HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to ensure:
*Three of four sampled patients with known suicide attempts and ideations (6, 7, and 8) had a suicide risk assessment completed and were placed on suicide precautions after arriving at the emergency department (ED).
*Four of four sampled patients with known suicide attempts and ideations (5, 6, 7, and 8) had one-to-one observations completed to ensure their safety.
Findings include:

1. Review of patient 5's electronic medical record (EMR) revealed:
*She had arrived at the ED on 8/18/22.
*Her history of present illness (HPI) stated:
-"Patient stated that she is tired of living and wants to cut her wrists or drink Drano. She believes she will do this of [if] left alone. Patient reports having mental and physical abuse at home and at work. Patient states that she almost cut her wrist yesterday but talked herself out of it. She reports that she has attempted to harm herself years ago..."
*There was no documentation that one-to-one observations had been put into place.

2. Review of patient 6's EMR revealed:
*He had arrived at the ED on 8/16/22.
*His HPI included:
-"...presenting with suicidal ideation..."
-"...States he has been taking all of his psychiatric medications as prescribed however they are not helping. Over the last few days has started to have increased suicidal ideation with plans to cut his wrists and his jugular..."
*There was no documentation that one-to-one observations, a suicide risk assessment, and/or suicide precautions had been put into place.

3. Review of patient 7's EMR revealed:
*She had arrived at the ED by emergency medical services (EMS) on 11/23/22.
*Her HPI included:
-"...presents to the emergency department via EMS for evaluation of suicide attempt. Patient reportedly overdosed on diazepam. Patient smells heavily of ethanol and has slurred speech. She admits she had been drinking..."
-"...Patient reports she took medications and drink [drank] because she 'wanted to be done.'..."
*There was no documentation that suicide precautions, a suicide risk assessment, and/or one-to-one observations had been completed.

4. Review of patient 8's EMR revealed:
*She had presented to the ED on 1/15/23.
*Her HPI included:
-"...hx [history of] anxiety, depression, PTSD [post-traumatic stress disorder], alcohol abuse, prior intentional drug overdose, presenting with reports of large alcohol consumption as well as took several of her hydroxyzine, quetiapine, acetaminophen. Patient tearful, drowsy, appears clinically intoxicated and over all poor historian..."
-"...Patient reports to be that she is suicidal and did take these medications to kill herself..."
*There was no documentation that suicide precautions, suicide risk assessment, and/or one-to-one observations had been completed.

Interview on 2/8/23 at 10:40 a.m. with director of nursing C revealed:
*Suicide screenings and precautions were supposed to have been implemented when someone with suicide ideations or suicide attempts arrived at the ED.
*Suicide risk assessments were a mandatory assessment that needed to have been completed.
*She agreed they had not been completed for patient's 5, 6, 7, and 8.
*She stated nursing staff would be receiving education regarding what the policy and process was related to patients at high risk for suicide.

Review of the provider's January 2019 Suicide Risk Assessment and Care Management policy revealed:
*"[Provider's name] strives to make every effort to provide proactive care to patients at risk for harming themselves. Patients seen in the Emergency Department and those admitted to the Medical-Surgical Floor will be assessed using the evidence-based suicide risk assessment in the Electronic Medical Record. The nursing staff will implement appropriate interventions as directed by guidelines within the suicide risk assessment and per Provider order."
*"All patients presenting with a suicide attempt will be assessed as 'high risk' and precautions will be implemented as appropriate."

Based on record review, interview, and policy review, the provider failed to ensure six of six sampled patients (1, 2, 3, 4, 9, and 10) had nutritional assessments completed within twenty-four hours after being admitted to the hospital. Findings include:

1. Review of patient 9's electronic medical record (EMR) revealed:
*He had been admitted to the hospital in November 2022.
*His admitting diagnosis was hyponatremia (low blood sodium level).
*He had not had the following completed:
-A nutritional screening.
-A mini nutritional assessment/screening.

2. Review of patient 10's EMR revealed:
*She had been admitted to the hospital in August 2022.
*Her admitting diagnosis was a urinary tract infection.
*She had not had the following completed:
-A nutritional screening.
-A mini nutritional assessment/screening.



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3. Review of patient 1's EMR revealed:
*She had been admitted on 10/10/22 and discharge on 10/17/22.
*Her admitting diagnosis was cellulitis of the face with a chin abscess.
*She had not had the following completed:
-A nutritional screening.
-A mini nutritional assessment/screening.

4. Review of patient 2's EMR revealed:
*He had been admitted on 1/31/23 and discharged on 2/7/23.
*His admitting diagnosis was cellulitis and abscess to his left thigh, acute congestive heart failure, and hypoxia.
*He had not had the following completed:
-A nutritional screening.
-A mini nutritional assessment/screening.

5. Review of patient 4's EMR revealed:
*He had been admitted on 2/4/23 and discharged on 2/8/23.
*His admitting diagnosis was cellulitis of his left leg.
*He had not had a nutritional screening completing.

6. Review of patient 3's EMR revealed:
*She was admitted on 2/4/23 and was currently hospitalized.
*Her admitting diagnosis was respiratory syncytial virus (RSV), methcillin resistant staph aureus, and respiratory failure.
*She had not had the following completed:
-A nutritional screening.
-A mini nutritional assessment/screening.

Interview on 2/8/23/ at 11:00 a.m. with health information management (HIM)/registered nurse (RN) D revealed:
*All patients were to have had a nutrition assessment and an age related mini nutritional assessment screening completed upon or within twenty-four hours of admission by the nursing staff.
*She agreed they should have completed the nutritional assessments on patients 1, 2, 3, 4, 9, and 10.

Interview on 2/8/23 at 1:30 p.m. with director of nursing B regarding the nutritional assessments for patients revealed she:*Agreed that the assessments had not been completed by the nursing staff on patients 1, 2, 3, 4, 9, and 10.
*Stated that was the policy to complete the assessments upon admission or within twenty-four hours of admission.

Review of the provider's January 2019 Nutritional Screening and Assessment by Registered Dietitian for Hospital policy revealed:
*"To provide guidelines for quality nutritional care of the patient. And to identify patients who may be at nutritional risk determine the most appropriate medical nutrition therapy and facilitate optimal patient outcome."
*"The nutritional screen is completed by Nursing as part of the nursing initial assessment form and is completed within 24 hours of admission..."