patient to undress into the paper scrubs...the medications were in the room and apparently the patient took all of the pills that were in the bottle...the medications had not been reconciled by the staff so we were not sure how many he took, however, the nursing staff reported the bottles were half full..."

Interview with PA #1 on 7/11/18 at 9:40 AM, in the conference room, revealed "...he came in with Suicidal and Homicidal Ideations and had a history of cutting himself as recent as the day before...the medication bottles were sitting on the [stainless steel tray] in the room but I had not looked at them...the nursing staff stated the bottles were half full. They were identified as Latuda and Trazodone...when I came back into the room he was slightly agitated and did not want to give his cell phone up or change into the paper scrubs. Security was called and came down and stayed with the patient..." Further interview revealed "...a little while later, the charge nurse advised me the patient had just took all of his medications. I went into the patient's room immediately and asked the patient if he took the medications and he confirmed he had taken all the Latuda and Trazodone medications...I called Poison Control..."

Interview with Vice President of Quality Risk Management on 7/11/18 at 2:30 PM, in the conference room, revealed "... the patient was admitted to the Critical Care Unit [CCU] after he was treated in the ED...the patient remained in the CCU until...he was transferred to an inpatient psychiatric facility..." Further interview confirmed the patients medications were not reconciled or removed from the patient's room; the camera was not turned on to monitor the patient; the Suicide Readiness Check List was not performed for the patient, and the patient was left unattended in the room with the medications in the patient's room. Continued interview confirmed the facility failed to ensure a safe environment for the patient.

Interview with Cardiologist #1 on 7/11/18 at 3:40 PM, in the conference room, revealed "...if a patient has a prolonged QT Interval this may lead to ventricular dysrhythmias which may be fatal if the ventricular rate gets too high. Certain medications may cause the prolonged QT intervals and Latuda would be one of those medications..."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of facility policy, medical record review, review of facility's video, and interview, the facility failed to provide nursing services to prevent injury for 1 patient (#1) of 4 patients reviewed for Suicide and Homicidal Ideations.

The findings included:

During the survey it was found one patient (#1) was admitted to the facility's Emergency Department (ED) on 6/26/18 with complaints of Depression, Suicidal and Homicidal Ideation, and a Previous Suicide Attempt. The patient was placed in a room in the ED, triaged by the nursing staff and evaluated by the Physician's Assistant (PA). On arrival to the ED, the patient had a cell phone, his clothing, and his home medications. Continued review revealed the medications were Latuda (used to treat bipolar disorder) 40 mg (milligrams) tablets and Trazodone (antidepressant) 150 mg tablets. Further review revealed the number of tablets in each bottle was not counted prior to being placed on a tray in the patient's room. Continued review revealed the medications were left on a tray in the patient's room and the patient was left unattended while he was to undress and change into paper clothing. Further review revealed the patient called his mother and told her he had took all of the pills in the medication bottles and the patient's mother then called the nursing staff and told the charge nurse the patient had taken the medications. Continued review revealed the patient confirmed he took the medications while he was left alone in the ED room. Further review revealed the patient required admission to the CCU (Critical Care Unit) for telemetry observation.

During a conference on 7/11/18 at 4:05 PM, in the conference room, with the Administrator, the Chief Operations Officer, the Chief Financial Officer, and the Vice President of Quality and Risk Management, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at 42 CFR PART 482.13, Conditions of Participation, Patient Rights.

Review of an Immediate Action Plan, which removed the Immediate Jeopardy on 7/11/18 revealed the following actions were implemented:

Failure to follow facility Behavioral Health Policies; failure to follow suicide prevention plan and failure to utilize facility tools and checklist.

1. The facility provided the following education to all ED staff members, Physicians and Licensed Individual Practitioners (LIP) who provide patient care which included:

All patients should be screened for suicidal ideation upon admission with any change in status and prior to discharge. Patients on suicide precautions should be reassessed at least once per shift by a Registered Nurse and at least daily by a physician or LIP. Any patient who responds to yes to any screening questions should be placed on suicide precautions and begin monitoring immediately.
* Do not leave patient alone. Call for help.
* Notify physician or LIP so they may assess patient to determine need for suicide precautions and place order.
* Notify Nursing Supervisor of suicide precaution orders and need for continuous monitoring.
* Implement Behavioral Observation Log
* Implement Suicide Safe Environment emergency room (ER)/Intensive Care Unit (ICU) Readiness Checklist.
* Secure all patient clothing, shoes, jewelry and belongings, including medications.
* Suicide precautions should be clearly communicated to staff members verbally (handoff or handover) and in writing (report/round sheets).
* Review of facility education revealed 47/48 (98%) of the ED staff received education on 7/11/18
* Review of 2 patient medical records that were currently admitted to the ED and remained on 1:1 observations, revealed the safe environment form was completed and no home medications were in the patients rooms.

2. Huddle message with Connect to Purpose (facility's education) distributed to Leadership and to be shared in Daily Huddles. Huddle message content includes screening requirements and safe environment expectations. (90% of staff will complete Huddle Message education).
* Individual Responsible for Actions: Chief Nursing Officer (CNO), Vice President of Quality and Risk Management, Unit Leaders
* Huddle message created 7/5/18.
* 7/11/18: Education and training related to the Huddle message was implemented to all ED staff which included the Physicians, LIP's and Security Staff.
* Review of facility educational training revealed 98% of the ED staff received education on 7/11/18 from 4:05 PM-7:45 PM.

3. Staff member who failed to follow policy and utilize safe environment checklist was suspended during the investigation; termination of staff member for failure to protect the patient.
Individual responsible for Actions: Director of Emergency Services and Vice President of Quality and Risk Management.
Suspension 6/27/18 and termination 7/2/18.
Review of the Suicide Safe Environment Readiness Checklist dated 7/2018 revealed the facility revised the checklist to include the following:
"...Warning!!! This patient had been identified as an imminent or high risk for suicide and/or violence directed at others. The Registered Nurse must be responsible to implement the following precautions immediately and the Nursing Supervisor will perform a second review of these precautions:
a. Remove all patient belongings, including medications from the patient's room and secure. Do not leave patient alone with belongings
b. place patient in paper scrubs or a gown with snaps
c. 2 staff members will accompany the patient to the bathroom and must have visual contact with the patient during all activities
d. patient has camera observation
e. document reason(s) why any intervention could not be implemented. Nursing Supervisor must approve..."

The form was placed on for online access for the staff to use on 7/9/18 and will be sent to the Medical Executive Committee (MEC) and the Governing Body (GB) for final approval.

100% of ER staff will attest to content of Huddle Message and the expectation of utilization of all behavioral health checklists and second level signature with completion of environmental safety checklist. Completion date 7/11/18.
* Review of facility documentation revealed 98% of the ED staff completed the required training on 7/11/18.

ED staff was also educated relative to the inventory, removal and storage of patient's home medications. The inventory will occur during validation of Safe Environmental Checklist. Education done 7/11/18, 47/48 (98%) of ED staff completed the education.


New Policy for monitoring of ED cameras and providing appropriate staff education.
1. Revise camera observation policy and define new process for ER patients on continuous camera observation. Medical Executive Committee (MEC) and Governing Body (GB) approve prior to implementation. Projected completion date: MEC 7/12/18 and GB 7/17/18.

2. 7/11/18: revised Sitter and Virtual Sitter staff competencies. 5/5/ have completed education
* Review of the competencies revealed the education was completed 7/11/18 and attestation forms were signed.

3. 7/11/18: educational process for staff members who will monitor Behavioral Health patients via camera have been initiated at the beginning of the shift and will be completed one on one by the House Supervisor. No staff member will be allowed to monitor camera without completed education.
* Review of educational training and educational sign-in sheets were reviewed.

4. Initiate algorithm to identify patients requiring a sitter/safety attendant. Algorithm will be sent for approval to the MEC on 7/12/18 and GB 7/17/18.
* Review of the algorithm revealed criteria for placing patient's on camera observation.
* Observation in the ED during the investigation revealed 2 patients who were placed on 1:1 observation. Both patients were on continuous camera monitoring and the cameras were in constant observation by the monitoring staff.

Facility does not have defined policy for Involuntary Commitment of patients experiencing psychiatric emergencies.
1. 7/10/18: drafted new policy defining specific expectations for the care, maintenance and treatment of all patients who have a Certificate of Need and are awaiting transfer to higher level of care.
* Individual Responsible for Actions: Vice President of Quality and Risk Management.
* Policy in draft. MEC 7/12/18 and GB 7/17/18.
* Review of facility documentation revealed the staff was given education regarding direct observation of patients and continuous monitoring. 98% of the ED staff received education on 7/11/18.

Staff failed to inventory and store patient's "home" medications securely.
1. House supervisors will assist with inventory, removal and storage of patient home medications. The inventory will occur during validation of Safe Environment Readiness Checklist.
2. ED staff was educated relative to inventory, removal, and storage of patient's home medications. The inventory will occur during validation of Safe Environment Readiness Checklist. Education done 7/11/18, 47/48 (98%) of staff have completed the education. Staff members currently on leave will complete the referenced education prior to returning to work. Director of ED Services will ensure education is completed with these staff members.
3. Individual Responsible for Actions: Director of Nursing, Director of ED Services, and Directors and Leaders. Completion date 7/11/18 and is ongoing.
* Review of facility documentation on 7/11/18 revealed 47 ED staff signed the education sign-in sheet or an attestation form.
* Observations in the ED during the investigation revealed no patient belongings or home medications in the rooms of those patients who were on 1:1 observation.

Please refer to A-0395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, review of facility checklist, medical record review, review of the facility's video, and interview, the facility failed to ensure nursing services were provided in a manner to prevent injury for 1 patient (#1) of 4 patients reviewed for Suicide and Homicidal Ideations.

The findings included:

Review of facility policy, Care of Personal Property/Belongings, last revised 3/1/12 revealed "...medications should be sent back home after medication reconciliation form completed. If this is not possible medication will be listed by nurse, placed in bag, sent to Pharmacy, and documented in patient valuables record...for psychiatric patients, a full inventory of belongings may be included in the patient record as part of the assessment process..."

Review of facility policy, Home Medications/Self Administration, last reviewed 5/18/16 revealed "...medications brought into the hospital by a patient should be sent home with the patient...or surrendered to the nursing supervisor who will place them in the pharmacy night cabinet/room...the nurse caring for the patient will list the drugs the patient has brought into hospital. They will count the contents of each bottle...the nurse will document each medicine...on the Record of Patient's Own Medications Storage sheet..."

Review of facility policy, Continuous Camera Observation/Virtual Sitter, last revised 5/25/17 revealed "...the camera monitoring system is for visual observation and assessment [no taping is involved] of patients who require closer observation to maintain patient safety. The monitor technician maintains twenty-four hour observation in the monitor room...a physician order is not required for a patient to receive camera observation..." Further review revealed "...patients with one or more of the criteria within the guidelines will be placed on camera observation which may be initiated by the Primary Nurse, Charge Nurse, or Nursing Supervisor..."

Review of facility policy, Suicide Prevention Plan, last revised 7/26/17 revealed "...patients at risk for suicide, homicide, and/or self-destructive behavior require intensive support, close observation and frequent re-assessment for their emotional and physical well-being at all times..." Further review revealed "...suicide precautions: utilize the following safe environment guideline...ER [emergency room ] or CCU [critical care unit] Suicide Safe Readiness Checklist will be completed in its entirety..."

Review of the Suicide Safe Environment Readiness Checklist, last revised 6/19/17, revealed "...this patient has been identified as at imminent or high risk for suicide and/or violence...the Registered Nurse must be responsible to implement the following precautions immediately and the Nursing Supervisor will perform a 2nd Tier [2nd level] review of these precautions...the list below includes interventions...guide you to implement an improved safe environment...patient is placed in paper scrubs...all patient clothing, shoes, jewelry and belongings are secured...patient is searched for any metal/sharps in their possession...staff must have visual contact with the patient during all activities...room has camera observation..."

Medical record review revealed Patient #1 was admitted to the facility's Emergency Department (ED) on 6/26/18 at 12:47 PM with complaints of Depression, Suicidal and Homicidal Ideation, and a Previous Suicide Attempt. Further review revealed the patient was discharged to an Inpatient Psychiatric facility on 6/29/18.

Medical record review of an ED Nursing Triage record dated 6/26/18 at 12:47 PM revealed "...states he was cutting himself last night, was planning on jumping off a bridge or building today...states he was going to hurt his mother, but had no plan...hx [history] of depression and bipolar..." Continued review revealed no documentation the facility completed the Suicide Safe Readiness Checklist for Patient #1.

Medical record review of an ED Physician's record dated 6/26/18 at 12:47 PM revealed the patient presented to the ED related to suicidal ideations and a suicide attempt while at home and had with thoughts of harming his mother...developed a plan today to walk to the bridge over [Interstate] 65 and states he wanted to jump off it and land in traffic in hopes of ending his life...states he has been abrading his skin over his left wrist...thoughts about hurting his mother however states he did not develop a plan...has history of previous psychiatric evaluation for suicidal attempt...has a large laceration to his left forearm from the previous attempt...is currently being treated for bipolar disorder and severe depression...takes Xanax [antianxiety medication] recreationally which he is not prescribed...patient has been admitted under 6404 [emergency commitment] as he has suicidal ideations with a plan and homicidal ideations without a plan..." Continued review revealed "...shortly after interview when I left the room patient grabbed his medications that he had on hand and took all of them. He had a bottle of Latuda 40 mg tablets and Trazodone 150 mg tablets which were both approximately half full...Poison Control was called at 1:35 PM...stated Latuda may cause hypotension...respiratory depression and prolonged QT interval [cardiac arrhythmia]...Trazodone this may cause respiratory depression, CNS [central nervous system] depression, hypotension, and possible seizure..."

Medical record review of an Admission History and Physical dated 6/26/18 at 5:13 PM revealed "...[AGE] year old male who was placed under [involuntary emergency commitment] for suicidal ideations with a plan and homicidal ideations without a plan...took unknown number of Latuda and Trazodone. Patient was in the ED...he was left alone. Both bottles were half way fall [full]. He grabbed a bunch of these medications in his hand and swallowed them while in the ED. Poison Control was notified. Patient was recommended for observation...[medications] may cause hypotension which responds to fluids so will continue with fluid hydration. Trazodone causes respiratory depression, CNS depression, hypotension, and possible seizure-like activity. He is to be monitored for cardiac arrhythmias...assessment and plan: admitted for active suicidal attempt..."
Medical record review of a Cardiology Consult dated 6/27/18 at 9:34 AM revealed "...consulted...no prior history of cardiac problems. Apparently...in our ED yesterday, the patient took several Trazodone and Latuda tablets. He is now awaiting inpatient psychiatric transfer...both medicines can cause prolonged QT interval...QT interval was slightly prolonged...this morning showed decrease...was mildly short of breath overnight but blames his asthma and felt better after breathing treatment. No sense of arrhythmia..."

Medical record review of a Pulmonary Critical Care Consult dated 6/27/18 at 6:23 PM revealed "...[Patient #1] history of depression, Attention Deficit Disorder, Bipolar Disorder admitted with drug overdose and suicidal ideations. He presented to ED with depressive symptoms and while in the ED took unknown quantity of Latuda and Trazodone. He thinks it was about 20 pills..."

Review of a facility video recording dated 6/26/18 revealed the following:
12:45 PM: the patient presented to the ED by EMS (Emergency Medical Services). The patient was ambulatory. The patient had his cell phone in his hands.
12:48 PM: the patient was taken to ED room #11 by the EMS and the charge nurse.
12:50 PM: the charge nurse and the secretary removed items from Room #11.
12:54 PM: the charge nurse and the Physician's Assistant (PA) were in the room with the patient.
1:07 PM: the charge nurse and the staff nurse were in the room with the patient.
1:16 PM: security guard was in the room with the patient.
1:18 PM: the security guard pulled the curtain and turned his back to the patient's room, leaving the patient alone. Metro police officer comes to the patient's room, but was standing outside the room. The staff nurse was outside the patient's room. The curtains were pulled and the patient could not be visualized by the staff.
1:21 PM: security officer pulled the curtain back and entered the patient's room. (the patient was left alone for 3 minutes and 36 seconds).
1:23 PM: the staff nurse returned to the patient's room with socks for the patient.
1:24 PM: security exited the patient's room with a patient's belongings bag.
1:28 PM: the charge nurse and the PA entered the patient's room (approximate time the patient's mother called the charge nurse).
1:30 PM: the patient was moved to room #8.

Interview with the ED Director on 7/10/18 at 11:15 AM, in the conference room, revealed the patient presented to the ED for a suicidal attempt and homicidal ideations. Further interview revealed "...the patient had his home medications with him...the Physician's Assistant saw the patient upon his arrival and after his assessment he decided the patient needed to be a 6404 patient [involuntary emergency commitment]...the charge nurse did the initial intake in the room and then handed the patient off to the primary ED nurse...the patient's medication bottles were on the [stainless steel tray], which was left in the patient's room...the primary nurse was in the room also and after a discussion with the patient, the nurse and security officer told the patient they would step out of the room while the patient changed into the paper scrubs...they pulled the curtain and left the patient in the room unattended with the medications still on the [stainless steel tray]...he had his cell phone in the room with him also..." Further interview revealed "...a few minutes later, the nurse and the security officer went back into the room, got the patient's clothes and cell phone, and took them out of the room...right after that, the patient's mother called the Charge Nurse...and told her they better go check on her son because he had called her and told her that he had taken all of his medications which were left at the patient's bedside...the charge nurse and the PA went to the patient's room immediately...they told the patient's primary nurse about the phone call...they asked the patient if he had taken the medications...he said that he had taken all of the pills in the bottles...the patient was immediately moved to a room closer to the nurses station and placed on a 1:1 observation..."

Interview with the Vice President of Quality and Risk Management on 7/10/18 at 12:05 PM, in the conference room, confirmed "...there were several things missed during this patient's admission...never took custody of the medications and the staff was not in constant observation of the patient. If they had removed the medications from the room, the patient would not have had the opportunity to ingest the medications...they did not reconcile the medications so they were not sure how much he took...the charge nurse reported the bottles were half full...that is not our policy, our policy is to reconcile the medications, remove them from the room, and store the medications in a secured storage cabinet...the charge nurse called...told them to activate the camera in the room. The technician told her she would activate the camera but she needed an order to do it. The camera did not get turned on...it was a system error and a communication error...the Suicide Readiness Checklist was not initiated or performed for the patient. Our policy states the checklist will be started by the admission nurse in the ED or the CCU...the house supervisor should have been notified to complete the 2nd tier of the checklist to ensure medications were removed, the camera was activated, and the patient's belongings were secured...the staff and security did not ensure the scrubs were placed on the patient upon admission. When the patient changed into the scrubs the nurse and security guard did not stay in the room with the patient, they left the patient unattended and pulled the curtain, and the patient took the medications...the facility's policy was not followed related to the patient left unattended or in direct observation..."

Interview with the ED Nurse Manager, on 7/10/18 at 1:40 PM, in the conference room, revealed "...the charge nurse called me and notified me of what had happened with the patient...the nurse stated she and the security guard left the patients room briefly to allow him to change into the paper scrubs...they stood right outside the room with the curtains closed and did not have direct sight of the patient...the patient took the medications during that time...the charge nurse was called by the patient's mother who told her the patient had taken the medications...there were multiple facility policies that were not followed during the care of this patient..."

Interview with Registered Nurse (RN) #1 on 7/10/18 at 3:30 PM, in the conference room, revealed "...the patient was brought in by the EMS with suicidal and homicidal ideations...the patient had his home medication bottles with him...the medications were Latuda and Trazodone and they appeared to half full...I did not count the pills in the bottle...we should have counted them and removed the bottles from the room...he had his cell phone with him and he did not want to give his phone up...he was talking with his mother on the phone and wanted me to talk to her...I gave the patient our direct line to the ED to give to his mother...he was becoming very upset and I was trying to calm him down...he had expressed thoughts of wanting to kill his mother and I was trying to de-escalate that situation by getting him off the phone with her...I know security was called to the room because the patient was getting aggressive with the staff...a few minutes after that, the secretary told me that the patient's mother was on the phone. When I picked up the phone, his mother told me that the patient had just called her and told her that he had taken all of his home medications while in the ED room...she said you better go check on him...I hung the phone up...myself and the PA went to the patient's room...the primary nurse was outside the room and security was in the room with him. I asked the patient if he had taken the medications and he said he had taken all of the pills...the bottles appeared to be half full when the patient arrived in the room..." Further interview confirmed the staff failed to reconcile and remove the patient's medications from the room of a psychiatric patient.

Interview with ED Medical Director on 7/11/18 at 9:00 AM, in the ED Hallway, revealed "...the patient came into the ED with Suicidal and Homicidal Ideations with a previous suicidal attempt...he was placed under an involuntary emergency commitment...there were medications identified as Latuda and Trazodone that were in the patient's room and they never were removed from the room..."

Interview with PA #1 on 7/11/18 at 9:40 AM, in the conference room, revealed "...he came in with Suicidal and Homicidal Ideations and had a history of cutting himself as recent as the day before...the medication bottles were sitting on the [stainless steel tray] in the room but I had not looked at them...a little while later, the charge nurse advised me the patient had just took all of his medications. I went into the patient's room immediately and asked the patient if he took the medications and he confirmed he had taken all the Latuda and Trazodone medications...I called Poison Control..."

Interview with Vice President of Quality Risk Management on 7/11/18 at 2:30 PM, in the conference room, revealed "... the patient was admitted to the Critical Care Unit [CCU] after he was treated in the ED...the patient remained in the CCU until 6/29/18 where he was transferred to an inpatient psychiatric facility..." Further interview confirmed the patients medications were not reconciled or removed from the patient's room; the camera was not turned on to monitor the patient; the Suicide Readiness Check List was not performed for the patient, and the patient was left unattended in the room with the medications in the patient's room.

Telephone interview with the Manager of Operations for the contracted Security, on 7/11/18 at 1:00 PM revealed the manager was made aware of the incident on 6/26/18 by the administrative staff. Further interview revealed "...I spoke with the officer involved...he said the patient had become very hostile with the staff and did not want to change clothes or give up his cell phone. The officer stated he was trying to do the patient a favor and allow him to have some privacy while he was undressing. He stated there was a conversation between the patient, the officer, and the nurse for the staff to step outside the room, pull the curtain, and let the patient undress himself..." Further interview revealed "...this was the wrong process to follow and the patient took the medications while the staff was outside behind the curtain..."

Interview with Vice President of Quality Risk Management on 7/11/18 at 2:30 PM, in the conference room, confirmed the patients medications were not reconciled or removed from the patient's room; the camera was not turned on to monitor the patient; the Suicide Readiness Check List was not performed for the patient, and the patient was left unattended in the room with the medications in the patient's room.