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Based on medical record review, interviews, and review of Medical Staff Bylaws and Rules and Regulations, the governing body failed to ensure the physician responsible for the care of PI (Patient Identifier) # 1 on January 31, 2010, a patient with a documented suicide attempt, was assessed for medical and/or psychiatric needs, after being notified of PI # 1's intent to leave the hospital AMA (Against Medical Advice). This affected Patient Identifier # 1, one of ten sampled patients.

Findings include:

A. Medical Record:

EMS Form Dated January 30, 2010 Includes:
Chief Complaint: "Decreased LOC" (Level of Consciousness)...
Assessment and Treatment: "46 y/o f (year old female) states she was attempting suicide. Pt. (patient) took multiple Lunesta, Alprazolam, Clonazepam. Pt. found in vehicle on side of road. No vehicle damage or collision. Pt. presents with decreased LOC...Equal bbs (bilateral breath sounds)... Meds (medications) taken brought w/ (with) pt.
Time not documented. HR (heart rate) 80, BP (blood pressure) 101/65, ... Respiratory Rate 12..."
.
Emergency Department (ED) Nursing Assessment Includes:
The (ED) Nursing Assessment, dated January 31, 2010, reveals PI # 1 arrived via ambulance in the ED at 12:15 AM. PI # 1's vital signs were Blood Pressure (BP): 101/57, Pulse (P): 88, Respirations (R): 20 and Temperature (T): 97.5, Oxygen Saturation: 100 percent.

The documented chief complaint is "overdose" with "onset at 10:00 PM."
The RN documented, "States took unknown quantity of drugs in an attempt to kill herself. Empty bottles / (with) patient: Lunesta, Clonazepam, Xanax, Quaaludes." The patient's reported daily use of alcohol is documented as "3d" (three per day?) and illicit drug type is documented as "many" (amount and duration not documented).
Neuro: "Awake, alert,oriented. Responds to verbal stimuli."
Psychological Status: "Depressed, sedated."

"Emergency Department /Vital" Form Includes:
2:00 AM: 97/52, 84, 16, SPO2: 97, Monitor: SR (sinus rhythm).
3:00 AM: 96/54, 82, 16, T: 97.6, SPO2 (Oxygen Saturation via Pulse Oximetry): 100, Monitor: SR (sinus rhythm).
4:00 AM: 99/58, 95, 18, SPO2: 100, Monitor: SR (sinus rhythm).
5:30 AM: 103/54, 88, 16, T: 98.3, SPO2: 99, Monitor: SR (sinus rhythm).

Emergency Department Nursing Notes Includes:
"12:40 AM: Status: Patient states repeatedly that she took pills in attempt to kill herself. At present, she's sedated but arouses to stimuli and is oriented @ (at) present. She cannot or will not tell us how much of what pills she took - she states enough.
12:45 AM: MD (ER Physician) at bedside for exam.
2:30 AM: Vital signs stable. No change in status. Patient resting with eyes closed, but does respond to verbal stimuli. Patient to be admitted. Awaiting disposition.
3:30 AM: Admit orders received and room requested, but on hold per house supervisor. Await clearance to transport patient to ICU (Intensive Care Unit).
5:30 AM: New room (room #) ready. Will call report. Patient is now more awake, alert and verbal."

Nursing Admission/Transfer:
Admit to Room: (room number).
Report called @ (time not documented) to: RN.
Transport 5:50 AM with RN and monitor.

Emergency Department Physician Orders 1/31/2010:
12:50 AM: Acetaminophen level
Etoh (alcohol) level
CMP (Complete Metabolic Profile)
CBC (Complete Blood Count)
ASA (Salicylate) level
UA (Urinalysis)...
UDS (Urine Drug Screen)

ER Form "1E- General Adult" Includes:
"Chief Complaint: AMS (Altered mental status) / OD (Overdose)."
History of Present Illness:
Duration:"2200." (10:00 PM)
Timing: "Still occurring."
Severity: "Moderate."
Quality: "Decreased mental status. Pt. (patient) found in parked car on side of road - Depression- ? impact."
Current /Associated Symptoms: "Pt.(patient) states she took OD (overdose)of multiple drugs and alcohol in an attempt to kill self." ...
Past Medical History: "+ (positive?) Psych (psychiatric), ? Dep (depression)."
Social History: Alcohol circled by physician (no amount or frequency documented).

Physical Exam Includes:
Psychiatric: Affect and mood not documented.
EKG: NSR (normal sinus rhythm), normal EKG.
Disposition: Name of Admitting Physician.
Certified Emergency? Yes (checked).
Clinical Impression: AMS (Altered Mental Status), OD (Overdose)
Signature of the ER Physician

Physician Orders 1/31/2010 - 3:30 AM (Written by the ER Physician for PI # 1's Admitting Physician):
Admit: (Name of admitting physician)
Dx: OD (Overdose)....
Activity: BR (bedrest with suicide precautions).
Vitals: routine...
Diet: NPO (nothing by mouth) for now
IVF: NS @ 100 cc/hr...

Intensive Care Nurses Notes:
1/31/ 2010 - 8:00 AM: "In room to assess pt.(patient). Pt. 'pullin' leads off. States she is leaving. Attempted to get her to stay for help 'n' treatment. Placed call to supervisor and dr. (name of admitting physician). Pt. irrational. Notified family. Pt. signed ama. D/c'd (discontinued) foley. D/c'd (discontinued) iv's."
1/31/ 2010 - 8:30 AM : "Pt. d/c'd via w/c (wheelchair) to pvt.(private vehicle) with sister and mom and dad. No distress noted."

Intensive Care Flowsheet Includes:
1/31/2010 - 8:30 AM :
Mood/Affect: Anxious, irritable.
Behavior: Inappropriate, crying, demanding, disruptive, restless
Judgment Impairment: Moderate.
Support System: Family at bedside.
Patient Complaints: Anxiety, Depression.
Notify: (Name of admitting physician) . No order received.
Orientation: Oriented to person, place, situation. Agitated.
Level of Consciousness: Alert.

Nursing Care Plan Includes:
1/31/ 2010 - 8:00 AM:
Problem: Actual Suicide Risk
Goal: Injury free.

Problem: Aggressive
Goal: Calm and cooperative.
Planned Intervention: Provide safe environment.

Problem: (actual): Taking care of demented mother
No goals documented.

Critical Care Data Sheet - January 31, 2010:
6:00 AM: Temperature (T): 98.6, Heart Rate: 92, Respiratory Rate: 24, Blood Pressure: Right Arm: 103/ 60, Left Arm: 99/6. (Nurse Signature not documented).
7:15 AM: T: 98, Heart Rate: 92, Respiratory Rate: 24, Blood Pressure: 102/50. "Off monitor @ 0800. AMA @ 0830." (Signature of Nurse).

B. Interviews:
Interview with Staff Identifier Number # 6, RN / Emergency Room Director, on March 24, 2010 at 3:00 PM:
The ER Director stated there is no inpatient psychiatric unit at Providence Hospital. When a patient presents to the ER and is determined to be a risk to themselves or others, the staff tries to transfer the patient to a facility with psychiatric services. "If we can't transfer the patient, the patient is usually admitted to ICU for one to one observation."

Telephone Interview with Staff Identifier Number # 1/ Admitting Physician, on March 24, 2010 at 4:10 PM:
The physician stated he did not give the RN an order to discharge the patient. The patient left AMA. The physician says he was called by the RN and told the patient's family came to pick up PI # 1. "They (family) said everything was fine. She (PI # 1) was not suicidal." The physician says he was told by the RN that PI # 1 was alert and oriented The physician was asked if the nurse informed him PI # 1 was on suicide precautions and he replied, "I don't recall." The surveyor read aloud PI # 1's History and Physical, dated January 31, 2010, and dictated by this physician. The physician confirmed he did not evaluate PI # 1 after she was admitted to the Medical Intensive Care Unit (MICU) or before the patient left the hospital AMA (Against Medical Advice).

Interview with Staff Identifier Number # 2/ RN on March 25, 2010 at 12:20 PM:
According to RN # 2, PI # 1 had already been admitted to MICU when this RN began her shift at 7:00 AM on January 31, 2010.

The nurse on duty when PI # 1 was admitted to MICU failed to document a complete admission assessment, and was unavailable for interview during the survey (March 24 - 26, 2010).

During shift change report, RN # 2 stated she was told by the off-going night shift RN that PI # 1 had taken some pills, smoked marijuana, was found on the side of the road, and brought to the ER.

RN # 2 said when she entered PI # 1's room, "Around 7:30 AM to 7:45 AM, PI # 1 was snatching leads off and about to pull out her IV." PI # 1 told RN # 2, "You're not making me stay here. I've been down this road before. I know the rules. My sister is a nurse."

RN # 2 stated PI # 1 refused to allow RN # 2 to do a complete assessment at the beginning of the day shift (7:00 AM - 7:00 PM). RN # 2 stated, "She (PI # 1) was having no part of it (assessment). She (PI # 1) was mad. When I tried to check her blood pressure, she (PI # 1) told me to get my hands off her." The RN described PI # 1 as, "Generally aggressive. I felt threatened. I realized she had had enough and was ready to leave."

RN # 2 stated she notified the RN House Supervisor of PI # 1's intent to leave the hospital against medical advice. Reportedly the supervisor told the RN that PI # 1 could not be held against her will.

RN # 2 stated she called PI # 1's admitting physician at 8:30 AM on January 31, 2010 and told the physician that, "(Name of PI # 1) is going AMA. He (physician) said okay. He asked me nothing about the patient " RN # 2 says she did not give the physician any information about PI # 1 because the admitting physician had been given patient information by the ER physician prior to PI # 1's admission. The RN reports no order was given by the physician. The RN verified with the surveyor that PI # 1 left AMA without being seen/evaluated by the attending physician.

RN # 2 was asked if she questioned PI # 1 if she (patient) was suicidal at the time P1 #1 stated her intent to leave the hospital. RN # 2 said, "No, I normally don't ask." RN # 2 verified PI # 1 was on suicide precautions when PI # 1 left the hospital against medical advice.

During an interview with Staff Identifier Number # 3/ ER Physician, on March 25, 2010 at 2:30 PM, the physician stated PI # 1 was admitted to the ICU because of medical and psychiatric issues. The rationale for ordering suicide precautions was due to PI # 1's stated history of self harm and in the context of her overdose. The ER physician reports he called (name of physician) because this physician was on call for the medicine service. The ER physician reports he told the admitting physician PI # 1 overdosed in an attempt to kill herself. The admitting physician agreed to admit PI # 1. The ER Physician verified the documentation of his discussion with the admitting physician. However, the documentation on the "1E- General Adult" form is only the name of the admitting physician in the disposition category as written by the ER physician.

Interview with Staff Identifier Number # 7/ Chief Nursing Officer (CNO), on March 25, 2010 at 2:10 PM:
The CNO stated there is no incident report regarding PI # 1 leaving against medical advise on January 31, 2010.

C. Medical Staff Bylaws / Rules and Regulations, Effective Date: 11/12/ 1996; revised March 2002:
Bylaws:
"Article II: Medical Staff Membership
2.5 -2 Except for the honorary staff, the ongoing professional responsibilities of each member of the medical staff include:
a. Providing patients with continuous, quality of care which meets the professional standards of the medical staff of this hospital."

Rules and Regulations:
"11. Admission and Discharge of Patients
...7. Members of the medical staff shall be available to attend the needs of patents...."
"8 (d). All patients who have attempted suicide or have taken a chemical overdose must be offered consultation and/or psychiatric treatment. Documentation must be made in the medical record that such service was offered."

Admitting Physician's History and Physical:
"Admit Date: 1/31/2010. History: History is provided by the emergency room physician. I did not actually get to see the patient. The patient was found alongside the road in her car with altered mental status. She was brought to the hospital and stated she had taken an overdose of multiple medications and alcohol in an apparent suicide attempt.

"In the emergency room, she was noted to be obtunded, but easily arousal and other than her neurological and ,mental status exams, her exam was stated as to be unremarkable by the emergency room physician."

"She was admitted to intensive care unit. Approximately four hours after admission, the patient's family came by to get her. The patient at the time was fairly alert. She was deemed by the nurse in the intensive care unit to be competent and the patient signed out against medical advice."

In summary, PI # 1 was brought to the ER via ambulance. PI # 1 stated she took an overdose of multiple drugs and alcohol in attempt to kill herself. On January 31, 2010 at or around 5:30 AM, PI # 1 was transferred to MICU and admitted to the hospital. PI # 1 was observed removing her cardiac monitor leads at 8:00 AM on January 31, 2010 by RN # 2. RN # 2 described PI # 1 as, "Agitated, anxious, irrational, irritable, inappropriate, crying, demanding to leave the hospital, disruptive and restless with moderately impaired judgment." RN # 2 notified the admitting physician of PI # 1's intent to leave. Despite notification of the change in PI # 1's condition, the admitting physician did not see, evaluate or attempt to speak with PI # 1 prior to PI # 1 leaving the hospital against medical advice.

Based on medical record review, interviews, and review of the hospital's Psychiatric On-Call Services Agreement (contract for psychiatric services by an outside provider), the governing body failed to ensure Patient Identifier (PI) # 1 was offered and/or received a psychiatric consultation based on the patient's diagnosis of Overdose in an attempt to kill herself.
This affected PI # 1, one of ten sampled residents.

Findings include:

A. Medical Record (Findings documented in Citation A 0068):

PI # 1 was brought to the ER via ambulance. PI # 1 stated she took an overdose of multiple drugs and alcohol in attempt to kill herself. On January 31, 2010 around 5:30 AM, PI # 1 was transferred to MICU (Medical Intensive Care Unit) and admitted to the hospital. PI # 1 was observed removing her cardiac monitor leads at 8:00 AM on January 31, 2010 by RN (Registered Nurse) # 2. RN # 2 described PI # 1 as agitated, anxious, irrational, irritable, inappropriate, crying, demanding to leave the hospital, disruptive and restless with moderately impaired judgment.
RN # 2 notified the admitting physician of PI # 1's intent to leave. However, PI # 1 left the hospital against medical advice without being seen / evaluated by the admitting physician or receiving a psychiatric evaluation.

B. Interviews:
During an interview with Staff Identifier # 6,
RN/ER Director, on March 24, 2010 at 3:00 PM, the director stated Providence Hospital does not have an inpatient psychiatric unit. When a patient presents to the ER and is determined to be a risk to themselves or others, the staff attempts to transfer the patient to a facility with psychiatric services. "If we can't transfer the patient, the patient is usually admitted to ICU (Intensive Care Unit) for one to one observation."

During an interview with Staff Identifier # 8,
Accreditation Manager on March 26, 2010 at
1:40 PM, the manager documented the hospital's
"Process for Psychiatric Referral:"
"All suicide attempts:
- Contact Case Management to arrange a consult (consultation) with (name of contracted psychiatric provider)
- Social Worker evaluates the patient
- Social Worker notifies psychiatric doctor on call
- Process followed day or night
- A computer message is sent by the RN (Registered Nurse) or unit secretary
- Case Management receives a print out which includes the admitting diagnosis
- An admitting diagnosis of attempted suicide /
overdose would trigger a case management visit."

C. Review of Hospital's Psychiatric On-Call Services Agreement dated 10/1/2008 Includes:
"...1. Engagement of (Name of Provider). Hospital hereby engages (Name of Provider) to provide Psychiatric Services on an on-call basis for its inpatients and observation patients at Hospital.
2. Services. (Name of Provider) hereby agrees to provide the Hospital the following:
2.2 (Name of Provider) will promptly (within 24 hours of request during Provider's normal business hours as defined below) furnish either a certified nurse practitioner ("the CRNP") or Psychiatrist who will provide the Psychiatric Services upon notice from the hospital. (Name of Provider) will not provide any Psychiatric Services outside of (Name of Provider) normal work week schedule. (Name of Provider) will not provide any Psychiatric Services to Hospital on any (Name of Provider) observed holiday..."

There is no documentation in PI # 1's medical record to indicate the hospitals's contracted psychiatric provider was contacted about PI # 1.

Based on medical record review, interviews, review of hospital policies and procedures and Fundamentals of Nursing (P. Potter and A. Perry), the hospital failed to assess Patient Identifier (PI) # 1's suicidal status on January 31, 1010 when PI # 1 was admitted to the Medical Intensive Care Unit (MICU) and when PI # 1 left the hospital AMA (Against Medical Advice). As a result, PI # 1 left the hospital without an assessment by staff of her suicidal risk. This affected PI # 1, one of ten sampled residents.

Findings include:

A. Medical Record:

1. Emergency Department (ED) Nursing Assessment Includes:
A review of the Emergency Department (ED) Nursing Assessment, dated January 31, 2010, reveals PI # 1 arrived via ambulance in the ED at 12:15 AM. PI # 1's vital signs: Blood Pressure (BP): 101/57, Pulse (P): 88, Respirations (R): 20 and Temperature (T): 97.5, Oxygen Saturation: 100 percent. The "chief complaint is overdose" with onset at 10:00 PM. The Registered Nurse (RN) documented the patient, "States took unknown quantity of drugs in an attempt to kill herself. Empty bottles of Lunesta, Clonazepam, Xanax and Quaaludes are with the patient. The patient admits to daily use of alcohol ( "3d (three per day ?) and illicit drugs (amount not specified)."

Emergency Department (ED) Nursing Notes 1/31/2010:
"12:40 AM: Status: Patient states repeatedly that she took pills in attempt to kill herself. At present, she's sedated but arouses to stimuli and is oriented @ (at) present. She cannot or will not tell us how much of what pills she took - she states enough."
"3:30 AM: Admit orders received and room requested, but on hold per house supervisor. Await clearance to transport patient to ICU."

Nursing Admission/Transfer:
Admit to Room: Medical Intensive Care Unit (MICU).
Report called @ (time not documented) to: (name of RN.
Transport 5:50 AM with RN and monitor.

ER Physician Form "1E- General Adult" 1/31/2010 Includes:
"Chief Complaint: AMS (Altered mental status / OD (Overdose)."
History of Present Illness: 2200 (10:00 PM)
Timing: Still occurring
Severity: Moderate
Current /Associated Symptoms: Pt. states she took OD of multiple drugs and alcohol in attempt to kill self."

Physician's Orders 1/31/2010 at 3:30 AM (Written by the ER Physician for PI # 1's Admitting Physician):
Admit: (Name of admitting physician)
Dx: OD (Overdose)...
Activity: BR (bedrest with suicide precautions).
Vitals: routine...
IVF: NS @ 100 cc/hr...

History and Physical (Documented by PI # 1's Admitting Physician):
Admit Date: 1/31/2010
"History: History is provided by the emergency room physician. I did not actually get to see the patient. The patient was found alongside the road in her car with altered mental status. She was brought to the hospital and stated she had taken an overdose of multiple medications and alcohol in an apparent suicide attempt."

"In the emergency room, she was noted to be obtunded, but easily arousable and other than her neurological and mental status exams, her exam was stated as to be unremarkable by the emergency room physician."

"She was admitted to intensive care unit. Approximately four hours after admission, the patient's family came by to get her. The patient at the time was fairly alert. She was deemed by the nurse in the intensive care unit to be competent and the patient signed out against medical advice."

B. Interviews:

Interview with Staff Identifier Number # 7/ Chief Nursing Officer (CNO), on March 25, 2010 at 11:00 AM:
The CNO stated all psychiatric services for the hospital's patients are provided via contract with (Name of Psychiatric Provider). This provider only sees patients during regular business hours and does not provide services to patients in the hospital's emergency department. The CNO said, "Normally, (name of admitting physician) would have seen the patient (PI # 1) and ordered a psychiatric consultation. The psychiatrist would have deemed if the patient (PI # 1) was suicidal."

Interview with Staff Identifier Number # 2/ RN, on March 25, 2010 at 12:20 PM:
According to RN # 2, PI # 1 had already been admitted to the Medical Intensive Care Unit (MICU) when RN # 2 began her shift at 7:00 AM on January 31, 2010. RN # 2 said the nurse working the night shift should have assessed the patient and documented the assessment. The RN referred the surveyor to the Critical Care Data Sheet, dated January 31, 2010, revealing PI # 1's vital signs were taken at 6:00 AM by another RN. This RN's initials are not documented. There is no documented assessment of PI # 1 at the time of the patient's admission to MICU.

When RN # 2 entered the room, "Around 7:30 AM to 7:45 AM, she (PI # 1) was snatching leads off and about to pull out her IV."

RN # 2 was asked if she questioned PI # 1 to determine if PI # 1 was suicidal when the patient stated her intention to leave AMA. The RN said, "No, I normally don't ask."

Interview with Staff Member Number # 7/ Chief Nursing Officer, on March 25, 2010 at 2:10 PM:
The CNO stated the RN who worked the night shift should have documented an assessment of the patient (PI # 1) when the patient was admitted to the Medical Intensive Care Unit. This RN is no longer employed at the hospital and could not be contacted by telephone for interview during the survey (March 24 - 26, 2010).

C. Hospital Policies and Procedures:

Code Number 2.01.12
Nursing Division Developed: 1962 Revised: July 2008
Subject: Leaving Against Medical Advice:

"... Procedure:
1. Notify the attending physician of the patient's concerns and the stated intent to leave.
2. Provide the physician with a current assessment of the patient's clinical condition and the following assessment findings:
a. Is the patient a threat to self or others?
b. Is the patient capable of making appropriate decisions about their health care?
c. Does the patient have an impairment/medical condition that could cause harm to self or others?..."

Code Number 2.01.132
Section: Administrative
Subject: Assessment of Patients
Developed: June 2002
Revised: April 2009 Includes:
"Policy: Patients who receive care at Providence Hospital are assessed and reassessed by qualified individuals to determine the patient's initial needs, continuing needs, and the outcomes of care and interventions...

Procedure: ...Initial/Screening Assessment
The following may be included in the design of a specific assessment.
1. The patient's chief complaint...
9. Initial discharge planning...

Reassessment: Each patient is to be reassessed according to the guidelines established by the clinical disciplines...
Scope and Responsibilities of Involved Disciplines:
A. Acute Care Nursing Division
A personal interaction between patient and staff member occurs upon arrival to the unit. The patient's initial assessment is the responsibility of the Registered Nurse..."

D. Standards of Nursing Practice:

According to the standards of Practice documented in Fundamentals of Nursing, P. Potter and A. Perry, Copyright 2005, Mosby, Inc., pages 280-282, "The nursing process begins with an assessment of a patient that must be relevant to a particular health problem. Assessment data must be descriptive and complete. Accurate assessment is crucial to ensure a patient's needs are properly identified and the right course of action is taken."

Based on medical record review and review of hospital policies and procedures, the hospital failed to provide discharge planning for Patient Identifier (PI # 1), a patient who attempted overdose on January 31, 2010. This affected PI # 1, one of ten sampled patients.

Findings include: (Refer to A 0068 for documentation)

Medical Record:
According to the medical record, PI # 1 was brought to the ER (Emergency Room) via ambulance on January 31, 2010. PI # 1 stated she took an overdose of multiple drugs and alcohol in attempt to kill herself. On January 31, 2010 at or around 5:50 AM, PI # 1 was transferred to the Medical Intensive Care Unit (MICU). At 8:00 AM on January 31, 2010, PI # 1 was observed removing her cardiac monitor leads. PI # 1 was described by RN (Registered Nurse) # 2 as "agitated, anxious, irrational, irritable, inappropriate, crying, demanding to leave the hospital, disruptive and restless with moderately impaired judgment ". RN # 2 notified the admitting physician of PI # 1's intent to leave. However,
PI # 1 left the hospital against medical advice.

There is no documentation in PI # 1's medical record that the hospital attempted to discuss psychiatric outpatient follow up with the patient and or PI # 1's family.

Hospital Policies and Procedures:
Code Number 2.01.132
Section: Administrative
Subject: Assessment of Patients
Developed: June 2002
Revised: April 2009 Includes:
"Policy: Patients who receive care at Providence Hospital are assessed and reassessed by qualified individuals to determine the patient's initial needs, continuing needs, and the outcomes of care and interventions..."

"Procedure: ...Initial/Screening Assessment
The following may be included in the design of a specific assessment.
1. The patient's chief complaint...
9. Initial discharge planning..."