HospitalInspections.org

Based upon surveyor observation, record review and staff interview, it has been determined that the hospital has failed to provide care in a safe setting relative to suicide precautions for 3 of 3 sample patients, (ID#'s 1, 2, & 15), and relative to safety for 4 of 6 patients, (ID#'s 5, 11, 12, & 13).

Findings are as follows:

I. The hospital's Nursing Policy and Procedure titled: "Guidelines and Responsibilities for Direct Observation of Suicide Precaution Patients", effective 8/9/2014, under policy states:

"Patients on suicide precautions receive continuous observation and supervision at all times. The person providing direct observation must have full view of the patient's face and hands."

Under Procedure, it states:

E. "...The RN will also provide the behavioral aide with the Guidelines and Flow Sheet for Patients on Suicide Precautions."

Review of the "Guidelines and Flow Sheet for Patients on Suicide Precautions", under "Room Safety Guidelines" states, in part:

Clear room of non-essential cords or tubing
Remove non-essential medical supplies
Remove clothing/belongings with potential to harm: belts, ties, stockings, drawstrings, shoe laces, and long necklaces
No objects that may be sharp when broken
No sharp scissors, syringes, knives, thumbtacks, razors, pencils, pens, money clips, nail clippers

1. Medical record review of patient ID# 1 revealed he/she arrived in the Emergency Department (ED) on 8/11/2015 at 2:03 PM presenting with depression and stated that he/she needs to return to the psychiatric hospital. The patient also stated he/she may be withdrawing from Klonopin as he/she hasn't had the medication in a few days and reports feeling poorly, legs are tremulous.

An ED Initial Evaluation MH (Mental Health) was conducted by the charge nurse (staff A) on 8/11/2015 at 2:46 PM. The patient reports suicidal ideation and plans to take all his/her medication. The patient is requesting to return to the psychiatric hospital. The ED Suicide Screen revealed the following:

Depressed last 2 weeks: Yes
Provider notified: Yes (MD's name provided)
Suicidal thoughts last 2 weeks: yes
Suicide last attempt timeframe: In past 24 hrs or today

A Behavioral Health Emergency Services Screen was conducted on 8/11/2015 at 6:30 PM. Under "History and Present Illness" it states: "Patient has a long and chronic history of suicide attempts that involved overdosing, and attempting to cut neck with a knife (visible scar). As a result, patient has spent quite a bit of time on psy units...". Under suicide plan details it states that the patient has a plan to walk into traffic, overdose on pills and hang [himself/herself]... has a history of all of these methods. Under behavior in hospital it states "patient states [he/she] was having thoughts while in the ER to cut the backs of [his/her] legs so...could hit the main vein."

Review of the ED documentation listing which patients are on observation status revealed that on 8/11/2015, for the 3 PM to 11 PM shift, there were 3 patients under constant observation; ID# 1 for suicide ideation, ID# 15 for suicide and homicide ideation, and alcohol intoxication, and ID# 11 for safety due to alcohol intoxication. These patients were being observed by 1 nursing assistant, (staff B) who was interviewed on 10/1/2015 at 3:00 PM.

Staff B stated that she was sent to the ED at approximately 3:00 PM on 8/11/2015 and was observing 3 patients. She stated that ID# 1 was tough, yelling and swearing. She also observed that the patient had possession of the television remote control. After the observation, she inquired of the previous sitter as to why and was told to just let the patient have the remote.

Staff B further stated that when she came to the ED, the patient had all of his/her belongings in the room, clothes, cell phone and charger, and additional clothing on the floor. At approximately 7:00 PM, the patient became aggressive and angry and was threatening to hurt himself/herself. At this time, security was called and that was when the patient's room was stripped, however, he/she was allowed to keep the remote. At approximately 11:14 PM, the patient stated that he/she was going to do something bad, and before Staff B could stop the patient, he/she took the batteries out of the remote and swallowed them.

The charge nurse (Staff A) was interviewed on 10/1/2015 at 3:10 PM and was unable to produce evidence as to why the suicide policy was not followed relative to stripping the patient's room at 2:46 PM after he/she was screened and found at risk for suicide, nor could she explain why the patient was allowed to keep the remote after the room was stripped at 7:00 PM.

2. Medical record review for patient ID# 2 revealed a long history of swallowing foreign objects. Diagnosis include: borderline personality disorder, obsessive compulsive disorder, post traumatic stress disorder, and depression. The patient was admitted and treated for swallowing foreign objects three times from 8/19/2014 to 9/7/2014. On 9/8/2014 at 6:30 PM, the patient arrived at the ED after swallowing a pen and was admitted.

An admission history, physical, and plan was completed on 9/9/2014 at 3:00 AM. One of the plan items identified was for a 1:1 sitter.

Additional review of the medical record revealed flow sheets for this patient from the time of admission to discharge on 9/10/2014. The flow sheets indicated that the patient received continuous observation and supervision at all times by a staff member.

On 9/10/2014, the patient was discharged from the acute care hospital and sent to a psychiatric hospital. Upon arrival at the psychiatric hospital, the patient informed the staff that she/he had swallowed a pencil while at the acute care hospital. The patient was immediately returned to the acute care hospital for removal of the pencil.

The hospital patient care coordinator was interviewed on 10/1/2015 at 10:00 AM and stated that, although patient was on a 1:1 constant observation at all times while in their care, that a proper "sweep" (searched for any and all items that could cause harm), of the patient's room was not conducted prior to the patient's arrival in the room per policy.

3. Medical record review of patient ID# 15 revealed he/she arrived in the ED via police escort on 8/11/2015 at 4:16 AM presenting with suicidal and homicidal ideation and alcohol intoxication. A nursing progress summary entered at this time states: "...admits to having thoughts of suicide and of hurting others but had not acted on them."

The ED Suicide Screen also conducted at this time revealed the following:

Depressed last 2 weeks: Yes
Provider notified: Yes (MD's name provided)
Suicidal thoughts last 2 weeks: yes
Suicide last attempt timeframe: no

An ED nursing note on 8/11/2015 at 10:06 AM states: "...pt was fully dressed and aware that he/she needs to get undressed and with cna in the bathroom changing."

The ED Clinical Manager was interviewed on 10/1/2015 at 12:50 PM and stated that when a patient comes in who is suicidal, all personal items are removed immediately and they are made to wear a paper Johnny.

This patient's personal items, including clothing were not removed until 10:00 AM, 6 hours after he/she had arrived in the ED.

Staff B, who was interviewed on 10/1/2015 at 3:00 PM, stated that she was sent to the ED at approximately 3:00 PM on 8/11/2015 and was observing 3 patients. She stated that ID# 1 was tough, yelling, swearing, and took all of her time.

II. The hospital's Nursing Policy and Procedure titled: "Guidelines and Responsibilities for Direct Observation and Management of Patient Safety", effective 8/4/2014, under procedure states:

"In collaboration with the RN the behavioral aide completes Safety Observation Flow Sheet. Patient behavior is documented at least every two hours, or more frequently, when the patient demonstrates at-risk behaviors. The RN assesses and documents the patient's mental status at least once every four hours. The RN reviews the Behavior & Safety Observation Flow Sheet with the behavioral aide throughout the shift and co-signs the document at the end of the shift."

4. Medical record review for patient ID# 11 revealed he/she arrived in the ED on 8/11/2015 at 2:35 PM with a diagnosis of alcohol intoxication. According to the hospital's ED policy, the patient was placed on constant observation for safety reasons.

An ED nursing note written by staff A revealed that at 3:44 PM, the patient was witnessed in the hallway urinating while ambulating, and slipped to the floor. Staff A was unable to reach the patient prior to the fall.

Staff B, who was providing constant observation for this patient was interviewed on 10/1/2015 at 3:00 PM and stated that she did not see this patient fall nor did she recall the fall. She further stated that she was very busy with patient ID# 1.

Further record review failed to reveal the required constant observation flow sheet for this patient.



21613

5. Record review for patient ID #5 revealed a primary diagnosis of Alzheimer's Disease. He/she was admitted on 1/23/2015 with shortness of breath and was started on a heparin drip in the ED and was admitted to the main hospital. At approximately 6:00 PM, the patient was found by a nurse in the bathroom and had pulled out his/her IV (Intravenous therapy is the infusion of liquid substances directly into a vein).

Subsequently, the patient was placed on constant observation starting on 1/24/2015 at 7:00 AM due to impulsive behavior which places the patient at risk for injury. Further record review failed to reveal evidence that the behavioral aide documented the patient's behavior at least every two hours nor that the RN assessed and documented the patient's mental status at least every four hours on 1/24/2015 from 3:00 PM to 11:00 PM.

During an interview with the Clinical Manager (staff C) on 10/2/2015 at 10:30 AM, she was unable to produce evidence that the patient's mental health had been assessed at least every 4 hours or that the assessment had been documented.

6. Record review and interview with the Clinical Manager (staff C) on 9/30/2015 at 11:30 AM revealed patient ID #12 was admitted to the hospital on 9/27/2015 with diagnosis of diabetic mellitus and a history of falls. The patient was placed on fall precaution secondary to not using the call light and trying to get out of bed without asking for assistance.

A review of the "Guidelines & Flow Sheet for Safety Observation" dated 9/28/2015 (11:00 PM -7:00 AM shift) and 9/29/2015 (3:00 PM-11:00 PM shift) failed to reveal that the nurses who were assigned to this patient co-signed the document with the behavioral aide at the end of the shift. Additionally, on 9/28/2015 on the 11:00 PM to 7:00 AM shift, there is no evidence that the patient's mental health had been reassessed relative to safety at least every 4 hours or that the assessment had been documented.

When questioned on 9/30/2015 at 12:00 PM, staff C was unable to produce evidence that the patient had been reassessed.

7. Record review and interview with a nurse (staff D) on 9/30/2015 at 10:30 AM revealed that patient ID #13 was admitted to the hospital on 9/28/2015 for shortness of breathing, syncope and alcohol withdrawal. The patient has a current care plan which indicates he/she will be free/safe from alcohol withdrawal. Subsequently, the patient was put on 1:1 observation by a behavioral aide.

A review of the "Guidelines & Flow Sheet for Safety Observation" revealed that the patient was observed on 9/30/2015 between 11:00 PM to 7:00 AM. There lacked evidence that the nurse assessed and documented the patient's mental status at least every four hours.

When questioned on 9/30/2015 at 11:00 AM, the Executive Director was unable to produce evidence that the patient had been assessed not that the assessments were documented at least every 4 hours.

Based on surveyor observation, staff interview and patient care policies, it was determined that the hospital failed to ensure that the physical condition of the Emergency Department and a Medical Floor are maintained in a manner to assure the safety and well-being of the patients for 3 of 3 patient's on suicide precautions, (ID#'s 1, 2, & 15).

Findings are as follows:

The hospital's Nursing Policy and Procedure titled: "Guidelines and Responsibilities for Direct Observation of Suicide Precaution Patients", effective 8/9/2014 states, under policy states:

"Patients on suicide precautions receive continuous observation and supervision at all times. The person providing direct observation must have full view of the patient's face and hands."

Under Procedure, it states:

E. "...The RN will also provide the behavioral aide with the Guidelines and Flow Sheet for Patients on Suicide Precautions."

Review of the "Guidelines and Flow Sheet for Patients on Suicide Precautions" flow sheet, under "Room Safety Guidelines" states, in part:

Clear room of non-essential cords or tubing
Remove non-essential medical supplies
Finger foods only
Remove clothing/belongings with potential to harm: belts, ties, stockings, drawstrings, shoe laces, and long necklaces
No objects that may be sharp when broken
No sharp scissors, syringes, knives, thumbtacks, razors, pencils, pens, money clips, nail clippers

1. Medical record review of patient ID# 1 revealed he/she arrived in the Emergency Department (ED) on 8/11/2015 at 2:03 PM presenting with depression and stated that he/she needs to return to the psychiatric hospital. The patient also states he/she may be withdrawing from Klonopin as he/she hasn't had the medication in a few days and reports feeling poorly, legs are tremulous.

An ED Initial Evaluation MH (Mental Health) was conducted by the charge nurse (staff A) on 8/11/2015 at 2:46 PM. The patient reports suicidal ideation and plans to take all his/her medication. The patient is requesting to return to the psychiatric hospital. The ED Suicide Screen revealed the following:

Depressed last 2 weeks: Yes
Provider notified: Yes (MD's name provided)
Suicidal thoughts last 2 weeks: yes
Suicide last attempt timeframe: In past 24 hrs or today

A Behavioral Health Emergency Services Screen was conducted on 8/11/2015 at 6:30 PM. Under "History and Present Illness" it states: "Patient has a long and chronic history of suicide attempts that involved overdosing, and attempting to cut neck with a knife (visible scar). As a result, patient has spent quite a bit of time on psy units...". Under suicide plan details it states that the patient has a plan to walk into traffic, overdose on pills and hang [himself/herself]... has a history of all of these methods. Under behavior in hospital it states "patient states [he/she] was having thoughts while in the ER to cut the backs of [his/her]his legs so...could hit the main vein."

Review of the ED documentation listing which patients are on observation status revealed that on 8/11/2015, for the 3 PM to 11 PM shift, there were 3 patients under constant observation; ID# 1 for suicide ideation, ID# 15 for suicide and homicide ideation, and alcohol intoxication, and ID# 11 for safety due to alcohol intoxication. These patients were being observed by 1 nursing assistant, (staff B) who was interviewed on 10/1/2015 at 3:00 PM.

Staff B stated that she was sent to the ED at approximately 3:00 PM on 8/11/2015 and was observing 3 patients. She stated that ID# 1 was tough, yelling and swearing. She also observed that the patient had possession of the television remote control. After the observation, she inquired of the previous sitter as to why and was told to just let the patient have the remote.

Staff B further stated that when she came to the ED, the patient had all of his/her belongings in the room, clothes, cell phone and charger, and additional clothing on the floor. At approximately 7:00 PM, the patient became aggressive and angry and was threatening to hurt himself/herself. At this time, security was called and that was when the patient's room was stripped, however, he/she was allowed to keep the remote. At approximately 11:14 PM, the patient stated that he/she was going to do something bad, and before Staff B could stop the patient, he/she took the batteries out of the remote and swallowed them.

The charge nurse (Staff A) was interviewed on 10/1/2015 at 3:10 PM and was unable to produce evidence as to why the suicide policy was not followed relative to stripping the patient's room at 2:46 PM after he/she was screened and found at risk for suicide, nor could she explain why the patient was allowed to keep the remote after the room was stripped at 7:00 PM.

2. Medical record review for patient ID# 2 revealed a long history of swallowing foreign objects. Diagnosis include: borderline personality disorder, obsessive compulsive disorder, post traumatic stress disorder, and depression. The patient was admitted and treated for swallowing foreign objects three times from 8/19/2014 to 9/7/2014. On 9/8/2014 at 6:30 PM, the patient arrived at the ED after swallowing a pen and was admitted.

An admission history, physical, and plan was completed on 9/9/2014 at 3:00 AM. One of the plan items identified was for a 1:1 sitter.

Additional review of the medical record revealed flow sheets for this patient from the time of admission to discharge on 9/10/2014. The flow sheets indicated that the patient received continuous observation and supervision at all times by a staff member.

On 9/10/2014, the patient was discharged from the acute care hospital and sent to a psychiatric hospital. Upon arrival at the psychiatric hospital, the patient informed the staff that she/he had swallowed a pencil while at the acute care hospital. The patient was immediately returned to the acute care hospital for removal of the pencil.

The hospital patient care coordinator was interviewed on 10/1/2015 at 10:00 AM and stated that, although patient was on a 1:1 constant observation at all times while in their care, that a proper "sweep" (searched for any items that could cause harm), of the patient's room was not conducted prior to the patient's arrival in the room. She was unable to provide evidence that the hospital policy had been followed.

3. Medical record review of patient ID# 15 revealed he/she arrived in the ED via police escort on 8/11/2015 at 4:16 AM presenting with suicidal and homicidal ideation and alcohol intoxication. A nursing progress summary entered at this time states: "...admits to having thoughts of suicide and of hurting others but had not acted on them."

The ED Suicide Screen also conducted at this time revealed the following:

Depressed last 2 weeks: Yes
Provider notified: Yes (MD's name provided)
Suicidal thoughts last 2 weeks: yes
Suicide last attempt timeframe: no

An ED nursing note on 8/11/2015 at 10:06 AM states: "...pt was fully dressed and aware that he/she needs to get undressed and with cna in the bathroom changing."

The ED Clinical Manager was interviewed on 10/1/2015 at 12:50 PM and stated that when a patient comes in who is suicidal, all personal items are removed immediately and they are made to wear a cloth Johnny.

This patient's personal items, including clothing were not removed until 10:00 AM, 6 hours after he/she had arrived in the ED.

Staff B, who was interviewed on 10/1/2015 at 3:00 PM, stated that she was sent to the ED at approximately 3:00 PM on 8/11/2015 and was observing 3 patients. She stated that ID# 1 was tough, yelling, swearing, and took all of her time.



21613