HospitalInspections.org

Based on interview and document review, the hospital failed to ensure verbalized feelings of worsening depression and suicidal ideation were comprehensively assessed and addressed using readily available mental health diagnostic services for 1 of 1 patient (P1) who presented to the emergency department (ED) reporting such symptoms.

Findings include:

On 6/9/21, at 3:45 p.m. P1's family member (FM)-B was interviewed. FM-B explained he found P1 at his home on the morning of 4/21/21, when he had been prompted to check on him after P1 began posting increasingly concerning and cryptic social media posts alluding to worsening depression and potential suicide ideation. P1 had been consuming alcohol when he was found; however, FM-B voiced he was unsure "how heavily." FM-B stated he convinced P1 to come over to his house, so as to be kept under closer supervision, when P1 voiced he felt he needed to be taken to the hospital as he "needed help." P1 and FM-B then presented to the Fairview Northland Regional Hospital ED on 4/21/21, in the early morning where P1 was screened and evaluated by the physician for his symptoms. FM-B voiced the physician talked to P1 regarding starting antidepressant medication and made P1 promise him (the physician) he would not harm himself before he discharged P1 back to his own care. FM-B stated there was no counseling or mental health evaluation(s) offered to P1 in the ED despite his worsening symptoms and suicidal ideation which "blew me [him] away," and made FM-B question if more review or questioning into P1's symptoms should have happened to ensure he did continue to worsen.

On 6/10/21, at 9:57 a.m. the hospital's ED was toured with charge registered nurse (RN)-A. The ED consisted of 17 beds with two rooms being used, as needed, for "mental health rooms" which had the ability to be locked down and ligature risks removed. RN-A voiced the hospital campus did not have inpatient mental health unit(s) available, however, if such service was needed then the patients would be housed at the ED until placement could be secured at another campus. RN-A explained these rooms were used on a case-by-case basis, however, often used for any type of "self-harm" behaviors or "any sort of suicidal ideation."

On 6/10/21, at 10:12 a.m. RN-A was interviewed and explained patients who present to the ED were triaged for their immediate suicide risk and, at times, a "contract for safety" is done with them. RN-A described this process as either a verbal or written 'contract' between the patient and the physician where they discuss statements such as, "Promise me you won't hurt yourself while here," or a statement to such effect with the patient. RN-A explained when patients present to the ED for mental health or suicidal ideation-related issues, it's often as they're in "a crisis situation," and a resource the ED has available to help these patients is "a DEC [Diagnostic Evaluation Center] process." RN-A described this as a tele-health visit which connects the patient to mental health professionals at another Fairview campus who are trained to evaluate and assist the ED staff, including the physicians, with reviewing the patient and their mental health situation. This often includes the current symptoms, current or future coping skills the patient has, identifying potential stressors which are exacerbating the patient's mental health issues, and providing the patients with resources to help the patient succeed when they leave the ED. RN-A stated this service was available to the ED on a 24/7 basis, and she expressed it was not implemented as part of a formal protocol or triage tool to her knowledge but rather is used solely when ordered by the provider at their discretion. RN-A voiced any patient who presented with suicidal ideation would typically have this process completed to her knowledge, as just allowing such patient to leave the ED under just their families care could be a "risky situation." Further, RN-A voiced she was unaware of any recent education or revisions to this DEC process within the past several months adding, "Nothing has changed [with it]."

On 6/10/21, at approximately 10:30 a.m. P1's medical record was reviewed with RN-A and the acting ED manager (EDM) which identified:

P1's ED Care Timeline, dated 4/21/21, identified P1 arrived in the ED on 4/21/21, at 5:47 a.m. and listed multiple complaints including, "Medication," and "Depression." An attached, "ED Notes" was completed by registered nurse (RN)-C which outlined P1 presented hoping to get started on antidepressant medications. The note continued, "[P1] reports feeling suicidal 'for the last 8 years.' When asked if he had any active suicidal thoughts he replied 'no.' Patient admits to ETOH [alcohol] tonight. Is calm and cooperative, has a friend here with him." P1's physician was assigned as medical doctor (MD)-A, and an ED Suicide Screening was completed at 5:56 a.m. which identified P1 as admitting to feeling down, depressed or hopeless in the past two weeks; however, P1 denied having thoughts of killing himself or attempting to kill himself when questioned. The section continued and identified, "Provider notified." Further, a section on the timeline listed as, "Adult Psych," outlined P1 as being calm, sad and cooperative with an additional subsection reading, "Suicide/Homicide Risk," which recorded P1's suicidality as, "WDL [within defined limits] except ... Chronic thought with no plan." In addition, the timeline identified discharge order(s) were placed for P1 to begin Zoloft (an anti-depressant medication) and P1 was discharged from the ED in stable condition at 6:24 a.m.

P1's ED Provider Note, authored by MD-A and dated 4/21/21, identified P1 presented to the ED with " ... concerns about increasing depression." The note continued and outlined P1 had a long-standing history of depression but had "more problems" in the past few months along with, "Occasional vague thoughts of harming himself but that has been present for years. No active plan." The note identified P1 had been hospitalized back in 2015 and started on an anti-depressant medication; however, it "made him angry." The note added, "[P1] was hoping to get started on something today in hopes of feeling better in the future. He feels safe going home and his friend is in agreement." A "Physical Exam" was provided which outlined a subsection labeled, "Psychiatric." This recorded, "Thought Content: ... includes suicidal (vague concept, no active thought/plan) ideation. Thought content does not include suicidal plan." An additional section, labeled "ED Course," outlined P1 was provided a prescription for Zoloft and MD-A directed him to return to the clinic to establish primary care in the coming weeks. The note concluded, "He contracted for safety and was appreciative. Verbal and written discharge instructions given. He and his friend are comfortable with this plan."

P1's corresponding After Visit Summary (AVS), dated 4/21/21, identified P1 was seen in the ED for depression and listed a section labeled, "Instructions." This outlined, "Start the Zoloft today. As we discussed ... It takes at least 4 - 6 weeks for the medication to have a full effect and you should be on it at least 6 months [for] hopes of inducing remission. Recheck in clinic in 3 - 4 weeks, before your prescription runs out. Please return to the ED if you worsen or have any thoughts of hurting yourself or anyone else." The summary then provided a pharmacy where the prescribed Zoloft could be picked-up along with two different physicians names P1 could use to establish care with in the future. The summary was then signed as being acknowledged and received by P1 along with RN-B. However, P1's record lacked evidence P1 had been provided and/or offered resources (i.e., mental health counseling contacts, the suicide hotline) to ensure his mental health condition did not deteriorate further. Further, there was no evidence the ED had consulted with it's available DEC resources to help assess and provide care to P1, despite his documented history or worsening depression, alcohol use, and long-standing thoughts of suicidal ideation. In addition, there was no rationale documented on why this consultation was not offered and/or provided to P1 despite those identified symptoms.

RN-A and EDM acknowledged P1's record and verified there was no evidence a DEC evaluation had been offered or provided to P1 despite the outlined symptoms and use of alcohol, nor was there evidence mental health counseling or resources were discussed or provided to P1. RN-A reiterated a DEC evaluation would typically be used if "there's any need for further mental health evaluation," and added she felt MD-A typically had a "good feel for people" and trusted his opinions and care.

On 6/10/21, at 2:15 p.m. RN-B was interviewed, and verified she was the nurse who worked with P1 when he presented to the ED on 4/21/21. RN-B recalled P1 explaining he was in the ED for depression and wanted to "get on something to feel better." P1 denied being actively suicidal at the time; however, RN-B affirmed she reviewed P1's suicide risk with MD-A who voiced P1 did not require active monitoring or supervision. RN-B voiced she did not recall a DEC evaluation being discussed or offered to P1 while he was present in the ED; however, acknowledged she was aware of the services and voiced such service' use was a physician decision. RN-B explained the DEC evaluation was not only intended for use when a patient was suicidal but rather the evaluation could be used for many mental health conditions or reasons, including worsening depression, adding there was no "specific criteria" for it's use to her knowledge. RN-B explained the DEC evaluation included providing the patient with resources which could be used for their mental health (i.e., suicide hotline, contact information for mental health professionals) needs, and voiced any hospital provided or offered mental health resources should be listed and recorded on the AVS. RN-B stated she could not recall what resources, if any, were reviewed with P1 before his discharge from the hospital. The interview continued and RN-B expressed a 'contract for safety' was typically completed in collaboration with the DEC evaluation team and the patient would a sign a "physical piece of paper" which outlines their plan for safety. However, RN-B voiced P1's completed contract was more "like a verbal agreement" than a physical signature adding she was "not sure" what , if any, steps or plans had been discussed between MD-A and P1 to ensure his condition did not worsen. Further, RN-B voiced she was unaware of any concerns or re-education being completed on the DEC evaluation process in the past few months.

On 6/10/21, at 2:56 p.m. the vice president of medical affairs (VP)-A and the director of quality (DOQ) were interviewed. VP-A voiced the physician and nurse were responsible to evaluate the patients presenting to the ED, and "based on that clinical assessment," they would determine if a DEC evaluation would be needed or beneficial to the patient. VP-A voiced there was a factor a "clinical judgement" which was used to determine if such evaluation would be needed and voiced the evaluation' use "can be different" from provider to provider. Further, VP-A expressed he was "not aware we have an actual contract we have patients sign" for situations which require such.

When interviewed on 6/11/21, at 8:30 a.m. MD-A verified he had reviewed P1's medical record and had been the physician who provided care to P1 in the ED on 4/21/21. MD-A explained the ED encounter on 4/21/21, had been the first time he had seen P1 regarding his depression. P1 voiced he had depression for "half of his life" along with "intermittent thoughts of suicide" but those had not changed; rather P1 presented to the ED as he had a work schedule which was not conducive to clinic hours and "wanted to get started on medicines" to help him mentally feel better. MD-A expressed he had been a family practice physician prior to working in the ED and felt "very comfortable" starting a new medication regimen for P1 until he was able to be seen in clinic which could have taken several more weeks. MD-A stated he felt they had a plan in place for P1 and "all three of us [P1, FM-B and MD-A]" were in agreement. MD-A voiced he did verbally contract for safety with P1 and directed him to return to the ED if his symptoms worsen adding he had reviewed P1's medical record several times since 4/21/21, and "still don't know what I would have done different" in hindsight. MD-A then explained the DEC evaluation process and voiced he felt he used the service routinely for patients for mental health concerns. MD-A verified the DEC evaluation process was not only consulted for suicide ideation but could be consulted for a variety of mental health issues. MD-A explained he did not consult or request the DEC evaluation for P1 as he didn't have "an active plan" for suicide, so they "moved on" and discussed starting new anti-depressant medication. MD-A described the DEC evaluation as doing "a nice job" of sorting out patient's mental health issues and helping the physician and patient "get to the bottom of things" and start to facilitate services for them. MD-A added, "[The DEC] was a good middleman" as mental health issues and concerns take time to address. MD-A voiced he did not consult with the DEC service for P1 on 4/21/21, as P1 wouldn't have met criteria for in-patient admission and, seeing as he just wanted medications, felt he "didn't want to waste the DEC's time." MD-A added he was unsure of the hospital's policy for when a DEC evaluation should be sought or completed but added, "If I have any doubt, I get the DEC involved." Further, MD-A stated he did not provide P1 with any resources (i.e., suicide hotline, mental health counseling contacts) on 4/21/21, as he reiterated P1 only presented for medication to help him feel better and "the DEC is not going to help with that."

On 6/11/21, at 9:00 a.m. the director of clinical triage and health (DCH) was interviewed and explained he helped to oversee the hospital's assessment services, including the DEC, which were available for mental health patients. DCH voiced ED(s) do not always have "the best resources" to assess mental health patients which the DEC evaluation could provide as it connects the patient to mental health professionals. They are then able to consult with the ED physician to help determine the next steps and plan for the patient. DCH verified this service was available to the hospital ED on a "twenty-four seven" basis, and could be used for a variety of mental health conditions, including suicidal ideation and worsening depression. DCH explained depression, or worsening depression, was actually one of the "most common" reasons they're consulted and using the DEC service would help to ensure a "comprehensive look at the situation" was completed. DCH voiced anytime a mental health concern presents to the ED, their recommendation is to "get us involved" as mental health takes time and resources to be adequately addressed adding, "[mental health] is not something that moves fast." P1's general presentation to the ED was then reviewed with DCH who voiced he felt the DEC evaluation could have helped P1, especially since anti-depressant medication does not have "immediate effect" and added had a DEC evaluation been completed it would have reviewed P1's triggers for his depression, coping skills and just overall "look more deeply at the full situation." DCH added the ED setting was usually "a snapshot in time" for a patient, and the DEC process helps to "build a movie, not a picture" of a patient's mental health situation. Further, DCH explained they were still working with many of their hospital system ED's to better address mental health needs and "be as prepared as possible" for situations like P1's.

On 6/11/21, at 12:08 p.m. DOQ, EDM, and the quality improvement consultant (QIC) were interviewed. They verified the DEC evaluation was used at physician or provider discretion along with being more "built into" their suicide risk policy. If a patient was not suicidal, then a DEC evaluation could be requested or treated like "any other consult" the hospital had available to it. Further, they were aware some concerns had been raised with the care and services provided to P1 on 4/21/21, and they were performing a root-cause style review of the situation and care provided to help determine if action needed to be done.

A provided DEC Crisis Assessment Services policy, dated 2018, identified the DEC as a standardized, comprehensive process developed to enhance the assessment and care planning for patients who experience a behavioral crisis. This included, " ... allows licensed mental health professionals to perform a crisis behavioral assessment, immediately access scheduling and facilitation of the care patients need and electronically coordinate care with all health care providers involved with the patient. The process also includes follow up with patients who are not admitted to an inpatient behavioral health unit to encourage that patients attend the follow-up appointments that were scheduled and/or recommended." The policy outlined patients' this service may benefit which included, "All mental health diagnoses, including co-occurring conditions ..." Further, the policy outlined by using the service that several benefits would be presented including a thorough risk assessment and development of a risk mitigation strategy, post-discharge follow-up contact and having a clinician spend time with patients without disrupting physician workload in other hospital settings.