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Based on interview and documentation review it was determined the Hospital failed to ensure a safe care setting was provided/maintained in the ED for all patient placed on a safety watch.

Findings included:

Review of Patient #1's clinical record indicated Patient #1 presented to the ED with self infected lacerations on the right wrist and admitted to wanting to commit suicide/do self harm. A safety watch was initiated per Hospital policy.

The ED Guidelines that addressed performing safety watches in the ED was review. The Guidelines stated patients who are placed on safety watch for suicidal ideation shall have constant surveillance while in the psychiatric area.

Review of hospital documentation indicated the registered nurse assigned to the area left to obtain medications and left the security officer to watch both rooms, a total of 6 patients. When Security Officer #2 relieved Security Officer #1, a walk through of room 10 was performed to check patients. Security Officer #2 upon entering room 10 heard gurgling sounds coming from one of the beds and witnessed Patient #1 struggling to breathe. Upon closer inspection it was discovered Patient #1 had wrapped pieces of blanket around his/her neck and tied the length of blanket to the back of the bed. The pieced of blanket was removed from Patient #1's neck and an examination by a physician found no ill effects from the attempted suicide.

Documentation indicated an internal investigation was performed. Changes that was put into place as a result of this review included a policy change to ensure that an additional nurse be dispatched to cover the nurse obtaining medications.

The Nurse Manager of the ED was interviewed in person on 6/6/11 at 1:10 PM and throughout the Survey. She said patients with psychiatric issues were placed in either room nine or room ten in the ED. Both rooms can have as many as 4 patient in each. Prior to this incident on 4/5/11, the area was staffed with one security officer, one registered nurse and one nursing technician. Since this incident, the area, when there is more than 6 patients, is now staffed with two registered nurses, two security officers and two nursing technicians.

Review of policies that addressed safety watches in the ED did not indicate a change had been made to the policy as identified in the May 2011 verbal report given to DPH.

The Nurse Manager of the ED said the policy had not been revised to reflect the staffing changes.

Based on interview and documentation review it was determined the Hospital failed to ensure the prompt implementation of preventive actions related to maintaining a safety watch in the ED.

Findings included:

Refer to Tag # A-0144