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Based on observation, review of facility security camera footage, staff interviews, record reviews, review of facility policy, and National Action Alliance for Suicide Prevention guidelines, the facility failed to ensure the emergency department unit (Section G) used to monitor the safety of patients with psychiatric concerns, including suicidal and homicidal ideations, was free hazards of firearms. (A-0144)

Based on observation, review of facility security camera footage, staff interviews, record reviews, review of facility policy, and National Action Alliance for Suicide Prevention guidelines, the facility failed to ensure the emergency department unit (Section G) used to monitor the safety of patients with psychiatric concerns, including suicidal and homicidal ideations, was free hazards of firearms. This affected four (Patients #6, #7, #8, and #9) of four patients placed on Section G who were in a psychiatric emergency. The hospital census was 297.

Findings include:

Review of the medical record for Patient #6 revealed he arrived at the emergency department on 08/28/25 at 8:26 A.M. via ambulance with auditory hallucinations. Patient #6 had a past medical history of bipolar disorder. Review of the triage and physician notes revealed Patient #6 was denying suicidal and homicidal ideations. Review of the telepsychiatry note dated 08/28/25 at 9:48 A.M. revealed the patient was hallucinating he was talking to God. Patient #6 reported he went on a long walk and ended up a town over. He got scared because he was seeing signs and hearing God, so he called the police. Patient #6 was diagnosed with severe manic bipolar disorder with psychotic behavior and recommended hospital admission once medically cleared. Patient #6 was placed in Section G Bed 26 of the emergency department. Patient #6 then had laboratory (lab) work drawn, an electrocardiogram, and a urine test. Patient #6's lab results and test results were all within normal limits. Review of the nursing note dated 08/28/25 at 11:26 A.M. revealed Patient #6 was transported to the trauma bay with the registered nurse (RN) doing chest compressions. A note at 11:32 A.M. documented the patient had a projectile through the head, all the way through, and was having pulsatile bleeding on the right. Patient #6 pronounced dead at 1:26 P.M. The discharge summary documents the patient was able to get ahold of a gun of an officer and shot himself in the head.

Review of the medical record for Patient #7 revealed he came to the emergency department on 08/28/25 with suicidal ideations. The patient was placed in the secure Section G in the emergency department.

Review of the medical record for Patient #8 revealed she came to the emergency department on 08/28/25 with suicidal ideations. The patient was placed in the secure Section G in the emergency department.

Review of the medical record for Patient #9 revealed arrival in the emergency department on 08/28/25 with homicidal ideations. The patient was placed in the secure Section G in the emergency department.

Observations during a tour of the emergency department on 09/02/25 at 10:33 A.M. revealed Section G to be a small locked area for psychiatric patients with five cots being separated by curtains. The curtains had a quick release hook at the ceiling. The bathroom inside the room had a brown paper bag for garbage. There was a telephone available for patient use with a short cord. At the front of the room was a nurse's station with staff present. The door was locked from the inside and outside and required a badge to enter or exit. On the outside of the door in the main emergency room hallway had a note posted elopement risk.

Interview on 09/02/25 at 10:35 A.M. with Emergency Room Nurse Manager Staff H confirmed an incident with Patient #6 happened in Section G.

Interview on 09/02/25 at 2:33 P.M. with Staff B revealed a shooting happened on the unit. The police officer immediately called for back up to secure his weapon. The nurse manager heard the gun shot and immediately called for assistance. Patient #6 was transported immediately to the trauma bay.

Interview on 09/03/25 at 8:10 A.M. with Director of System Protective Services Staff L reported on 08/28/25 his officer entered the locked Section G area of the emergency department to complete his rounds. He stopped at the nurse's desk to speak to staff and check emails on his phone. The officer's arms were raised on the counter exposing his gun in its holster on his right hip. The officer had a level three holster on his right hip holding his weapon. This holster requires the strap be removed, the gun rocked at a certain angle, and a button be pressed before it will release the gun from the holster. Patient #6 came up behind the officer, removed the gun and immediately shot himself in the head. Staff L reported there was no struggle to remove the gun and by the time the officer turned around Patient #6 was already falling to the ground.

Interview on 09/03/25 at 8:30 A.M. Staff A, Staff B, and Staff C stated the police are not to bring their weapons onto the psychiatric units in the hospital, but Section G was not a dedicated psychiatric area. They confirmed the area was modified for patient safety and used for patients when they are assessed at risk for self harm, harm to others, or elopement. They do place medical patients in that room.

Interview on 09/03/25 at 8:44 A.M. with RN Staff M confirmed she was caring for Patient #6 during his stay in the emergency department. She reported Patient #6 was in Bed 26. He only got up once from his bed and attempted to open the door to the room but went back to bed when he realized it was locked. Staff M reported the officer came into the room to do rounds, as they frequently do, and was standing at the nurse's desk with his back to the patients in the room talking to the technicians. She reported she had just sat down at the desk when she saw Patient #6 get up from the bed, walk behind the officer, and reach for the officer's gun. Staff M reported she screamed "Your gun" but by the time she screamed Patient #6 had shot himself in the head and was on the ground. Staff M reported she immediately ensured the other three patients in the room were safe.

Review of the security camera footage on 09/03/25 at 9:40 A.M. of the 08/28/25 incident involving Patient #6 revealed the officer came onto the Section G unit and stopped at the nursing desk speaking to staff sitting at the desk. He placed his arms on the desk, with his back to the patient beds, and began scrolling on his phone while talking to the staff member. His gun belt was exposed. The officer stood in this position for greater than two minutes with his arms resting on the counter scrolling on his phone. Patient #6 jumped up from the bed, approaching the officer from behind on the left side, went to the officer's right side, grabbed the gun out of the holster, and immediately placed the gun to his head and pulled the trigger. Patient #6 fell to the ground, the officer turned around and immediately grabbed his weapon, which had flown five feet from Patient #6. The whole incident took less than five seconds before Patient #6 was on the ground.

Additional interview on 09/03/25 at 12:44 P.M. with Staff A, Staff B, and Staff C revealed while the locked unit Section G in the emergency department was not a designated psychiatric area it is a quiet locked area they prefer to have psychiatric patients go to. They reported the police round hourly, but they are not given report on the patient's in this unit to alert them if any of the patients are psychiatric patients with suicidal or homicidal ideations, or just medical patients. All staff members confirmed at the time of the incident on 08/28/25 all patients in the room were psychiatric patients and two had suicidal ideations. They also confirmed the only way in and out of Section G was with a badge. Staff C reported the policy for weapons on the psychiatric unit does not apply to this emergency department room as it is not a designated psychiatric patient only area. Staff also reported the police do not have a specific rounding policy and the expectation is if they are not responding to a call they are to be patrolling their environment.

Review of National Action Alliance for Suicide Prevention document titled "Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe" (2018) https://theactionalliance.org/sites/default/files/actionalliancerecommendedstandardcarefinal.pdf revealed lethal means reduction is a crucial part of safety planning. It involves identifying means of self-harm that are available to the individual, especially ones that may have been considered, such as use of a weapon or overdosing on medications, and reducing access by taking specific steps such as self-storage. Reducing access to lethal means has repeatedly been shown effective community-wide prevention and has been cited as a crucial factor in success of the prevention efforts. Emergency departments identify suicide risk among patients who have harmed/injured themselves or have mental illness or substance use disorder. Emergency rooms must provide a space for the patients that is safe, monitored, and clear of items the patient could use to harm themselves or others.

Review of the facility policy titled "Firearms Policy," approved 05/20/20, revealed all department issued firearms will be given to all police officers. Officers firearm is to always remain in their holster except when cleaning the gun or on the psychiatric unit.