HospitalInspections.org

Based on a review of documentation and interviews with staff, the hospital failed to comply with §489.24, as they failed to provide an appropriate medical screening exam and stabilizing treatment for two of twenty six patients reviewed. Refer to A2406

Based on facility policy, patient record review and confirmed in interviews, the facility failed to provide an appropriate and thorough medical screening examination (MSE), within the capability of the hospital's emergency department, including a psychiatric evaluation available to the emergency department for two of twenty six patients who presented to the emergency department (ED). (Patient ID #A and #B).

Findings included:

Review of the facility policy Triage Procedure (Version 3, 04/12/2022) it stated "to provide a standardized system whereby patients presenting to the Emergency Center are treated in order of priority based upon acuity utilizing the Emergency Severity Index (ESI) five level triage system.

Level 1: Critical
Level 2: Emergent
Level 3: Urgent
Level 4: Non-urgent
Level 5: Routine"

Patient #A
Review of the patient chart revealed Patient #A presented to the emergency department via walk in on 06/30/2024. "Patient complains of [suicide ideation]. Last drink last night, [history] of alcohol abuse. Reports chest pain x 1 year and anxious in triage."

Nurse (Staff #10 ) triaged the patient and assigned an acuity of 2 (Emergent).
Staff #10 assessed Patient #A for suicide risk on 07/29/2024 at 3:29 PM that included the following screening prompts and corresponding answers from the patient.

In the past two weeks, have you felt down, depressed or hopeless? patient #A responded "yes"
In the past two weeks, have you had thoughts of killing yourself? patient #A responded "yes"
In your lifetime, have you ever attempted to kill yourself? patient #A responded "yes"
If yes, when did this happen? within 24 hours? patient #A responded "yes"

Nurse Staff #13 reassessed Patient #A on 07/30/2024 at 3:59 PM that included the following Mental Status and Psych Assessment
Affect: Anxious
Thought Content: Appropriate
Mood: depressed
Attention and Concentration: Impaired
Behavior: Anxious
Hallucination: denied
Delusions: denied

In an interview with the ED Director (Staff #12) on 08/21/2024 at 10:05 AM, he stated "most patients with current, acute suicidal ideation or homicidal ideation will require a consult from the behavioral assessment team, and together with their recommendation will determine if patient psych needs will require further medical evaluation (inpatient treatment)."

Review of the physician notes (Staff #11) revealed no request for consult from the behavioral assessment team; no documentation of prior suicide attempts, thoughts of suicide ideation in the past month, delusions, impaired thought processes, or hallucinations. No documentation of the evaluation of the patient's behavior, speech, mood, thought process, perception, cognition, and insight. No follow up as to the questions and answers from the nursing staff of his mood and/or affect. Psychiatric evaluation is incomplete.

Review of the patient record revealed no documentation of a plan for immediate safety or clear outpatient follow-up other than generic referrals.

Review of the website from the NIH (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4724471), it stated "while all substances elevate the risk for suicidal behavior, alcohol and opioids are the most common substances identified in suicide decedents (22% and 20%, respectively), far above rates of marijuana (10.2%), cocaine (4.6%), and amphetamines (3.4%)....The 24-hour period following alcohol intoxication is associated with a seven-fold increase in the risk for suicidal behavior. Moreover, alcohol intoxication is related to greater lethality of attempt methods, making suicide fatalities more likely. Over a third of suicide decedents test positive for alcohol; 63.5% of whom have blood concentrations demonstrating intoxication, and more suicide decedents test positive for alcohol than other substances..Importantly, asking a patient about suicidal thoughts or plans does not incite or encourage suicidal behavior, and providers should ask specific questions about the nature and content of suicidal thoughts, as described below in greater detail. Information from appropriate "collateral" sources is particularly important for suicidal patients; relevant sources include prehospital or police personnel, the patient ' s family or friends, or outpatient healthcare providers. Asking the patient for permission enhances rapport, but an ED provider can make these contacts without consent when necessary to protect the individual or the public from an imminent and serious safety threat."

Patient #B
Review of the patient chart revealed Patient #B presented to the emergency department via police on 07/06/2024. "PD [police department] bringing patient in under emergency detention order for repeating the same phrases, yelling he is schizophrenic, with family and friends."

Nurse (Staff #15 ) triaged the patient and assigned an acuity of 2 (Emergent).

Review of Patient #B History of Present Illness included "The patient presents with psychiatric problem. The onset was just prior to arrival. The course/duration of symptoms is unknown. Character of symptoms paranoid. The degree of symptoms is moderate. Patient brought to the ER by police for belligerent behavior. Patient is currently has a history of schizophrenia and was acting out at home. Patient's wife was alert who called police. Patient was placed on EDO."

Nurse (Staff #15) assessed suicide risk from patient on 07/06/2024 at 04:29 AM and documented 'patient unable to complete' for the following prompts

In the past two weeks, have you felt down, depressed or hopeless?
In the past two weeks, have you had thoughts of killing yourself?
In your lifetime, have you ever attempted to kill yourself?

Review of the patient chart nursing notes available revealed no documentation of the Columbia Suicide Screening at triage or at any time at reassessments.

While in the ED (emergency room), Patient #B required placement with a 1:1 sitter and immediate physical and chemical restraints. Per the provider's notes (Staff #17), she stated "patient presents with clinical picture of acute psychosis, and severe agitation which is a threat to themselves and staff...multiple IM antipsychotic and sedative medications are used to control the patient's dangerous behavior."

Review of patient chart revealed Patient #B also had physical restraints (2 full length/4 half siderails on ankles and wrists) on 07/06/2024 at 06:20 AM for cognitive impairment that interferes with medical care and safety.

Review of patient chart revealed Patient #B received the follow antipsychotic medication: Ativan 2mg IM, Benadryl 25 mg IM and Haldol 5 mg IM on 07/06/2024 at 07:18 AM for patient's combative and aggressive behavior.

Further review of the physician notes (Staff #17) indicated "Reevaluation at bedside - patient alert, oriented, and cooperative. No longer agitated. Is able to answer questions appropriately. No suicidal ideation, homicidal ideation, signs or symptoms of acute psychosis. Not responding to internal stimuli, directable with questioning, and regretful for behavior earlier."

In an interview with the ED Director (Staff #12) on 08/21/2024 at 10:05 AM, he stated "most patients with current, acute suicidal ideation or homicidal ideation will require a consult from the behavioral assessment team, and together with their recommendation will determine if patient psych needs will require further medical evaluation (inpatient treatment)."

Review of the physician notes (Staff #17) revealed no request for consult from the behavioral assessment team; no documentation of prior suicide attempts, thoughts of suicide ideation in the past month, delusions, impaired thought processes, or hallucinations. No documentation of the evaluation of the patient's behavior, speech, mood, thought process, perception, cognition, and insight. Psychiatric evaluation is incomplete.