HospitalInspections.org

Based on record review and interview, the hospital failed to ensure services were provided free of neglect. This deficient practice was evidenced by failure to provide one to one psychiatric observation and failure to ensure a patient on a Physician's Emergency Certificate (PEC) was free from harmful objects for 1 (#1) of 5 (#2, #3, #4, #5) patients sampled who were all in the Emergency Department under a PEC and on one to one psychiatric observation.
Findings:

Review of the policy and procedure titled, "Patient Rights and Responsibilities", effective date 10/14/2021 read in part, Hospital "commits to respect and promote the rights of all patients." Further review revealed, "Policy Implementation - 2. Safe Environment - reading in part, every patient has the right to receive care in a safe setting and the right to personal safety (free from mental, physical, sexual and verbal abuse, or humiliation, neglect and exploitation)".

Review of the policy and procedure titled, "Care of the Psychiatric Patients in the Emergency Department of Louisiana Facilities", revealed in part, "Purpose: This policy provides guidance for the patient presenting with a psychiatric complaint in the Emergency Department, patients documented on a Psychiatric Hold, patients assessed at risk for suicide, homicide, and/or patients gravely disabled and patients requiring psychiatric observation. Definitions including in part: PEC - Physician Emergency Certificate One to One Psychiatric Observation - A staff member will maintain constant visual contact with the assigned patient at all times on a ratio of one to one and be capable of immediately intervening if needed by the patient".

Review of the policy and procedure titled, "Identifying and Reporting Suspected Adult/Elder Abuse, Neglect, Exploitation and/or Extortion" revealed in part, "H. Neglect: The failure, by a caregiver responsible for an adult's care or by other parties, to provide the proper or necessary support or medical, surgical, or any other care necessary for his well-being." The policy goes on to define a caregiver as "I. Any person or persons, either temporarily or permanently, responsible for the care of an aged personnel or a physically or mentally disabled adult".

Review of Patient #1's medical record revealed he was a 39 year old male admitted on 04/18/2022 at 11:54 a.m. with the chief complaint of drug overdose with intent to commit suicide. Further review revealed Patient #1 was admitted under a PEC with physician's order for one to one psychiatric observation.
Review of Patient #1's medical record revealed S4Sitter was the assigned staff member to perform the one to one psychiatric observation for Patient #1.

In interview on 05/10/22 at 9:17 a.m., S4Sitter indicated that she gave Patient #1 an ink pen to write with. S4Sitter further indicated she shouldn't have given him the ink pen because he used it to hurt himself. S4Sitter stated that she had another patient coming in and for a little bit was thinking about that. S4Sitter stated that when she went to sit down she was charting on the laptop, looked up and saw "blood shooting up in the air like a fountain". S4Sitter then called for help.

Review of Patient #1's medical record revealed S5RegisteredNurse (S5RN) was assigned to Patient #1.

In interview on 05/10/22 at 11:30 a.m., S5RN indicated he was assigned to Patient #1 who was in the Emergency Department (ED) under a PEC. S5RN further indicated he went into Patient #1's room to administer eye drops and observed Patient #1 with an ink pen and paper and at the time he did not think Patient #1 was incapable of having an ink pen so he took no action. S5RN stated about 4 minutes later he was called to Patient #1's room by S4Sitter where he said he observed blood on the floor. S5RN indicated he removed the sheets from Patient #1's upper torso and found the arteriovenous (AV) fistula of the left upper arm bleeding. S5RN called for additional help related to Patient #1's aggressive behavior including aiming the stream of blood towards S5RN and to provide pressure to the site of the injury.

Review of Patient #1's medical record revealed on 04/19/2022 physician's orders at 5:55 a.m. for an inpatient consult to vascular surgery and at 7:39 a.m., for a laceration repair with the use of 3 stitches. Further review of Patient #1's medical record revealed a physician's order on 04/19/2022 at 8:24 a.m. for an inpatient consult to psychiatry related to the suicide attempt.

Review of Patient #1's medical record revealed he was discharged on 04/20/22 at 8:44 p.m. to an inpatient psychiatric hospital.

In interview on 05/09/2022 at 1:40 p.m., 2DirectorofQualityImprovement(S2DQI) indicated the team concluded the injury was caused by the ink pen, because after the patient was moved to another room and during clean up, the staff found a pen on the ground in Patient #1's room.

In interview on 05/10/2022 at 11:18 a.m., S3AssistantVicePresidentoftheEmergencyDepartment (S3AVPED) indicated S4Sitter should not have given Patient #1 an ink pen.