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Based on interview and record review, the facility failed to ensure care in a safe setting for two(2) of six(6) sampled patients who presented with overdose or suicidal ideation [Patient ID # 5, 8 ]. The facility failed to ensure :

a. a suicide risk assessment and/ or re-assessment was performed per policy (Patient ID 5, 8)
b. a Discharge Safety Plan was developed and signed by the patient prior to discharge ( Patient ID # 5, 8)


Findings included:

Record review of facility policy titled "Safe Care of The Suicidal Patient," dated July 2022, showed:

-all patients who are being evaluated or treated for behavioral health conditions as their primary reason for care are screened for suicidal ideation (SI) using a validated tool, Columbia Suicide Severity Rating Scale and Screen ( C-SSRS);

-patients identified as being at risk ( MODERATE or HIGH) of suicide are reassessed at a minimum of each shift, with changes in behavior using the - Columbia Suicide Severity Rating Scale and Screen ( C-SSRS);

-Documentation: screening and assessment findings shall be documented in the patient's medical records and communicated to the LIP and interdisciplinary team;

-Discharge Planning: for patients previously identified as a suicide risk:

a. Evaluation of risk is performed prior to patient's discharge using the C-SSRS;
b. A Discharge Safety Plan is developed by the nurse with the patient involved for patients with SI who are not being transferred to an inpatient behavioral health unit.

Review of facility form titled " Discharge Safety Plan" showed sections titled:

1. Warning Signs
2. Social situations and people that can help to distract me
3. People whom I can ask for help
4. Professionals or agencies I can contact during a crisis (spaces for clinician and hospital names and telephone numbers, as well as Suicide Prevention Lifeline number

*Section designated for patient and nurse's signature and date.

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Record review on 2/2/2023 of the electronic records of six (6) ER patient who presented with overdose or suicidal ideation showed the following:

Patient ID # 5 :

Patient ID# 5 was a 15 year old female who presented to the ER with an overdose on 1/11/2023 at 2055 . Patient stated "took 7 pills of 25 mg sertraline."
"Risk Assessment : Do you want to hurt yourself or someone else? Patient reports desire /thoughts of hurling themselves or someone else. Provider notified."

ER Staff RN-E was unable to locate/ verify that a Columbia Suicide Severity Rating Scale and Screen (C-SSRS) had been completed on admission and prior to discharge. Unable to verify Patient # 5's level of suicide risk upon admission and discharge.

Patient # 5 was discharged on 1/12/2023 at 3:02 AM in the care of her grandmother. There was documentation the grandmother would call patient's psychiatrist this day and she also ensures patient's safety. RN Staff -E was unable to locate a "Discharge Safely Plan" for Patient # 5. Staff E stated a Discharge Safety Plan should have been part of this patient's discharge.


Patient ID # 8 :


Patient ID# 8 was a 16 year old female who presented to the ER with an overdose on 06/05/2022 at 2057 . Patient had a history of depression and a prior suicide gesture. Patient #8 had "ingested 60 to 20 mg Prozac" and stated " she does not want to be here anymore."

An initial C-SSRS was completed upon admission 6//5/2022 ( not timed). Patient # 8 was assessed as High Risk for suicide. Interventions were implemented and documented.

Patient # 8 was evaluated by Gulf Coast crisis response team on 6/6/2022 at 4:27 AM. Recommendation was inpatient behavioral health admission. Aunt and patient declined inpatient transfer. Provider contacted CPS and mental health deputy.

Review of physician progress note 6/6/22 (9:31) : long discussion with uncle and patient. Patient # 8 denied SI; no plan to kills self, has appointment with psychiatrist that day. Family comfortable taking her home; weapons locked up. CPS came to hospital and evaluated the situation. Physician documented at 1131 that "no concerning signs for him." (CPS caseworker)

Patient # 8 was discharged home with family on 06/06/2022 at 12:10 . ER Staff RN-E was unable to locate/ verify that a Columbia Suicide Severity Rating Scale and Screen (C-SSRS) had been completed prior to discharge.

Review of the form titled "Discharge Instructions," dated 6//6/2022 read: "Intentional Drug Overdose": instructions were to "follow up with private physician as needed-recheck today's complaints." RN Staff -E was unable to locate a "Discharge Safely Plan" for Patient # 8. Staff E stated a Discharge Safety Plan should have been part of this patient's discharge.