HospitalInspections.org

Based upon observations, interviews and record reviews the hospital failed to provide care in a safe setting by:

1)Failing to have a mechanism in place to ensure psychiatric patients being held in the
Emergency Department requiring 1:1 or continuous monitoring as ordered by the MD were continuously monitored to date.

Failing to provide 1:1 supervision (or continuous supervision)as ordered by MD allowing patient #22 the opportunity to elope from the ED and

2).Failing to follow policy and procedures by placing patients who presented to the Emergency Department with complaints of suicidal ideation, in a room with multiple equipment cords, unlocked cabinets and medical supplies.

Findings:
1)
On 07/10/12 at 2:25 p.m. S3 RN interviewed.When asked about the 1:1 supervision, ordered by ER MD confirmed the RN may check the boxmarked 1:1 supervision; however, "that was not what they do" and added the psychiatric patient was directly observed from the ED nursing station. When asked if someone was always at the nurse's station when a patient requiring 1:1 or direct supervision was in the hall, he stated "no, not always". No additional
staff is provided when multiple 1:1 patients are in the Emergency Room to date.

Patient # 22
Record review for #22 revealed a 17 year old female presented to the ED alone on 06/18/12 at 1554 (3:54 p.m.) with the chief complaint of "I'm suicidal," having thoughts of harming self by cutting her wrist and overdosing on medication. Triaged at 15:56 (3:56pm) by S4 RN.Abrasions to left inner arm and wrist noted, no lacerations or bleeding where patient had attempted to slice herself with a shaving razor x 6 (six times).

Review of the "Harm Assessment" form completed by S4 RN dated and timed 6/28/12 at 16:02 (4:02) revealed patient was spending a lot of time planning how she would hurt herself, and had a plan for hurting herself. S4 RN further documented the patient was aggressive, agitated, restless, ambivalent and had a self-inflicted injury, had a history of inpatient psychiatric treatment, does not take medications regularly and the level of supervision needed was "1on1". Patient was placed on a hallway stretcher in direct sight of the nursing station.

Review of the Emergency Department Physician assessment dated/timed 06/18/12, 5:00 p.m. revealed patient #22 had suicidal thoughts/gestures that were severe with the clinical impression of suicide attempt. The ED Physician placed the patient under a Physician Emergency Certificate that was dated/timed 06/18/12 at 5:19 p.m. indicating by check mark the patient was in need of immediate psychiatric treatment because she was dangerous to herself and unable to seek voluntary admission.
.
Continued review of ED Patient Progress Notes, completed by ER RN revealed on 06/18/12 at "1822 (6:22 p.m.) Pt. (Patient) missing from hall stretcher while staff attending to other patients. Security and Police called."
"1825 (6:25 p.m.) - ____ (Local police department) present, searching hospital grounds."
"0039 (12:39 a.m.) - Called ____ city police, haven't found or seen pt., still looking for pt."
"0148 (1:48 a.m.) - Called number on face sheet, not a working number, called in case of emergency number, great grandmother, hasn't seen pt., gave number of someone else, called number, left voice mail."

Review of the hospital's occurrence report log revealed the following:
06/18/12 - Patient (#22) in ED (Emergency Department) with attempted suicide, PEC'd, Harm Assessment done. Patient went to bathroom "no distress noted". Next time nurses noticed (busy ED) patient was missing from hall bed. ___ (Local Police Department) called/searched hospital grounds/did not find patient.

On 07/10/12 at 2:25 p.m., a face-to-face interview was conducted with the S1, S2, and S3 confirmed they had reviewed the Emergency Department record for Patient #22. S3 confirmed the patient was PEC'd and eloped from the Emergency Department and the staff called the police department and security, but the patient was not found and never returned to the Emergency Department.

Review of the hospital policy titled "Care of the Psychiatric Patient", effective date 10/11/2011, provided as current policy by S3 RN revealed in part the following:
Admission to the Emergency Department, #2. The patient will be placed in one of the stretchers with direct observation from the nurses' station, if available, or the patient can be placed into another bed with ED staff assigned to watch the patient. 5. d. The RN will observe and document patient status every hour.

2)
On 07/09/12 at 11:00 a.m. Interview with S3 RN revealed approximately 10-15 psychiatric patients per month were in the ED an average length of stay of 2 days. When asked where the psychiatric patient was placed, S3 RN replied the patient was placed either on a stretcher in the hallway across from the ED nursing station, Cardiac Room 1 or Trauma Bed A to afford direct visual observation of the patient from the nursing station. An observation of the Cardiac Room 1 revealed multiple cardiac monitor cords, otoscope and opthalmoscope cords were noted on the wall over the patient stretcher and, multiple unlocked cabinets with supplies were noted in the room. S3RN verified that all cords were not removed from the room when a Physicians Emergency Certificate (PEC) patient was placed in the room. When asked about the psychiatric patient supervision in case of a "code" or influx of patients, S3 RN responded they could get security to observe the patient, however, S3 RN confirmed the security staff had no specialized training in monitoring the PEC'd patient.

Review of the hospital's policy and procedure titled, Care of the Psychiatric Patient, effective 10/11/2011, provided as current policy by S3 RN, revealed in part 5. If the Emergency Room Physician has determined the patient is at risk for suicide, the staff will implement suicide risk precautions based on the Physicians orders. a. ..determine the need for one to one staff supervision. b. patient belongings will be removed... There is no documented evidence in the policy that refects the environment will be rendered safe for suicidal patients.


17091

Based on record review and interview, the hospital failed to include in their Quality Assessment Performance Improvement (QAPI) activities high-risk, high-volume, and/or problem prone areas of patient care related to the Emergency Department (ED) as evidenced by failure to include and track ED patients under Physician Emergency Certificate (PEC) for supervision/observation (#27, #29, #31, #32, #37), and elopement from the ED (#22). Findings:

Review of the ICU (Intensive Care Unit)/ER (Emergency Room) Performance Improvement Team binder presented by S2 Director of Clinical Systems Improvement as the current quality improvement data for the ICU/ED, revealed no documented evidence that the medical records of ED patients under PEC were reviewed to determine that ED policy was followed regarding the one-to-one supervision of patients in the ED. There was no documented evidence that tracking and trending of PEC'd patient elopements from the ED was done.

Review of the Emergency Department Stats reported to the Quality Care and Patient Safety Committee revealed in part the following:
January 2012
PEC Days - 22
PEC Patients - 10
February 2012
PEC Days - 27
PEC Patients - 13
March 2012
PEC Days - 13
PEC Patients - 7

Review of the Emergency Department PEC'd patient medical records from June 11, 2012 to present revealed there were 14 PEC'd patients treated in the ED.

Review of the medical record for Patient #22 revealed the patient was a 17 year old female who presented to the ED on 06/18/12 at 3:54 p.m. The triage record entered on 06/18/12 at 3:56 p.m. by S4 RN revealed in part, "Presented to triage crying stating, "I'm suicidal" thoughts of harming self by cutting wrist and over dosing on medication. Attempted to slice left inner arm and wrist with shaving razor X 6 (Six times). Abrasions to left inner arm, no lacerations, no bleeding....."

Review of the "Harm Assessment" dated/timed 06/18/12 at 16:02 (4:02 p.m.) revealed that the RN supervision was "1 on 1", and patient was placed in direct sight of station. Review of the patient's PEC revealed it was signed on 06/18/12 at 5:19 p.m. due to Patient #22 was dangerous to self and unable to seek voluntary admission. Review of the entire medical record revealed no documented evidence of 1 on 1 visual observation of Patient #22.

Review of the Patient Progress Notes (Nurses documentation) revealed in part the following:
18:00 (6:00 p.m.) - Ambulated to restroom, no distress noted.
18:22 (6:22 p.m.) - Pt. missing from hall stretcher while staff attending to other patients. security and police called....
00:39 (12:39 a.m.) - Called ____ city police, haven't found or seen pt., still looking for pt.

On 07/10/12 at 2:25 p.m., an interview with S3 RN after patient #22 eloped from the ED, the nursing staff called the police department and security, but the patient was not found and never returned to the Emergency Department. When asked how the level of supervision was determined, S3 RN stated the triage nurse does the Harm Assessment and documents the information in patient's record; however, Emergency Physician may also order the level of supervision. S3 RN stated they do not assign staff to 1 on 1 supervision adding "They are in line of sight" and S3 RN stated he did not know why the nurse checked 1 on 1 supervision because that was not what they do. When asked if someone was always at the nurse's station when a PEC patient was in the hall, he replied "no, not always".

Review of the medical record for Patient #27 revealed the patient was a 19 year old female admitted to the emergency room on 6/11/12, with a triage time of 17:57 (5:57 p.m.). The patient's chief complaint was listed as suicide attempt by cutting left wrist with broken piece of glass. Review of the Physician Emergency Certificate dated 6/11/12 and timed 7:00 p.m., revealed she was suicidal, was dangerous to self, and unwilling to seek voluntary admission to a hospital. Review of the Harm Assessment dated 6/11/12 at 18:10 (6:10 p.m.) revealed she had tried to hurt and kill herself in the past, and currently she had a specific plan with a specific time, and she had access to the plan to commit suicide. The precautions taken were listed as; supervision would be 1 on 1 and continuous and the patient was placed in direct sight of the nurse's station. Review of the physical assessment electronic record revealed the patient was assessed hourly on 6/11/12 from 18:14 (6:14 p.m.) to 05:06 (5:06 a.m.). There was no documentation the patient was assessed or supervised by the RN from 05:06 (5:06 a.m.) on 6/12/12 to 08:30 (8:30 a.m.) on 6/12/12, which was a 3 and 1/2 hour consecutive time period. Further review of the nurse's documentation revealed no hourly assessments from 08:30 (8:30 a.m.) to 10:40 (10:40 a.m.) on 06/12/12 (2 hours consecutive time period).

Review of Patient #29's ED record revealed the patient was a 29 year old female who arrived at the ED by ambulance on 06/18/12 at 22:52 (10:52 p.m.). The Triage Record revealed the patient's chief complaint was, "I'm here to get help. I wanna get off the pills and the dope so I can get my babies back. I lost custody of my babies." Review of the Harm Assessment documented at 23:00 (11:00 p.m.) revealed the patient expressed suicidal thoughts, but did not have a plan. Review of the supervision revealed continuous supervision was checked and the patient was placed in direct sight of station. Review of the PEC dated/timed 06/18/12 at 0015 (12:15 a.m.) revealed the patient was suicidal, was dangerous to self, and was unwilling to seek voluntary admission. Review of the physical assessment electronic record revealed the patient was assessed at 23:08 (11:08 p.m.) and 23:55 (11:55 p.m.) on 6/18/12. There was no documentation the patient was assessed or supervised by the RN again until 07:20 (7:20 a.m.) on 06/19/12, 7 hours later. There was no documented evidence of hourly assessments of the patient's status between 11:55 p.m. on 06/18/12 to 7:20 a.m. on 06/19/12. Review of the record revealed the patient was discharged to another facility on 06/19/12 at 12:56 p.m.

Review of the Emergency Department Record for Patient #31 revealed he was admitted on 6/25/12 at 8:12 p.m. with the chief complaint of suicidal thoughts and was discharged on 6/26/12 at 9:10 a.m. to a local psychiatric facility. Further review revealed Patient #31 had a Physician Emergency Certificate (PEC) dated 6/25/12 at 8:32 p.m. The certificate listed the patient as being a danger to self, a danger to others, and unable to seek voluntary admission. Review of the Harm Assessment form for Patient #31 dated 6/25/12 at 1718 (5:18 p.m.) revealed the form was completed by S9 Registered Nurse (RN). Further review revealed Patient #31 was listed as requiring 1 on 1 supervision and was placed in direct sight of the station (nursing station). Review of the Emergency Department notes revealed no nursing assessment documented between 18:03 (6:03 p.m.) and 20:14 (8:14 p.m.). Further review revealed no nursing assessment had been documented between 6/25/12 at 21:58 (9:58 p.m.) and 6/26/12 at 08:00 (8:00 a.m.). No documentation of 1 on 1 observation had been recorded. In an interview on 7/11/12 at 9:30 a.m. with S3 E.D. Manager, he verified the nursing assessments had not been completed on Patient #31 hourly as per the hospital policy for PEC'd patients.
Review of the Emergency Department Record for Patient #32 revealed he had arrived to the Emergency Department on 6/24/12 at 00:10 (a.m.) with the chief complaint of suicidal thoughts and was discharged on 6/26/12 at 13:31 (1:31 p.m.) to a local psychiatric facility. Further review revealed he had a PEC dated 6/24/12 at 1:55 a.m. The certificate listed the patient as having been dangerous to himself and unable to seek voluntary admission. Review of the Harm Assessment form for Patient #32 dated 6/24/12 at 0045 (00:45 a.m.) revealed the form had been completed by S10 RN. Further review revealed Patient #32 was assessed as needing continuous supervision and was placed in direct sight of the nursing station. Review of the Emergency Department notes revealed no nursing assessment had been documented between 6/24/12 at 23:42 (11:42 p.m.) and 6/25/12 at 05:58 (a.m.). Further review revealed no documented nursing assessment between 6/25/12 at 20:25 (8:25 p.m.) and 6/26/12 at 00:50 (a.m.).
Review of the Emergency Department record for Patient #37 revealed the patient was a 45 year old male admitted to the emergency room on 6/22/12, with a triage time of 0815 (8:15 a.m.). His chief complaint was listed as he stated, "I'm suicidal, I tried to hang myself this morning, but someone stopped me and I am depressed." Review of the Physician Emergency Certificate dated 6/22/12 and timed 8:30 a.m., revealed he was suicidal and he was dangerous to self and unwilling to seek voluntary admission to a hospital. Review of the Harm Assessment dated 6/22/12 at 0820 (8:20 a.m.) revealed he had tried to hurt and kill himself in the past, and currently he had a specific plan with a specific time, and he had access to the plan to commit suicide. Also he had recently thought about harming and killing others. Suicidal thoughts were documented as observed while the patient was in ED (Emergency Department). The precautions taken was listed as; supervision would be continuous and the patient was placed in direct sight of the nurse's station. Review of the physical assessment electronic record revealed the patient was assessed hourly on 6/22/12 from 08:22 (8:22 a.m.) to 1800 (6 p.m.). There was no documentation the patient was assessed or supervised by the RN from 1800 on 6/22/12 to 06:04 (6:04 a.m.) on 6/23/12, which was 12 hour consecutive time period. According to the medical record the patient had verbalized to the RN on the harm assessment form he had a current plan to commit suicide and harm others and he had access to the plan.

Review of the hospital's policy and procedure titled, Care of the Psychiatric Patient, effective date 10/11/2011, provided as current policy by S3 Emergency Department Manager, revealed in part the following:
Admission to the Emergency Department:
2. The patient will be placed in one of the stretchers with direct observation from the nurses' station, if available, or the patient can be placed into another bed with ED staff assigned to watch the patient.
5. If the EDP (Emergency Department Physician) has determined that the patient is at risk for suicide, the staff will implement suicide risk precautions based upon the EDP's orders.
d.. The RN will observe and document patient status every hour.

Review of the hospital's policy, titled, "Plan for Improving Organizational Performance", effective date of 02/28/12, and provided by S2 Director of Clinical Systems Improvement as their current QAPI (Quality Assessment and Performance Improvement) policy, revealed in part the following: .....This plan provides the hospital with the mechanisms to identify opportunities for performance improvement and a process to improve identified deficiencies....Jennings American Legion Hospital recognizes that monitoring performance through data collection is the foundation of all performance improvement activities. Leadership decides which processes to monitor and which data to collect as related to the hospital mission, vision, available resources, functions as well as concerns of the individuals served, their families, staff, payers and other customers. Data Collection includes but is not limited to: .....Patient safety and the National Patient Safety Goals, Outcomes of processes or services, Staffing effectiveness, High risk, high volume and problem prone processes....

On 07/11/12 at 9:40 a.m., interview with S1 RN and S3 RN revealed when asked to explain the procedure for 1 on 1 Supervision and Continuous Supervision, S3 RN replied 1 on 1 would be the staff sitting next to the patient and Continuous Supervision would be direct observation of the patient from the nurse's station. S3 RN stated the RN can determine the supervision level; however, he did not recall doing any 1 on 1 supervision in the Emergency Department for PEC'd patients. When asked to provide a number of PEC'd patients that had eloped from the Emergency Department S3 RN stated he did not track the number of elopements only a log of PEC'd patients. When asked if he did any tracking or trending of the elopements, he stated "no". S3 RN stated Patient #22 was the only elopement that was not found and brought back to the Emergency Department and added there had been 1-2 PEC elopements from the Emergency Department in the last 6 months. When asked if an occurrence report was documented for PEC elopement patients that were returned to the ED, he stated he did not document occurrence reports if the patient was returned.

In a face-to-face interview on 07/11/12 at 1:00 p.m., S2 Director of Clinical Systems Improvement indicated development of quality indicators for performance improvement focused on high-risk, high-volume, and/or problem prone areas. S2 confirmed the ED patients under PEC would be considered a high-risk, problem-prone area for the ED. S2 confirmed there were no current quality improvement indicators for monitoring PEC'd patients, and no tracking and trending of PEC'd patient elopements. S2 confirmed that occurrence reports had not been documented for PEC'd patients that eloped and returned to the ED. S2 confirmed the occurrence report for the elopement of PEC'd Patient #22 on 06/18/12, was not completed timely and as of 07/11/12, no corrective action had been taken by the hospital. S2 confirmed the identified problem of the lack of monitoring of PEC'd patients in the ED had not been identified by the hospital.

Based on review of Emergency Department Medical Records, Policies and Procedures and staff interviews the hospital failed to ensure a registered nurse supervised and provided an ongoing nursing assessment in accordance to the hospital's policy as evidence by:
1. Patient #22 was admitted to the emergency room and assessed by a physician as needing a Physician Emergency Certificate (PEC) due to suicidal ideation and recent self inflicted wounds on her arms and visible agitation. A registered nurse assessed the patient as needing 1:1 supervision; however, this was not provided and the patient eloped from the emergency room and the local officials were unable to locate Patient #22 .
2. The hospital failed to follow established ED policy and procedure by failing to provide PEC patients with appropriate supervision while in the emergency room for 7 out of 14 PEC patients reviewed out of a total sample of 38 (Patient #22, #27, #28,#29, #31, #32 # 37).
Findings:

1)
Review of the medical record for Patient #22 revealed the patient was a 17 year old female who ambulated alone into the emergency department on 06/18/12 at 15:54 (3:54 p.m.). The triage record revealed the patient was triaged at 15:56 (3:56 p.m.) and had a chief complaint of, "Presented to triage crying stating, "I'm suicidal" thoughts of harming self by cutting wrist and over dosing on medication. Attempted to slice left inner arm and wrist with shaving razor X 6 (Six times). Abrasions to left inner arm, no lacerations, no bleeding. Lives with boyfriend and having trouble at home. History of previous inpatient psych treatment. Does not take medication regularly." The triage form was signed by S4 RN.

Review of the "Harm Assessment" form dated/timed 06/18/12 at 16:02 (4:02 p.m.) revealed the RN documented the patient indicated she had tried to hurt herself, had tried to hurt herself in the past, had recently thought about killing herself, was spending a lot of time planning how she would hurt herself, and had access to a plan for hurting herself. The RN documented the patient was agitated, restless, aggressive, had verbal threats, and had self-inflicted injury. The patient's behavior was also documented as anxious, ambivalent, and withdrawn. The RN documented supervision was "1 on 1", and patient was placed in direct sight of the ED nursing station.

Review of the Emergency Physician Record dated/timed 06/18/12 at 5:00 p.m. revealed the clinical impression was Suicide Attempt. The ED Physician initiated a PEC dated/timed 06/18/12 at 5:19 p.m., with the following findings: "Patient having problems with boyfriend and cut left wrist today." Part A of the PEC identified "I am of the opinion that the above person named is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill or suffering from substance abuse so that he/she is dangerous to self" and "unable to seek voluntary admission".

Review of the Patient Progress Notes (Nurses documentation) revealed in part, the following:
16:17 (4:17 p.m.) - Arrival to ED room Hall, siderails up.
17:03 (5:03 p.m.) - ED physician in room.
17:15 (5:15 p.m.) - Pt. (Patient) changed into PEC gown, belongings collected and placed in bag at nurses station.....
17:47 (5:47 p.m.) - Tolerated 80% of supper.
18:00 (6:00 p.m.) - Ambulated to restroom, no distress noted.
18:22 (6:22 p.m.) - Pt. missing from hall stretcher while staff attending to other patients. security and police called....
00:39 (12:39 a.m.) - Called ____ city police, haven't found or seen pt., still looking for pt.

On 07/10/12 at 2:25 p.m., interview with S3 RN revealed when asked how the level of supervision was determined, he stated the triage nurse does the Harm Assessment and puts it on the patient's record; however, the Emergency Physician may also order supervision level and added "They are in line of sight". S3 RN confirmed the RN documented 1 on 1 supervision on the Harm Assessment and stated he did not know why the nurse checked 1 on 1 supervision because "that was not what they do". When asked if someone was always at the nurse's station when a PEC patient was in the hall, he stated "no, not always".

Further interview with S3 RN on 07/11/12 at 9:40 a.m. revealed when asked to explain the Emergency Department procedure for 1 on 1 supervision and Continuous Supervision he replied 1 on 1 would be the staff sitting next to the patient and Continuous Supervision would be direct observation of the patient from the nurse's station. S3 RN stated the RN can determine the supervision level; however, he did not recall doing any 1 on 1 supervision in the Emergency Department.

On 07/11/12 at 1:15 p.m. a telephone interview was conducted with S4 RN and it was confirmed she had worked in the Emergency Department on 06/18/12 and recalled Patient #22 and her elopement. S4 RN stated she triaged "the little girl" and brought her into the ER and placed her on a stretcher in the hall across from the nurse's station. The patient was ambulated to the restroom and during this time two patients presented to the ED with over doses and she was attending to one. S4 RN further stated she did not see Patient #22 come back from the restroom, and when she checked, the patient was not on the stretcher. The Emergency Physician, security, and the police department were notified and she also looked for the patient. S4 RN confirmed she completed the Harm Assessment on Patient #22 and assessed her as needing 1 on 1 supervision. When asked what 1 on 1 supervision was, she stated 1 on 1 means the patient needs to have one on one staff member at all times watching her and further stated "That didn't happen" and "We were all looking after all the patients." S4 RN verified Patient #22 was not returned to the Emergency Department and she did not know what happened to the patient. S4 further stated, "I know it, it should have been 1 on 1."


30364

2)
Review of the medical record for Patient #27 revealed the patient was a 19 year old female admitted to the emergency room on 6/11/12, with a triage time of 17:57 (5:57 p.m.). The patient's chief complaint was listed as suicide attempt by cutting left wrist with broken piece of glass. Occurred 2 days ago, however boyfriend stopped patient. Small scratch noted to left wrist.... Review of the Physician Emergency Certificate dated 6/11/12 and timed 7:00 p.m., revealed she was suicidal, was dangerous to self, and unwilling to seek voluntary admission to a hospital.

Review of the Harm Assessment dated 6/11/12 at 18:10 (6:10 p.m.) revealed she had tried to hurt and kill herself in the past, and currently she had a specific plan with a specific time, and she had access to the plan to commit suicide. Suicidal comments were documented as observed while the patient was in the ED (Emergency Department). The precautions taken were listed as; supervision would be 1 on 1 and continuous and the patient was placed in direct sight of the nurse's station.

Review of the physical assessment electronic record revealed the patient was assessed hourly on 6/11/12 from 18:14 (6:14 p.m.) to 05:06 (5:06 a.m.). There was no documentation the patient was assessed or supervised by the RN from 05:06 (5:06 a.m.) on 6/12/12 to 08:30 (8:30 a.m.) on 6/12/12, which was a 3 and 1/2 hour consecutive time period. Further review of the nurse's documentation revealed no hourly assessments from 08:30 (8:30 a.m.) to 10:40 (10:40 a.m.) on 06/12/12 (2 hours consecutive time period). According to the medical record the patient had verbalized to the RN on the harm assessment form she had a current plan to commit suicide and she had access to the plan.

Review of the patient electronic vital sign record revealed the patient's vital signs were monitored on admission to the ED on 6/11/12 at 17:57 (5:57 p.m.) and 23:28 (11:28 p.m.) by a ET (Emergency Technician). On 6/12/12 her vital signs were monitored by a ET at 04:10 (4:10 a.m.) and an RN at 11:00 (11:00 a.m.). The patient was discharged to another hospital on 6/12/12 at 13:00 (1:00 p.m.).

An interview was conducted with S3 RN on 7/11/12 at 9:40 a.m. and he reported there was no assessment or observation documentation during a 3 and 1/2 hour consecutive time period for Patient #27 and the nurse failed to the follow the ED policy for documentation of assessment and observation every one hour for a PEC patient. S3 RN Confirmed the policy for vital sign monitoring for PEC'd patients in the Emergency Department was not followed and Patient #27's vital signs were not monitored every 4 hours while she was admitted to the emergency room under a PEC.

Review of Patient #28's Emergency Department Record revealed the patient arrived by ambulance on 06/12/12 at 11:18 (11:18 a.m.). Review of the Triage Record revealed the patient was a 65 year old female with a chief complaint that she was brought to the ED under an Order of Protective Custody (OPC) and patient was expressing paranoid thoughts. The Triage Record revealed the patient's husband was present and reported patient had hallucinations, paranoid thoughts, and had been off her medications. Review of the triage vital signs revealed the following: Blood Pressure of 145/82, Pulse of 124, Respirations of 22.

Review of the Harm Assessment dated/time 06/12/12 at 11:35 a.m. revealed the patient was observed to be confused and delusional. Supervision was documented as Continuous and the patient was placed in direct sight of the ED nursing station.

Review of the physical assessment electronic record revealed the nurse had made hourly entries into the record, but there was no documented evidence of an assessment of the patient's status in any of the entries. Review of the vital sign documentation revealed the only other vital signs that were taken were at 16:55 (4:55 p.m.), over 5 hours after the vital signs were taken at triage. Review of the record revealed the patient was discharged to another hospital on 06/12/12 at 5:36 p.m.

On 07/11/12 at 9:40 a.m. in a face-to-face interview with S3 RN and he confirmed there were no hourly assessments of the patient's status documented and the vital signs were not monitored according to ED policy.

Review of Patient #29's Emergency Department Record revealed the patient was a 29 year old female who arrived by ambulance on 06/18/12 at 22:52 (10:52 p.m.). The Triage Record revealed the patient's chief complaint was, "I'm here to get help. I wanna get off the pills and the dope so I can get my babies back. I lost custody of my babies."

Review of the Harm Assessment documented at 23:00 (11:00 p.m.) revealed the patient expressed suicidal thoughts, but did not have a plan. Review of the supervision revealed continuous supervision was checked and the patient was placed in direct sight of station.

Review of the PEC dated/timed 06/18/12 at 0015 (12:15 a.m.) revealed the patient was suicidal, was dangerous to self, and was unwilling to seek voluntary admission.

Review of the physical assessment electronic record revealed the patient was assessed at 23:08 (11:08 p.m.) and 23:55 (11:55 p.m.) on 6/18/12. There was no documentation the patient was assessed or supervised by the RN again until 07:20 (7:20 a.m.) on 06/19/12, 7 hours later. There was no documented evidence of hourly assessments of the patient's status between 11:55 p.m. on 06/18/12 to 7:20 a.m. on 06/19/12. Review of the record revealed the patient was discharged to another facility on 06/19/12 at 12:56 p.m.

On 07/11/12 at 9:40 a.m., S3 RN was interviewed and he confirmed there was no documented evidence that hourly assessments of the patient's status were done from 11:55 p.m. to 7:20 a.m. the next morning. S3 confirmed the ED policy was to document as assessment of the patient's status every one hour when the patient was under a PEC.

Review of the Emergency Department Record for Patient #31 revealed he was admitted on 6/25/12 at 8:12 p.m. with the chief complaint of suicidal thoughts and was discharged on 6/26/12 at 9:10 a.m. to a local psychiatric facility. Further review revealed Patient #31 had a Physician Emergency Certificate (PEC) dated 6/25/12 at 8:32 p.m. The certificate listed the patient as being a danger to self, a danger to others, and unable to seek voluntary admission.
Review of the Harm Assessment form for Patient #31 dated 6/25/12 at 1718 (5:18 p.m.) revealed the form was completed by S9 RN. Further review revealed Patient #31 was listed as requiring 1 on 1 supervision and placed in direct sight of the station (nursing station).
Review of the Emergency Department notes revealed no nursing assessment documented between 18:03 (6:03 p.m.) and 20:14 (8:14 p.m.). Further review revealed no nursing assessment had been documented between 6/25/12 at 21:58 (9:58 p.m.) and 6/26/12 at 08:00 (8:00 a.m.). No documentation of 1 on 1 observation had been recorded. In an interview on 7/11/12 at 9:30 a.m. with S3 E.D. Manager, he verified the nursing assessments had not been completed on Patient #31 hourly as per the hospital policy for psychiatric patients.
Review of the Emergency Department Record for Patient #32 revealed he had arrived to the Emergency Department on 6/24/12 at 00:10 (a.m.) with the chief complaint of suicidal thoughts and was discharged on 6/26/12 at 13:31 (1:31 p.m.) to a local psychiatric facility. Further review revealed he had a PEC dated 6/24/12 at 1:55 a.m. The certificate listed the patient as having been dangerous to himself and unable to seek voluntary admission.
Review of the Harm Assessment form for Patient #32 dated 6/24/12 at 0045 (00:45 a.m.) revealed the form had been completed by S10 RN. Further review revealed Patient #32 was listed as having needed continuous supervision and to have been placed in direct sight of the nursing station.
Review of the Emergency Department notes revealed no nursing assessment had been documented between 6/24/12 at 23:42 (11:42 p.m.) and 6/25/12 at 05:58 (a.m.). Further review revealed no documented nursing assessment between 6/25/12 at 20:25 (8:25 p.m.) and 6/26/12 at 00:50 (a.m.). Review of the vital sign record for Patient #32 revealed on 6/24/12 vital signs were only recorded as having been taken at 03:23 (a.m.), 10:35 (a.m.), 15:54 (3:54 p.m.), and 20:25 (8:25 p.m.). Further review revealed on 6/25/12 vital signs had only been recorded as having been taken three times at 02:00 (a.m.), 18:27 (6:27 p.m.) and 22:40 (10:40 p.m.). Review of the 6/26/12 record revealed vital signs had only been recorded twice at 03:10 (a.m.) and at 13:17 (1:17 p.m.).
In an interview on 7/11/12 at 9:30 a.m. with S3 RN, he verified the vital signs had not been taken on Patient #32 every four hours as per the hospital policy. He also verified nursing assessments had not been completed every hour on Patient #32 as per the hospital policy for a psychiatric patient.

Review of the medical record for Patient #37 revealed the patient was a 45 year old male admitted to the emergency room on 6/22/12, with a triage time of 0815 (8:15 a.m.).His chief complaint was listed as he stated, "I'm suicidal, I tried to hang myself this morning, but someone stopped me and I am depressed." Review of the Physician Emergency Certificate dated 6/22/12 and timed 8:30 a.m., revealed he was suicidal and he was dangerous to self and unwilling to seek voluntary admission to a hospital.

Review of the Harm Assessment dated 6/22/12 at 0820 (8:20 a.m.) revealed he had tried to hurt and kill his self in the past, and currently he had a specific plan with a specific time, and he had access to the plan to commit suicide. Also he had recently thought about harming and killing others. Suicidal thoughts were documented as observed while the patient was in ED (Emergency Department). The precautions taken was listed as; supervision would be continuous and the patient was placed in direct sight of the nurse's station.

Review of the physical assessment electronic record completed by the RN revealed the patient was assessed hourly on 6/22/12 from 08:22 (8:22 a.m.) to 1800 (6 p.m.). There was no documentation the patient was assessed or supervised by the RN from 1800 on 6/22/12 to 06:04 (6:04 a.m.) on 6/23/12, which was for a 12 hour consecutive time period. According to the medical record the patient had verbalized to the RN on the harm assessment form he had a current plan to commit suicide and harm others and he had access to the plan.

An interview was conducted with S3 RN on 7/11/12 at 9:40 a.m. and he confirmed there was no assessment or observation documentation during a 12 hour consecutive time period for Patient # 37 and the nurse failed to the follow the ED policy for documentation of assessment and observation every one hour for a PEC patient. He also reported the patient was placed in the hallway on a stretcher across from the nurse's station. He stated there was not always a nurse present at the nurse's station to watch the PEC patients located in the hallway and it was possible that PEC patients could wander into other rooms in the ED.

Review of the patient electronic vital sign record revealed his vital signs were monitored on admission to the ED on 6/22/12 at 0815 (8:15 a.m.), 1902 (7:02 p.m.) by a CNA (Certified Nursing Assistant and 2300 ( 11 p.m.) by a CNA. On 6/23/12 his vital signs were monitored by a CNA on 03:10 (3:10 a.m.) and 08:41 (8:41 a.m.). The patient was discharged to another hospital on 6/23/12 at 09:11 (9:11 a.m.).

Interview with S3 RN on 7/11/12 at 9:30 a.m. revealed the ED's policy for monitoring PEC patient's vital signs were not followed and were not monitored every 4 hours for Patient #37 while he was admitted to the emergency room under a PEC.

Review of the hospital's policy and procedure titled, Care of the Psychiatric Patient, effective date 10/11/2011, provided as current policy by S3 Emergency Department Manager, revealed in part the following:
Admission to the Emergency Department:
2. The patient will be placed in one of the stretchers with direct observation from the nurses' station, if available, or the patient can be placed into another bed with ED staff assigned to watch the patient.
5. If the EDP (Emergency Department Physician) has determined that the patient is at risk for suicide, the staff will implement suicide risk precautions based upon the EDP's orders.
a. The EDP and RN will determine the need for one-to-one staff supervision.
b. All of the patient's personal belongings will be removed.
d. The RN will observe and document patient status every hour.
e. Vital signs will be done every hour (every 4 hours if the patient has been PEC'd)
Care of the patient under PEC:

There was no documented evidence in the policy of what one-to-one staff supervision required, and there was no documented evidence in the policy of what continuous supervision required.


17091

Based on interview and record review, the hospital failed to provide patient safety by not distributing drugs and biologicals in accordance with applicable standards of practice. The hospital failed to have a pharmacist review all medication orders (except in emergency situations) for appropriateness before the first dose was dispensed for 2 of 2 (#23, #26) patients' medical records reviewed for pharmacy review out of a total sample of 38 patients. Findings:
A review of Patient #23's medical record revealed she was admitted to the hospital on 6/22/12 at 22:40 (10:40 p.m.) with the chief complaint of syncopal episode with chest pain. Review of the medication orders for Patient #23 revealed orders for Celexa (antidepressant) 20 mg (milligrams) one dose by mouth, Lovastatin (medication to lower cholesterol) 20 mg at bedtime, and Levothyroxine (thyroid hormone) 0.15 mg daily. Review of the Medication Record revealed the Celexa and Lovastatin were administered to Patient #23 at 11:19 p.m. on 6/22/12. Further review revealed Levothyroxine was administered at 5:12 a.m. on 6/23/12. Review of the Medication Order History revealed the medications for Patient #23 had not been reviewed by a pharmacist for appropriateness until 8:24 a.m. and 8:25 a.m. on 6/23/12.
A review of Patient #26's medical record revealed she was admitted to the hospital on 7/6/12 at 2214 (10:14 p.m.) with diagnosis which included mental status changes, frequent falls and debility. Review of the medication orders for Patient #26 revealed orders for Namenda (medication for Alzheimer's symptoms) 5mg BID (twice per day), Coreg (medication for heart failure and high blood pressure) 6.25 mg BID, and Lortab (pain medication) 5mg PRN (as needed) every 4 hours for pain. Review of the Medication Record revealed the Namenda and Coreg had been administered to Patient #26 at 23:22 (11:22 p.m.) on 7/6/12 and the Lortab had been administered on 7/6/12 at 23:23 (11:23 p.m.). Review of the Medication Order History revealed the medications for Patient #26 had not been reviewed by a pharmacist for appropriateness until 7:10 a.m. and 7:11 a.m. on 7/7/12.
In an interview on 7/9/12 at 10:30 a.m. with S8, RN, she stated when first dose medications were ordered for patients after the pharmacists had left for the day, the medications were not checked by a pharmacist before administration. She said two nurses checked the medications for potential problems and the pharmacist would review the medications when they began their shift the next morning.
In an interview on 7/9/12 at 11:30 a.m. with S7, Pharmacy Manager, she stated the pharmacy hours were 6:00 a.m. to 6:00 p.m. from Monday through Friday and 7:00 a.m. to 4:00 p.m. on the weekends. She said the Pharmacists did not do a first dose review of medications after pharmacy operating hours. She said when a routine medication was ordered at night, the first dose was reviewed by two nurses for accuracy. She also said the medications were reviewed retrospectively by the Pharmacist when they began their shift the next day.



26351

An interview was conducted with S6 Intensive Care Nurse Manager on 7/19/12 at 2:15 p.m. When questioned if the pharmacist reviews all the first doses of medications administered in the intensive care unit, she reported if the pharmacy was not open, two nurses would check the medication prior to administration and the pharmacist would review the medication, after the medication was administered, when the pharmacy reopened.

On 07/09/12 at 3:04 p.m., an interview was conducted with S13 RN on Tower Unit One. When asked if the pharmacist reviewed all the first doses of medications administered on the unit, S13 stated the pharmacist does not review until the next morning. S13 stated if a new medication was ordered in the evening after the pharmacist left, then 2 nurse would check the new medication and the pharmacist would review the following morning.



17091

Based upon observations, interviews and record reviews the hospital failed to provide care in a safe setting by:

1)Failing to have a mechanism in place to ensure psychiatric patients being held in the
Emergency Department requiring 1:1 or continuous monitoring as ordered by the MD were continuously monitored to date.

Failing to provide 1:1 supervision (or continuous supervision)as ordered by MD allowing patient #22 the opportunity to elope from the ED and

2).Failing to follow policy and procedures by placing patients who presented to the Emergency Department with complaints of suicidal ideation, in a room with multiple equipment cords, unlocked cabinets and medical supplies.

Findings:
1)
On 07/10/12 at 2:25 p.m. S3 RN interviewed.When asked about the 1:1 supervision, ordered by ER MD confirmed the RN may check the boxmarked 1:1 supervision; however, "that was not what they do" and added the psychiatric patient was directly observed from the ED nursing station. When asked if someone was always at the nurse's station when a patient requiring 1:1 or direct supervision was in the hall, he stated "no, not always". No additional
staff is provided when multiple 1:1 patients are in the Emergency Room to date.

Patient # 22
Record review for #22 revealed a 17 year old female presented to the ED alone on 06/18/12 at 1554 (3:54 p.m.) with the chief complaint of "I'm suicidal," having thoughts of harming self by cutting her wrist and overdosing on medication. Triaged at 15:56 (3:56pm) by S4 RN.Abrasions to left inner arm and wrist noted, no lacerations or bleeding where patient had attempted to slice herself with a shaving razor x 6 (six times).

Review of the "Harm Assessment" form completed by S4 RN dated and timed 6/28/12 at 16:02 (4:02) revealed patient was spending a lot of time planning how she would hurt herself, and had a plan for hurting herself. S4 RN further documented the patient was aggressive, agitated, restless, ambivalent and had a self-inflicted injury, had a history of inpatient psychiatric treatment, does not take medications regularly and the level of supervision needed was "1on1". Patient was placed on a hallway stretcher in direct sight of the nursing station.

Review of the Emergency Department Physician assessment dated/timed 06/18/12, 5:00 p.m. revealed patient #22 had suicidal thoughts/gestures that were severe with the clinical impression of suicide attempt. The ED Physician placed the patient under a Physician Emergency Certificate that was dated/timed 06/18/12 at 5:19 p.m. indicating by check mark the patient was in need of immediate psychiatric treatment because she was dangerous to herself and unable to seek voluntary admission.
.
Continued review of ED Patient Progress Notes, completed by ER RN revealed on 06/18/12 at "1822 (6:22 p.m.) Pt. (Patient) missing from hall stretcher while staff attending to other patients. Security and Police called."
"1825 (6:25 p.m.) - ____ (Local police department) present, searching hospital grounds."
"0039 (12:39 a.m.) - Called ____ city police, haven't found or seen pt., still looking for pt."
"0148 (1:48 a.m.) - Called number on face sheet, not a working number, called in case of emergency number, great grandmother, hasn't seen pt., gave number of someone else, called number, left voice mail."

Review of the hospital's occurrence report log revealed the following:
06/18/12 - Patient (#22) in ED (Emergency Department) with attempted suicide, PEC'd, Harm Assessment done. Patient went to bathroom "no distress noted". Next time nurses noticed (busy ED) patient was missing from hall bed. ___ (Local Police Department) called/searched hospital grounds/did not find patient.

On 07/10/12 at 2:25 p.m., a face-to-face interview was conducted with the S1, S2, and S3 confirmed they had reviewed the Emergency Department record for Patient #22. S3 confirmed the patient was PEC'd and eloped from the Emergency Department and the staff called the police department and security, but the patient was not found and never returned to the Emergency Department.

Review of the hospital policy titled "Care of the Psychiatric Patient", effective date 10/11/2011, provided as current policy by S3 RN revealed in part the following:
Admission to the Emergency Department, #2. The patient will be placed in one of the stretchers with direct observation from the nurses' station, if available, or the patient can be placed into another bed with ED staff assigned to watch the patient. 5. d. The RN will observe and document patient status every hour.

2)
On 07/09/12 at 11:00 a.m. Interview with S3 RN revealed approximately 10-15 psychiatric patients per month were in the ED an average length of stay of 2 days. When asked where the psychiatric patient was placed, S3 RN replied the patient was placed either on a stretcher in the hallway across from the ED nursing station, Cardiac Room 1 or Trauma Bed A to afford direct visual observation of the patient from the nursing station. An observation of the Cardiac Room 1 revealed multiple cardiac monitor cords, otoscope and opthalmoscope cords were noted on the wall over the patient stretcher and, multiple unlocked cabinets with supplies were noted in the room. S3RN verified that all cords were not removed from the room when a Physicians Emergency Certificate (PEC) patient was placed in the room. When asked about the psychiatric patient supervision in case of a "code" or influx of patients, S3 RN responded they could get security to observe the patient, however, S3 RN confirmed the security staff had no specialized training in monitoring the PEC'd patient.

Review of the hospital's policy and procedure titled, Care of the Psychiatric Patient, effective 10/11/2011, provided as current policy by S3 RN, revealed in part 5. If the Emergency Room Physician has determined the patient is at risk for suicide, the staff will implement suicide risk precautions based on the Physicians orders. a. ..determine the need for one to one staff supervision. b. patient belongings will be removed... There is no documented evidence in the policy that refects the environment will be rendered safe for suicidal patients.


17091

Based on review of Emergency Department Medical Records, Policies and Procedures and staff interviews the hospital failed to ensure a registered nurse supervised and provided an ongoing nursing assessment in accordance to the hospital's policy as evidence by:
1. Patient #22 was admitted to the emergency room and assessed by a physician as needing a Physician Emergency Certificate (PEC) due to suicidal ideation and recent self inflicted wounds on her arms and visible agitation. A registered nurse assessed the patient as needing 1:1 supervision; however, this was not provided and the patient eloped from the emergency room and the local officials were unable to locate Patient #22 .
2. The hospital failed to follow established ED policy and procedure by failing to provide PEC patients with appropriate supervision while in the emergency room for 7 out of 14 PEC patients reviewed out of a total sample of 38 (Patient #22, #27, #28,#29, #31, #32 # 37).
Findings:

1)
Review of the medical record for Patient #22 revealed the patient was a 17 year old female who ambulated alone into the emergency department on 06/18/12 at 15:54 (3:54 p.m.). The triage record revealed the patient was triaged at 15:56 (3:56 p.m.) and had a chief complaint of, "Presented to triage crying stating, "I'm suicidal" thoughts of harming self by cutting wrist and over dosing on medication. Attempted to slice left inner arm and wrist with shaving razor X 6 (Six times). Abrasions to left inner arm, no lacerations, no bleeding. Lives with boyfriend and having trouble at home. History of previous inpatient psych treatment. Does not take medication regularly." The triage form was signed by S4 RN.

Review of the "Harm Assessment" form dated/timed 06/18/12 at 16:02 (4:02 p.m.) revealed the RN documented the patient indicated she had tried to hurt herself, had tried to hurt herself in the past, had recently thought about killing herself, was spending a lot of time planning how she would hurt herself, and had access to a plan for hurting herself. The RN documented the patient was agitated, restless, aggressive, had verbal threats, and had self-inflicted injury. The patient's behavior was also documented as anxious, ambivalent, and withdrawn. The RN documented supervision was "1 on 1", and patient was placed in direct sight of the ED nursing station.

Review of the Emergency Physician Record dated/timed 06/18/12 at 5:00 p.m. revealed the clinical impression was Suicide Attempt. The ED Physician initiated a PEC dated/timed 06/18/12 at 5:19 p.m., with the following findings: "Patient having problems with boyfriend and cut left wrist today." Part A of the PEC identified "I am of the opinion that the above person named is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill or suffering from substance abuse so that he/she is dangerous to self" and "unable to seek voluntary admission".

Review of the Patient Progress Notes (Nurses documentation) revealed in part, the following:
16:17 (4:17 p.m.) - Arrival to ED room Hall, siderails up.
17:03 (5:03 p.m.) - ED physician in room.
17:15 (5:15 p.m.) - Pt. (Patient) changed into PEC gown, belongings collected and placed in bag at nurses station.....
17:47 (5:47 p.m.) - Tolerated 80% of supper.
18:00 (6:00 p.m.) - Ambulated to restroom, no distress noted.
18:22 (6:22 p.m.) - Pt. missing from hall stretcher while staff attending to other patients. security and police called....
00:39 (12:39 a.m.) - Called ____ city police, haven't found or seen pt., still looking for pt.

On 07/10/12 at 2:25 p.m., interview with S3 RN revealed when asked how the level of supervision was determined, he stated the triage nurse does the Harm Assessment and puts it on the patient's record; however, the Emergency Physician may also order supervision level and added "They are in line of sight". S3 RN confirmed the RN documented 1 on 1 supervision on the Harm Assessment and stated he did not know why the nurse checked 1 on 1 supervision because "that was not what they do". When asked if someone was always at the nurse's station when a PEC patient was in the hall, he stated "no, not always".

Further interview with S3 RN on 07/11/12 at 9:40 a.m. revealed when asked to explain the Emergency Department procedure for 1 on 1 supervision and Continuous Supervision he replied 1 on 1 would be the staff sitting next to the patient and Continuous Supervision would be direct observation of the patient from the nurse's station. S3 RN stated the RN can determine the supervision level; however, he did not recall doing any 1 on 1 supervision in the Emergency Department.

On 07/11/12 at 1:15 p.m. a telephone interview was conducted with S4 RN and it was confirmed she had worked in the Emergency Department on 06/18/12 and recalled Patient #22 and her elopement. S4 RN stated she triaged "the little girl" and brought her into the ER and placed her on a stretcher in the hall across from the nurse's station. The patient was ambulated to the restroom and during this time two patients presented to the ED with over doses and she was attending to one. S4 RN further stated she did not see Patient #22 come back from the restroom, and when she checked, the patient was not on the stretcher. The Emergency Physician, security, and the police department were notified and she also looked for the patient. S4 RN confirmed she completed the Harm Assessment on Patient #22 and assessed her as needing 1 on 1 supervision. When asked what 1 on 1 supervision was, she stated 1 on 1 means the patient needs to have one on one staff member at all times watching her and further stated "That didn't happen" and "We were all looking after all the patients." S4 RN verified Patient #22 was not returned to the Emergency Department and she did not know what happened to the patient. S4 further stated, "I know it, it should have been 1 on 1."


30364

2)
Review of the medical record for Patient #27 revealed the patient was a 19 year old female admitted to the emergency room on 6/11/12, with a triage time of 17:57 (5:57 p.m.). The patient's chief complaint was listed as suicide attempt by cutting left wrist with broken piece of glass. Occurred 2 days ago, however boyfriend stopped patient. Small scratch noted to left wrist.... Review of the Physician Emergency Certificate dated 6/11/12 and timed 7:00 p.m., revealed she was suicidal, was dangerous to self, and unwilling to seek voluntary admission to a hospital.

Review of the Harm Assessment dated 6/11/12 at 18:10 (6:10 p.m.) revealed she had tried to hurt and kill herself in the past, and currently she had a specific plan with a specific time, and she had access to the plan to commit suicide. Suicidal comments were documented as observed while the patient was in the ED (Emergency Department). The precautions taken were listed as; supervision would be 1 on 1 and continuous and the patient was placed in direct sight of the nurse's station.

Review of the physical assessment electronic record revealed the patient was assessed hourly on 6/11/12 from 18:14 (6:14 p.m.) to 05:06 (5:06 a.m.). There was no documentation the patient was assessed or supervised by the RN from 05:06 (5:06 a.m.) on 6/12/12 to 08:30 (8:30 a.m.) on 6/12/12, which was a 3 and 1/2 hour consecutive time period. Further review of the nurse's documentation revealed no hourly assessments from 08:30 (8:30 a.m.) to 10:40 (10:40 a.m.) on 06/12/12 (2 hours consecutive time period). According to the medical record the patient had verbalized to the RN on the harm assessment form she had a current plan to commit suicide and she had access to the plan.

Review of the patient electronic vital sign record revealed the patient's vital signs were monitored on admission to the ED on 6/11/12 at 17:57 (5:57 p.m.) and 23:28 (11:28 p.m.) by a ET (Emergency Technician). On 6/12/12 her vital signs were monitored by a ET at 04:10 (4:10 a.m.) and an RN at 11:00 (11:00 a.m.). The patient was discharged to another hospital on 6/12/12 at 13:00 (1:00 p.m.).

An interview was conducted with S3 RN on 7/11/12 at 9:40 a.m. and he reported ther

Based on interview and record review, the hospital failed to provide patient safety by not distributing drugs and biologicals in accordance with applicable standards of practice. The hospital failed to have a pharmacist review all medication orders (except in emergency situations) for appropriateness before the first dose was dispensed for 2 of 2 (#23, #26) patients' medical records reviewed for pharmacy review out of a total sample of 38 patients. Findings:
A review of Patient #23's medical record revealed she was admitted to the hospital on 6/22/12 at 22:40 (10:40 p.m.) with the chief complaint of syncopal episode with chest pain. Review of the medication orders for Patient #23 revealed orders for Celexa (antidepressant) 20 mg (milligrams) one dose by mouth, Lovastatin (medication to lower cholesterol) 20 mg at bedtime, and Levothyroxine (thyroid hormone) 0.15 mg daily. Review of the Medication Record revealed the Celexa and Lovastatin were administered to Patient #23 at 11:19 p.m. on 6/22/12. Further review revealed Levothyroxine was administered at 5:12 a.m. on 6/23/12. Review of the Medication Order History revealed the medications for Patient #23 had not been reviewed by a pharmacist for appropriateness until 8:24 a.m. and 8:25 a.m. on 6/23/12.
A review of Patient #26's medical record revealed she was admitted to the hospital on 7/6/12 at 2214 (10:14 p.m.) with diagnosis which included mental status changes, frequent falls and debility. Review of the medication orders for Patient #26 revealed orders for Namenda (medication for Alzheimer's symptoms) 5mg BID (twice per day), Coreg (medication for heart failure and high blood pressure) 6.25 mg BID, and Lortab (pain medication) 5mg PRN (as needed) every 4 hours for pain. Review of the Medication Record revealed the Namenda and Coreg had been administered to Patient #26 at 23:22 (11:22 p.m.) on 7/6/12 and the Lortab had been administered on 7/6/12 at 23:23 (11:23 p.m.). Review of the Medication Order History revealed the medications for Patient #26 had not been reviewed by a pharmacist for appropriateness until 7:10 a.m. and 7:11 a.m. on 7/7/12.
In an interview on 7/9/12 at 10:30 a.m. with S8, RN, she stated when first dose medications were ordered for patients after the pharmacists had left for the day, the medications were not checked by a pharmacist before administration. She said two nurses checked the medications for potential problems and the pharmacist would review the medications when they began their shift the next morning.
In an interview on 7/9/12 at 11:30 a.m. with S7, Pharmacy Manager, she stated the pharmacy hours were 6:00 a.m. to 6:00 p.m. from Monday through Friday and 7:00 a.m. to 4:00 p.m. on the weekends. She said the Pharmacists did not do a first dose review of medications after pharmacy operating hours. She said when a routine medication was ordered at night, the first dose was reviewed by two nurses for accuracy. She also said the medications were reviewed retrospectively by the Pharmacist when they began their shift the next day.



26351

An interview was conducted with S6 Intensive Care Nurse Manager on 7/19/12 at 2:15 p.m. When questioned if the pharmacist reviews all the first doses of medications administered in the intensive care unit, she reported if the pharmacy was not open, two nurses would check the medication prior to administration and the pharmacist would review the medication, after the medication was administered, when the pharmacy reopened.

On 07/09/12 at 3:04 p.m., an interview was conducted with S13 RN on Tower Unit One. When asked if the pharmacist reviewed all the first doses of medications administered on the unit, S13 stated the pharmacist does not review until the next morning. S13 stated if a new medication was ordered in the evening after the pharmacist left, then 2 nurse would check the new medication and the pharmacist would review the following morning.



17091

Based on record review and interview, the hospital failed to include in their Quality Assessment Performance Improvement (QAPI) activities high-risk, high-volume, and/or problem prone areas of patient care related to the Emergency Department (ED) as evidenced by failure to include and track ED patients under Physician Emergency Certificate (PEC) for supervision/observation (#27, #29, #31, #32, #37), and elopement from the ED (#22). Findings:

Review of the ICU (Intensive Care Unit)/ER (Emergency Room) Performance Improvement Team binder presented by S2 Director of Clinical Systems Improvement as the current quality improvement data for the ICU/ED, revealed no documented evidence that the medical records of ED patients under PEC were reviewed to determine that ED policy was followed regarding the one-to-one supervision of patients in the ED. There was no documented evidence that tracking and trending of PEC'd patient elopements from the ED was done.

Review of the Emergency Department Stats reported to the Quality Care and Patient Safety Committee revealed in part the following:
January 2012
PEC Days - 22
PEC Patients - 10
February 2012
PEC Days - 27
PEC Patients - 13
March 2012
PEC Days - 13
PEC Patients - 7

Review of the Emergency Department PEC'd patient medical records from June 11, 2012 to present revealed there were 14 PEC'd patients treated in the ED.

Review of the medical record for Patient #22 revealed the patient was a 17 year old female who presented to the ED on 06/18/12 at 3:54 p.m. The triage record entered on 06/18/12 at 3:56 p.m. by S4 RN revealed in part, "Presented to triage crying stating, "I'm suicidal" thoughts of harming self by cutting wrist and over dosing on medication. Attempted to slice left inner arm and wrist with shaving razor X 6 (Six times). Abrasions to left inner arm, no lacerations, no bleeding....."

Review of the "Harm Assessment" dated/timed 06/18/12 at 16:02 (4:02 p.m.) revealed that the RN supervision was "1 on 1", and patient was placed in direct sight of station. Review of the patient's PEC revealed it was signed on 06/18/12 at 5:19 p.m. due to Patient #22 was dangerous to self and unable to seek voluntary admission. Review of the entire medical record revealed no documented evidence of 1 on 1 visual observation of Patient #22.

Review of the Patient Progress Notes (Nurses documentation) revealed in part the following:
18:00 (6:00 p.m.) - Ambulated to restroom, no distress noted.
18:22 (6:22 p.m.) - Pt. missing from hall stretcher while staff attending to other patients. security and police called....
00:39 (12:39 a.m.) - Called ____ city police, haven't found or seen pt., still looking for pt.

On 07/10/12 at 2:25 p.m., an interview with S3 RN after patient #22 eloped from the ED, the nursing staff called the police department and security, but the patient was not found and never returned to the Emergency Department. When asked how the level of supervision was determined, S3 RN stated the triage nurse does the Harm Assessment and documents the information in patient's record; however, Emergency Physician may also order the level of supervision. S3 RN stated they do not assign staff to 1 on 1 supervision adding "They are in line of sight" and S3 RN stated he did not know why the nurse checked 1 on 1 supervision because that was not what they do. When asked if someone was always at the nurse's station when a PEC patient was in the hall, he replied "no, not always".

Review of the medical record for Patient #27 revealed the patient was a 19 year old female admitted to the emergency room on 6/11/12, with a triage time of 17:57 (5:57 p.m.). The patient's chief complaint was listed as suicide attempt by cutting left wrist with broken piece of glass. Review of the Physician Emergency Certificate dated 6/11/12 and timed 7:00 p.m., revealed she was suicidal, was dangerous to self, and unwilling to seek voluntary admission to a hospital. Review of the Harm Assessment dated 6/11/12 at 18:10 (6:10 p.m.) revealed she had tried to hurt and kill herself in the past, and currently she had a specific plan with a specific time, and she had access to the plan to commit suicide. The precautions taken were listed as; supervision would be 1 on 1 and continuous and the patient was placed in direct sight of the nurse's station. Review of the physical assessment electronic record revealed the patient was assessed hourly on 6/11/12 from 18:14 (6:14 p.m.) to 05:06 (5:06 a.m.). There was no documentation the patient was assessed or supervised by the RN from 05:06 (5:06 a.m.) on 6/12/12 to 08:30 (8:30 a.m.) on 6/12/12, which was a 3 and 1/2 hour consecutive time period. Further review of the nurse's documentation revealed no hourly assessments from 08:30 (8:30 a.m.) to 10:40 (10:40 a.m.) on 06/12/12 (2 hours consecutive time period).

Review of Patient #29's ED record revealed the patient was a 29 year old female who arrived at the ED by ambulance on 06/18/12 at 22:52 (10:52 p.m.). The Triage Record revealed the patient's chief complaint was, "I'm here to get help. I wanna get off the pills and the dope so I can get my babies back. I lost custody of my babies." Review of the Harm Assessment documented at 23:00 (11:00 p.m.) revealed the patient expressed suicidal thoughts, but did not have a plan. Review of the supervision revealed continuous supervision was checked and the patient was placed in direct sight of station. Review of the PEC dated/timed 06/18/12 at 0015 (12:15 a.m.) revealed the patient was suicidal, was dangerous to self, and was unwilling to seek voluntary admission. Review of the physical assessment electronic record revealed the patient was assessed at 23:08 (11:08 p.m.) and 23:55 (11:55 p.m.) on 6/18/12. There was no documentation the patient was assessed or supervised by the RN again until 07:20 (7:20 a.m.) on 06/19/12, 7 hours later. There was no documented evidence of hourly assessments of the patient's status between 11:55 p.m. on 06/18/12 to 7:20 a.m. on 06/19/12. Review of the record revealed the patient was discharged to another facility on 06/19/12 at 12:56 p.m.

Review of the Emergency Department Record for Patient #31 revealed he was admitted on 6/25/12 at 8:12 p.m. with the chief complaint of suicidal thoughts and was discharged on 6/26/12 at 9:10 a.m. to a local psychiatric facility. Further review revealed Patient #31 had a Physician Emergency Certificate (PEC) dated 6/25/12 at 8:32 p.m. The certificate listed the patient as being a danger to self, a danger to others, and unable to seek voluntary admission. Review of the Harm Assessment form for Patient #31 dated 6/25/12 at 1718 (5:18 p.m.) revealed the form was completed by S9 Registered Nurse (RN). Further review revealed Patient #31 was listed as requiring 1 on 1 supervision and was placed in direct sight of the station (nursing station). Review of the Emergency Department notes revealed no nursing assessment documented between 18:03 (6:03 p.m.) and 20:14 (8:14 p.m.). Further review revealed no nursing assessment had been documented between 6/25/12 at 21:58 (9:58 p.m.) and 6/26/12 at 08:00 (8:00 a.m.). No documentation of 1 on 1 observation had been recorded. In an interview on 7/11/12 at 9:30 a.m. with S3 E.D. Manager, he verified the nursing assessments had not been completed on Patient #31 hourly as per the hospital policy for PEC'd patients.
Review of the Emergency Department Record for Patient #32 revealed he had arrived to the Emergency Department on 6/24/12 at 00:10 (a.m.) with the chief complaint of suicidal thoughts and was discharged on 6/26/12 at 13:31 (1:31 p.m.) to a local psychiatric facility. Further review revealed he had a PEC dated 6/24/12 at 1:55 a.m. The certificate listed the patient as having been dangerous to himself and unable to seek voluntary admission. Review of the Harm Assessment form for Patient #32 dated 6/24/12 at 0045 (00:45 a.m.) revealed the form had been completed by S10 RN. Further review revealed Patient #32 was assessed as needing continuous supervision and was placed in direct sight of the nursing station. Review of the Emergency Department notes revealed no nur