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Based on MR review, P/P review, review of the discharge planning program, and staff interview, this facility failed to inform patients of their admission status which potentially could have prevented patients and families from making appropriate decisions about their care in 4 out of 5 MR reviewed (Pt. #1, 2, 4, and 5); of observation status patients out of a total of 13 MR reviewed. Failure to provide information that affects decision making about hospital/post-hospital care has the potential to affect all patients recieving care in this facility.

Findings include:

MR reviews for Pt.'s #1-5 were conducted in the presence of RN F on 10/2/2012 from 1:40 p.m. through 2:30 p.m. for the computer portions of the MR. The paper portions of Pt. #1-4's MR were reviewed on 10/2/2012 from 2:52 p.m.-4:15 p.m., and Pt. #5's paper portion MR was reviewed on 10/3/2012 from 5:45 a.m.-6:15 a.m. and continued at 8:00 a.m.-8:45 a.m.

The facility's policy titled, "Patient Rights and Responsibilities," dated 3/2010, was reviewed on 10/2/2012 at 10:35 a.m. The policy states in part on page 2. #14, that patients have the right, "To be informed about the outcomes of your care, treatment and services, including unanticipated outcomes."

Pt.s #1-5 were admitted to this facility as "Observation" or "Bedded out" (BDO) patients which means that according to the physician, these patients did not meet the hospital's criteria to be considered an inpatient.

In an interview with RN Case Mgmt Supv D on 10/2/2012 at 1:24 p.m., RN D described the algorithm used to determine inpatient vs. observation patient status. RN D stated, and produced, a hospital form used for observation patients which notifies them of what observation status means and the potential impact it may have on them. If this form is given to the patient, after signing and dating the form, a copy is retained and put on the chart, and the yellow copy is given to the patient.

There is no evidence or documentation in the MR of Pt.s 1, 2, and 4 that they were informed their hospital status was "observation bed". Dir of Risk Mgmt C was informed of this on 10/3/2012 at 9:00 a.m.

MD O admitted Pt. #5, a 90 year old with multiple medical issues, as a BDO patient after surgery to evacuate a hematoma (remove the accumulated blood in a traumatic wound) on 7/13/2012 in the p.m. As part of the admission orders MD O ordered physical and occupational therapy to evaluate Pt. #5 and also for the Social Worker (SW) to evaluate for possible rehabilitation needs after discharge.

SW I did see Pt. #5 on 7/14/2012 in the a.m. (note documented at 11:16 a.m.) and discussed need for Subacute Rehabilitation (SAR) needs after discharge from the hospital. There is no indication that SW I discussed that due to the status of "observation" Pt. #5's SAR stay would not be covered by Medicare and, according to family, would place a financial burden on Pt. #5.

On 7/14/2012 a note documented by RN Case Mgr H at 12:05 p.m. indicates an assessment of Pt. #5 for discharge planning needs was done by RN H. The note indicates that RN H was aware that Pt. #5 would have a need for additional help in the home, and possibly the need for rehabilitation after discharge. There is no indication that RN H discussed the "observation" status of the patient and what impact that would have on Pt. #5 in regards to continuing care after discharge.

On 7/16/2012 when Pt. #5 was scheduled to be discharged to a SAR, Pt. #5 and the family were then notified of the "observation" status and the financial impact it would have for SAR care. With this information, the need for a wound vac (mechanical device placed on a wound to aide in healing), and the need for further physical therapy, the family felt unsafe in taking Pt. #5 home and the facility of choice was unable to take Pt. #5 due to the extensive needs for a Assisted Living facility. There was no safe discharge plan in place due to this and Pt. #5's discharge was delayed until 7/17/2012 and alternate arrangements could be made.

In an interview with RN Case Mgr L on 10/3/2012 at 10:13 a.m., RN L stated that L did not think SW I, looks at patient admission status. RN L did agree that if SW I is talking to patients about SAR needs after discharge, that SW I should be aware of the admission status and be discussing that with the patient and family and documenting this.

RN L also stated that RN H would have been aware of the admission status and should also have discussed this with the patient and family.

RN L confirmed that there is no documentation in Pt. #5's MR regarding "observation status" and the patient and family were not aware, until the day Pt. #5 was supposed to be discharged, that Pt. #5 was considered an "observation" patient and the financial impact it would have on them.

Based on P/P review, MR review of 6 out of 6 ED MRs identified as suicide risks (Pt. #6, 7, 9, 10, 11, and 13) out of a total of 13 MR reviewed, and staff interview, this facility failed to provide a safe environment for suicide risk patients in the ED. Failure to provide a safe environment for patients has the potential to affect all patients who present for care in this facility.

Findings include:

The facility's policy titled, "Patient Rights and Responsibilities," dated 3/2010, was reviewed on 10/2/2012 at 10:35 a.m. The policy states in part on page 1, #7 that patients have the right, "To expect safe surroundings...."

The facility's policy titled, "Patient Care: Suicide Precautions," was reviewed on 10/2/2012 at 12:35 p.m. The policy indicates that, "Patients with a known or current threat of suicide will be placed on Suicide Precautions until a medical evaluation determines the patient is no longer at risk." The policy also states on page 2, #3. "The patient on Suicide Precautions will have 1:1 (one-to-one) continuous observation by an assigned staff member." On page 3., 1.a. states,"The patient accessing care in the Emergency Department will be placed in a high visibility room (if available) with 1:1 observation."

MR reviews for Pt.s #6-13

Pt. #6's MR was reviewed on 10/3/2012 at 12:52 p.m. in the presence of ED RN Supvr M and ED RN Mgr E. Pt. #6 was brought to the ED voluntarily by police with feelings of wanting to harm self by drowning or hypothermia on 8/6/2012 at 5:41 p.m. by police.

Pt. #6 was triaged by an RN at 5:44 p.m. and brought to a room that, according to Mgr E, was highly visible from the nurses station. The triage RN indicated Pt. #6 was suicidal, which, according to Mgr E, would have triggered the need for suicide precautions on the patient information light "board" visible to staff in the ED.

The first documented nursing assessment, performed by RN Q, was at 6:52 p.m., over an hour after Pt. #6 arrived in the ED. The remainder of the RN assessments by RN N are documented as follows:
7:40 p.m. (50 minutes between assessments), Pt. #6 was in the room with friends.
8:30 p.m. (50 minutes between assessments), Pt. #6 up walking in hallway without difficulty, waiting for discharge.
9:21 p.m. (40 minutes between assessments), Pt. #6 feels shaky now, MD was notified.
9:54 p.m. (35 minutes between assessments), no documentation regarding this assessment.
10:40 p.m. (40 minutes between assessments), documentation regarding discharge.
11:00 p.m. Pt. #6 was discharged from this facility and transferred to an alternate mental health facility.

There is no evidence of documentation regarding 1:1 observation of a suicidal patient, or that Pt. #6 was being continuously observed for whereabouts and safety in the ED. These findings were confirmed by Supvr M and Mgr E during the MR review.

Pt. #7's MR was reviewed on 10/3/2012 at 12:22 p.m. in the presence of ED RN Supvr M and ED RN Mgr E. Pt. #7 came to the ED with a family member on 8/24/2012 at 3:36 p.m. voicing a suicide plan. The triage RN indicated Pt. #7 was suicidal however the admitting RN did not do a suicide risk assessment.

The RN documented a nursing assessment at 5:19 p.m.-almost 2 hours after Pt. #7's arrival to the ED, and no other nursing assessments or observations are documented until Pt. #7 left the ED with security at 7:29 p.m. (another 2 hour time span) for an admission to the facility.

Pt. #9's MR was reviewed on 10/3/2012 at 12:33 p.m. in the presence of ED RN Supvr M and ED RN Mgr E. Pt. #9, a 14 year old, came to the ED with a family member on 8/24/2012 at 6:18 p.m. with actual self harm (non-life threatening lacerations to the wrists).

Initially the triage RN did not indicate the self harm, which did not trigger the suicide risk light and the admitting RN did not do a suicide assessment.

The following times are documented as an assessment by an RN for Pt. #9: 6:46 p.m. the initial assessment was documented; 7:32 p.m., 8:11 p.m., 8:24 p.m. (vitals signs were taken), 10:02 p.m. (vital signs were taken), 10:10 p.m., 10:27 p.m., and 10:47 p.m. Pt. #9 was transferred to an alternate facility at 10:52 p.m.

At 10:33 p.m. an addendum to the MR for Pt. #9 was made in the triage assessment and it was indicated that Pt. #9 was a suicide risk and at 10:33 p.m. an addendum to the ED MR was made to complete a suicide assessment.

Pt. #10's MR was reviewed on 10/3/2012 at 11:15 a.m. in the presence of ED RN Supvr M and ED RN Mgr E. Pt. #11 came to the ED on 8/6/2012 at 9:47 p.m. with actual self harm (lacerations to the wrists) and indicated to be at risk for suicide. Pt. #10 was discharged at 4:11 a.m. to an alternate facility.
The RN assessments for Pt. #10 are at 9:59 p.m., 10:07 p.m., 11:30 p.m., 11:45 p.m., 12:20 a.m., 1:19 a.m., 2:22 a.m., 3:14 a.m., 3:26 a.m., and 4:11 a.m. upon discharge.

Pt. #11's MR was reviewed on 10/3/2012 at 11:30 a.m. in the presence of ED RN Supvr M and ED RN Mgr E. Pt. #11 came to the ED on 8/6/2012 at 9:57 a.m. with drug withdrawal and indicated as a risk for suicide. Pt. #10 was discharged from the ED at 2:13 p.m. when Pt. #10 was admitted to this facility.
RN assessments are documented as being done at 9:57 a.m. (triage), 10:55 a.m., 11:52 a.m., 12:30 p.m., and 1:11 p.m.

Pt. #13's MR was reviewed on 10/3/2012 at 12:05 p.m. in the presence of ED RN Supvr M and ED RN Mgr E. Pt. #13 came to the ED on 8/6/2012 at 7:07 p.m. with an overdose and indicated as a risk for suicide. Pt. #13 was discharged from the ED at 10:55 p.m. when Pt. #13 was transferred to another facility.

RN assessments are documented as being done at 7:13 p.m. (triage), 7:35 p.m., 8:20 p.m., 9:15 p.m., 9:35 p.m., 10:00 p.m., 10:50 p.m., and 10:55 p.m. at the discharge.

There is no evidence of documentation regarding 1:1 observation of a suicidal patient, or that Pt. #7, 9, 10, 11, or 13 were being continuously observed for whereabouts and safety in the ED per hospital policy. These findings were confirmed by Supvr M and Mgr E during the MR review.