Based on interview, and record review, the facility failed to ensure the following:
1. The hospital staff appropriately monitored Patient 1, conducted a contraband search of Patient 1's personal belongings when Patient 1 presented to the Emergency Department (ED) with suicidal ideations (thoughts of killing oneself). This failure resulted in Patient 1 attempting suicide with her personal belt.
2. Registered Nurse's (RN 3) triage suicide risk screening for Patient 1 was accurate. This failure resulted in Patient 1's triage suicide risk assessment inaccurate.
3. There was documented evidence Patient 1 received a Social Services consult as ordered by the physician. This failure resulted in no documented evidence Patient 1 received a Social Services consult.
4. The Registered Nurse (RN 4) conducted a complete triage assessment for Patient 2. This failure resulted in Patient 2 not being accurately assessed.
5. Vital signs were obtained per policy and procedure for Patient 2. This failure resulted in Patient 2's vital signs not being obtained per policy and procedure.
6. Verbal orders for a medication order was documented for Patient 2. This failure resulted in no documented evidence of a physician medication order.
Findings:
1. During a review of Patient 1's clinical record, indicated Patient 1 presented on August 11, 2017 with a chief complaint (the patient's reported reason for seeking medical care) of suicidal ideations (thoughts of killing oneself).
During a review of the "Triage Report," dated August 11, 2017, indicated, "Pt (Patient) BIBA (brought in by ambulance) with SI (suicidal ideations). Pt was found in middle of highway waiting to get hit by car with intent to die. Pt (Patient) HX (history) SI, depression, bipolar (a mental illness that causes dramatic shifts in a person's mood, energy and ability to think clearly), Schizo (Schizophrenia- a severe mental disorder that affects how a person thinks, feels, and behaves), Meth (Methamphetamine an illegal drug that is abused for its euphoric high that provides increased energy).
During an interview with a Registered Nurse 1 (RN 1) on November 17, 2017 at 8:35 AM, RN 1 stated she was the assigned night shift nurse for Patient 1 on August 11, 2017. RN 1 stated Patient 1 verbalized she had suicidal ideations and attempted to kill herself in the past. RN 1 stated she attempted to conduct a contraband search on Patient 1, however Patient 1 refused and she did not document her attempt. RN 1 stated she visualized the metal belt on Patient 1 but did not attempt to conduct another contraband search.
A review of the "Daily Focus Assessment Report," completed by RN 1 dated August 11, 2017 at 11:34 PM, indicated the following:
History of suicide Attempts-Yes
Ideations-Suicidal thoughts now
Patient at Risk-Yes
A review of Patient 1's "Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment," dated August 12, 2017 at 8:47 AM, indicated, "Based upon the above information, there is probable cause to believe that said person is, as a result of mental disorder: A danger to herself."
During an interview with Registered Nurse 2 (RN 2) on November 16, 2017 at 12:16 PM, she stated she was the assigned day shift nurse for Patient 1 on August 12, 2017 [the day of the incident]. RN 2 stated the nursing staff was responsible to conduct a contraband search for patients who present to the ED with suicidal ideations. RN 2 stated a contraband search was not conducted for Patient 1 and her personal belongings were not removed and the facility's policy and procedure was not followed. RN 2 stated Patient 1's clothes should have been removed and Patient 1 should have been placed in a hospital gown or paper scrubs but she did not why it was not done. RN 2 stated CCRT (Community Crisis Response Team-a crisis response program for those experiencing a psychiatric emergency utilizing specially trained mobile crisis response teams to provide crisis interventions, and assessments) evaluated Patient 1 and Patient 1 was deemed to be a danger to herself but the information was not communicated with her.
RN 2 stated on August 12, 2017 at 9:40 AM, Patient 1 requested to use the restroom, Patient 1 ambulated to the restroom by herself. RN 1 stated she was timing Patient 1 and after some time went by [approximately 10 minutes], she went to check on Patient 1. RN 1 stated she knocked on the restroom door and called out Patient 1's name but there was no answer. RN 1 attempted to open the restroom door but it was locked. RN 1 retrieved the restroom key and unlocked the door. RN 1 stated she opened the door and Patient 1 was found lying on the restroom floor tied to the side rail with her belt around her neck. RN 1 stated "she [Patient 1] was blue I thought she was dead." RN 1 stated she palpated for a pulse. RN 1 stated she released the belt around Patient 1's neck and Patient 1 gasped for air and Patient 1 was angry she was still alive. RN 1 stated Patient 1 was assisted on the gurney and was transported bed 3. RN 1 stated once Patient 1 was in bed 3 she was observed to have jerking movements, the physician was notified of the incident and Patient 1 was administered Ativan (a medication used to treat seizures).
A review of Patient 1's "Physician Emergency Department Record," indicated "I was called by the nursing staff because the patient [Patient 1] had hung herself in the bathroom and turned blue. Shortly after the patient was removed from the bathroom and placed in the room 3, she [Patient 1] began to have a seizure, she was administered Ativan 1 MG (milligrams). She will now have one-on-one supervision/monitoring ..."
During an interview with the Emergency Department Director (EDD) on November 16, 2017 at 10:27 AM, he stated a contraband check was not conducted on Patient 1, she was not given a hospital gown, and she remained in her street clothes. The EDD stated the process was not followed. The EDD stated Patient 1 was deemed a danger to herself and was not monitored by the ED staff. The EDD stated the expectation was for Patient 1 to have a safety attendant.
The facility's policy and procedure titled, "Emergency Department 5150 Procedures," dated November 2010, indicated, "...All psychiatric patients who are admitted to a nursing unit must submit to a contraband search by Public Safety and/or hospital staff.
The facility's policy and procedure titled, "Emergency Department Scope of Service," dated December 2015, indicated, "...H. Psychiatric patients ...including suicidal patients, shall receive careful considerations of both physical and psychosocial needs...1. A definite follow-up plan to ensure safety of the patient ...shall be arranged as needed."
3. During a review of Patient 1's clinical record, the facesheet (demographics) indicated Patient 1 presented on August 11, 2017 with a chief complaint (the patient's reported reason for seeking medical care) of suicidal ideations (thoughts of killing oneself).
During a review of the "Triage Report," dated August 11, 2017, indicated, "Pt (Patient) BIBA (brought in by ambulance) with SI (suicidal ideations). Pt was found in middle of highway waiting to get hit by car with intent to die. Pt (Patient) HX (history) SI, depression, bipolar (a mental illness that causes dramatic shifts in a person's mood, energy and ability to think clearly), Schizo (Schizophrenia- a severe mental disorder that affects how a person thinks, feels, and behaves), Meth (Methamphetamine an illegal drug that is abused for its euphoric high that provides increased energy). Suicide Risk: Screened-No Risk."
During an interview with Registered Nurse 3 (RN 3) on November 17, 2017 at 8:20 AM, she stated she completed the Triage Report for Patient 1. RN 3 stated Patient 1 was a suicide risk. RN 3 stated the "Suicide Risk," question was answered incorrectly, it was an error.
During an interview with the Emergency Department Director (EDD) on November 16, 2017 at 10:27 AM, he stated Patient 1's triage suicide screening question was incorrect. The EDD stated RN 3 documented incorrectly.
4. During a review of Patient 1's clinical record, the facesheet (demographics) indicated Patient 1 presented on August 11, 2017 with a chief complaint (the patient's reported reason for seeking medical care) of suicidal ideations (thoughts of killing oneself).
A review of the physician orders dated August 12, 2017, indicated "Consult Social Services."
During an interview with Social Services (SS) on November 17, 2017 at 9:23 AM, he reviewed the clinical record and was unable to find documented evidence of a social service consult. The SS stated he evaluated Patient 1 but did not have time to document his consult.
During an interview with the Interim Director Case Manager (IDCM) on November 17, 2017 at 9:25 AM, she stated her expectation was for her staff to document the Social Services assessment and plan.
The facility's policy and procedure titled, "It is the policy of (name of facility) to make social services available to patients, families and hospital personnel."
5. During a review of Patient 2's clinical record, indicated Patient 2 presented to the Emergency Department(ED) on August 27, 2017 with a chief complaint of shortness of breath.
A review of Patient 2's "Triage Report," dated August 27, 2017 at 6:19 PM, indicated, Vital Signs as follow:
BP (Blood Pressure) 205/130 (normal ranges are between 120/80 and 140/90)
Temperature 97.8
Pulse 111 (normal ranges are between 60-100)
Respirations 24
SpO2 84 % (amount of oxygen in the blood-normal ranges are between 95 to 100)
Acuity 3 (triage algorithm that categorizes emergency department patients by evaluating both patient acuity and resource needs- acuity 3=urgent)
During an interview with Registered Nurse 4 (RN 4) on November 15, 2017 at 4:17 PM, she stated she was the triage nurse who completed Patient 2's triage assessment. RN 4 stated Patient 2's vital signs were abnormal, Patient 2's BP was high 205/130, pulse of 111 was high, and his oxygen saturation level was low at 84%. RN 4 stated she did not listen to Patient 2's lung sounds, therefore Patient 2 did not receive a complete triage assessment and the process was not followed. RN 2 stated the acuity of 3 she assigned to Patient 2 was inappropriate. RN 2 stated Patient 2 should have been assigned a more appropriate acuity of 2 (Emergent-conditions that require immediate evaluation and treatment to prevent further complications or deterioration).
During an interview with the Emergency Department Director (EDD) on November 16, 2017 at 10:27 AM, he stated Patient 2's assigned triage acuity level of 3 was inappropriate. The EDD stated Patient 2's low oxygen level of 84% and high blood pressure of 205/130 should have been an indication to assign a higher acuity. The EDD stated an acuity level of 1 or 2 would have been appropriate.
The facility's policy and procedure titled, "Emergency Department Assessment," dated May 2009, indicated, "...Patients shall receive a physical assessment ..."
6. During a review of Patient 2's clinical record, indicated Patient 2 presented to the Emergency Department(ED) on August 27, 2017 with a chief complaint of shortness of breath.
A review of Patient 2's "Triage Report," dated August 27, 2017 at 6:19 PM, indicated, Vital Signs as follow:
BP (Blood Pressure) 205/130 (normal ranges are between 120/80 and 140/90)
Temperature 97.8
Pulse 111 (normal ranges are between 60-100)
Respirations 24
SpO2 84 % (amount of oxygen in the blood-normal ranges are between 95 to 100)
A review of Patient 2's "Vital Sign Report," dated August 27, 2017, indicated the following:
At 6:24 PM (Triage vital signs)
BP 205/130
02 sats 84%
Pulse 111
Resp (Respirations) 24
Temp (Temperature) 97.8
No documentation of vital signs between 6:24 PM and 8:28 PM.
At 8:28 PM
BP 123/83
02 sats 91%
Pulse 98
Resp 20
During an interview with Registered Nurse 6 (RN 6) on November 17, 2017 at 8:40 AM, she stated she was the assigned nurse for Patient 2 on August 27, 2017. RN 6 reviewed the clinical record and was unable to find documentation of Patient 2's vital signs from the time of triage at 8:24 PM to 8:28 PM (for a total of 1.5 hours).
A review of Patient 2's "Order Report," dated August 27, 2017, indicated, "Labetalol (a medication to treat high blood pressure) 20 MG (milligrams) intravenous (in the vein)."
RN 6 stated Patient 2's BP and pulse maintained high at 220's/130's and pulse 110's but she did not document. RN 6 stated the physician was notified of Patient 2's high blood pressure and high pulse and new orders were received. RN 6 stated she administered Labetalol 20 MG IV (intravenous-in the vein) as ordered. RN 6 stated she obtained vital signs prior to administering Labetalol to Patient 2 but did not document.
During an interview with the Emergency Department Director (EDD) on November 16, 2017, at 10:27 AM, he stated Patient 2's vital signs should have been obtained more frequently. The EDD stated the expectation was for Patient 2 to have vital signs taken every 30 minutes since Patient 2's vital signs were abnormal in triage. The EDD stated the blood pressure was not taken prior to the administration of Labetalol and the expectation was for RN 6 to obtain vital signs prior to administering medications that treat blood pressure.
The facility's policy and procedure titled, "Emergency Department Assessment," dated May 2009, indicated, "...Patient's shall receive a physical assessment including vital signs...2. All patients shall have vital signs taken to include: blood pressure, heart rate, respiratory rate, temperature...4. Frequency of assessment shall be dictated by the patient's condition and shall be adequately monitored to assure patient safety. a. Minimum standard for reassessment is every 2 hours."
7. During a review of Patient 2's clinical record, indicated Patient 2 presented to the Emergency Department(ED) on August 27, 2017 with a chief complaint of shortness of breath.
A review of the "Daily Focus Assessment Report," dated August 27, 2017 at 7:30 PM, indicated "...Lasix administered."
During an interview with Registered Nurse 6 (RN 6) on November 17, 2017 at 8:40 AM, she stated she was the assigned nurse for Patient 2 and documented on August 27, 2017. RN 6 reviewed the clinical record and was unable to find documentation of a physician order for Lasix (a medication that treats fluid buildup). RN 6 stated she received a verbal order for Lasix 100 MG (milligrams) IV (Intravenous) and administered the medication as ordered. RN 6 stated she did not document the verbal medication order or entered it into the system. RN 6 stated since she did not enter the order into the system therefore she was not able to document the medication administration on the Medication Administration Record (MAR).
During an interview with the Director of Pharmacy (DOP) on November 16, 2017 at 11:15 AM, she reviewed the clinical record for Patient 2 but was not able to find documentation of the physician order for Lasix 100 MG. The DOP stated RN 6 documented Lasix was administered but there was no order in the system. The DOP stated the medication order should have been documented in the system or written as a verbal order.
The facility's policy and procedure titled, "Verbal and Telephone Orders, Validating Accuracy," dated November 2016, indicated,"...4. Computerized physician order entry (CPOE) shall be used for all orders by providers ...5. Verbal and telephone orders guidelines: ...record the order directly on to the physician order sheet in patient's medical record ..."
The facility's policy and procedure titled, "Medication Administration," dated April, 2017, indicated, "...c. The nurse administering medications must document on the eMAR."