HospitalInspections.org

Based on review of the facility policies and procedure, Medical Staff Bylaws and Rules and Regulations, Medical Record (MR) review and interviews with staff it was determined the facility failed to:

1. Identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) in the facility bylaws or rules and regulations.

2. Provide 1:1 observation for a patient at risk for suicide.

3. Prevent a patient at risk for suicide from leaving the Emergency Department (ED) prior to the completion of the MSE.

4. Reassess a patient diagnosed with Suicide Ideation (SI) with a suicide attempt to demonstrate capacity to sign out Against Medical Advice (AMA)

The findings include:

Refer to A 2406 and A 2407 for findings.

Based on review of the facility policies and procedure, Medical Staff Bylaws and Rules and Regulations, Medical Record (MR) review and interviews with staff it was determined the facility failed to:

1. Identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) in the facility bylaws or rules and regulations.

2. Provide 1:1 observation for a patient at risk for suicide.

3. Prevent a patient at risk for suicide from leaving the Emergency Department (ED) prior to the completion of the MSE.

This deficient practice affected 1 of 2 MR reviewed of psychiatric patients who eloped from ED, including Patient Identifier (PI) # 13 and had the potential to affect all patients treated at this facility.

Findings include:

Policy: (Emergency Medical Treatment and Labor Act) EMTALA.0002
Title: Medical Screening Exams and Stabilization
Effective Date: 1/6/2020

Policy:

...6. MSE's are provided by Qualified Medical Personnel described below:

a. ED Physicians and Advanced Practice Providers working under the direct supervision of an ED Physician...

Policy: P.PC.007
Title: Suicide Prevention
Effective Date: 1/21

Purpose: To identify patients at risk for suicide, assess the severity and immediacy of risk and implement precautions/processes to prevent patients from harming themselves by providing intervention, mental health consultation when appropriate and safer transition of care.

Guideline: Patients are screened for suicide risk using the primary screening tool (Patient Health Questionnaire-2) in the... ED setting. Secondary screening using the Columbia-Suicide Severity Rating Scale (C-SSRS) completed on patients with positive response to primary screen and/or the primary reason for care is a behavioral health condition.

Procedure:

...3. Positive (yes) responses to the primary screen prompts further assessment using the C-SSRS...

...5. Risk level and interventions are determined by patient response to C-SSRS:
a. High Risk: Place patient on continuous 1:1 (1 to 1) observation...

6. Documentation of observations:
a. For High Risk patients that are on 1:1 observation document Q (every) 15 minutes...

7. Suicide precautions/interventions:

...b. Notify security to scan patient.
...c. Ask the patient to remove clothing and have patient dress in hospital issued paper scrubs or gown.
d. Patient belongings searched for any unsafe items or ligature risks that may be a safety risk.
e. Assess the physical environment; remove any items from the room that may be unsafe for a patient at risk for suicide and document on the Non-Dedicated Room Environment form...

...11. Initiate psychiatric consult as directed by physician.

...Sitters for 1:1 Observation:

14. When a patient has been identified at high risk for suicide...the nurse notifies the unit director and/or clinical supervisor of the need for a sitter.

...17. Nurse provides the sitter with the 1:1 Observation documentation form.

18. Sitter documents on the form clearly in ink every 15 minutes observations of behavior, activity, and location.

...25. Completed Observation forms are placed into the MR.

...31. Sitter remains with the patient at all times - this includes...when visitors are present.


1. The facility bylaws and rules and regulations were received from Employee Identifier (EI) # 1, Director of Emergency Services, on 4/6/2021.

Review of the facility bylaws and rules and regulations on 4/6/2021 revealed no documentation to identify and approve the individual(s) qualified to perform the MSE in the ED.

An interview was conducted with EI # 2, President, on 4/6/2021 at 4:57 PM who confirmed there was no documentation to identify and approve the individual(s) qualified to perform the MSE in the facility Medical Staff Bylaws and Rules and Regulations.

2. PI # 13 presented to the ED on 1/4/21 at 9:49 AM with a chief complaint of Psych (Psychiatric) - High Risk.

Review of the ED Triage Form dated 1/4/21 at 9:50 AM revealed "patient is a known drug abuser. He/She is reporting that he/she has had thoughts of wanting to hurt himself/herself..." A Suicide Risk Screening was performed of which the patient answered "yes" to both having a little interest or pleasure in doing things over the last month and feeling down, depressed, or hopeless over the last month. A C-SSRS was completed and the patient scored a 5 which is documented as "high risk." PI # 13 vital signs were; Blood Pressure (BP) 128/82, Pulse 108, Respirations 16, Pulse oximetry 100 %, and Temperature 99.5.

Review of the MR revealed no documentation of a nursing assessment throughout the patient's ED stay from 9:49 AM until 4:29 PM, which was 6 hours and 40 minutes.

Review of the ED Physician examination dated 1/4/21 at 10:14 AM revealed documentation of "pt (patient)...presenting with report of suicidal thoughts, pt reports he/she does not feel suicidal but has been having the thoughts, pt reports last night, to stop the thoughts he/she snorted 6 500 mg (milligram) Tylenol...pt reports he/she does not want to die but wants the thoughts to stop....Psychiatric Complaints: reports: Suicidal Ideation (SI)...Suicide Risk Assessment: drug or ETOH (alcohol) abuse, organized plan, frightened friends-family. Suicidal Attempt Method: reports: overdose."

Review of the nursing notes dated 1/4/21 at 10:30 AM revealed documentation a request was placed for a "...psych assessment for SI, known drug use."

Review of the physician orders revealed an inpatient consult for psych was ordered on 1/4/21 at 10:33 AM.

Review of the nursing notes revealed laboratory testing was obtained from the patient on 1/4/21 at 10:38 AM. There was no further documentation of patient interventions after the laboratory testing was obtained.

Review of the nursing notes dated 1/4/21 at 4:15 PM revealed documentation of "called Decatur West (facility inpatient psychiatric hospital) to request evaluation for this patient."

Review of the nursing notes dated 1/4/21 at 4:29 PM revealed documentation of "patient and his/her father left befor (before) treatment completed."

Review of the ED physician departure note dated 1/4/21 at 4:29 PM revealed documentation of discharge disposition as "left before treatment comp (completed)" and a diagnosis of "SI, Substance Abuse."

Review of the Decatur West Patient Notes dated 1/4/21 at 4:29 PM revealed documentation of "logged on to see patient. After waiting 15 mins (minutes) was informed that patient and his/her father had left the ER (Emergency room)."

Review of the ED Census on 1/4/21 from 9:00 AM until 4:30 PM revealed PI # 13 was placed in the ED main waiting area following triage and the ED physician examination and was not documented as leaving the waiting area for the entire ED stay from 9:49 AM until 4:29 PM, which was 6 hours and 40 minutes. Further review of the ED Census on 1/4/21 from 9:00 AM until 4:30 PM revealed an ED bed was not available until another patient was discharged at 3:10 PM from ED bed 14. ED bed 14 was filled with a patient who arrived at 3:42 PM with inability to void for 24 hours.

Review of ED Staffing Report dated 1/4/21 from 9:00 AM until 4:30 PM revealed the ED had standard staffing for 1/4/21.

Review of the MR revealed no documentation security was notified to scan the patient, the patient was placed on 1:1 observation, the staff observed the patient leave, the patient was issued paper scrubs or a gown, the patient's belongings were searched for any unsafe items or ligature risks, a sitter was requested nor remained with the patient per the facility policy. The patient was placed in the ED waiting area for over 6 hours with no documentation the physical environment was assessed for items that may be unsafe for a patient at risk for suicide.

The facility failed to ensure a patient at risk for suicide was provided a complete MSE, including a physician ordered psychiatric evaluation, by not following facility policy and procedure for suicide precautions and allowing the patient to leave prior to the completion of the MSE.

An interview was conducted on 4/7/21 at 4:29 PM with Employee Identifier (EI) # 1, Director of Emergency Services, who confirmed the patient received the triage assessment and ED physician evaluation in the triage area of the ED and then was placed in the ED waiting area, in which the patient remained until leaving the ED. EI # 1 also confirmed there was no documentation of a 1:1 observation nor another intervention was completed following the laboratory test being obtained at 10:38 AM and the patient was allowed to leave prior to the ordered inpatient psychiatric evaluation being completed. During the interview, EI # 1 was asked if the facility policy allowed for the 1:1 observation to be performed by a family member or another person other than facility staff. EI # 1 stated, "No, we require it to be a member of our staff. All of our staff are trained to be sitters."

An interview was conducted via email on 4/16/21 at 1:18 PM with EI # 10, Vice President of Clinical Operations, who confirmed on 1/4/21 ED bed 14 was open from 3:10 PM, when another patient was discharge, until a patient was placed in the bed who arrived at 3:42 PM with inability to void for 24 hours. EI # 10 also confirmed the ED had standard staffing on 1/4/21 between the hours of 9:00 AM and 4:30 PM.

Based on review of the facility policies and procedures, medical records (MRs) and staff interviews it was determined the facility failed to ensure a patient diagnosed with Suicide Ideation (SI) with a suicide attempt were reassessed to demonstrate capacity to sign out Against Medical Advice (AMA).

The deficient practice affected 1 of 5 patients reviewed who left AMA with a psychiatric diagnosis, including Patient Identifier (PI) # 21 and had the potential to affect all patients served by the facility Emergency Department (ED).

Findings include:

Policy: P.RI.0002
Title: Discharge AMA
Effective Date: 1/2021

Purpose:
Decatur Morgan (DMH) recognizes that every adult with decision making capacity has the right to make informed decisions regarding discharge...

Procedure:

...f. Patients decision making capacity at time of AMA is documented.

Policy: P.PC.007
Title: Suicide Prevention
Effective Date: 1/2021

Purpose: To identify patients at risk for suicide, assess the severity and immediacy of risk and implement precautions/processes to prevent patients from harming themselves by providing...safer transition to care.

Guideline: Patients are screened for suicide risk using the primary screening tool (Patient Health Questionnaire-2) in the... ED setting. Secondary screening using the Columbia-Suicide Severity Rating Scale (C-SSRS) completed on patients with positive response to primary screen and/or the primary reason for care is a behavioral health condition.

Procedure:

...3. Positive (yes) responses to the primary screen prompts further assessment using the C-SSRS...

...13. Discharge:
a. Reassess patient for suicide risk prior to discharge...

1. PI # 21 presented to the ED on 3/15/21 at 9:34 PM.

Review of the triage assessment dated 3/15/21 at 9:34 PM revealed documentation the chief complaint was Suicide Attempt and the following vital signs: blood pressure (b/p) 134/91, temperature 98.9, pulse 89 and respirations 21. The history of the present illness was documented as "pt (patient) took Xanax and Marijuana for depression and attempted to cut bilateral wrist, no lacerations present. Friend on scene told EMS (Emergency Medical Services) he/she tried to overdose and pt denies. Vomiting was induced at scene." A suicide risk screening was documented with PI # 21 answering "yes" to both over the last month have you had little interest or pleasure in doing things and over the last month have you felt down, depressed, or hopeless. There was no documentation a C-SSRS was performed per facility policy.

Review of the nursing assessment dated 3/15/21 at 10:29 PM revealed documentation of the description of symptoms as "SI thoughts and depression..." The pupilary response was noted to be "sluggish." The past mental health history was documented as "Bipolar, Depression, Schizophrenia/Schizoaffective Disorder, Substance Abuse."

Review of the nursing note dated 3/15/21 at 11:12 PM revealed documentation of "...pt (patient) pulled all monitoring leads off and refused to keep leads on. Primary nurse asked pt to keep them on, pt throws hand up and says 'you need to get away and stay away from me'..."

Review of the ED physician assessment at 11:19 PM revealed documentation of the nature of presenting problem as "...SI, admits to taking 2 pills, 2 mg (milligram) Xanax and by cutting his/her left wrist tonight. No laceration to either wrist. Has attempted suicide prior to tonight by jumping out of a vehicle, taking overdoses, attempting to shoot himself/herself in the head but the gun jammed..." The onset/duration was documented as "reports: just prior to arrival", the timing as "reports: still present", and severity as "reports: severe." The psychiatric complaints are documented as "reports: angry, agitated, anxiety, depressed, irritability, SI..." The suicide risk assessment was documented as "...depressed, prior attempt, drug or ETOH (alcohol) abuse, organized plan" with a clinician's estimation of suicide risk of "high risk." The suicidal attempt method is documented as "reports: overdose, stabbing/cutting." The ED physician's physical exam documented neurological findings of "agitated, anxious", Behavior/Eye Contact/Speech finding of "cooperative, avoids eye contact, threatening eye contact" and thoughts/hallucinations as "flight of ideas."

Review of the urine drug screen dated 3/16/21 at 1:29 AM, revealed documentation PI # 21 was positive for Benzodiazepine and Cannabinoids.

Review of the nursing documentation revealed on 3/16/21 at 2:19 AM, the facility inpatient psychiatric hospital (Decatur Morgan West) was called to evaluate PI # 21.

Review of the Decatur Morgan West (DMW) assessment dated 3/16/21 at 4:09 AM revealed the following documentation: Specific reason for referral..."pt. presenting at Decatur Main after reportedly taking Xanax and smoking Marijuana in a suicide attempt. Pt friend induced vomiting on the scene and phoned police. Once at ED pt told his/her nurse and this screener that he/she only took 2 or 3 Xanax in order to 'clear my head.' pt has been diagnosed with Bipolar Disorder, Depression, Schizophrenia and Schizoaffective Disorder and hx (history) of substance abuse..." Presenting problem in patient's own words: "I have been hearing these voices in my head for years and they just don't stop. Last night I thought that if I took the Xanax they might go away... Suicide Ideation: "Yes"; Suicidal Plan: "No: 'I really don't have a plan.' " Has patient attempted suicide within the last 48 hours: "Yes"; Explain: "Overdose and attempted to cut wrist."... Patient having Hallucinations: "Yes...auditory...'people talking in my head...sometimes I talk to them, other times I try to ignore them" When did (the) patient last have hallucinations: "Always, every day." History of aggression towards self or others: "yes"... Experiencing any anger issues: "frequent outbursts, breaks/throws things, frequent fights, threatening, hitting. "... Consciousness: Clouded; Patient Appearance: Disheveled; Orientation: Place; Speech Patterns: Pressured; Mood Description: Depressed, sad, anxious; Affect description: Sad, Anxious; Thought Process: Circumstantial; Memory: Short Term impaired; Judgement/Insight: Poor;...Patient Behavior: Suicidal statements, tearful, pressured speech...Admit per physician's order: "No"; Explain why or why not: "pt not appropriate for DMW..."

Review of the nursing documentation dated 3/16/21 at 5:25 AM, revealed documentation of "patient is very agitated and coming to his/her room door yelling he/she wants to leave the hospital and cussing at staff with his/her fists balled at his/her sides making threatening gestures and being very disruptive."

Review of the ED physician departure documentation dated 3/16/21 at 5:37 AM, revealed a diagnosis of "Suicide Ideation" and a discharge disposition of AMA with additional instructions of "I attempted to convince him/her to stay. It didn't work since West (DMW) wanted to transfer." The condition of PI # 21 was documented as "poor."

Review of the Release from Responsibility for Discharge Against Medical Advice for dated 3/16/21 at 5:37 AM revealed PI # 21 signed out AMA.

Review of the MR revealed no documentation the physician reassessed PI # 21 to demonstrate capacity to sign out AMA nor SI.

Review of the DMW patient note dated 3/16/21 at 5:54 AM revealed documentation of "per ED staff at Decatur Main, pt left AMA." There was no documentation DMW was notified of the patient requesting to leave AMA prior to PI # 21's departure from the facility in order to reassess PI # 21's ability to demonstrate capacity to sign out AMA nor SI.

An interview was conducted on 4/7/21 at 4:25 PM with Employee Identifier (EI) # 1, Director of Emergency Services, who was asked about the documentation PI # 21 was not appropriate for DMW. EI # 1 verbalized PI # 21 was documented as not appropriate for DMW due to PI # 21's "dual diagnosis." EI # 1 also confirmed there was no documentation a physician and/or DMW reassessed PI # 21 to demonstrate capacity to sign out AMA. EI # 1 was then asked if the physician should have reassessed PI # 21's mental capacity prior to the patient leaving AMA. EI # 1 stated, "I assume so."