HospitalInspections.org

Based on interview and record review, the facility failed to ensure 1 (Sample Patient #1) out of 2 patients selected for psychiatric services received care in a safe setting, by 1) not ensuring the evaluation of the consulted psychiatrist prior to discharge; 2) not ensuring sitter documentation was completed for a suicidal patient (Sample Patient #1) who had a physician order for a one to one sitter throughout her length of stay.

The findings include:
Record review reflects that Patient #1 was admitted to the facility on 8/2/2012 and subsequently discharged on 8/3/2012. She was admitted and Baker Act via the facility ' s emergency department with a chief complaint including suicidal ideation. Her diagnosis includes (but is not limited to): depression. She was admitted on the medical floor in the facility and assigned a one to one sitter for safety, due to the suicidal ideation.
Review of the physician orders reveal the following: 8/2/2012: consultation with psychiatrist for suicide attempt; 8/3/2012: discharge if " ok " with attending physician; after psychiatry evaluation; 8/3/2012 (telephone order): " ok " to discharge patient home from psychiatric standpoint as per psychiatrist; read back, verified. There is no evidence on the medical record that the patient had been evaluated by the psychiatrist.
Review of a physician progress note, from psychiatry, dated 8/31/2012 reveals: " late entry, " On 8/2/2012 a consult was placed to the system for psychiatry to evaluate this patient (Sample Patient #1); consult was called on 8/3/2012 in the AM; I will see the patient today late or early in am ; came to see the patient on 8/4/2012 early in AM; patient was discharged already; patient was also off my list; apparently the patient was discharged late on 8/3/2012; I did not see the patient nor did I evaluate her.
Interview (telephone) with psychiatrist on 9/17/2012 at 3:35pm; he confirmed that he was the consulted psychiatrist for Sample Patient #1; and by the time he went to see her, she had already been discharged from the facility. He reports that he does not know why the patient was discharged without seeing him. He reports he normally see patients he is consulted on, in this case he is guessing the attending physician allowed the patient to be discharged prior to seeing the psychiatrist. He confirms that he does not have a recollection of this patient, nor does he have any recollection of giving a " telephone order " to the staff directing them to discharge a patient he had not yet physically evaluated. He conforms that the telephone order to discharge Patient #1, without out psychiatric evaluation was an inappropriate order as well as odd.
Review of facility Rules and Regulations regarding Consultations reveal: Except in emergency, consultation is required in the following instances: d) in unusually complicated situations where specific skills of other practitioners may be needed.
Consultation reports should contain a written opinion by the consultant based on an examination of the patient and his record. This must be dated and signed by the consulting physician.
2)Sample Patient #1 was admitted under the Baker Act and was to have a one to one sitter for suicidal ideation, by physician order. Review of the medical record reflects that there is no documentation that the one to one sitter was assigned, nor does documentation exist of the one to one sitter documentation of the hourly assessment of this patient, per the facility order.
Interview via telephone with sample patient #1 care technician on 9/18/2012 at 3:38pm revealed; she was assigned to provide one to one sitter duties for Patient #1 on 8/3/2012. She confirms that she worked with another patient care technician the night of 8/3/2012; however, she does not recall Patient #1. She reports that when she is assigned one to one sitter duties, she typically does document on the facility one to one form, hourly, of the patient activities and that their safety is maintained.
Interview with the Interim CNO on 9/18/2012 at 1:38pm revealed that it is the facility ' s policy for one to one sitters to complete documentation of patient activities when they are assigned this duty. She confirms that there is no one to one sitter documentation on the medical record for Patient #1.
Review of facility policy and procedure titled " Sitter " reveals: The need for a sitter may be determined based on the following criteria: 1) Suicide watch outside the critical care unit. Attached to the policy is an example of the form titled, " Sitter Record. " The form reveals a section for date, time, staff name, signature, comments, all in hourly increments from 12:00AM to 11:00PM.