HospitalInspections.org

Based on review of facility documents, observation, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure a suicidal patient ordered one-on-one Direct Visualization was not left unattended behind a closed bathroom door (MR1); the facility failed to ensure the 1:1 sitter had direct visualization of a suicidal patient ' s hands, arms and face (MR22) and the facility failed to ensure a 1:1 sitter was not behind a closed door with a patient ordered on direct visual observation (MR23) and the facility failed to ensure a patient expressing suicidal thoughts was rescreened as per facility policy for one of one applicable medical record reviewed (MR1).

Findings include:

Review on March 14, 2025, of the facility's "Patient rights & responsibilities" brochure, A-775-001 F ENG-BR Dev. 6/21, revealed "...Care delivery You or your authorized representative or guardian have the right to...Receive kind, respectful, safe, quality care delivered by skilled staff..."

Review on March 14, 2025, of the facility's "Guidelines for the Care of Behavioral Health in the Emergency Department" policy, last template version 22.02 May 16, 2022, revealed "Purpose To Provide care for patients with behavioral health complaints or psychotic manifestations including homicidal or suicidal ideation. To provide guidelines for a comprehensive assessment and maintenance of patient safety during their time in the Emergency Department (ED). This includes but is not limited to the completion of a suicide risk screening, medical screening exam (MSE), assessment of the environment and referral for behavioral health evaluation...Steps A. Process for direct admission to Behavioral Health Holding Area (BHHA) 1. Patients presenting with behavioral health complaints (including suicidal or homicidal ideation) or signs of psychosis to triage or via EMS (without overt signs/symptoms of medical issues) will be triaged by trained personnel, suicide Risk screening completed, and will have an Emergency Severity Index (ESI) level determined...If Columbia screening results in "NA", staff will consider use of CVM. Staff will follow procedures outline in the policy: "Suicide/Self-harm Precautions-Nursing". 2. Patient will be roomed according to ESI Level and need for safety/security...10. Patients requiring 1:1 direct visualization must be observed by nursing staff for safety while in the bathroom and shower..."

Review on March 14, 2025, of the facility's "Suicide / Self-Harm Precautions - 10.60.4" policy, last committee approval October 11, 2022, revealed "Purpose The purpose of this policy is to ensure an effective method for suicidal assessment, monitoring, and treatment of patients at risk for suicide/self-harm or who may endanger others. Patients presenting with acute medical care needs may also be assessed for exhibiting acute psychiatric conditions, chronic mental disturbances, substance abuse and be at risk of self-harm...Definitions Columbia Suicide Severity Rating Scale (C-SSRS) - Evidence based suicide risk assessment tool to assess suicidal ideation. Continuous observation - continuous in person 1:1 observation monitoring for high risk patients Direct Visual Observation - constant observation in person or by video for moderate risk patients. Observation of multiple patients (no more than 2:1 in person) or can utilize in person and video monitoring for patients simultaneously per nursing/provider judgement...Suicide Ideation - specific behaviors/thoughts/ verbal cues which may be indicative of an individual's intent to kill oneself...Procedure...Any patient that arrives to Emergency department with active suicide attempt is automatically placed on high risk 1:1 observation. Emergency Department Complete the Columbia Suicide Severity Rating Scale (C-SSRS) on every Adult patient and the RSQ-4 for pediatric patients 11-17 years of age. The patient will be re-assessed with any change in patient behavioral condition to determine if a change in risk level (adults) and/or intervention is needed ... "

Review on March 14, 2025, of the facility's "Geisinger Health Suicide Assessment Risk Score & Interventions" protocol, no review date, revealed "Low Risk Locate patient close to nurses' station, if possible. Rescreen patient using CSSR if change in behavior, statement, or condition. Ensure resources are provided at discharge, if needed. Moderate Risk Alert provider and charge nurse of status. Psych consult as ordered by practitioner. Assign to direct visual observation, may assign video and/or continuous in person. Locate patient close to nurses' station, if possible. Complete room and body search immediately for any potentially harmful objects. Screen all visitor belongings. Complete room checks each shift. Rescreen patient using CSSR if change in behavior, statements, or condition. Ensure resources are provided at discharge. High Risk Alert provider and charge nurse of status. Assign to 1:1 continuous in person visual observation. May use video monitoring as secondary precaution in conjunction with direct 1:1. Psych Consult as ordered by practitioner. Locate patient close to nurses' station, if possible. Complete room and body search immediately for any potentially harmful objects. Remove pt. belongings. Screen all visitor belongings. Paper scrubs. Plastic dinnerware. Complete room checks each shift. Rescreen patient using CSSR if change in behavior, statements, or condition. Ensure resources are provided at discharge."

1. Review of MR1 on March 14, 2025, revealed this patient presented to the Emergency Department (ED) on March 10, 2025, at 0316 due to a reported seizure.

Review on March 14, 2025, of nursing documentation dated March 10, 2025, at 0335 revealed MR1 was found pacing the hallway; pacing in the room; grabbed the phone in the room and lifted to cord to the neck; stating to the nurse to step out of the room as this patient needed to make an important call. The phone and cord were removed for MR1's room at that time. The ED physician ordered MR1 on Suicide Precautions and one-on-one Direct Visualization on March 10, 2025, at 0343.

Review of MR1 on March 10, 2025, at 1617 revealed documentation MR1 was transferred from ED room 32 to the locked ED Behavioral Health unit (Nurses Station 4) room 31.

Review on March 14, 2025, of MR1's nursing documentation dated March 11, 2025, at 1030 revealed EMP5 opened the bathroom door; visualized MR1 in a fetal position on the ground with a plastic bag around the neck attempting to strangle self. Scissors were used to remove the plastic bag from around MR1's neck. MR1 was escorted back to the locked ED Behavioral Health unit (Nurses Station 4) and assessed for injury.

Interview with EMP1 revealed EMP6 escorted MR1 out of the locked ED Behavioral Health unit (Nurses Station 4) to the bathroom directly outside this unit and left MR1 unattended in the bathroom for an undetermined amount of time.

There was no nursing documentation indicating the time MR1 was escorted to the bathroom located outside of the locked ED Behavioral Health unit (Nurses Station 4).

Interview with EMP1 on March 14, 2025, confirmed the above findings at the time of the medical record review. EMP1 revealed EMP6 was the assigned one-on-one direct visual observer assigned to MR1.

Observation on March 14, 2025, of the bathroom located directly outside the locked ED Behavioral Health unit (Nurses Station 4) revealed the following ligatures that pose a hanging threat to a patient with suicidal thoughts or ideas:
A slotted paper towel holder
A nurse call bell cord
A commode with exposed pipe
Handrails along the back and left side of the commode with an open rail
Goose neck faucet
Louvered hot and cold-water handles
Goose neck sink drainpipe
A metal hook on the back of the door that was not break away
Louvered door hand

Interview with EMP1, EMP3 and EMP4 confirmed the above ligatures in the bathroom. EMP1, EMP3 and EMP4 confirmed the above ligatures pose a risk to a person with suicidal thoughts or ideas.

2. Review of MR22 on March 14, 2025, revealed this patient presented to the ED on March 14, 2025, at 0121 following a suicide attempt by crashing of the motor vehicle. The facility completed a Columbia - Suicide Severity Rating Scale and determined MR22 met the criteria for Suicide 1:1/Direct Visual Observation. MR22's Suicide 1:1/Direct Visual Observation began on March 14, 2025, at 0150.

Observation of MR22 on March 14, 2025, at approximately 1330 revealed this patient lying in bed facing down with hands and arms not visible to the 1:1 observer.

Interview with EMP1 and EMP3 confirmed the above findings. EMP1 confirmed it is necessary to see a suicidal patients, hands, arms and face to ensure their safety.

3. Review of MR23 on March 14, 2025, revealed this patient presented to the ED on March 13, 2025, at 1203 following suicidal behaviors and statements. Nursing documentation dated March 13, 2025, indicating MR23's parent reported violent outbursts of biting, hitting, kicking and verbally threatening prior to coming to the ED. Nursing documentation dated March 13, 2025, revealed nursing also reported MR23 had violent outbursts of biting, hitting, kicking and verbally threatening nursing staff on admission to the ED. The ED physician ordered MR23 on Suicide Precautions on one-to-one Direct Visualization. MR23's one-to-one Direct Visualization began at 1207 on March 13, 2025.

Observation of MR23 on March 14, 2025, at approximately 1330 revealed this patient's ED room door closed with the one-to-one Direct Visualization sitter behind this closed door.

Interview with EMP1 and EMP3 confirmed the above findings. EMP1 confirmed it is necessary for one-to-one Direct Visualization sitters to leave the patient room door open to ensure the staff safety.

4. Review of MR1 on March 14, 2025, revealed this patient presented to the Emergency Department (ED) on March 10, 2025, at 0316 due to a reported seizure. The facility completed a Columbia Suicide Severity Rating Scale on MR1 on admission to the ED and determined this patient's risk for suicide was zero.

Review on March 14, 2025, of nursing documentation dated March 10, 2025, at 0335 revealed MR1 was found pacing the hallway; pacing in the room; grabbed the phone in the room and lifted to cord to the neck; stating to the nurse to step out of the room as this patient needed to make an important call. The phone and cord were removed for MR1's room at that time. The ED physician ordered MR1 on Suicide Precautions and one-on-one Direct Visualization on March 10, 2025, at 0343.

There was no documentation in MR1 indicating the facility completed a reassessment of MR1's suicide risk by completing another Columbia Suicide Severity Rating Scale.

Interview with EMP1 confirmed the above finding at the time of the medical record review.

Cross reference
482.13 Patient Rights