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.

WILKES-BARRE GENERAL HOSPITAL 575 NORTH RIVER STREET WILKES-BARRE, PA 18764 Sept. 18, 2020
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.13 Tag A-0144

The information reviewed during the survey provided evidence the facility failed to ensure suicidal patients were under continuous observation by a one to one observer in the Emergency Department (ED) crisis area resulting in a suicidal patient being able to obtain and ingest hand sanitizer. The facility failed to ensure security officers did not leave the security post in the ED crisis area without proper coverage.

A discussion took place with the survey team and the facility's administrative staff (EMP4, EMP5, EMP6 and EMP7) regarding the survey team's concerns related to Patient's Rights on September 17, 2020 at approximately 5:00 PM.


Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 Nursing Services
482.23 (a) Organization of Nursing Services
482.23 (b)(6) Supervision of Contracted Staff

Repeat deficiency
September 14, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of facility documents and medical records (MR), observation and staff interview (EMP), the facility failed to provide continuous observation as ordered by the physician for four of four applicable patients (MR1, MR2, MR3 and MR4) assessed as being a suicide risk; the facility failed to ensure security officers did not leave the security post in the ED crisis area without proper coverage for one of one medical record reviewed (MR1) and the facility failed to ensure patients admitted to the crisis area of the ED were wanded (handheld metal detector) and checked for contraband before entry into the ED for seven of nine applicable medical records reviewed (MR1, MR2, MR3, MR4, MR6, MR10 and MR11).

Findings include:

Review on September 17, 2020, of the facility's "Patient's Bill of Rights" policy, last approved May 2, 2017, revealed "... You have the right to: ... An environment that is safe, preserves dignity and contributes to a positive self-image. ..."

Review on September 17, 2020, of the facility's "Suicide Precautions" policy, last reviewed April 2019 revealed "Purpose: To outline a mechanism for observation and protection of patients who are assessed to be at risk for suicide or have expressed suicidal ideations. Policy: ... 3. A patient monitor is assigned until the patient is either transferred to an appropriate facility or is determined to be no longer at risk and discontinued. ... 13. The patient monitor is to be seated at the foot of the patient's bed (beyond arms length but in direct proximity of the patient). ... 11. [sic] the patient monitor must accompany the patient at all times. 12. [sic] While utilizing the bathroom, the door must remain ajar and the patient monitor must keep the patient in sight at all times. ... 16. The patient monitor or other hospital personnel must document patient observation checks every 15 minutes on the patient Observer Monitoring Checklist Form..."

Review on September 17, 2020, of the facility's "Suicide Risk Assessment and Interventions: Columbia Protocol In Non-Behavioral Health Setting " policy, last revised May 31, 2019, revealed "Policy All adolescent and adult patients (ages equal or greater [sic] 11 years of age) who present for care and services will be screened for suicide ideation and behavior using the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS) ... Based on the severity and immediacy of suicide risk assessed using the Columbia Protocol, patient safety measures and interventions will be implemented as a means to keep patients from inflicting harm to self. ... Definitions ... One to One (one to one) Observation: Intervention for high risk for suicide. Continuous observation and staff are able to see the patient in clear view and staff can respond immediately to intervene and assure safety at all times, including while the patient sleeps, uses the toilet, bathes, etc. ..."

Review on September 17, 2020, of the facility's "Crisis Post Orders," no review date, revealed "A. Post Protocol ... 5. Officers will remain at their post unless instructed otherwise by a direct supervisor, or until properly relieved by the Shift Supervisor or Lead Security Officer. ... 7. Two security officers will assume the security post, one must monitor the crisis patient rooms at all times via video surveillance ... 8.Under no circumstances will an officer leave his post without being properly relieved and informing his immediate supervisor for the need to do so ... C. Upon Receiving Patient /Visitor ...7. At desk: ... b. Wand patient in camera view. ... H. 1. Failure to adhere to these post orders will result in disciplinary action. ..."

A request was made of EMP4, EMP5, EMP6, EMP7 and EMP11 for a facility policy, procedure or guideline staff follow regarding checking patients with a wand (handheld metal detector) for contraband before entry into the crisis area of the Emergency Department (ED). None was provided.

1.The facility failed to provide continuous observation as ordered by the physician for four of four applicable patients (MR1, MR2, MR3 and MR4) assessed as being a suicide risk

a. Review of MR1 on September 17, 2020, revealed this patient was admitted to the crisis area of the ED on a 201 (Voluntary psychiatric commitment) on September 7, 2020. Nursing documentation indicated MR1 had attempted suicide by drinking a cleaning product and hand sanitizers in the past. Nursing completed a C-SSRS and determined MR1's level of suicide risk as high and initiated one to one observation for this patient's safety.

Interview with EMP6 on September 17, 2020, at approximately 10:30 AM confirmed MR1 was admitted to the ED crisis area on a 201; Nursing documentation indicated MR1 had attempted suicide by drinking a cleaning product and hand sanitizers in the past; MR1 was assessed to have a high level of suicide risk; and one to one observation for this patient's safety was initiated.

Review on September 17, 2020, of facility documentation provided by EMP6 revealed facility staff escorted MR1 to the bathroom and left this patient unattended while in the bathroom with the door closed. The facility staff did not accompany MR1 when returning to the patient room.

Interview with EMP6 on September 17, 2020, at approximately 10:45 AM confirmed facility staff escorted MR1 to the bathroom and left this patient unattended while in the bathroom with the door shut. The facility staff did not accompany MR1 when returning to the patient room.

Interview with EMP6 on September 17, 2020, at approximately 10:50 AM confirmed MR1 went behind the security desk, opened the wall mounted hand sanitizer dispenser and removed the container of hand sanitizer. MR1 then put the container of hand sanitizer under their scrub top and returned to their room. MR1 put the container of hand sanitizer under their pillow.

The staff person, who provided the one the one observation of MR1, was not available for interview.

Review on September 17, 2020, of facility documentation provided by EMP6 revealed
MR1 requested to go to the bathroom, picked up a paper cup and proceeded to the bathroom. The facility documentation revealed sounds were heard from the bathroom. Security opened the closed door and facility staff noted MR1 was disposing a crushed hand sanitizer container into the trash. EMP6 revealed MR1 stated they poured the hand sanitizer into the paper cup and drank it.

Interview with EMP6 on September 17, 2020, at approximately 10:45 AM confirmed MR1
requested to go to the bathroom, picked up a paper cup and proceeded to the bathroom. Staff heard sounds from the bathroom. Security opened the closed door and facility staff noted MR1 was disposing a crushed hand sanitizer container into the trash. EMP6 confirmed MR1 stated they poured the hand sanitizer into the paper cup and drank it.

b. Review of MR2 on September 17, 2020, revealed this patient was admitted to the ED crisis area on September 15, 2020, on a 302 (Involuntary Commitment) for suicidal ideation with a gun. The facility completed a C-SSRS and determined MR2's level of suicide risk as high and initiated one to one observation for this patient's safety.

Observation of EMP1 on September 17, 2020, revealed this employee sitting on a chair outside MR2's room facing away from MR2 looking down the hallway. EMP1 was not seated at the foot of MR2's bed in direct proximity of the patient as stated in the facility's current policy.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, at the time of the observation confirmed EMP1 was seated on a chair outside MR2's room facing away from MR2 looking down the hallway. EMP4, EMP5 and EMP6 confirmed EMP1 was not seated at the foot of MR2's bed and in direct proximity of the patient. EMP5 confirmed MR2 was admitted to the ED crisis area on a 302 for suicidal ideation with a gun, the facility completed a C-SSRS and determined MR2's level of suicide risk as high and initiated one to one observation for this patient's safety.

c. Review of MR3 on September 17, 2020, revealed this patient was admitted to the ED crisis area on September 16, 2020, with a psychiatric problem and auditory hallucinations for two days. The facility completed a C-SSRS and determined MR3's level of suicide risk as high and initiated one to one observation for this patient's safety.

Observation of EMP2 on September 17, 2020, revealed this employee sitting on a chair outside MR3's room facing away from MR3 looking down the hallway. EMP2 was not seated at the foot of MR3's bed in direct proximity of the patient as stated in the facility's current policy.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, at the time of the observation confirmed MR3 was admitted to the ED crisis area with a psychiatric problem and auditory hallucinations for two days. MR3 was assessed to have a high level of suicide risk and one to one observation was initiated for this patient's safety. EMP4, EMP5 and EMP6 confirmed EMP2 was seated on a chair outside MR3's room facing away from MR3 looking down the hallway. EMP2 was not seated at the foot of MR3's bed in direct proximity of the patient.

d. Review of MR4 on September 17, 2020, revealed this patient was admitted to the ED crisis area on September 16, 2020, with a psychiatric problem and was having suicidal ideations of taking a bottle of pills and going to sleep. Nursing completed a C-SSRS assessment and determined MR4's level of suicide risk as high and initiated one to one observation for this patient's safety.

Observation of EMP3 on September 17, 2020, revealed this employee sitting on a chair outside MR4's room facing away from MR3 looking down the hallway. EMP3 was not seated at the foot of MR4's bed in direct proximity of the patient as stated in the facility's current policy.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, at the time of the observation confirmed EMP3 was seated on a chair outside MR4's room facing away from MR3 looking down the hallway. EMP4, EMP5 and EMP6 confirmed EMP3 was not seated at the foot of MR4's bed in direct proximity of the patient.

2. The facility failed to ensure security officers did not leave the security post in the ED crisis area without proper coverage for one of one medical record reviewed (MR1)

Review on September 17, 2020, of facility documentation provided by EMP6 revealed
when MR1 was returning to their room, they went behind the security desk, opened the wall mounted hand sanitizer dispenser and removed the container of hand sanitizer. MR1 then put the container of hand sanitizer under their scrub top. MR1 returned to their room and put the container of hand sanitizer under their pillow.

Interview with EMP6 on September 17, 2020, at approximately 10:50 AM confirmed MR1 went behind the security desk, opened the wall mounted hand sanitizer dispenser and removed the container of hand sanitizer. MR1 put the container of hand sanitizer under their scrub top. MR1 returned to their room and put the container of hand sanitizer under their pillow. EMP6 revealed hand sanitizer poses a risk to a person if it is ingested.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, revealed one security officer stepped away from the security desk to assist in taking the lunch tray cart out of the unit and the second security officer was involved in completing a written report and not watching the security monitors.

The staff persons, who provided security, were not available for interview.

3. The facility failed to ensure patients admitted to the crisis area of the ED were wanded (handheld metal detector) and checked for contraband before entry into the ED for seven of nine applicable medical records reviewed (MR1, MR2, MR3, MR4, MR6, MR10 and MR11).

Interview with EMP4, EMP5, EMP6, EMP7 and EMP11on September 17, 2020, revealed security staff wand and check all patients for contraband before entry into the crisis area of the ED and this information is documented in the patient's medical record.

a. Review of MR1 on September 17, 2020, revealed this patient was admitted to the ED crisis area on September 6, 2020. There was no documentation in MR1 indicating this patient was wanded and checked for contraband before entry into the crisis area of the ED.

b. Review of MR2 on September 17, 2020, revealed this patient was admitted to the ED crisis area on September 15, 2020. There no documentation in MR2 indicating this patient was wanded and checked for contraband before entry into the crisis area of the ED.

c. Review of MR3 on September 17, 2020, revealed this patient was admitted to the ED crisis area on September 16, 2020. There was no documentation in MR3 indicating this patient was wanded and checked for contraband before entry into the crisis area of the ED.

d. Review of MR4 on September 17, 2020, revealed this patient was admitted to the ED crisis area on September 16, 2020. There was no documentation in MR4 indicating this patient was wanded and checked for contraband before entry into the crisis area of the ED.

e. Review of MR6 on September 17, 2020, revealed this patient was admitted to the ED crisis area on September 8, 2020. There was no documentation in MR6 indicating this patient was wanded and checked for contraband before entry into the crisis area of the ED.

f. Review of MR10 on September 17, 2020, revealed this patient was admitted to the ED crisis area on September 8, 2020. There was no documentation in MR10 indicating this patient was wanded and checked for contraband before entry into the crisis area of the ED.

g. Review of MR11 on September 17, 2020, revealed this patient was admitted to the ED crisis area on September 8, 2020. There was no documentation in MR11 indicating this patient was wanded and checked for contraband before entry into the crisis area of the ED.

Interview with EMP5 on September 18, 2020, confirmed MR1, MR2, MR3, MR4, MR6, MR10 and MR11 were admitted to the ED crisis area and there was no documentation in these patient medical records indicating these patients were wanded and checked for contraband before entry into the crisis area of the ED.

Cross reference
482.13 Patient Rights
482.23 Nursing Services
482.23 (a) Organization of Nursing Services
482.23 (b)(6) Supervision of Contracted Staff

Repeat deficiency
September 14, 2018
VIOLATION: NURSING SERVICES Tag No: A0385
Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.23 Tag A-0386
The information reviewed during the survey provided evidence the nursing department failed to provide physician ordered one to one monitoring for patients identified as high risk for suicide in the Emergency Department (ED) and the facility failed to complete a nursing assessment on a suicidal patient following ingestion of hand sanitizer for one of one medical record reviewed.

482.23 Tag A-0398
The information reviewed during the survey provided evidence the facility failed to ensure the staff involved in a patient safety event reported the event in the event reporting system as soon as possible or by the end of the work shift

A discussion took place with the survey team and the facility's administrative staff (EMP4, EMP5, EMP6 and EMP7) regarding the survey team's concerns related to Nursing Services on September 17, 2020 at approximately 5:00 PM.

Cross reference
482.13 Patient Rights
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 (a) Organization of Nursing Services
482.23 (b)(6) Supervision of Contracted Staff

Repeat deficiency
September 14, 2018
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on review of facility documents, review of medical records (MR), observation, and staff interview (EMP), it was determined the nursing department failed to provide physician ordered one to one monitoring for patients identified as high risk for suicide in the Emergency Department (ED) for six of eight applicable medical records reviewed (MR1, MR2, MR6, MR7, MR10 and MR11) and the facility failed to complete a nursing assessment on a suicidal patient following ingestion of hand sanitizer for one of one medical record reviewed (MR1).

Findings include:

Review on September 17, 2020, of the "Chief Nursing Officer" job description, last revised May 2013, revealed "Position Purpose A senior administrative member of Wyoming Valley Health Care System, Hospital Division, who plans, organizes, directs and controls the overall clinical care functions. ... General Duties ... 3 Responsible for coordination of operations of patient Care/Clinical Care service functions, specifically in the areas of personnel assignments, staffing requirements and staff development programs ... 10 Coordinate the activities of all professional and support staff within the Clinical Services department with other departments to assure quality care ..."

Review on September 17, 2020, of the "Administrative Director of Nursing" job description, last revised November 2019 revealed "Position Purpose This senior Clinical Services leadership position is responsible for planning, directing, and coordinating Clinical Services. ... 13 Develop and maintain staffing to meet Hospital needs, working with Department Directors ..."

Review on September 17, 2020, of the facility's "Suicide Precautions" policy, last reviewed April 2019 revealed "Purpose: To outline a mechanism for observation and protection of patients who are assessed to be at risk for suicide or have expressed suicidal ideations. Policy: ... 3. A patient monitor is assigned until the patient is either transferred to an appropriate facility or is determined to be no longer at risk and discontinued. ..."

Review on September 17, 2020, of the facility's "Suicide Risk Assessment and Interventions: Columbia Protocol In Non-Behavioral Health Setting Policy," last revised May 31, 2019, revealed "I. Policy All adolescent and adult patients (ages equal or greater [sic] 11 years of age who present for care and services will be screened for suicide ideation and behavior using the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS). ... Based on the severity and immediacy of the suicide risk assessed using the Columbia Protocol, patient safety measures and interventions will be implemented as a means to keep patients from inflicting harm to self. ... III. Definitions ... B. One to One (one to one) Observation: Intervention for high risk for suicide. Continuous observation and staff are able to see the patient in clear view and staff can respond immediately to intervene and assure safety at all times, including while the patient sleeps, uses the toilet, bathes, etc. ..."

Review on September 17, 2020, of the facility provided Material Safety Data (MDS) sheet for "[name] Advanced Hand Sanitizer Gel" last revised September 5, 2018, revealed "... Section 3. Composition/Information on Ingredients Hazardous components Chemical name and concentration (percent) Ethyl Alcohol [greater than or equal to] 50 percent [and] [less than] 70 [percent] Isopropyl Alcohol [greater than or equal to] 1 percent [and] [less than] 5 [percent] ...Section 4. First Aid Measures ... If swallowed: If swallowed, Do Not induce vomiting. Obtain medical attention. Rinse mouth with water. ..."

A request was made of EMP4, EMP5 and EM6 on September 18, 2020, for a facility policy, procedure or guideline nursing staff would follow when assessing a patient following ingestion of a chemical. None was provided.

1. The nursing department failed to provide physician ordered one to one monitoring for patients identified as high risk for suicide in the Emergency Department (ED) for six of eight applicable medical records reviewed (MR1, MR2, MR6, MR7, MR10 and MR11)

a. Review on September 17, 2020, of MR1's Suicide Patient Observer Monitoring Checklist dated September 7, 2020, revealed no documentation of a one to one sitter from 2300 to 0700. Further review revealed nursing documented a one to one sitter was not available to sit with the patient during these hours.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, confirmed MR1's Suicide Patient Observer Monitoring Checklist dated September 7, 2020, revealed no documentation of a one to one sitter from 2300 to 0700 and nursing documented a one to one sitter was not available to sit with this patient during these hours.

Review on September 17, 2020, of MR1's Suicide Patient Observer Monitoring Checklist dated September 8, 2020, revealed no documentation of a one to one sitter from 0845 to 1100 and from 1915 to 2100. Further review revealed nursing documented a one to one sitter was not available to sit with this patient from 0845 to 1100 and from 1915 to 2100.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, confirmed MR1's Suicide Patient Observer Monitoring Checklist dated September 8, 2020, revealed no documentation of a one to one sitter from 0845 to 1100 and from 1915 to 2100, and nursing documented a one to one sitter was not available to sit with this patient from 0845 to 1100 and from 1915 to 2100.

Review on September 17, 2020, of MR1's Suicide Patient Observer Monitoring Checklist dated September 9, 2020, revealed no documentation of a one to one sitter from 0315 to 0700 and from 1500 to 1630.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, confirmed MR1's Suicide Patient Observer Monitoring Checklist dated September 9, 2020, revealed no documentation of a one to one sitter from 0315 to 0700 and from 1500 to 1630.

b. Review on September 17, 2020, of MR2's Suicide Patient Observer Monitoring Checklist dated September 15, 2020, revealed no documentation of a one to one sitter from 0245 to 0800 and on September 17, 2020, from 1830 to 2345.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, confirmed MR2's Suicide Patient Observer Monitoring Checklist dated September 15, 2020, confirmed there was revealed no documentation of a one to one sitter from 0245 to 0800 and on September 17, 2020, from 1830 to 2345.

Interview with EMP5 on September 17, 2020, confirmed there was no documentation in MR2 indicating this patient had continuous one to one observation during these times.

c. Review on September 17, 2020, of MR6's Suicide Patient Observer Monitoring Checklist dated September 8, 2020, revealed no one to one sitter documentation from 1430 to 1515 and on September 9, 2020, from 1500 to 1700 and from 1800 to 1900.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, confirmed MR6's Suicide Patient Observer Monitoring Checklist dated September 8, 2020, revealed no one to one sitter documentation from 1430 to 1515 and on September 9, 2020, from 1500 to 1700 and from 1800 to 1900.

Interview with EMP5 on September 17, 2020, confirmed there was no documentation in MR6 indicating this patient had continuous one to one observation during these times.

d. Review on September 17, 2020, of MR7's Suicide Patient Observer Monitoring Checklist dated September 9, 2020, revealed no one to one sitter documentation from 1915 to 2230 and on September 10, 2020, from 1600 to 1700 and from 1800 to 1900.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, confirmed MR7's Suicide Patient Observer Monitoring Checklist dated September 9, 2020, revealed no one to one sitter documentation from 1915 to 2230 and on September 10, 2020, from 1600 to 1700 and from 1800 to 1900.

Interview with EMP5 on September 17, 2020, confirmed there was no documentation in MR7 indicating this patient had continuous one to one sitter observation during these times.

e. Review on September 17, 2020, of MR10's Suicide Patient Observer Monitoring Checklist dated September 8, 2020, revealed no one to one sitter documentation from 0300 to 0700.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, confirmed MR10's Suicide Patient Observer Monitoring Checklist dated September 8, 2020, revealed no one to one sitter documentation from 0300 to 0700.

Interview with EMP5 on September 17, 2020, confirmed there was no documentation in MR10 indicating this patient had continuous one to one sitter observation during these times.

f. Review on September 17, 2020, of MR11's Suicide Patient Observer Monitoring Checklist dated September 8, 2020, revealed no one to one sitter documentation from 0330 to 0700.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, confirmed MR11's Suicide Patient Observer Monitoring Checklist dated September 8, 2020, revealed no one to one sitter documentation from 0330 to 0700.

Interview with EMP5 on September 17, 2020, confirmed there was no documentation in M11 indicating this patient had continuous one to one sitter observation during these times.

2.The facility failed to complete a nursing assessment on a suicidal patient following ingestion of hand sanitizer for one of one medical record reviewed (MR1).

Review on September 17, 2020, of facility documentation provided by EMP6 revealed while MR1 was in the bathroom, staff heard sounds coming from the bathroom. Security opened the closed door and facility staff noted MR1 was disposing a crushed hand sanitizer container into the trash. EMP6 revealed MR1 stated they poured the hand sanitizer into the paper cup and drank it.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, at approximately 10:45 AM confirmed MR1 stated they poured hand sanitizer into a paper cup and drank it.

Review of MR1 on September 17, 2020, revealed no documentation nursing staff assessed the inside of MR1's mouth or skin integrity around the mouth following this patient's report of drinking hand sanitizer.

Interview with EMP4, EMP5 and EMP6 on September 17, 2020, at approximately 10:45 AM confirmed there was no documentation nursing staff assessed the inside of MR1's mouth or skin integrity around the mouth following this patient's report of drinking hand sanitizer.


Cross reference
482.13 Patient Rights
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 Nursing Services
482.23 (b)(6) Supervision of Contracted Staff

Repeat deficiency
September 14, 2018
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on review of facility documents, medical records (MR), and staff interview, it was determined the facility failed to ensure the staff involved in a patient safety event reported the event in the facility event reporting system as soon as possible or by the end of the work shift for one of one event reports reviewed.

Findings include:

Review on September 17, 2020, of facility, "Event Reporting Policy," revised May 2020, revealed "Purpose: Patient safety event reporting systems in healthcare are a mainstay of efforts to detect patient safety events and quality problems. Event reporting is a general term for all voluntary patient safety event reporting systems, which rely on those involved in events to provide a detailed information. Initial reports often come from the frontline personnel directly involved in an event or the actions leading up to (e.g., the nurse, pharmacist, or physician caring for a patient when a medication error occurred), rather than management or patient safety professionals. The purpose of this policy is to provide guidance for communicating, reporting, investigating and acting upon a patient safety event including near miss, precursor and serious safety events, sentinel events, serious reportable/never event and hospital acquired conditions. ...Policy: All staff report patient safety events via the Event Reporting System (ERS) or an Event Report form in the event of ERS downtime. ...Procedure: Required Action Steps (All Staff) ...2. Report the patient safety event to immediate supervisor. ...5. Staff involved in the patient safety event to report the event in ERS as soon as possible or by the end of the work shift. ...Definitions: Patient Safety Event: A patient safety event is an event, incident, or condition that resulted or could have misses) [sic], and hazardous conditions. ...Behavioral-Patient Protection Events ...contraband, self-inflected harm ..."

Review on September 17, 2020, of MR1 revealed MR1 was admitted to the Emergency Department (ED) on September 7, 2020 with suicidal ideations. MR1 was ordered 1:1 continuous observation due to their risk for suicide being assessed as high. MR1 revealed this patient went to the bathroom and on the way back to their room, they went behind security desk, opened the hand sanitizer dispenser, removed the container of [Name of Sanitizer], put it under their scrub top. The patient then put the hand sanitizer under their pillow when returned to their room. On MR1's next trip to the bathroom, the sitter closed the bathroom door and left MR1 unattended in the bathroom.

Interview on September 17, 2020, with EMP5 and EMP6 confirmed MR1 was admitted to the ED on September 7, 2020 with suicidal ideations. EMP5 and EMP6 confirmed MR1 was ordered 1:1 continuous observation due to their risk for suicide being assessed as high. EMP5 and EMP6 confirmed this patient went to the bathroom and on the way back to their room, went behind security desk, opened the hand sanitizer dispenser, removed the container of [Name of Sanitizer], put it under their scrub top then put then put the hand sanitizer under their pillow on return to their room. On MR1's next trip to the bathroom, the sitter closed the door and left MR1 unattended in the bathroom. MR1 picked up a paper cup and was escorted to the bathroom; MR1 was left unattended in the bathroom with the door shut; sounds were heard from the bathroom; security opened the closed door and facility staff noted MR1 was disposing the crushed hand sanitizer container into the trash. EMP6 revealed MR1 stated they poured the hand sanitizer into the paper cup and drank it.

Review on September 17, 2020, of the facility event report for MR1 revealed EMP5 completed the report on September 10, 2020, at 16:19 PM and the occurrence date was documented as September 7, 2020, at 12:15 PM. Discovery date was September 8, 2020.
Interview on September 18, 2020, at approximately 9:30 AM, with EMP5 confirmed the facility event report for MR1 was completed on September 10, 2020, at 16:19 PM and the occurrence date was documented as September 7, 2020, at 12:15 PM. EMP5 confirmed discovery date was September 8, 2020. EMP5 confirmed the staff involved in the patient safety event did not report the event in the facility event reporting system as soon as possible or by the end of the work shift.

Cross reference
482.13 Patient Rights
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 Nursing Services
482.23 (a) Organization of Nursing Services