HospitalInspections.org

Based on document and interview, the facility failed to ensure care in a safe setting in one instance for 1 of 10 patient (P1) medical records reviewed.


Findings include:

1. Facility policy titled "Patient Rights Policy", revision date: 03/07/2022. Patient Rights: Personal privacy and safety.

2. Facility policy titled "Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting", revision date: 06/08/2022, indicated All adolescent and adult patients who present for care will be screened for suicide ideation and behavior using the Columbia Protocol (Columbia-Suicide Severity Rating Scale (C-SSRS). On page 6, Table 1: Patient Safety Measures and Interventions Based on Screening Responses, Level of Risk: High- Initiate continuous observation (1:1 or in dedicated, secured, ligature resistant area or room), - RN to notify MD and MD to order Mental Health Professional face-to-face consult before leaves the area/unit, - All staff to use communication/de-escalation techniques, - If family/significant other with patient: Nurse to provide "Support Person Education", RN to Re-assess suicidal risk and need for suicidal precautions if there is an observed or stated change in behavior. Registered Nurse observe patient every 15 minutes and utilize the Frequent Observation Flow Sheet.

3. MR indicated P1 was admitted to the facility on 01/10/2025 at 1532 hours for suicidal ideation. MR indicated Notice of "Patient Rights and Responsibilities", was signed by P1 on 01/10/2025 at 1650 hours which included but not limited to patient have the right to an environment that is safe, preserves dignity and contributes to a positive self -image. Columbia-Suicide Severity Rating Scale (C-SSRS) was completed on 01/10/2025 at 1705 hours on P1, indicated patient level of risk is high. MR lacked documentation of completed 15-minute checks and having a sitter at bedside while a patient at the facility. Nurse Note dated 01/11/2025 at 1618 hours written by N1 (Registered Nurse) indicated security guard and ER tech notified nurse that patient in room ED11 was blue. Patient found on the floor, not breathing, cool to the touch, and mottled, no pulse was detected, MD1 notified. P1 was pronounced expired at this time by MD1 (Emergency Room Medical Doctor) on 01/11/2025 at 1625 hours.

4. In interview on 01/23/2025 at approximately 1430 hours, with A1 (Chief Nursing Officer, CNO), confirmed the patient (P1) did not have a sitter at the bedside and 15 minute checks were not completed for P1.

5. In phone interview with N1 (Registered Nurse) on 01/27/2025 at 1030 hours verified that P1 did not have a sitter assigned on 01/11/2025 and should have.

Based on document review and interview, the registered nurse failed to ensure patient assessment and/or vital signs every 4 (four) hours, failed to provide a sitter, and failed to document 15-minute monitoring safety checks for 1 of 10 patient (P1) medical records reviewed.

The cumulative effect of these systematic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, nursing services failed to assess patient and/or vital signs every 4 (four) hours, failed to document 15-minute monitoring safety checks, and failed to provide a sitter at the bedside for 1 of 10 patient (P1) medical records reviewed.

Findings include:
1. Facility policy titled "ED Assessment and Reassessment", revision date 09/24/2024. To provide guidelines for standardizing the frequency of assessing and reassessing of patients that present in the emergency department including patients triaged and in the ED waiting area. Vital signs will be recorded every four hours or at a minimum on admission and at time of discharge and as needed by the patients condition.

2. Facility policy titled "Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting", revision date: 06/08/2022, indicated All adolescent and adult patients who present for care will be screened for suicide ideation and behavior using the Columbia Protocol (Columbia-Suicide Severity Rating Scale (C-SSRS). On page 6, Table 1: Patient Safety Measures and Interventions Based on Screening Responses, Level of Risk: High- Initiate continuous observation (1:1 or in dedicated, secured, ligature resistant area or room), - RN to notify MD and MD to order Mental Health Professional face-to-face consult before leaves the area/unit, - All staff to use communication/de-escalation techniques, - If family/significant other with patient: Nurse to provide "Support Person Education", RN to Re-assess suicidal risk and need for suicidal precautions if there is an observed or stated change in behavior. Registered Nurse observe patient every 15 minutes and utilize the Frequent Observation Flow Sheet.

3. Review of P1 medical record indicated:
a. Patient was admitted to the facility on 01/10/2025 for suicidal ideation. Columbia-Suicide Severity Rating Scale (C-SSRS) was completed on P1 indicated patient to be at a high risk for suicide. MR lacked documentation of completed 15-minute checks and lacked documentation of sitter at bedside while a patient at facility.
b. Initial Medical Screen dated 01/10/2025 at 1620 hours indicated P1 was assessed by the triage nurse vital signs: pulse 84 bpm (beats per minute) (normal range 60-100 bpm), respiratory rate 16 brpm (breaths per minute) (normal range 10-21 brpm), blood pressure 165/97 mmHg (millimeters of mercury) (normal range systolic 95-120 and diastolic 59-81). MR lacked documentation that P1 had vital signs rechecked during his/her time in the Emergency Department or re-assessed by a registered nurse for any changes in medical or psychiatric conditions.

4. Interview with A1 (Chief Nursing Officer) on 01/23/2025 at approximately 1400 hours, confirmed that P1 medical record lacked documentation of patient re-assessment and/or vital signs being repeated, lacked documentation of having a sitter at the bedside, and lacked 15-minute monitoring of the patient safety checks for the duration P1 was in the ED.

5. In phone interview with N1 (Registered Nurse) on 01/27/2025 at 1030 hours verified that P1 did not have a sitter assigned on 01/11/2025 and should have.