Observations:
Based on review of facility documents, observation, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure a suicidal patient ordered one-on-one Direct Visualization was not left unattended behind a closed bathroom door (MR1); the facility failed to ensure the 1:1 sitter had direct visualization of a suicidal patient ' s hands, arms and face (MR22) and the facility failed to ensure a 1:1 sitter was not behind a closed door with a patient ordered on direct visual observation (MR23) and the facility failed to ensure a patient expressing suicidal thoughts was rescreened as per facility policy for one of one applicable medical record reviewed (MR1).
Findings include:
Review on March 14, 2025, of the facility's "Patient rights & responsibilities" brochure, A-775-001 F ENG-BR Dev. 6/21, revealed "...Care delivery You or your authorized representative or guardian have the right to...Receive kind, respectful, safe, quality care delivered by skilled staff..."
Review on March 14, 2025, of the facility's "Guidelines for the Care of Behavioral Health in the Emergency Department" policy, last template version 22.02 May 16, 2022, revealed "Purpose To Provide care for patients with behavioral health complaints or psychotic manifestations including homicidal or suicidal ideation. To provide guidelines for a comprehensive assessment and maintenance of patient safety during their time in the Emergency Department (ED). This includes but is not limited to the completion of a suicide risk screening, medical screening exam (MSE), assessment of the environment and referral for behavioral health evaluation...Steps A. Process for direct admission to Behavioral Health Holding Area (BHHA) 1. Patients presenting with behavioral health complaints (including suicidal or homicidal ideation) or signs of psychosis to triage or via EMS (without overt signs/symptoms of medical issues) will be triaged by trained personnel, suicide Risk screening completed, and will have an Emergency Severity Index (ESI) level determined...If Columbia screening results in "NA", staff will consider use of CVM. Staff will follow procedures outline in the policy: "Suicide/Self-harm Precautions-Nursing". 2. Patient will be roomed according to ESI Level and need for safety/security...10. Patients requiring 1:1 direct visualization must be observed by nursing staff for safety while in the bathroom and shower..."
Review on March 14, 2025, of the facility's "Suicide / Self-Harm Precautions - 10.60.4" policy, last committee approval October 11, 2022, revealed "Purpose The purpose of this policy is to ensure an effective method for suicidal assessment, monitoring, and treatment of patients at risk for suicide/self-harm or who may endanger others. Patients presenting with acute medical care needs may also be assessed for exhibiting acute psychiatric conditions, chronic mental disturbances, substance abuse and be at risk of self-harm...Definitions Columbia Suicide Severity Rating Scale (C-SSRS) - Evidence based suicide risk assessment tool to assess suicidal ideation. Continuous observation - continuous in person 1:1 observation monitoring for high risk patients Direct Visual Observation - constant observation in person or by video for moderate risk patients. Observation of multiple patients (no more than 2:1 in person) or can utilize in person and video monitoring for patients simultaneously per nursing/provider judgement...Suicide Ideation - specific behaviors/thoughts/ verbal cues which may be indicative of an individual's intent to kill oneself...Procedure...Any patient that arrives to Emergency department with active suicide attempt is automatically placed on high risk 1:1 observation. Emergency Department Complete the Columbia Suicide Severity Rating Scale (C-SSRS) on every Adult patient and the RSQ-4 for pediatric patients 11-17 years of age. The patient will be re-assessed with any change in patient behavioral condition to determine if a change in risk level (adults) and/or intervention is needed ... "
Review on March 14, 2025, of the facility's "Geisinger Health Suicide Assessment Risk Score & Interventions" protocol, no review date, revealed "Low Risk Locate patient close to nurses' station, if possible. Rescreen patient using CSSR if change in behavior, statement, or condition. Ensure resources are provided at discharge, if needed. Moderate Risk Alert provider and charge nurse of status. Psych consult as ordered by practitioner. Assign to direct visual observation, may assign video and/or continuous in person. Locate patient close to nurses' station, if possible. Complete room and body search immediately for any potentially harmful objects. Screen all visitor belongings. Complete room checks each shift. Rescreen patient using CSSR if change in behavior, statements, or condition. Ensure resources are provided at discharge. High Risk Alert provider and charge nurse of status. Assign to 1:1 continuous in person visual observation. May use video monitoring as secondary precaution in conjunction with direct 1:1. Psych Consult as ordered by practitioner. Locate patient close to nurses' station, if possible. Complete room and body search immediately for any potentially harmful objects. Remove pt. belongings. Screen all visitor belongings. Paper scrubs. Plastic dinnerware. Complete room checks each shift. Rescreen patient using CSSR if change in behavior, statements, or condition. Ensure resources are provided at discharge."
1. Review of MR1 on March 14, 2025, revealed this patient presented to the Emergency Department (ED) on March 10, 2025, at 0316 due to a reported seizure.
Review on March 14, 2025, of nursing documentation dated March 10, 2025, at 0335 revealed MR1 was found pacing the hallway; pacing in the room; grabbed the phone in the room and lifted to cord to the neck; stating to the nurse to step out of the room as this patient needed to make an important call. The phone and cord were removed for MR1's room at that time. The ED physician ordered MR1 on Suicide Precautions and one-on-one Direct Visualization on March 10, 2025, at 0343.
Review of MR1 on March 10, 2025, at 1617 revealed documentation MR1 was transferred from ED room 32 to the locked ED Behavioral Health unit (Nurses Station 4) room 31.
Review on March 14, 2025, of MR1's nursing documentation dated March 11, 2025, at 1030 revealed EMP5 opened the bathroom door; visualized MR1 in a fetal position on the ground with a plastic bag around the neck attempting to strangle self. Scissors were used to remove the plastic bag from around MR1's neck. MR1 was escorted back to the locked ED Behavioral Health unit (Nurses Station 4) and assessed for injury.
Interview with EMP1 revealed EMP6 escorted MR1 out of the locked ED Behavioral Health unit (Nurses Station 4) to the bathroom directly outside this unit and left MR1 unattended in the bathroom for an undetermined amount of time.
There was no nursing documentation indicating the time MR1 was escorted to the bathroom located outside of the locked ED Behavioral Health unit (Nurses Station 4).
Interview with EMP1 on March 14, 2025, confirmed the above findings at the time of the medical record review. EMP1 revealed EMP6 was the assigned one-on-one direct visual observer assigned to MR1.
Observation on March 14, 2025, of the bathroom located directly outside the locked ED Behavioral Health unit (Nurses Station 4) revealed the following ligatures that pose a hanging threat to a patient with suicidal thoughts or ideas:
A slotted paper towel holder
A nurse call bell cord
A commode with exposed pipe
Handrails along the back and left side of the commode with an open rail
Goose neck faucet
Louvered hot and cold-water handles
Goose neck sink drainpipe
A metal hook on the back of the door that was not break away
Louvered door hand
Interview with EMP1, EMP3 and EMP4 confirmed the above ligatures in the bathroom. EMP1, EMP3 and EMP4 confirmed the above ligatures pose a risk to a person with suicidal thoughts or ideas.
2. Review of MR22 on March 14, 2025, revealed this patient presented to the ED on March 14, 2025, at 0121 following a suicide attempt by crashing of the motor vehicle. The facility completed a Columbia - Suicide Severity Rating Scale and determined MR22 met the criteria for Suicide 1:1/Direct Visual Observation. MR22's Suicide 1:1/Direct Visual Observation began on March 14, 2025, at 0150.
Observation of MR22 on March 14, 2025, at approximately 1330 revealed this patient lying in bed facing down with hands and arms not visible to the 1:1 observer.
Interview with EMP1 and EMP3 confirmed the above findings. EMP1 confirmed it is necessary to see a suicidal patients, hands, arms and face to ensure their safety.
3. Review of MR23 on March 14, 2025, revealed this patient presented to the ED on March 13, 2025, at 1203 following suicidal behaviors and statements. Nursing documentation dated March 13, 2025, indicating MR23's parent reported violent outbursts of biting, hitting, kicking and verbally threatening prior to coming to the ED. Nursing documentation dated March 13, 2025, revealed nursing also reported MR23 had violent outbursts of biting, hitting, kicking and verbally threatening nursing staff on admission to the ED. The ED physician ordered MR23 on Suicide Precautions on one-to-one Direct Visualization. MR23's one-to-one Direct Visualization began at 1207 on March 13, 2025.
Observation of MR23 on March 14, 2025, at approximately 1330 revealed this patient's ED room door closed with the one-to-one Direct Visualization sitter behind this closed door.
Interview with EMP1 and EMP3 confirmed the above findings. EMP1 confirmed it is necessary for one-to-one Direct Visualization sitters to leave the patient room door open to ensure the staff safety.
4. Review of MR1 on March 14, 2025, revealed this patient presented to the Emergency Department (ED) on March 10, 2025, at 0316 due to a reported seizure. The facility completed a Columbia Suicide Severity Rating Scale on MR1 on admission to the ED and determined this patient's risk for suicide was zero.
Review on March 14, 2025, of nursing documentation dated March 10, 2025, at 0335 revealed MR1 was found pacing the hallway; pacing in the room; grabbed the phone in the room and lifted to cord to the neck; stating to the nurse to step out of the room as this patient needed to make an important call. The phone and cord were removed for MR1's room at that time. The ED physician ordered MR1 on Suicide Precautions and one-on-one Direct Visualization on March 10, 2025, at 0343.
There was no documentation in MR1 indicating the facility completed a reassessment of MR1's suicide risk by completing another Columbia Suicide Severity Rating Scale.
Interview with EMP1 confirmed the above finding at the time of the medical record review.
Cross reference
482.13 Patient Rights
| | Plan of Correction - To be completed: 04/22/2025
It was found by the DOH that GCMC was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals; 482.13(c)(2) PATIENT RIGHTS: CARE IN SAFE SETTING. The patient has the right to receive care in a safe setting.
This REQUIREMENT is not met as evidenced by:
-facility failed to ensure a suicidal patient ordered one-on-one Direct Visualization was not left unattended behind a closed bathroom door (MR1).
-facility failed to ensure the 1:1 sitter had direct visualization of a suicidal patient's hands, arms and face (MR22).
-facility failed to ensure a 1:1 sitter was not behind a closed door with a patient ordered on direct visual observation (MR23).
-facility failed to ensure a patient expressing suicidal thoughts was rescreened as per facility policy for one of one applicable medical record reviewed (MR1).
ACTIONS TAKEN
Regarding the findings with MR1, after the event with the patient, immediate actions were taken on March 11, 2025:
-immediate review of events by the Emergency Department (ED) Nursing Manager
-Coaching sessions were done by the ED Nursing Manager with the ED Charge RN, ED Behavioral Health (BH) RN, the ED BH Technician, and Security regarding the importance, and significance, of not leaving a patient unattended in a bathroom; that they must always maintain direct visual observation of the patient as a moderate or high risk.
-Plastic bag removed with Paper bag placed in ED bathroom garbage can; Education and coaching by the ED Nursing Manager occurred with the EVS employee
-Risk and Patient Safety RN investigation
-review of patient chart by Regional Director Quality and Safety and the Regulatory Performance Improvement (PI) Team Coordinator
On March 12, 2025, the following took place:
A multidisciplinary team meeting made up of the ED Nursing Manager, Director of Nursing, Regional Director Quality and Safety, Regulatory PI Team Coordinator, Regulatory PI Coordinators, and the Risk and Patient Safety RN met, and immediate steps were taken to re-educate ED BH Unit staff and Security staff on the "Contingency Plan" that was previously put into place while the locked unit's BH bathroom was being renovated. In addition, education of the following began, "Suicide/Self Harm Precautions-Nursing" policy, "Guidelines for the Care of Behavioral Health in the Emergency Department" policy and "Geisinger Health Suicide Assessment Risk Score & Interventions".
The "Contingency Plan" put into place on March 3, 2025, when the BH bathroom was being renovated is as follows:
- We will utilize the bathroom directly outside of the locked unit. It is approximately 12 feet from the unit.
- If a patient requests/needs a shower, we will utilize the Decontamination shower.
- A Columbia Suicide Severity Rating Scale (C-SSRS) is done on every patient.
- Interventions initiated will be based on the level of risk assigned per C-SSRS as outlined in the Geisinger Health Suicide Risk Assessment Interventions.
- Staff will accompany the patient to the bathroom or the shower.
- A 1:1 Sitter is assigned per the "Suicide/Self-harm Precautions" policy based on the Columbia Screening or if the patient is categorized as a 302 commitment. This will be 1:1 continuous in person visual observation.
- Security is available as necessary to assist the 1:1 Sitter upon request.
- Security will increase rounding in the Behavioral Health area.
- The locked unit is monitored 24/7 by an Emergency Department Technician sitting at the cameras.
On March 19, 2025, a multidisciplinary team meeting made up of the AVP Nursing Services, ED Nursing Manager, Director of Nursing, ED Administrative Team Coordinator, Regional Director Quality and Safety, Regulatory PI Coordinators, Nursing Professional Development (NPD) Manager, NPD Specialist, and the Regional Operations Director Police and Security met to review these findings. The following were reviewed, with no changes made:
- Patient rights and responsibilities brochure
- Suicide/Self Harm Precautions-Nursing policy
- Guidelines for the Care of Behavioral Health in the Emergency Department policy
- Geisinger Health Suicide Assessment Risk Score & Interventions
*Please note that the policy entitled "Suicide/Self-Harm Precautions-10.60.4" was inadvertently given to the survey team. This policy was an old policy and replaced by the "Suicide/Self Harm Precautions-Nursing" policy. Moving forward, the Regulatory PI (RPI) team will ensure that when a policy is requested, RPI will reach out to the Subject Matter Expert to ensure that we have a current policy. An email memorandum was sent out by the Regional Director Quality and Safety regarding this subject matter to the Regulatory PI team on March 24, 2025.
A plan was put into place to address these findings:
-facility failed to ensure a suicidal patient ordered one-on-one Direct Visualization was not left unattended behind a closed bathroom door (MR1). The employee (EMP6) was suspended pending investigation.
-facility failed to ensure the 1:1 sitter had direct visualization of a suicidal patient's hands, arms and face (MR22). Real time education and coaching occurred with this employee on March 14, 2025.
-facility failed to ensure a 1:1 sitter was not behind a closed door with a patient ordered on direct visual observation (MR23). Real time education and coaching occurred with this employee on March 14, 2025.
-facility failed to ensure a patient expressing suicidal thoughts was rescreened as per facility policy for one of one applicable medical record reviewed (MR1). Education and coaching occurred with this employee on March 12, 2025.
EDUCATION
Education of the ED staff by ED Leadership and the ED NPD Specialist took place on multiple dates with a final summarization of the ED staff education taking place on 3/20/2025 via email communication. Education consisted of the following and will continue via discussion at huddles and will be verified using email read receipts and/or sign off sheets.
- "Suicide/Self Harm Precautions-Nursing" policy
- "Guidelines for the Care of Behavioral Health in the Emergency Department" policy
- "Geisinger Health Suicide Assessment Risk Score & Interventions"
- All patients who are ordered 1:1 direct visualization must not be left unattended behind a closed bathroom door.
- All patients who are ordered a 1:1 sitter must have direct visualization of a suicidal patient's hands, arms, and face.
- A 1:1 sitter should not be behind a closed door with a patient ordered on direct visual observation. The door should remain open to help ensure staff safety.
- All patients expressing suicidal thoughts will be rescreened/reassessed with any change in patient behavioral condition to determine if a change in risk level and/or intervention is needed.
Education of the Security staff by Security leadership took place on multiple dates with a final summarization of the education taking place on 3/20/2025 via email communication. Education consisted of the following and will continue via discussion at huddles and will be verified using email read receipts and/or sign off sheets.
- All patients who are ordered 1:1 direct visualization must not be left unattended behind a closed bathroom door.
- All patients who are ordered a 1:1 sitter must have direct visualization of a suicidal patient's hands, arms, and face.
- A 1:1 sitter should not be behind a closed door with a patient ordered on direct visual observation. The door should remain open to help ensure staff safety.
Education was distributed by the NPD team to all Nursing and Nursing Support Staff (this includes the Sitters who may be Patient Companions, ED Technicians, Nursing Assistants, or Patient Care Technicians) via email communication on 3/21/2025. Education consisted of the following and will continue via discussion at huddles and will be verified using email read receipts and/or sign off sheets.
- "Suicide/Self Harm Precautions-Nursing" policy
- All patients who are ordered 1:1 direct visualization must not be left unattended behind a closed bathroom door.
- All patients who are ordered a 1:1 sitter must have direct visualization of a suicidal patient's hands, arms, and face.
- A 1:1 sitter should not be behind a closed door with a patient ordered on direct visual observation. The door should remain open to help ensure staff safety.
- All patients expressing suicidal thoughts will be rescreened/reassessed with any change in patient behavioral condition to determine if a change in risk level and/or intervention is needed.
All Education will be tracked and completed by April 21, 2025.
MONITORING
Preliminary observations will begin in parallel with education.
Beginning April 22, 2025, ED Leadership/designee will conduct thirty (30) 1:1 Direct Visualization/1:1 sitter observations per 30 calendar days spanning all shifts. Monitoring will include that
- All patients who are ordered 1:1 direct visualization must not be left unattended behind a closed bathroom door.
- All patients who are ordered a 1:1 sitter must have direct visualization of a suicidal patient's hands, arms, and face.
- A 1:1 sitter should not be behind a closed door with a patient ordered on direct visual observation. The door should remain open to help ensure staff safety.
The audits will continue until there are 3 consecutive 30-day cycles of 100% compliance and then random observational tracers will be conducted to ensure on-going compliance.
Beginning April 22, 2025, ED Leadership/designee will conduct thirty (30) behavioral health chart review audits per 30 calendar days, looking to ensure any patient that expresses suicidal thoughts will be rescreened/reassessed with any change in patient behavioral condition to determine if a change in risk level and/or intervention is needed.
The audits will continue until there are 3 consecutive 30-day cycles of 100% compliance and then random chart reviews will be conducted to ensure on-going compliance.
RESULTS
The results of the audits will be reviewed by ED Leadership to determine if the processes are being followed. Any areas of non-compliance will be addressed by Emergency Department leadership on a one-on-one basis with staff. Data will be reported at the monthly Emergency Department meeting. Findings will be forwarded to the Regulatory Performance Improvement Department for review and reported to the Performance Improvement Committee as applicable.
RESPONSIBLE PERSON
Associate Vice President Nursing Services
Director of Nursing
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