Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure patients presenting to the Emergency Department (ED) with suicidal thoughts were provided adequate monitoring to prevent self-harm for two of two medical records reviewed (MR1 and MR2); the facility failed to provide physician ordered 1:1 observation monitoring for patients presenting with suicidal thoughts for four of four medical records reviewed (MR3, MR4, MR5 and MR6); and failed to follow the established staffing policy to ensure consistent categories of nursing personnel based on the facility's staffing grid and schedules in the Emergency Department.
Findings include:
Review on September 12, 2018, of the facility's "Suicide Risk Assessment and Interventions in a Non-Behavioral Health Setting" policy, last revised August 2017, revealed "Policy: All patients who are admitted for care and services will be assessed for suicide ideation and /or suicide risk factors during initial intake/admission assessment process. In addition, patients who present for evaluation and treatment with a primary diagnosis or complaint of an emotional or behavioral disorder or substance abuse; or display the symptoms of an emotional or behavioral disorder, will be assessed for suicide risk. Based on the level of suicide risk, interventions will be implemented as a means to keep patients form inflicting harm to self or others. Purpose: To identify patients at risk for suicide and provide safety interventions. ... Definitions: ... Suicidal Ideation: Thoughts of harming or killing oneself. Intensity determined by assessing the frequency, duration and intensity of these thoughts; in addition to the presence of a plan. Suicide Attempt: A non-fatal, self-inflicted destructive act with explicit of inferred intent to die. ... Level of Supervision A. Continuous visual surveillance (Level 1) - one patient to one observer (1:1). Observer must maintain 1:1 direct observation and be able to respond to the patient immediately. De-escalation techniques will be used as appropriate. B. Continuous visual surveillance (Level 2). Patient is under direct observation at all times and observer must be able to respond to the patient rapidly. Ratio may be more than 1:1 as long as observer is able to attend to the immediate needs of one patient without sacrificing surveillance and attendance to the immediate needs of another patient(s). Observer must have direct line of sight of patient. If de-escalation techniques are ineffective, patient will be escalated to Activity Level 1. C. Close observation (Level 3): Patient may not be left alone without support person (may be reliable family/friend). Observation is required by hospital staff at intervals at a maximum of 15-minute intervals. Supportive family/friend must receive education from staff on expected responsibilities and be willing to sign a contract to stay with the patient at all times or know and agree to communicate with/seek staff assistance if chooses to leave for any concerns. In absence of reliable support person, patient will be escalated to Activity Level 2. D. Intermittent observation (Level 4): Observation at a maximum of 30-minute intervals by clinical staff. E. General observation (Level 5): Routine check by clinical staff at a maximum of one-hour intervals. ..."
Review on September 12, 2018, of the facility's "Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting" form, last reviewed April 12, 2018, revealed "Level 1 Definition Requires immediate life-saving intervention. Immediate danger to self or others. Observed Violent Behavior Possession of weapon Self-Destructive act that resulted in physical harm Reported Verbal commands to do harm to self or others (command hallucinations) violent/self-destructive behavior Behavior that has resulted in harm to self or others, including actual suicide attempt Interventions Continuous visual surveillance 1:1 ratio: direct observation by staff at all times. must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation. Level 2 High-risk situation Risk of danger to self or others and/or Severe behavioral disturbance Observed Extreme agitation Physically/verbally/aggressive Uncooperative hallucinations/delusions/paranoia distorted perception of reality May or has require(d) restraint/seclusion Words or behavior reflect high risk of elopement (pacing, hovering near doorway) signs of severe depression (Activities of Daily Living impacted) Reported threat to harm self or others Suicidal ideation (thoughts of suicide) with or without a plan acute drug or alcohol intoxication with history of suicide attempt or ideation Psychotic symptoms: Hallucinations, delusions, paranoid ideas, thought disorder, unusual or agitated behavior Overwhelming symptoms of depression Interventions Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation. ..."
Review on September 12, 2018, of the facility's "Suicide Precautions" policy, last revised November 2017, revealed "Purpose: To outline a mechanism for observation and protection of patients who are assessed to be at for suicide, or have expressed suicidal ideations. Policy: 1. A physician's order must be obtained for suicide precautions and psychiatric consult obtained. 2. Suicide precautions must be re-ordered daily. 3. A patient monitor is assigned until the patient is either transferred to an appropriate facility or is determined to be no longer at risk and discontinued. 4. The nurse will inform the patient that he/she is being placed on suicide precautions and explain the rational. 5. The patient on suicide precautions should be assigned the bed near the door in a semi-private room. 6. An environmental safety check of the patient's room will be performed. 7. Patient belongings will be checked closely and all potentially harmful items will be removed, labeled and secured in the designated area on each department. ... 13. The patient monitor is to be seated at the foot of the patient's bed (beyond arms length but in direct proximity of the patient). 10. (sic) The patient monitor will report any potentially unsafe behaviors to the assigned nurse. ..."
Review on September 12, 2018, of the facility's "Prevention/Alternatives and Use of Restraints/Protective Devices" policy, last revised December 2016, revealed "Philosophy: The patient has the right to be free from restraints of any form that are not absolutely medically or behaviorally necessary. Our approach to restrain will protect the patient's health and safety and maintain the patient's dignity. ... Policy: ... 5. The use of restraint must be implemented in accordance with safe and appropriate restraint techniques as determined by hospital policy in accordance with State law. ..."
Review on September 10, 2018, of the facility's "Trauma Alert Activation" policy, last reviewed January 2018, revealed "Purpose: The purpose of this policy is to activate a prescribed group of trained personnel to respond within the hospital and standardize the activation of the trauma team when a trauma patient, who meets the criteria described in this policy, arrives at Wilkes-Bare General Hospital. Scope: This policy applies to any member of the trauma team but is most likely to be initiated by the Emergency Department (ED) attending physician or nurse. Definitions: Trauma Alert (Level I, II, and III): For all patients greater than fourteen (14) years of age. ... Pediatric Trauma Alert: For all patients fourteen (14) years of age or less Trauma Alert - OB: For all patients greater than or equal to 20 weeks gestation Resuscitation: This intense period of patient assessment and medical care to save life or limb Trauma Team: A group of health care professionals organized to provide care and monitor the trauma patient in coordinated and timely fashion Trauma Resuscitation Area: A space used for trauma resuscitation. It must be of adequate size to accommodate for full trauma resuscitation, and equipment. Trauma Resuscitation Team: Major trauma resuscitations require a multidisciplinary team of health care providers who work in synergy to rapidly assess and treat the patient. The trauma attending or appropriate designee must lead the team. ... Procedure: The Trauma Alert response will be determined prior, if at all possible, to the patient's arrival by the Emergency Department physician and /or ED RN or Trauma surgeon. All level I and II trauma alerts will be taken to the trauma resuscitation rooms upon pre-hospital arrival. The Emergency Department physician and /or ED RN or the Trauma Surgeon will initiate a Trauma Alert prior to the arrival of the patient if prior information is available. If no prior notification is obtained, then the Trauma Alert will be called on the patient's arrival in the Emergency Department. The ED physician will give medical commend to ALS/BLS units. The designated Trauma Nurse will notify the switchboard of the classification of Trauma Alert and the estimated time of arrival. ... The ED nurse at the direction of the ED physician activates Trauma Alert Level II. The switchboard will notify the response team to be present upon patient arrival. Trauma Team that will respond will include the following: ... 3. Designated emergency Department trauma nurse ... The ED nurse at the direction of the ED physician activates Trauma Alert Level III. The Trauma surgeon will be paged by the ED physician or Nurse. 1. Emergency Department physician 2. Trauma Surgeon 3. Designated emergency Department trauma nurse. ..."
Review on September 11, 2018, of the facility's "Staffing the Emergency Department" policy, effective June 2015, revealed "Purpose: The purpose of this policy is to explain the methodology for properly staffing the Emergency Department. Policy: Patients presenting to the emergency department are seen as quickly as possible. Staffing must be appropriate for this to occur. ... Procedure: ... 2. Scheduling a. In accordance with the CBA [Collective Bargaining Agreement] and Hospital Policy, emergency Department Leadership issues a six-week schedule in the electronic scheduling program with the maximum number of staff members in each title that would be required at a given hour of the day. ..."
Review of MR1 on September 11, 2018, revealed this patient was admitted to the ED on August 11, 2018, for evaluation and treatment of suicidal ideations and major depression with a history of cutting self. The ED physician ordered 1:1 sitter at the bedside for constant observation at all times on August 11, 2018, on admission to the ED.
Review on September 11, 2018, of MR1's Suicide Risk/Behavioral Disorder assessment dated [DATE], at 2:15 PM revealed the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio: Direct observation by staff at all times. Must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation.
Review of MR1 on September 11, 2018, revealed nursing documentation dated August 11, 2018, at 3:00 PM that MR1 was wanded (hand held metal detector) by security. There was no documentation security identified any concealed metal items or safety hazards.
Review of MR1 on September 11, 2018, revealed nursing documentation dated August 11, 2018, at 3:20 PM there was no sitter at the bedside because no sitter was available.
Review of MR1 on September 11, 2018, at 4:45 PM revealed nursing documentation this patient had multiple open lacerations on the arms and front of the neck. MR1's incision/wound charting revealed there were six open lacerations on the arms and front of the neck requiring sutures and 11 lacerations on the arms and front of the neck requiring steri-strips to close the wounds.
Interview with EMP1, EMP3 and EMP7 September 11, 2018, at approximately 9:15 AM confirmed MR1 was admitted to the ED for evaluation and treatment of suicidal ideations and major depression; the ED physician ordered 1:1 sitter at the bedside for constant observation at all times; MR1 was wanded by security; that no concealed metal items or safety hazards were found and MR1's nursing documentation revealed there was no sitter at the bedside because no sitter available. EMP1, EMP3 and EMP7 confirmed MR1's nursing documentation this patient had multiple open lacerations on the arms and front of the neck and this patient's incision/wound charting revealed there were six open lacerations on the arms and front of the neck requiring sutures and 11 lacerations on the arms and front of the neck requiring steri-strips to close the wounds.
Review of MR2 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, at 1:18 AM for evaluation and treatment of a suicidal attempt.
Review on September 13, 2018, of MR2's admission Suicide Risk/Behavioral Disorder assessment dated July 29, 2018, revealed the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio: Direct observation by staff at all times. must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation. The ED physician ordered Continuous visual surveillance 1:1 direct observation on this patient.
Review on September 13, 2018, of MR2's Physician's Restraint/Seclusion Orders Violent - Self Destructive order sheet dated July 29, 2018, at 1:10 AM revealed a physician order instructing nursing staff to apply four-point leather restraints. ED nursing staff applied leather restraints to MR2's both wrists and both ankles.
Review of MR2 on September 13, 2018, revealed nursing documentation dated July 29, 2018, at 1:30 AM this patient was being obstructive to self and others by kicking and screaming to staff, thrushing (sic) around in bed, and trying to bite staff. At 1:35 AM on July 29, 2108, nursing documented this patient was able to strangle self with the gown strings. Oxygen was applied to the patient; the patient was hypoxic (inadequate oxygenation of the blood related to suffocation) and the doctor was made aware.
Review of MR2 on September 13, 2018, revealed physician documentation that MR2 was cyanotic (blue discoloration of the skin due to having low oxygen in the blood) and initially not responsive. MR2 was bagged for a few seconds and became awake.
Review of MR2 on September 13, 2018, revealed no documentation this patient was provided a sitter for 1:1 direct observation.
Review of MR2 on September 13, 2018, revealed nursing documentation dated July 29, 2018, at 9:52 AM, 11:03 AM and 3:00 PM that this patient was ordered Level 1 (Continuous visual surveillance). Nursing documentation revealed there was no sitter at the bedside due to the lack of staffing.
Interview with EMP1, EMP3 and EMP7 September 13, 2018, at approximately 9:20 AM confirmed MR2 was admitted to the ED for evaluation and treatment of a suicidal attempt: the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio and that MR2 was placed in four-point leather restraints. EMP1, EMP3 and EMP7 confirmed nursing documented this patient was able to strangle self with the gown strings and MR2 became hypoxic requiring oxygen administration. EMP1 and EMP3 confirmed there was no documentation this patient was provided a sitter for 1:1 direct observation and that nursing documented there was no sitter at the bedside due to the lack of staffing.
Review of MR3 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self.
Review on September 13, 2018, of MR3's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 29, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation.
There was no documentation in MR3 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight.
Review of MR4 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self.
Review on September 13, 2018, of MR4's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 29, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation.
There was no documentation in MR4 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight.
Review of MR5 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self.
Review on September 13, 2018, of MR5's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 29, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation.
There was no documentation in MR5 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight.
Review of MR6 on September 13, 2018, revealed this patient was admitted to the ED on July 28, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self.
Review on September 13, 2018, of MR4's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 28, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation.
There was no documentation in MR6 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight.
Interview with EMP3 on September 13, 2018, at approximately 2:45 PM confirmed MR3, MR4, MR5 and MR6 were admitted to the ED for evaluation and treatment of suicidal thoughts with a plan to injure self and the ED physician ordered these patients on Level 2 Continuous visual surveillance 1:1 ratio for observation at all times by designated staff with direct line of sight. EMP3 confirmed there was no documentation in MR3, MR4, MR5 and MR6 indicating these patients were on a Level 2 Continuous visual surveillance 1:1 ratio with observation at all times by designated staff with direct line of sight.
Interview with EMP29, EMP30 and EMP31 on September 10, 2018, revealed there is not always a Flow/Trauma Nurse always assigned to cover this position. These employees revealed when a trauma patient presents to the ED, and there is no Flow/Trauma Nurse coverage, a RN is pulled from their patient assignment to cover the trauma.
Review on September 11, 2018, of the ED staffing sheets for August 1, 4, 8, 12, 13, 14, 17, 19, 20, 21, 22, 25, 26, 27 and 28, 2018, revealed no designated Flow/Trauma Nurse coverage.
Review on September 11, 2018, of the ED trauma list for August 2018, revealed the following trauma patients presented to the ED:
August 8, 2018: 2 - Level II trauma patients
August 13, 2018: 1 - Level 2 trauma patients
August 20, 2018: 1 - Level I trauma patient
August 21, 2018: 1 - Level I trauma patients
August 25, 2018: 1 - Level I trauma patient; 3 - Level II trauma patients and 1 - Level III trauma patient
August 26, 2018: 1 - Level I trauma patient and 1 - Level III trauma patient
August 29, 2018: 1 - Level I trauma patient
Interview with EMP3 and EMP7 on September 11, 2018, at approximately 10:45 AM confirmed there was no designated Flow/Trauma Nurse coverage on August 1, 4, 8, 12, 13, 14, 17, 19, 20, 21, 22, 25, 26, 27 and 28, 2018. EMP7 confirmed when trauma patients present to the ED and there is no designated Flow/Trauma Nurse coverage, a RN is pulled from their assignment to cover the trauma.
Review on September 11,2 018, of the ED staffing sheets for September 4, 5, 6, 7 and 9, 2018, revealed no designated Flow/Trauma Nurse coverage.
Review on September 11, 2018, of the ED trauma list for September 2018, revealed the following trauma patients presented to the ED:
September 4, 2018: 3 - Level I trauma patients and 1 - Level II trauma patient
September 5, 2018: 1 - Level 2 trauma patients
September 6, 2018: 1 - Level I trauma patients; 2 - Level II trauma patients and 1 - Level III trauma patient
September 7, 2018: 2 - Level II trauma patients
Interview with EMP3 and EMP7 on September 11, 2018, at approximately 12:00 PM confirmed there was no designated Flow/Trauma Nurse coverage on September 4, 5, 6, 7 and 9, 2018. EMP7 confirmed when trauma patients present to the ED and there is no designated Flow/Trauma Nurse coverage, a RN is pulled from their assignment to cover the trauma.
Review on September 10, 2018, of the facility provided the "Emergency Department Staffing Grid " dated June 16, 2018, revealed the required staffing at 7 AM is 10 Registered Nurses (RN's), 1 RN for Crisis, 2 Techs; 1 Nurse Assistant (NA) and 1 Unit Secretary (US); at 9 AM the required staffing is 12 RN's, 1 RN for Crisis, 2 Techs; 2 NA's and 1 US; at 11 AM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 3 PM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 7 PM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 11 PM the required staffing is 14 RN's, 1 RN for Crisis, 2 Techs; 2 NA's and 1 US; and at 3 AM the required staffing is 8 RN's, 1 RN for Crisis, 2 Techs; 1 NA and 1 US."
Interview with EMP3 on September 10, 2018, at approximately 8:00 PM revealed the time from 11:00 AM to 7:00 PM are the busiest times with more patient visits in the ED. EMP3 revealed staffing numbers are increased during this time due to the increase in patient visits.
Interview with EMP29, EMP30, EMP31, EMP32, EMP33, EMP34, EMP35, EMP36, EMP37 and EMP38 on September 10, 2018, revealed there is inadequate staffing of Registered Nurses (RN), Techs, Nursing Assistants (NA's) and Unit Secretary's (US) in the ED.
On September 10, 2018, a random sample of the ED staffing sheets for August 2018 and September 2018 were selected for review.
Review on September 11, 2018, of the staffing sheets for August 1, 3, 4, 5, 6, 10, 11, 12, 20, 21, 25, 27, and 31, 2018, revealed the facility did not meet the required staffing per the staffing grid for the ED.
Interview with EMP3 on September 11, 2018, at approximately 10:15 AM confirmed the facility did not meet the required staffing for RN's, Techs, NA's and Unit Secretary's per the established staffing grid in the ED for August 1, 3, 4, 5, 6, 10, 11, 12, 20, 21, 25, 27, and 31, 2018.
Review on September 11, 2018, of the staffing sheets for September 2, 4, 5, 6, and 9, 2018, revealed the facility did not meet the required staffing per the staffing grid for the ED.
Interview with EMP3 on September 11, 2018, at approximately 12:00 PM confirmed the facility did not meet the required staffing for RN's, Techs, NA's and Unit Secretary's per the established staffing grid in the ED for September 2, 4, 5, 6, and 9, 2018.