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Based on medical record review and interview, the facility did not notify a minor patient's parent of a change in health status in 1 of 1 records reviewed (Patient #1). Not informing the responsible person of a change in status could compromise the ability to make an informed decision regarding care.

Findings include:

Review of the Emergency Department (ED) medical record for Patient #1 dated 3/14/18 at 4:52 PM revealed the patient presented to the ED with suicidal ideation and plan to cut wrists. The patient's clothing and other belongings were removed except for socks and underwear. The patient was provided a gown and placed in the behavioral health room. At approximately 12:00 AM on 3/15/18 the patient removed a razor from her sock and cut her wrist. The area was cleansed and bandaid applied. There is no documentation to indicate the patient's parent was notified of the event.

Interview with Staff (C), ED Nurse Manager on 5/17/18 revealed that the patient's parent was not notified at the time of the event.

Interview with Staff (B), Corporate Director on 5/16/18 revealed that the facility does not have a policy in place regarding the notification of a minor patient's parent/guardian in the event of a change in health status.

Based on medical record review and interview, the facility did not provide Patient #1 with a safe setting for care. Not providing a safe environment could result in patient injury.

Findings include:

Review of facility policy, Patient Suicide Risk Assessment and Environmental Risk Evaluation last revised 2/8/18 revealed that all patients who are admitted with or who answer yes to one of the following: 1. Emotional or behavioral disorder 2. Feeling down, depressed or hopeless or, 3. Any thoughts of harming self or better off not being alive, will have a suicide risk assessment utilizing the SAD PERSONS scale (assessment tool to determine suicide risk) completed.

Review on 5/16/18 of policy # 7C-0167.25 titled: Suicidal and/or Agitated Patients, Observation of - last revised 10/15 revealed: All patient belongings should be removed and patient placed in a gown. The patient will be maintained on 1:1 observation at all times, unless otherwise ordered by a physician.

Review of the Emergency Department (ED) medical record for Patient #1 dated 3/14/18 at 4:52 PM revealed the patient presented to the ED with suicidal ideation and plan to cut wrists. The patient's clothing and other belongings were removed except for socks and underwear. The patient was provided a gown and placed in the behavioral health room. At approximately 12:00 AM on 3/15/18 the patient removed a razor from her sock and cut her wrist. The area was cleansed and bandaid applied. There was no documentation to indicate a SAD PERSONS assessment was completed or that 1:1 observation was implemented

Interview on 5/18/18 with Staff (R), ED RN verified that the patient's clothing was not completely removed, that a SAD PERSONS assessment was not completed and that the patient was not placed under 1:1 observation in accordance with facility policy.

Based on medical record review, interview and policy review 4 out of 10 Emergency Department (ED) medical records had incomplete triage assessments (Patient #1-4). An incomplete assessment could result in patient needs not being addressed.

Findings include:

Review of facility policy, Patient Suicide Risk Assessment and Environmental Risk Evaluation last revised 2/8/18 revealed that all patients who are admitted with or who answer yes to one of the following: 1. Emotional or behavioral disorder 2. Feeling down, depressed or hopeless or, 3. Any thoughts of harming self or better off not being alive, will have a suicide risk assessment utilizing the SAD PERSONS scale (assessment tool to determine suicide risk) completed. The SAD score as well as evaluations of the person's physical condition are addressed upon triage and are documented in the electronic medical record.

Review on 5/18/18 of ED medical records revealed a SAD PERSONS evaluation was not completed during triage for Patient #1-4, despite documentation of mental health concerns and suicidal ideation on presentation to the ED.

Interview with Staff (A), Vice President of Patient Care Services and Staff (B), Corporate Director on 5/18/18 at 1:00 PM verified the above findings.