HospitalInspections.org

Based on the suicide precaution policy the facility failed to ensure 1 (Patient 10) of 1 emergency department (ED) psychiatric sampled patient was monitored one-to-one (a staff member within line of sight and arms reach designated to one patient to watch safety) for suicidal thoughts with a plan (a patient who voiced how they will end their life) per facility policy. The facility failed to ensure 1 of (Patient 10) 1 transfer consent form was complete with last vital signs and patient-specific risks and benefits by the physician. This failed practice has the potential to cause harm or death to any patient who presents to the facility for care. According to facility provided data the ED saw an average of 422 patients per month, and transferred an average of 34 patients per month.

See citation A2407 and A2049, that also resulted in A2400 to not be met.

Based on policy review, medical record review and medical staff interview the facility failed to ensure a suicidal precaution one-to-one order and interventions were placed for 1 (Patient 10) of 1 emergency department (ED) psychiatric sampled patient with an emergency medical condition (EMC) (a condition that requires the patient to receive emergent care) high risk suicidal ideation with two plans (a person with thoughts of harm who voice the way they will end their own life) per facility policy. This failed practice has the potential to cause harm or death to any patient who presents to the facility for care. According to facility provided data the ED saw an average of 422 patients per month.

See citation A2400, that also resulted in A2407 and A2409 to not be met.

Findings include:

A. Review of facility policy, Suicide Screening and Precautions, last approved 4/2025 revealed, suicide risk levels are determined based on patient responses using the Columbia-Suicide Severity Rating Scale (C-SSRS) tool (a screening tool that defines the suicide risk level for a patient with interventions for staff to follow. The risk levels include: no risk, low risk, moderate risk and high risk).

Interventions for patients at high risk for suicide include:
-Notify the physician to discuss level of risk.
-Implement one-to-one monitoring.
-Document initiation of one-to-one monitoring.
-Document every 15-minute safety visual checks while on one-to-one monitoring.
-One-to-one monitoring continues until a psychiatric physician, nurse practitioner or primary physician sees and assesses the patient and order discontinuation of one-to-one monitoring.

One-to-one monitoring is defined as one observer to one patient within line of sight and arms reach, with no physical barriers in the same room or area.

B. Review of P10's medical record revealed, P10 presented to the critical access hospital on 2/13/2025 at 9:28AM via car, walk in, with a chief complaint of suicidal thoughts. At 9:35AM Registered Nurse-A (RN-A) documented P10's C-SSRS score as high risk. At 9:39AM RN-A documented P10's suicidal plans of cutting or suffocation. P10's medical screening exam (MSE) (an exam from a physician that determines whether or not an emergency medical condition exists) started at 9:45AM by Physician-A.

P 10's medical record lacked evidence of nurse to physician notification regarding the C-SSRS high risk level.
P10's medical record lacked evidence of a suicidal precaution one-to-one monitoring order, confirmed by Administrator-A.
P10's medical record lacked evidence of suicidal one-to-one monitoring documentation per facility policy, confirmed by Administrator-A.
P10's medical record lacked evidence of patient-specific risks and benefits on the physician certification transfer form.

C. During an interview on 6/4/2025 at 8:55AM, Physician-A confirmed P10's medical record lacked a suicide precaution order and documentation of one-on-one monitoring of safety on 2/13/2025 from 9:28AM to 1:30PM until transferred to another facility for inpatient psychiatric care.

Based on policy review, and medical record review the facility failed to ensure 1 (Patient 10) of 1 transfer consent form was complete with patient-specific risks and benefits by the physician and last vital signs. This failed practice has the potential to cause negative outcomes for any patients who require transfer to a higher level of care. According to facility provided data the ED transferred an average of 34 patients per month.

See citation A2407 and A2049, that also resulted in A2400 to not be met.

A. Review of facility policy, Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department (EMTALA), last approved 8/2024 revealed, "physician certification refers to the written certification signed by a physician prior to ordering the transfer of an individual with an EMC (Emergency medical condition), or if a physician is not physically present at the time of transfer, signed by a QMP (qualified medical professional) after consultation with a physician, who subsequently signs the certification. All Physician Certifications shall include a summary of the benefits and risks upon which the certification is based."

-The hospital will send to the receiving facility copies of all pertinent medical records available at the time of transfer, including......(8) a copy of the completed applicable sections of the "Transfer Consent."

B. Review of P10's medical record revealed, P10 presented to the critical access hospital on 2/13/2025 at 9:28AM via car, walk-in, with a chief complaint of suicidal thoughts. The patient was accepted by a capable facility for transfer to a higher level of care.

P10's medical record lacked evidence of patient-specific risks and benefits on the physician certification transfer form.

P10's medical record transfer consent form lacked evidence of vitals prior to departure and time [blank].