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The Hospital failed to ensure care was maintained in a safe environment for 1 Patient (#2) out of a total sample of 12 patients. Patient #2 presented to the Emergency Department (ED) after attempting to self-harm at his/her group home. Patient #2 was evaluated in the ED. Patient #2 continued to have self-harming behaviors requiring chemical restraint. Patient #2 was admitted (2 hours later) to the inpatient psychiatry unit. Patient #2's behavior was not communicated with the inpatient MD, who ordered 15 min checks. Shortly after admission to the inpatient psychiatry unit, Patient #2 was discovered attempting to choke himself/herself with socks.

Cross Reference:
482.13(c)(3)- Care in a Safe Setting (A0144)

Based on interviews and records reviewed, the Hospital failed to ensure care was maintained in a safe environment for 1 Patient (#2) out of a total sample of 12 patients. Patient #2 presented to the Emergency Department (ED) after attempting to self-harm at his/her group home. Patient #2 was evaluated in the ED. Patient #2 continued to have self-harming behaviors requiring chemical restraint. Patient #2 was admitted (2 hours later) to the inpatient psychiatry unit. Patient #2's behavior was not communicated with the inpatient MD, who ordered 15 min checks. Shortly after admission to the inpatient psychiatry unit, Patient #2 was discovered attempting to choke himself/herself with socks.

Findings included:
Review of Hospital Policy "Patient Rights and Responsibilities", effective 09/29/21, indicated:
-Patients have the right to expect reasonable safety in hospital practices and the environment.
-Patients have the right to be treated in a caring, safe and compassionate way.

Patient #2 arrived at the Emergency Department (ED) by ambulance on 12/27/24 from his/her group home after becoming aggressive and attempting to peel his/her skin with a potato peeler. Patient #2 was agitated and impulsive and endorsed auditory hallucinations (AH) and visual hallucinations (VH).

Patient #2's medical record indicated that on 12/27/24 at 9:57 P.M. Patient #2 became increasingly agitated and aggressive with staff and received Droperidol (an antipsychotic) 2.5 milligrams (mg) injection and Midazolam (a sedating medication) 5mg injection in response to his/her agitation and aggression. Patient #2's Suicide Risk Assessment dated 12/28/24 at 10:21 A.M. indicated the Patient endorses thoughts of harm to self or others, recent self-harm behaviors, recent violent urges, prior suicidal behaviors or attempts and was assessed as a moderate suicide risk.

Review of Patient #2's Psychiatry Admission Note dated 12/30/24 at 10:34 A.M. indicated the Patient received multiple chemical restraints on 12/27, 12/28 and 12/29 and that at the time of the visit, Patient #2 was standing in the doorway laughing inappropriately and saying that he/she needs to get to school and when asked about recent concerns that Patient #2 was going to hurt staff members and peel his/her skin off with a potato peeler, the Patient stated "zombies told him/her to do it. I am strong I do not need medications". The Note further indicated that Patient #2 required multiple chemical restraints in the Emergency Room and continues to be paranoid and delusional and the Patient will be admitted to the inpatient Psychiatry unit on a Section 12B (allows for an individual to be admitted to a psychiatric unit for up to three business days against the individual's will or without the individual's consent) on 15-minute safety checks.

Review of ED Provider Note Assessment and Plan addendum dated 12/30/24 at 10:45 A.M. indicated that Patient #2 became increasingly agitated again and had pulled some trim off the psychiatric room door and was trying to hurt him/herself using the nails that were in the trim. Patient #2 also tried to take the tag off the back of a stretcher and use the metal piece of this to hurt themself. Patient #2 was unable to hurt themself but was increasingly agitated and not redirectable. Patient #2 will be treated with intramuscular (IM) Droperidol and Versed.

Review of Nursing Admission Note dated 12/30/24 at 2:21 P.M., indicated Patient #2 was admitted at 11:45 A.M. from the ED via stretcher. Patient #2 declined a skin check and started getting agitated and kicking his/her feet. Patient #2 was disorganized in thought, paranoid, impulsive and agitated. Patient #2 was maintained on 15-minute safety checks.

Review of Significant Event Note dated 12/30/24 at 4:29 P.M., indicated that at around 2:45 P.M., Patient #2 came to the nurses' station and asked for socks because his/her feet were cold. At around 2:50 P.M., the Registered Nurse (RN) was notified by housekeeping that Patient #2 needed help in the bathroom, and he/she was on the floor. The RN observed that Patient #2's neck had two socks tied together tightly around his/her neck and immediately untied the socks. The Note further indicated the Medical Doctor (MD) assessed Patient #2 and placed the Patient on 1:1 for safety.

During an interview on 3/6/25 at 8:16 A.M., the Director of Patient Safety said that in response to Patient #2's event there was an informal leadership meeting between the ED and Psychiatry doctors but that no minutes or notes were available as this was a verbal discussion. The Director provided the survey team with an undated document that he said had been typed up the previous day in response to the survey team's request for any documentation of opportunities identified or implemented as a result of this and said there was no other documentation of corrective actions implemented.

During an interview on 3/6/25 at 9:21 AM., the Interim Psychiatry Chair said the admission psychiatrist in the ED completed the admission orders and ordered checks. The Chair said that between the time of the admission assessment and Patient #2's arrival to the floor there was another episode of agitation for Patient #2, and said the inpatient psychiatry team was not aware of the event. The Interim Chair said this event was discussed with the Chair of Emergency Medicine and that opportunities regarding communication between providers were identified. The Interim Chair said that the ED provider needs to notify the Psychiatry team who is receiving the patient of an event like this, and the goal is to have a clear path of communication. The Interim Chair said that for medical changes in condition that occur after someone is accepted for admission there is a verbal Pass Off (verbal handoff from unit to unit) between providers to ensure that any new information is communicated. He said this is not currently done for any psychiatric events and they are trying to implement this for psych services. He said all of the discussions around the events for Patient #2 has been verbal.

During a follow up interview on 3/7/25 at 9:50 A.M. the Interim Chair of Psychiatry said there was a period of time after admission orders had been completed for Patient #2 when there was a worsening of clinical status which required further restraint due to self-harm and psychotic behaviors. He said he considered this to be a gap in communication between providers and that after the event it was identified that communication could have been better. The Interim Chair said there should have been provider education regarding what providers should do when there is a change in behavioral clinical status. The Interim Chair said there was an initial meeting between ED and Psychiatry leadership after this event, but he hasn't circled back yet with Emergency Medicine since then to implement any identified opportunities. The Interim Chair said there needs to be clear communication with providers written and distributed which outlines a plan of who did they notify, how did they do it and what the next steps are. He said this will likely entail provider education and a shift in what they will do. The Interim Chair said that if Patient #2 required restraints after his/her admission paperwork, the ED staff should they have called the unit.

During an interview on 3/7/25 at10:57 A.M., the Associate Chief of Medicine said leadership of ED and Psych met on 1/21/25 to discuss the event and opportunities for improvement but the case was not formally discussed with all providers. The Associate Chief of Medicine said the Hospital started to obtain attestations from providers to communicate between units if a patient's risk changes or any new event as it relates to patient risk. The Associate Chief said the attestations had just started today.

Although the Hospital began to implement corrective actions while the survey team was on-site as a result of Patient #2's self-harm event, the Hospital failed to provide evidence of fully implementing identified corrective actions to prevent a like occurrence from happening.