HospitalInspections.org

Based on document review and interview, it was determined for 4 of 6 (Pt #1, Pt #8, Pt #9, Pt #11) patients records reviewed, the Hospital failed to ensure a safe environment for behavioral health patients . This has the potential to affect all staff, visitors and patients with an average monthly census of 3500 patient visits.

Findings include:

1. The policy titled "Suicide Prevention" (revised 1/1/22) was reviewed on 5/3/22. The policy noted "IV... C. Upon admission, all patients... are screened for suicide risk using the Columbia Suicide Severity Rating Scale (C-SSRS)... D... If the answers to any of the three questions are "YES", then additional questions are asked... E... suicide precautions. 1. Low risk: ... question 1 and/or 2 2. Moderate risk: ... question 3 3. High: ... question 4, 5 or 6... 5. All patients on high, risk level are placed on a 1:1 observation... B. The patient is searched and gowned and the patient is placed on elopement precautions... The patient's belongings are secured out of the sight of the patient... belongings... searched for contraband... If the patient is discharged from the ED (Emergency Department), discharge safety plans are developed collaboratively with the patient by the clinician and/or nurse prior to discharge."

2. The policy titled "Elopement Precautions" (revised 1/1/22) was reviewed on 5/4/22. The policy noted "C... Emergency Department 1. Patient is changed into a gown. His/Her clothing is not returned to him/her until the time the treatment team deems clinically appropriate. His/her shoes are removed-socks can be kept on if hospital slippers are not available..."

3. Pt #1 DOS (Date of Service): 8/6/21 at 4:36 PM
Diagnosis: Unspecified mood (affective) disorder. The record was reviewed on 5/3/22 at approximately 10:00 AM. The BH (Behavioral Health) Admission Patient History dated 8/6/21 at 6:27 PM noted "Patient reported he/she is suicidal with a plan to put himself/herself in dangerous situation where someone will kill him/her." The C-SSRS conducted on 8/6/21 at 4:55 PM noted "Yes" to questions 1, 2 and 3 and lacked documentation 4, 5 or 6 were assessed. The record noted Pt #1 was moved to Emergency Department (ED) room #6 (non-safe room) and lacked documentation suicide precautions were implemented prior to transfer to the ED BH unit at 8:58 PM. The "Emergency Department Frequent Observation Flowsheet" lacked documentation of the suicide precaution level, belongings were removed and secured, a body search was conducted or if the patient was placed in a gown.

4. Pt #8 DOS: 9/5/21 at 10:39 PM
Diagnosis: Psychiatric Evaluation. The record was reviewed on 5/3/22 at approximately 12:30 PM. An order for a Behavioral Health Crisis Evaluation was placed on 9/5/21 at 11:00 PM. The "Notice Regarding Restricted Rights of Individuals dated 9/5/21 at 11:04 PM noted Pt #8 was placed in a physical hold, placed in restraints and administered emergency medicine for "Pt verbally, physically aggressive toward staff. Pt attempted to hit staff members, and was grabbing at staff. Pt isn't redirectable." The ED Provider Note noted Pt #8 had a history of psychiatric hospitalization, was unable to review systems related to "Psychiatric disorder", was inattentive, anxious, angry, inappropriate, speech was rapid and pressured, agitated, aggressive, paranoid and impulsive. The ED Provider Note noted "Pt has been evaluated by behavioral health and staffed with psychiatry... Has no mental health history..." The record noted Pt #8 was discharged to a cousin on 9/6/21 at 8:30 AM, without a psychiatric evaluation.

5. Pt #9 DOS: 7/10/21 at 11:46 PM
Diagnosis: Mood Disorder. The record was reviewed on 5/3/22 at approximately 1:30 PM. The record noted Pt #9 arrived via police with complaint of suicidal statements made during an argument. The Behavioral Health Clinician (E#4) note dated 7/11/21 at 12:48 AM "...Patient's father is coming to pick (Pt #9) up. Patient's mother gave consent to send (Pt #9) home with (Pt #9) father." A nurse's note dated 7/11/21 at 1:20 AM noted "Patient discharged and walked out by behavioral health. No discharge vitals were done and no discharge instructions were given to patient." The record lacked any physician orders.

6. Pt #11 DOS: 6/30/21 at 6:55 PM
Diagnosis: Possible overdose, suicidal statements and a history of psychiatric diagnoses. The record was reviewed on 5/3/22 at approximately 2:30 PM. The C-SSRS conducted on 6/30/21 at 6:57 PM noted "Yes" to question 6. although lacked a suicide precaution risk level. The Patient Safety Companion Frequent Observation Flowsheet lacked documentation of suicide precautions. The ED Provider Note noted Pt #11 was depressed, uncooperative, agitated, suicidal, impulsive, inappropriate and "Patient has tried leave the hospital multiple times including making it almost to the bus station while in the hospital gown barefoot." The record noted on 7/1/21 at 3:40 AM, the RN (Registered Nurse) noted Pt #11 was verbally abusive to the RN and security guard, witnessed throwing food across the room and "... contacted behavioral health staff to get an update but no update was available as to when the pt would be seen." The record noted on 7/1/21 at 4:59 AM "... contacted BH (Behavioral Health) team for an update on assessment and still no time frame available." The record noted on 7/1/21 at 9:23 AM "... Contacted BH for update. Per, BH, patient has been calling frequently to ask them about what is happening." The record noted on 7/1/21 at 9:41 AM "... Threw water, food and phone at staff. BH updated patient that (Pt #11) would not be going home but would be admitted... Restraints will be initiated at this time..R. Approved of patient being taken to jail. Patient is medically cleared by physician and psychiatrist."

6. During an interview on 5/3/22 at approximately 4:30 PM. E#1 (Clinical Nurse Educator) reviewed Pt #1, Pt #8, Pt #9 and Pt #11's records. E#1 verbally agreed the C-SSRS's were not appropriately completed and should have been; verbally agreed suicide precautions were not accurately assessed and documented and should have been; behavioral health/psychiatric evaluations were not conducted and should have been.

Based on a document review and interviews, it was determined in 1 of 2 (E#2) Mental Health Associates personnel files reviewed, the Hospital failed to ensure that staff involved in restraint/seclusion usage maintained current CPR (cardiopulmonary resuscitation) certification. This has the potential to affect all staff, visitors and all patient with an average monthly census of approximately 3500 patient visits.

Findings include:

1. The personnel files of the currently employed Mental Health Associates were reviewed on 5/4/2022 at approximately 11:30 AM. E#2's file lacked a current CPR certification.

2. During an interview on 5/4/2022 at approximately 11:50 AM, E#3 (Manager of Human Resources) verbally confirmed that E#2's file lacked CPR certification and should have been completed.