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Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to follow adopted policies related to documentation of psychiatric evaluations and/or documentation indicating the need or lack of need of psychiatric consultation and/or follow up in two of 23 medical records (MR1, MR13 ), failed to follow adopted policies related to documentation of continuous patient observation in nine of 23 medical records (MR1, MR3, MR4, MR13, MR16, MR19, MR21, MR23, MR24 ), and failed to follow adopted policies related to documentation of belongings search and/or removal of patient belongings in four of 23 medical records reviewed. (MR1, MR4, MR19, MR21 ) (A1104)

Findings include:

Review of the facility's policy entitled "Subject: Psychiatric Patients", dated December 2012, stated "A. Triage. 1. The psychiatric patient should be triaged in the same manner as any other patient. They should receive priority care. 2. Examination room #4 should be used, when available. 3. A potentially suicidal or violent patient shall be under continuous observation. 4. A member of the Emergency Department staff, or security shall be assigned to observe the patient. B. Emergency Department evaluation should include: 1. A basic history should exclude organic problems such as listing of head trauma, endocrine disorders, drug/alcohol abuse, medications including over-the-counter preparations and history of psychiatric problems. 2. Physical exam should look for evidence of the aforementioned including wrist scars, multiple surgical scars, cigarette burns, needle tracks. 3. Basic laboratory as indicated, a blood sugar in particular should be considered. 4. Psychiatric interview should be conducted using open-ended questions and should result in basic information on the nature of the problem and its duration. 5. The patient shall be searched for weapons and/or medication, undressed and given hospital attire to wear. All personal belongings and clothing will be removed from the patient's room and placed in the nurses' station. C. Referral/Consultation* - For suspected life-threatening disorders. (Patient may be dangerous to himself or to others). Clear documentation of thee (sic) Emergency Department evaluation impression, need or lack of need for immediate consultation and the disposition or follow up care ... D. For non-life threatening disorders where immediate admission is not necessary: 1. If the patient is currently under therapy by an agency or private counselor, referral will be made back to that counseling source. 2. If the patient is not currently under therapy, he/she will be referred as follows: a. For psychiatric disorders - Arrangements will made by contacting the Center for Community Resources ... c. Or to the Psychiatric service of their insurance company. The patient or his family may be given instructions to take this action, but the Emergency Department may facilitate this by directly contacting the appropriate counseling service. E. High Risk Patients. 1. While the patient is in the Emergency Services Department as an involuntary commitment or as a high risk voluntary commitment, visual observations will occur as per hospital patient care policy #144 and as a standing order per Medical Director of Emergency Services. 2. Documentation of that observation will be done as defined in hospital patient care policy #144. Observation can only be discontinued with a written order from the physician. 3. Security will be notified of all patients who exhibit the potential harm self or others and a security officer or other appropriate personnel will be stationed at the exam door to maintain visual observation ... ."

Review of the facility's policy entitled "P.C. No.: 144, Subject: Care of Psychiatric or Substance Abuse Patients in the Acute Care Setting", effective date July 2012, review date June 2012, revealed "Procedure: If the patient presents to the Emergency Department with a psychiatric or substance abuse diagnosis, and the patient is medically stable, the Emergency Department physician or attending physician may request a psychiatric assessment. Following the assessment, the results will be discussed with the patient or designee, and the patient will then be referred to the appropriate level of care depending on the results of the assessment ... Some patients with behavioral health and/or substance abuse issues may require close observation to ensure a safe and therapeutic environment for the patient and others. One on One Observation: A staff member is assigned to observe/check the patient every 15 minutes. The RN makes the decision if the patient should be placed in hospital attire following his/her assessment/reassessment. The patient's activity/behavior is documented every 15 minutes on the monitoring log ... A physician order is needed to discontinue 15 Minute Observation. A staff member is assigned to remain within arms length of the patient at all times. The patient's activity/behavior is documented every 15 minutes on the monitoring log. All potentially harmful items are removed from the room, i.e. sharp objects, belts, hangers, ropes, mirrors, glass, matches, lighters, electrical appliances, blood pressure apparatus, etc ... The patient is placed in hospital attire ... Precautions if a Patient Threatens to Harm Others: a. If a patient verbalizes ideation, threat, or intent to harm another person or defined group to any staff member, the staff member reports this verbalization to the charge nurse. b. The charge nurse informs the nurse manager and/or shift coordinator and attending physician. c. The attending physician may order a psychiatric consult. d. The staff member to whom the patient verbalized the ideation, threat, or intent to harm another person or defined group documents in the medical record the exact words verbalized by the patient using quotation marks ... ."

Review of the facility's policy entitled "Subject: Emergency Medical Treatment and Active Labor Act (EMTALA), dated August 2010, revealed "... Policy ... 1. All individuals who come to the Emergency Department (ED), Urgi-Care (UC), and Labor and Delivery are of the Obstetrical Department requesting examination and treatment shall be provided with an appropriate MSE ... 4. The MSE will include any appropriate ancillary services ... routinely available to the ED or UC, and must be similar for patients presenting with similar symptoms. 5. The MSE will be performed in order to determine if the patient is experiencing an emergency medical condition. a. An emergency medical condition is defined as a condition manifesting symptoms (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) which, in the absence of immediate medical attention, is likely to cause serious dysfunction or serious jeopardy to the health of individual or unborn child ... ."

A review of the Medical Staff Bylaws/Rules and Regulations, dated December 8, 2011, revealed "Rules and Regulations ... Article IV. Consultations ... Section 5. Psychiatric Consultations. Psychiatric consultation and treatment shall be requested for and offered to all patients who have engaged in self-destructive behavior (e.g., attempted suicide, chemical overdose). If psychiatric care is recommended, evidence that such care has at least been offered and/or an appropriate referral made must be documented in the patient's medical record ... ."

1) During review of MR1 and MR13, it was noted that the medical records did not contain documentation of a psychiatric evaluation and/or documentation indicating the need or lack of need for immediate psychiatric consultation and/or follow up care.

Review MR1 revealed "... States [they are] having suicidal thoughts ... Also having homicidal thoughts ... OTH1 into speak with pt and pt to be D/C'd ... ." Continued review of MR1 revealed no physician documentation of a psychiatric evaluation related to suicidal/homicidal thoughts. It was also noted that the record did not contain documentation indicating the need or lack of need of psychiatric consultation and/or follow up.

Interview with OTH1, in the presence of EMP6 and EMP12, on September 5, 2012, at 10:20AM, revealed "... I remember asking [the patient] why [they] felt that way. I failed to document. I asked [the patient] if [they] were suicidal/homicidal now, and [the patient] said no. I didn't think [the patient] was psychotic or a danger ... ."

Review of MR13 revealed "... Pt being evaluated for suicide attempt ... Pt. denies suicidal and homicidal thoughts. Pt. has bye scratched on left forearm and texted ... that [they were] going to harm [themselves] ... ." Subsequent documentation revealed "... Denies suicidal thoughts. Will be staying with ... tonight. Discharged in good condition ... ."
Continued review of MR13 revealed physician documentation which stated "... History of Present Illness. Chief Complaint - Drug Overdose. This occurred just prior to arrival ... [Ambulance Service] reports pt sent text ... stating [they were] going to hurt [themselves] ... Pt has reddened area on ... left forearm that says "bye" ... Pt denies any suicidal/homicidal thoughts upon arrival to ED ...Physical Exam ... Neuro: Alert. Oriented x 3. Mood/affect normal. Speech normal. No motor deficit. No sensory deficit ... Progress and Procedures. Patient counseled in person regarding the patient's condition, test results and diagnosis ... Disposition: Condition: good. Discharged home. Discharged home in good condition. Clinical Impression. Mild depression (major disorder). Accidental overdose ... ."
It was noted that the record did not contain documentation indicating the need or lack of need of psychiatric consultation and/or follow up.
Interview with EMP3 on September 5, 2012, revealed "This is when the discharge bundle would come in, including Mobile Crisis and contract for safety."
2) During review of MR1, MR3, MR4, MR13, MR16, MR19, MR21, MR23, and MR24, it was noted that all patients presented to the Emergency Department with Suicidal Ideation and/or attempted self harm. Review of all of the medical records revealed no documentation that the patients were placed in continuous/one on one observation, following triage.

An interview on July 26, 2012, at approximately 10:05 AM, with EMP3, regarding the expectations when an individual comes in with suicidal/homicidal thoughts, EMP3 replied "A psychological assessment is done, and give proper treatment, contract for safety and follow up as outpatient." Further interview with EMP3 revealed "The policy states the patient should be on suicide precautions ... Should be continuous observation."

Interview with EMP3, regarding MR3, and documentation of continuous observation, on July 26, 2012, revealed "It's not clear documentation. I cannot tell that someone was in the room the whole time."
During review of MR4, EMP3 stated on July 26, 2012, that the policy states the patient should be on suicide precautions, and confirmed that there should have been continuous observation and confirmed that continuous observation is not documented in the nurse's notes.
During review of MR24, EMP3 confirmed on July 26, 2012, that there is no documentation of one on one observation/continuous observation in the medical record.
EMP6 confirmed on September 10, 2012, that the facility found no documentation of one on one observations related to MR13, MR16, MR19, MR21, and MR23.
3) Review of MR1, MR4, MR19, and MR21, revealed all patients presented to the Emergency Department with Suicidal Ideation and/or attempted self harm. During the review of MR1, MR19, and MR21, it was noted that there was no documentation indicating that patient's belongings were removed from the room and/or searched by facility staff for weapons or medication.
Review of MR4 revealed the patient had personal belongings in their possession. Review of MR4, dated July 3, 2012, revealed nursing documentation which stated "... Pt arrives into ER via PSP with ETOH and being suicidal. Pt well known to PSP and trooper sts that pt frequently does this when [they] drink. Pt with superficial lacerations to left wrist and scratches to chest. Pt sts did this with a knife. Hx of cutting. Pt sts [they] are crazy and was upset b/c [they] can't see [their] grandchildren ... Belongings searched by EMP14 and PST troopers ... Continue review of the medical record revealed the following additional nursing documentation: July 3, 2012, 0315: "Pt getting undressed at this time. PSP stated pt had no weapons on person except for nail clippers ... ."July 3, 2012, 0325: "Upon entering room to inform pt that [they] could get dressed, pt was found to be laying on [their] stomach with brown belt around neck and anchored to bed. Pt with strong grip on end of belt that required Trooper ... to release with force. Multiple staff in room along with Dr ... ." Belt was loosened and removed from around pt neck. Pt with redness noted to neck ... Stretcher, linens and pt gown removed from room, mattress placed on floor. PSP remain in Dept. Security called. Pt then per PSP proceeded to attempt to put finger in light sockets."
Interview with EMP3 on July 26, 2012, confirmed that the patient associated with MR4 had retained a belt in their possession.