117.41 Emergency patient care
(b) Policies and procedures for
emergency patient care should, at a
minimum, do the following:
(10) Instruct personnel in special
procedures for handling persons who
are mentally ill, under the influence
of drugs or alcohol, victims of
suspected criminal acts, or
contaminated by radioactive material
or who otherwise require special care
or have other conditions requiring
special instructions.
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Observations:
Based on review of facility documents, staff interview (EMP), and review of medical records, it was determined the facility failed to ensure patients who were identified as moderate and high risk for suicide were provided physician ordered sitters and documentation completed as per policy for two of two medical records reviewed (MR1, MR2).
Findings include:
Review on August 20, 2024, of facility policy, "Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Settings" revised February 2023, revealed "Policy: All adolescent and adult patients (ages > 11 y.o.) who present for care and services will be screened for suicide ideation and behavior using the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS). ... Based on the severity and immediacy of suicide risk assessed using the Columbia Protocol, patient safety measures and interventions will be implemented as a means to keep patient from inflicting harm to self. This policy is applicable to patients admitted to non-behavioral health settings whether inpatient or outpatient (ED OBS, ASC, OR) during the nursing admission assessment, triage, or initial intake. ... Definitions: ... One to One (1:1) Observation: Intervention for high risk for suicide. Continuous observation and staff are able to see the patient in clear view and staff can respond immediately to intervene and assure safety at all times, including while the patient sleeps, uses the toilet, bathes, etc. Video monitoring should only be used when it is unsafe for a staff member to be physically located in the patient's room. Frequent Observation (every 15 min checks): Intervention for moderate risk for suicide. Observation of patient in clear view every 15 minutes and respond immediately to intervene and assure safety. ...Table 1: Patient Safety Measures and Interventions Based on Screening Responses ...3. Have you been thinking about how you might kill yourself Indicates Thoughts with method (without specific plan or intent to act) Level of Risk Moderate Patient Safety Measures and Interventions with Last "Yes" Answer ...More frequent observation (every 15 min. checks)... 4. Have you had thoughts and had some intention of acting on them? Indicates Intent without plan 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Indicates Intent with plan High Initiate continuous observation (1:1 or in dedicated, secured, ligature-resistant area or room) ..."
Review on August 20, 2024, of MR1, revealed this patient presented to the Emergency Department (ED) with complaint of Suicidal Ideations (SI) on August 1, 2024, at 2150. C-SSR was completed. MR1 was identified as moderate risk for suicide and ordered for sitter at bedside. Every (q) 15- minute checks started. There was no documentation 15-minute checks were completed on August 2, 2024, from 0315 until 0630.
Interview on August 20, 2024, with EMP2, at approximately 10:00 AM, confirmed the above findings.
Review on August 20, 2024, of MR2, revealed this patient presented to the ED with complaint of having auditory and visual hallucinations with SI and a plan on July 19, 2024, at 1702. C-SSR was completed and MR2 identified as high risk for suicide and ordered for sitter at bedside. No documentation a sitter was placed at the bedside.
Interview on August 20, 2024, of MR2, at approximately 10:20 AM, confirmed the above findings.
| | Plan of Correction - To be completed: 10/03/2024
The Chief Nursing Officer is ultimately responsible for the implementation of the plan of correction and the monitoring of the same. The facility's Chief Nursing Officer and Chief Quality Officer reviewed the facility's Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting (rev date 2/2023), on September 6, 2024 and determined no changes were necessary. The facility reviewed the gaps in the documentation of high and moderate risk suicidal patients identified in the survey and determined the gaps were a result of the need for additional trained observer (sitters) and ED crisis clinicians. The minimum number of crisis clinicians determined to be needed to address the historical volume and acuity of ED crisis patients was determined to be 4.2 full time equivalents. The ED director reviewed the published job postings and determined that no changes were necessary. The facility hired an experienced ED crisis clinician at the 0.2 FTE that completed orientation on 8/26/2024. The facility is continuing the search for two additional ED crisis clinicians. The ED crisis clinician schedule was adjusted to faciltate a minimum of twelve hours of ED crisis clinician coverage effective 8/20/2024. The facility will continue to pursue the option of a professional services aggrement to staff the ED crisis clinician role in the future. The minimum number of trained observers determined to be needed to address the historical volume and acuity of ED crisis patients was deteremined to be 22 full time equivalents. The facility hired four trained obervers with pending start dates, one full time trained observer will start orientation on 9/9/2024 and there is one posted full time trained observer the facility will continue to recruit for. The facility will continue to pursue the option of a professional services aggrement to staff the trained observer role in the future. ED staff will be educated on the use of trained observers to complete moderate risk monitoring as appropriate and available via a computerized training module no later than September 30, 2024. Trained observers will be educated on their role in completing moderate risk monitoring and documentation via a computerized training module no later than September 30, 2024. Audits to identify gaps in the monitoring of moderate and high risk ED crisis patients will be completed by the ED director or her designee on a weekly basis. Gaps in documentation will be addressed through re-training or through the progressive disciplinary process as appropriate. Audits will be conducted and reported to the patient safety committee until compliance has reached 100% for three consecutive months. Reports to the patient safety committee will be shared with the Medical Executive Committee and Board of Trustees monthly.
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