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Based on medical record review, staff interview and review of policy and procedures, the facility failed to ensure 1 (Patient 5) of 5 sampled patients with documented suicidal ideation's received care in a safe environment while in the Emergency Department. The failure to order Suicide Precautions 1:1 for patients identified as high risk for self harm as per the facility policy. This failed practice has the potential to cause harm or negative outcomes to all patients who present to the hospital for care. The facility inpatient census at the time of entrance was 157.

Findings are:

A. Review of the policy titled, Care of the Behavioral Health Patient in the Emergency Department (effective 6/2024) revealed:
-Behavior Health patients will be seen and assessed by an RN (Registered Nurse).
1) All patients presenting with suicidal ideation will have 1:1 observation and high risk visual patient safety checks implemented until suicide risk assessment is made.
2) The Columbia-Suicide Severity Rating Scale (C-SSRS a standardized assessment tool that supports suicide risk assessment through a series of simple, plain-language question that anyone can ask,with scoring results of high, moderate, and low risk) will be utilized on patients >6 years of age along with critical thinking skills, clinical observation, nursing assessments, and presenting symptoms in determining the level of suicide risk.
3) Suicide precautions will be implemented based on the suicide risk assessment level.
a) If nursing judgement indicates the patient should be monitored at a higher level than the risk assessment specifies, if appropriate to implement the higher level precautions; however, it is not appropriate to implement precautions at a lower level than the suicide risk assessment specifies.
b)Consider implementing high risk interventions for patients who are in emergency protective custody (EPC) or on a court hold as well as those patients who are potentially violent or a flight risk.
-LOW RISK PRECAUTIONS;
a) implement every 30 minute visual safety checks and document on Suicide Precaution Flow Record.
b) Modify the environment to mitigate ligature risks if not in a ligature-resistant environment.
c) Complete "Environmental Safety Checklist in the Emergency Department."
d) Educate patient on suicide precautions, interventions, and restrictions.
e) Notify Security or other designee to complete "Initial Emergency Department Safety Clearance."
f) Assure meal trays contain no glass, silverware or other sharp objects.
-MODERATE RISK PRECAUTIONS;
a) Implement every 15-minute visual safety checks and document on the "Suicide Precaution Flow Record."
-HIGH RISK PRECAUTIONS;
a) Implement all elements listed as Low and Moderate Risk Precautions AND the following:
1) Implement 1:1 observation and document every 15-minute visual safety checks on the "Suicide Precaution Flow Record."
2) In the event a patient is displaying actively violent behavior, implementation of 1:1 observation should be modified to ensure safety of staff.
a) It may be appropriate for staff to observe the patient at a distance greater than arm's length to maintain safety.
b)Direct line of sight should be considered.
4) The Emergency Department (ED) charge nurse and medical provider will be notified of the risk level on all Behavioral Health patients.
5) The C-SSRS will be re-evaluated and documented minimally every eight hours while awake or more frequently as clinically indicated.
a) if reassessment of the C-SSRS indicates the patient is no longer high-risk, the nurse may collaborate with the provider to determine if 1:1 observation can be discontinued.

B. Review of the medical record for Patient 5 (Pt 5) identified that the patient arrived to the Emergency Department on 5/17/25 at 9:48 PM for a mental-health evaluation for severe depression and feelings of suicide. The patient had a history of major depression disorder, bipolar, and a history of previous suicide attempts (last attempt in 2023). The patient stated that they have stopped their mental health medication in the last year. Patient 5 endorses profound self worthlessness and apathy for their own mental health. The patient is tearful, flat affect with no specific plan, but has thought of different ways of suicide. The patient was placed in a room in the Emergency Department.
Review of the Nurse Practitioners NP-A Emergency Room Provider Note dated 5/17/25 at 11:08 PM, identified Pt 5 revealed, "that (gender) has has not been taking care of their mental or physical health recently. The patient agreed to voluntarily stay for inpatient treatment. At 11:46 PM the patient was wanting to leave, I did not feel safe discharging the patient home. The NP-A discussed leaving Against Medical Advice and then Pt 5 agreed to stay. The patient admitted at this time that (gender) is at the lowest she has ever been and stated that didn't want to be alive but didn't want to die either. If patient does attempt to leave, I would recommend a board of mental health hold at this time. Pt 5 does understand that would be a recommendation and is agreeable to stay."

Review of the Columbia Suicide Severity Rating Scale (CSSR-S a standardized assessment tool that supports suicide risk assessment through a series of simple, plain-language question that anyone can ask,with scoring results of high, moderate, and low risk) assessment of the patient revealed:
-5/17/25 10:22 PM identified result at moderate risk
-5/18/25 8:05 AM a 2 question reassessment completed (9 1/2 hours after 1st assessment)
-5/18/25 1:00 PM identified result at moderate risk

The medical record lacked an order for suicide precautions upon admission to the Emergency Department.

A review of the Psychiatric telehealth Nurse Practitioner Assessment Note that provided mental health assistance revealed:
-Psychiatric Nurse Practitioner B (NP-B) had a provider to provider consultation 5/18/25 at 12:54 AM; NP-B reviewed the medical record, discussed Pt 5's case with the ED provider. The Pt endorsed that (gender) had thought about asphyxiation, driving accident, or death by cop. The chart noted previous suicide attempt in 2023 and also has stopped taking psychiatric medications this last year. "Based on presentation noted the patient demonstrates to be a significant risk to self and meet criteria for inpatient general acute care psychiatric admission with a provisional diagnosis of major depressive disorder, recurrent severe without psychotic features.

-Psychiatric Nurse Practitioner C (NP-C) Assessment Note completed after the patient and NP-C had a telehealth face to face assessment on 5/18/25 at 11:53 AM; NP-C identified under Assessment and Plan- Bipolar Disorder, current episode depressed, severe; GAD (Generalized Anxiety Disorder); PTSD (Post Traumatic Stress Disorder; Insomnia; R/O (rule out) Sleep disorder. TREATMENT PLAN: 1) Disposition: Patient does meet criteria for inpatient psychiatric hospitalization. Please find a bed if medically stable. Currently recommend a general acute psychiatric bed. 2) Orders: admit to inpatient general acute psychiatric unit with precautions. Will obtain TSH, T3 and T4 labs. (thyroid lab tests). Start Abilify (a medication used for mental health mood stabilization) 10 mg (milligrams) PO (by mouth) Q HS (every bedtime) for mood stabilization. Hydroxyzine (medication used for anxiety) 25 mg PO Q 6 H PRN (by mouth every 6 hour as needed) for breakthrough anxiety. Trazodone (medication to treat insomnia and depression) 50 mg PO Q HS PRN for sleep promotion. Melatonin (medication to promote sleep) 3 mg PO Q HS PRN for circadian rhythym (natural sleep cycle). Prilosec (med to treat high acid level) 40 mg PO Q day for GERD (gastroesophageal reflux disease). 3) The patient did agree with plan mentioned above. 4) Informed consent was obtained verbally. The risks, benefits, side effects, alternatives and patient questions/concerns were address and discussed in detail.

-Psychiatric Nurse Practitioner D (NP-D) Assessment Note completed after the patient and NP-D had a telehealth face to face assessment on 5/19/25 at 9:43 AM; NP-D revealed, patient is not in imminent risk and is able to contract for safety. (Pt 5) did acknowledge that is in need of outpatient psych for medication management and therapy. Patient is not willing to sign inpatient psych voluntarily at this time, and is amenable to discharge with an outpatient appointment scheduled to ensure is able to get medications and therapy. (Pt 5) has a good relationship with mother in law and the mother in law has agreed to picking up the patient and following the patients safety plan. The patient denies SI (suicide ideations), HI (homicidal ideations) and audio/visual hallucinations. Patient is able to contract for safety but agreed to return to the ED if unable to keep self safe. C-SSRS completed and moderate risk; Action Plan to Address Risk Level: provide with community and/or crisis resources, provide psychoeducation regarding suicide warning signs, pending PICC (psychologically informed consultation and training) appointment scheduled 5/23/25.

C. A tour of the Emergency Department on 6/17/25 at 10:46 AM with RN-U of room 9 where the patient was initally placed after being triaged, was a standard ED room, accommodations were made per RN-U including removing the long call light cord, the unnecessary wall articles (i.e.. oxygen flow meter and tubing, suction meter and tubing, monitor cables, thermometer and otoscope units) as we can to make it safe. When inquired if the computer cables were all removed routinely in this type of case of mental health patient with SI, RN-U stated, "We are not able to take the cables for the computers and monitors all out, we push them back." When inquired if the patients were then on a 1:1 at all times? RN-U "no, not a 1:1, we try and keep them in the line of sight, but acknowledges that there is not a staff scheduled at the work area at all times, so unable to say that are always in line of sight.

D. Interviews conducted with staff caring for Patient 5 during the 5/17/25-5/19/25 included:
-Interview with NA-T (nurse aide-T) on 6/16/25 at 9:33 AM revealed, "yes, I do remember (Pt 5), I got the patient a toothbrush, and toothpaste, and escorted the patient to the shower."

-Interview with RN-S (registered nurse-S) on 6/16/25 at 10:17 AM revealed, "Yes I remember (Pt 5). The patient stated, "that they wanted to leave. I talked with the patient and explained that the NP (nurse practitioner) that examined the patient previously, gave orders that if the patient tried to leave AMA (against medical advise) to contact the county attorney for a temporary board of mental health (a procedure that gives the ability for the medical staff to evaluate if the patient is safe to be discharged. It is used when the patients are suffering suicidal thoughts and possible harm). I arranged for this patient to speak to the Psychiatric Nurse Practitioner via telehealth health and offered to assist with calling family or other support people for the patient. Following visiting with the Psychiatric Nurse Practitioner (NP-C), the patient was willing to stay and get admitted for an inpatient treatment. A call was placed to the transfer center and awaiting an available bed. The hospital did not have an available bed for the level of psychiatric care the patient needed."

-Interview with Psychiatric Nurse Practitioner NP-C on 6/16/25 at 10:33 AM revealed, "Yes, I remember the patient (Pt 5). Came in for suicide thoughts, said to staff no plan, but talked about asphyxiation, a driving accident, and death by cop. Had previous suicide attempts with the last one 2 years ago. A lot of red flags and did not feel would be safe discharge at the time we talked. Stated, no real support system, agreed to restart medication and to voluntarily wait for an inpatient psychiatric bed available. If (gender) would not of agreed to voluntary inpatient treatment, would have recommended a board of mental health hold."

-Interview with RN-T on 6/16/25 at 11:08 AM revealed, "Yes, I vaguely remember (Patient 5), I did triage when came in, complained of depression, suicidal ideations, not been on (gender) meds for a few months, tearful, and wanted to get back on meds. I also cared for (gender) in the psychiatric ED room while waiting on an inpatient bed on 5/18/25 from 7 PM-7 AM. Was louder in that area, wanted a shower, wanted to talk to the psych provider, wanted a patient rights information, asked about leaving AMA. I got the patient rights information from the registration people and gave it to the patient, I told the NA, as soon as possible to take for a shower, and told the patient would reach out to the psychiatric provider, but after took medication and got the patient rights book information, went to room and rested. Was sleeping yet when I left my shift on 5/19/25."

-Interview with NP-A ED provider on 6/16/25 at 11:53 AM revealed, "Yes, I remember this patient (Pt 5) well. Came in for mental health evaluation, and was in mental health crisis and suicidal thoughts, including ways to kill themselves. Had attempted several times in the past and the last was just 2 years ago. Talked about factors going on in life, 2 small children, divorcing, self employed in health care, depression, weight gain, financial problems and a lot of things going on. Talked with the patient for a long time. Was agreeable to staying for psychiatric evaluation and inpatient psychiatric care. Also did inform patient that while here voluntarily, but if decided to leave AMA prior to treatment for suicidal thoughts, depression, that would need to file a Board of Mental Health hold, due to I just do not feel that at this time the patient would be safe for discharge."

-Interview with Psychiatric Nurse Practitioner NP-D on 6/17/25 at 9:33 AM revealed, "Yes, I remember the patient (Pt 5). Had come in voluntarily, agreed to inpatient psychiatric treatment initially, but no beds available in the hospital psychiatric units and offered to transfer to another in town hospital (Hospital B) but patient refused transfer, offered to transfer to a hospital (Hospital C) in another state 17 miles away but patient declined after the facility was unable to accept the patients insurance. The patient was "now feeling better, escalating that they wanted to leave". I did an assessment and spent quite a bit of time with the patient. I told the patient that there had to be a safety plan in place with someone that could come and get the patient and provide support for the patient once the patient went home. The patient was agreeable to this so a safety plan was implemented, arranged a PICC therapist appointment, contacted the pt's in law that was supportive of patient and the patient and the family agreed to the plan. With that the family came and signed patient out, all information was printed for the patient with the safety plan, the appointment information, the medications and felt the patient was then safe to discharge."

- Interview with the RN ED Manager (RN-U) on 6/17/25 at 10:17 AM revealed, "we have a few rooms that we use for the mental health patients in the main ED. We initiate precautions for the room, removing the long call light cord, the unnecessary wall articles (i.e. oxygen flow meter and tubing, suction meter and tubing, monitor cables, thermometer and otoscope units) as we can to make it safe. If not seen by a provider should be a 1:1." When asked how would all staff know who would be a 1:1, the RN-U stated, "They use the patient tracking board." When asked if the patient had a 1:1 while in the main ED, RN-U stated, "No, I did not see 1:1 charted."

- Interview with the Quality Director on 6/17/25 at 11:15 AM, verified that the policy titled Care of the Behavioral Health Patient in the Emergency Department indicated a patient with SI, would be on a 1:1 until a provider saw the patient and that the C-SSRS were to be done a minimum of every 8 hours. The Quality Director verified that Pt. 5's medical record for this visit lacked the 1:1 and the every 8 hour C-SSRS as per the policy.