HospitalInspections.org

Based on record review and interview the hospital failed to ensure the safety of a patient by failing to follow their policy and procedure for direct psychiatric observation of a PEC'd (Physician's Emergency Certificate) psychiatric patient. This was evidenced by Security Guard acting in the capacity of a sitter to accompany the patient into the x-ray room resulting in the patient leaving through an unlocked door in the room, exiting the emergency room and eloping from the hospital for 1 of 13 samples patients (#10). Findings:

Review of the medical record for Patient #10 revealed a 28 year old female admitted to the hospital on 10/23/11 at 11:02 am for suicidal thoughts. Patient #10 stated to the staff she had taken 30 sleeping pills and wanted to kill herself. According to the Nursing Notes dated/timed 10/3/11 at 11:19am revealed Patient #10 had taken her cousin s Darvocet prescription about 45 minutes ago after a fight with her boyfriend. At 11:43am Patient #10 was placed under direct psychiatric observation per policy and a sitter was stationed outside of the opened door to her (#10's) room.

Review of Policy Number OHS.NURS.038 titled "Care of the Psychiatric Patient in the Emergency Room" date of issue 11/10 and submitted as the one currently in use revealed..... "D. All patients will be placed under direct a direct psychiatric observation status unless otherwise ordered by the physician. Psychiatric observation will be ordered to decrease the risk of elopement, risk of suicide and ensure patient and staff safety ....."

Review of the Physician's Notes for Patient #10 dated/timed 10/23/11 at 1305 (1:05pm) a Psychiatric Evaluation was performed at which time Patient #10 was PEC ' d (Physician Emergency Certificate) and an explanation given to the patient that she would have no choice but to remain at the hospital. A chest x-ray was also ordered in anticipation of placement into an inpatient psychiatric facility.

Review of the medical record revealed Patient #10 was escorted to the x-ray room located in the Emergency Department by Radiology Tech S8 and Security Guard S4 at approximately 2:00pm.

In a face to face interview on 10/25/11 at 2:30pm Security Guard S4 indicated he had been employed by the hospital for a little over two and a half years in the position of security guard. Further he indicated it was part of his job duty to sit with psychiatric patients in the Emergency Department and sitting was included in his job description. S4 indicated that on 10/23/11 he was called to the Emergency Department around 1:30pm to relieve MHT (Mental Health Tech) S5 so that she could go to lunch. S4 verified he was observing Patient #10. Further he indicated that around 2:00pm the Radiology Tech came to the room and they both escorted Patient #10 to the Radiology Room located in the hallway to the left of the designated psych room in the ED for a chest x-ray. S4 indicated he stayed outside the door leading into the hallway of the ED while the Radiology Tech took the patient into the x-ray room. S4 indicated sometimes security goes into the room with the patient depending on the behavior of the patient; however Patient #10 appeared calm and was cooperative, so he stayed outside. S4 indicated about 10-15 minutes later the tech opened the door and asked him if he had seen Patient #10 because she was no longer in the room.

In a face to face interview on 10/26/11 at 10:10am Radiology Tech S8 (Date of Hire:10/01/06)indicated she went to the ED to get Patient #10 and that she and Security Guard S4 accompanied #10 to the x-ray room located in the ED. S8 confirmed S4 stayed outside during the test. Further S8 indicated Patient #10 was cooperative but stayed on her cell phone constantly until she had to ask her to move the phone so that she perform proper placement of her arms for the films. S8 indicated Radiology Tech S7 was also in the room and stationed in the processing area while she (S8) did the positioning. When the tests were completed, Radiology Tech S8 instructed Patient #10 to sit in the chair next to the unlocked door leading to the " Fast Track " area while she processed the films in the same room. The processing area of the room provided an obstructed view of the patient. During this time Patient #10 left the room using the unlocked door. S8 indicated she opened the door and asked S4 if he had seen Patient #10 because she was no longer in the room.

In a face to face interview on 10/26/11 at 10:10am Radiology Tech S7 (Date of Hire:12/14/09)indicated she was in the room during the time of the testing for Patient #10 on 10/23/11. Further S7 indicated she did not see Patient #10 leave the room.

In a face to face interview on 10/15/11 at 1:30pm Quality Director S3 indicated when employees are assigned as sitters, even nurses, that is the only job duty he/she is expected to perform. Further S4 indicated Administration made this decision so that there would be no confusion as to what was expected to be done.

Review of the "Guide to Risk Sitting - Information for Sitter" submitted by the hospital as the one currently in use revealed.... "B. Sitters will maintain visual contact with the patient at all times. E. Sitting Tips: 8. Never leave the patient."

Based on record review and interview the hospital failed to ensure the Registered Nurse supervised the care of the psychiatric patient as evidenced by all psychiatric patients with orders for direct psychiatric supervision failig to have documented evidence of observations being performed every fifteen minutes for 4 of 13 sampled medical records (#1, #2, #7, #10). Findings:

Patient #1
Review of the medical record for Patient #1 revealed a 27 year old female admitted to the hospital Emergency Department (ED) on 09/24/11 at 1325 (1:35pm) for suicidal ideation times one month and cutting her arms. Further she continues to experience flashbacks of her rape ten years ago and of her son catching his shirt on fire one year ago. Patient #1 indicated she was hearing voices telling her to jump off the bridge.

Review of the Nursing Noted dated/timed 09/24/11 at 1358 (1:58pm) revealed a psychiatric evaluation was performed and Patient #1 was PEC'd (Physician's Emergency Certificate) at that time for severe depression and suicidal ideation. Further review revealed Patient #1 was positive for opiates.

Review of the Nursing Notes revealed a sitter was placed with Patient #1 on 09/24/11 at 1619 (4:19pm). Further review revealed Patient #1 was discharged on 09/26/11 at 1716 (5:16pm).

Review of the Guide to Risk Sitting Flowsheet revealed the following instructions: Circle level of observation and all activities that apply every 15 minutes. Review of the Guide to Risk Sitting Flowsheet dated 09/26/11 for Patient #1 revealed no documented evidence the patient had been observed by the sitter from 1401 (2:01pm) through 1716 (5:16pm) the time of discharge.

Patient #2
Review of the medical record for Patient #2 revealed a 27 year old female admitted to the hospital on 10/03/11 at 12:07pm for severe depression and ingestion of 90 pain pills in four days in an attempted suicide and transferred to ICU (Intensive Care Unit) at 1607 (4:07pm).

Review of the Guide to Risk Sitting Flowsheet for Patient #2 revealed documentation of observation from 1545 (3:45pm) through 1645 (4:45pm).

In a face to face interview on 10/26/11 at approximately 9:00am Quality Director S3 indicated the Sitter Flowsheet is sent to the medical records department and may not have been placed with the chart as of this time.

Patient #7
Review of the medical record for Patient #7 revealed a 26 year old female admitted on 09/21/11 at 1339 (1:39pm) to the Emergency Department of the hospital still drowsy after being discharged from the hospital the previous day from an overdose on Xanax and Methadone with a possibility of ingesting additional medication. Further review of the medical record revealed Patient #7 was transferred to an inpatient psychiatric facility on 09/22/11 at 0211 (2:11am).

Review of the Nursing Notes dated/timed 09/21/11 at 1641 (4:41pm) revealed a sitter was placed with Patient #7 for direct psychiatric observation (maintain direct visual contact with the patient at all times). Review of the Guide to Risk Sitting Flowsheet for Patient #7 revealed documented evidence she (#7) was monitored from 09/21/11 at 1600 (4:00pm) through 09/21/11 at 1815 (6:15pm). The hospital could not provide any further documentation Patient #7 had been monitored by direct visual contact until the time of transfer.

In a face to face interview on 10/26/11 at approximately 9:00am Quality Director S3 verified no further observation documentation could be located for Patient #7.

Patient #10
Review of the medical record for Patient #10 revealed a 28 year old female admitted to the hospital on 10/23/11 at 11:02 am for suicidal thoughts. Patient #10 stated to the staff she had taken 30 sleeping pills and wanted to kill herself.

Review of the Physician's Orders for Patient #10 dated/timed 10/23/11 at 1139 (11:39am) revealed an order for Direct Psychiatric Observation.

Review of the Nursing Notes for Patient #10 dated/timed 1143 (11:43am) revealed a sitter was placed to observe Patient #10 for Direct Psychiatric Observation.

Review of the Guide to Suicide Risk Sitting Flowsheet for Patient #10 revealed no documentation of observation from 10/23/11 at 11:45am through 13:15(1:15pm). Further review revealed a notation Patient #10 eloped at 1445 (1:45pm) and returned at 1645 (4:45pm).

Based on record review and interview the hospital failed to ensure all entries into the medical record were timed, dated and authenticated as evidenced by Suicide Risk Assessments not dated, timed and/or signed by the person performing the assessment for 6 of 13 sampled medical records (#1, #3, #5, #6, #8, #10). Findings:

Patient #1
Review of the medical record for Patient #1 revealed a 27 year old female admitted to the hospital Emergency Department (ED) on 09/24/11 at 1325 (1:35pm) for suicidal ideation times one month and cutting her arms. Further she continues to experience flashbacks of her rape ten years ago and of her son catching his shirt on fire one year ago. Patient #1 indicated she was hearing voices telling her to jump off the bridge.

Review of the Suicide Risk Assessment/Observation/Checklist submitted as part of the medical record for Patient #1 revealed the Suicide Risk Assessment with a score of "8" revealed no documented date, time or name of person performing the assessment and the Suicide Risk Assessment/Observation/Checklist without a completed score revealed no documented time or the name/signature of the person who had been performed the assessment.


Patient #3
Review of the medical record for Patient #3 revealed a 26 year old male admitted on 08/06/11 at 0718 (7:18am) to the Emergency Department of the hospital for an overdose of Klonopin and Fioricet in an attempt to harm himself.

Review of the Suicide Risk Assessment/Observation/Checklist submitted as part of the medical record for Patient #3 revealed the Suicide Risk Assessment with a score of "6" revealed no documented date, time or name of person performing the assessment and the Suicide Risk Assessment/Observation/Checklist with a score of "10" revealed no documented date or time the assessment had been performed and signed by the person performing the assessment.


Patient #5
Review of the medical record for Patient #5 revealed a 21 year old female admitted on 09/26/11 at 0401 (4:01am) to the Emergency Department of the hospital for an overdose on Tramadol after a fight with her boyfriend.

Review of the Suicide Risk Assessment/Observation/Checklist submitted as part of the medical record for Patient #5 revealed the Suicide Risk Assessment with a score of "6" revealed no documented date, time or name of person performing the assessment.


Patient #6
Review of the medical record for Patient #6 revealed a 26 year old female admitted to the Emergency Department of the hospital on 09/22/11 at 0001 12-01am) for an overdose of Seroquel and a history of anxiety, schizophrenia and bi-polar disorder. Further review of the medical record revealed Patient #6 was PEC'd (Physician Emergency Certificate) on 09/21/11 at 1515 (3:15pm).

Review of the Suicide Risk Assessment/Observation/Checklist submitted as part of the medical record for Patient #6 revealed the Suicide Risk Assessment with a score of "9" revealed no documented date, time or name of person performing the assessment.


Patient #8
Review of the medical record for Patient #8 revealed a 29 year old female admitted to the hospital Emergency Department of the hospital on 10/23/11 for suicidal ideation. Past history included anemia schizophrenia and bi-polar disorder.

Review of the Suicide Risk Assessment/Observation/Checklist submitted as part of the medical record for Patient #8 revealed the following:
Suicide Risk Assessment labeled page 4 of 9 with a score of "8" revealed no documented date, time or name of person performing the assessment;
Suicide Risk Assessment labeled page 5 of 9 with a score of "3" revealed no documented time the assessment had been performed or signed by the person performing the assessment; and
Suicide Risk Assessment labeled page 7 of 9 with a score of "3" revealed no documented time the assessment had been performed or signed by the person performing the assessment.

Patient #10
Review of the medical record for Patient #10 revealed a 28 year old female admitted to the hospital on 10/23/11 at 11:02 am for suicidal thoughts. Patient #10 stated to the staff she had taken 30 sleeping pills and wanted to kill herself.

Review of the Suicide Risk Assessment/Observation/Checklist submitted as part of the medical record for Patient #10 revealed the following:
Suicide Risk Assessment dated 10/23/11 with a score of "7" revealed no documented time the person performed the assessment and the Suicide Risk Assessment dated 10/24/11 with a score of "2" revealed no documented time the person performed the assessment.

In a face to face interview on 10/26/11 at 9:00am Quality Director S3 indicated verified the Risk Management Assessment forms should be dated, timed and signed by the person completing the assessment.