HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to ensure for one (Patient #4) of 10 sampled patients that the Hospital provided care in a safe setting.

Refer to TAG: A-0144.

Based on interviews and record reviews, the Hospital failed to provide care in a safe setting when they failed for 1 of 10 Patients (Patient #4) to provide a suicide risk assessment and safe transfer from one Emergency Department pod to another for further medical work up ordered by the Physician.

Findings include:

Review of the Hospital's Care of Patients at Risk for Suicide policy dated 7/22/2020, indicated that the Hospital has a practice to screen all patients during entry to the Emergency Departments and direct admissions to the inpatient areas.

1. Suicide Risk Screen: A Registered Nurse or another designated clinician completes a suicide screen upon triage, admission or when new information is obtained that indicates the patients may be at risk for suicide. This will be completed using the Suicide Risk Screener tool. The level of risk is documented in the medical record.

Review of the Hospitals Suicide Risk Screening and Mitigation Planning Process, undated, indicated that when a patient arrives in the Emergency Department/Inpatient/Intensive Care Unit or patient/family notifies staff of suicidality, the Nurse conducts a Suicide Risk Screener in the electronic medical record (EMR) and determines a patient's risk level.

Patient #4 is a 41-year-old patient who self-presented to the Emergency Department with complaints of an attempted suicide overdose of Klonopin (A controlled substance) and heroine in 9/2021.

Record review indicated that Patient #4 arrived in the Emergency Department at 8:59 A.M. Patient #4 was seen by the triage nurse, Nurse #1, at 9:00 A.M. The EMR indicated that Patient #4 was then transferred to a room off the floor (OTF) at 9:01 A.M. Patient #4 was transferred into the Emergency Mental Health (EMH) Pod of the Emergency Department at 9:02 A.M. There was no evidence of a suicide screen performed on Patient #4 at triage or in the EMH Pod.

Review of the Emergency Department Care Timeline indicated that Physician #1 evaluated Patient #4 at 9:21 A.M.

Review of the Emergency Room Provider Notes indicated that Patient #4 is a 41-year-old with a history of post-traumatic stress disorder and type 1 bipolar disorder with a report of suicidal ideation and possible suicide attempt. Nursing report received information that he/she had taken Klonopin and heroine. He/she was uncooperative with Physician #1 and refused to tell him what he ingested. The record indicated that Patient #4 was very clearly somnolent but wakes to verbal stimuli and breathing comfortably.

Physician #1 indicated in the Emergency Department Physician Progress notes that Patient #4 comes with apparent suicidal ideation, possible suicide attempt. Report of Klonopin and heroin, but patient refuses to tell Physician #1 more. Therefore, we will need an EKG and blood work including aspirin and Tylenol level. At this time, he/she is not medically appropriate for emergency mental health (EMH) and requires further emergency department work-up. Alerted EMH and they will have him/her transferred to a medical bed.

Review of the Emergency Medicine (nursing) Progress Notes on 9/2/21 at 9:27 A.M. indicated that Patient was sent to EMH from triage. Patient reports taking Clonazepam (Klonopin) and Heroine in a suicide attempt. Patient is slumped over and lethargic. Patient is uncooperative with intake and answered few questions. Patient was transferred back to South Pod (SH7) for further medical clearance.

Review of the Patient Care Timeline indicated that on 9/2/21 at 10:00 A.M., Patient #4 was discharged, not transferred to South Pod.

Review of the Emergency Medicine (nursing) Progress Notes addendum indicated that Nurse #2 was alerted that Patient #4 left the Emergency Department without being seen.

Review of the Physician Progress Notes dated 9/2/21 at 11:09 A.M. indicated that when Physician #1 went to inquire why labs and EKG were not done yet, he was informed that Patient #4 had been released from the hospital by South Pod nurse and police without informing any physician. The patient had clearly indicated a suicidal overdose and therefore meets Section 12 criteria.

During an interview on 5/10/22 at 11:25 A.M., the triage nurse, RN #1, said that a suicide assessment is part of triage, but if a suicidal patient comes in to the Emergency Department and they don't have a medical complaint they go directly to EMH if there is a bed available.

During an interview on 5/10/22 at 12:10 P.M. RN #2 said that Patient #4 was being movedfrom EMH to South Pod for a medical evaluation. She said that she had to call the police to help with the transfer because Patient #4 didn't want to be transferred. Nurse #2 said that she talked to a nurse on South Pod prior to the transfer but can't remember which nurse. Nurse #2 said that the Police did escort Patient #4 to South Pod. Nurse #2 said that she found out after the transfer to South Pod that Patient #4 had left because he was giving the police a hard time and wasn't being compliant. She said she doesn't know why she didn't document any of the communication events that took place, including calling security to assist in the transfer and doing a nurse-to-nurse hand-off.

During an interview on 5/10/22 at 12:34 P.M. Physician #1 said that after his evaluation of Patient #4, he determined that Patient #4 needed to be transferred to the medical side of the Emergency Department and that the EMH nurse set up the transfer. He said that the unidentified South Pod nurse must not have known that Patient #4 was suicidal and let the patient leave.

The lack of suicide risk assessment during triage and in the EMH unit, along with the undocumented transfer of Patient #4, left Patient #4 without proper nurse to nurse hand off and without observation as a high risk for suicide patient allowing him/her to leave the facility in a suicidal and somnolent state without receiving the medical care ordered by Physician #1 due to intentional overdose of Klonopin and heroine.

The Condition of Participation of Quality Assessment & Performance Improvement Program was not met.

Findings included:

The Hospital failed to identify opportunities for improvement, consider the incidence, prevalence, and severity of problems and implement changes that will lead to improvement for 1 (Patient #4) of 10 patient records reviewed.

Refer to TAG: A-0286.

Based on interviews and record reviews, the Hospital failed for 1 of 10 (Patient #4) patients to investigate, analyze and provide system wide implementation of preventative actions after Patient #4 did not receive a suicide screening and vitals signs were not taken during triage, a suicide screening assessment was not performed in the Emergency Mental Health (EMH) POD of the Emergency Department and when Patient #4 was discharged from the Emergency Department instead of being transferred from the EMH Pod to South Pod for medical evaluation due to intentional overdose of Klonopin (a controlled subtance) and herione.

Findings include:

Review of the Hospital's Quality Assessment and Performance Improvement Plan, dated January 2022, indicated that the Hospital's Quality and Safety Plan facilitates a multidisciplinary, systematic performance inprovement approach to identify and persue improved patient outcomes and reduce the risks associated with patient safety.

Review of the Hospital's Suicide Screening and Mitigation Planning policy, dated 6/18/2020, indicated that any patient 12 or older will be screened for suicidal ideation when being evaluated or treated for behavioral health conditions as their primary reason for care using a validated screening tool.

1. A Registered Nurse or another designated clinician completes a suicide screening upon triage, admission or when new infomation is obtained that indicates the patient may be at risk for suicide. This will be completed using the Suicide Risk Screener tool. The level of risk is documented in the medical record.

Review of the Hospital's Clinical Documentation Guidelines for Patients in the Emergency Department policy, dated 11/2019, indicated that: All Emergency Department patients should have the following items documented within the medical record: Emergency Severity Index (ESI) Level, a completed triage, weight and height, allergy review review of medications, an initial pain assessment and as clinically appropriate with interventions Vital signs as follows: ESI Level 1 every 5 - 15 and PRN (until clinically stable) minutes, ESI Level 2 Every 1 hour and PRN (Until Clinically Stable.

Review of the Hospital's Safety Reporting Patient and Visitor policy, dated 12/22/2020, idicated that The Hospital has a process for identifying and documenting adverse events, unanticipated outcomes and medical device incidents that cause harm or have the portential to cause harm to a patien or visitor.

Patient #4 is a 41-year-old patient who self presented to the Emergency Department with complaints of an attempted suicide over dose of Klonopin (a controlled substance) and heroine in 9/2021.

Record review indicated that Patient #4 arrived in the Emergency Department at 8:59 A.M. Patient #4 was seen by the triage nurse, Nurse #1, at 9:00 A.M. The EMR (electronic medical record) indicated that Patient #4 was then transferred to a room off the floor (OTF) at 9:01 A.M.. Patient #4 was then transferred to the Emergency Mental Health (EMH) Pod of the Emergency Department at 9:02 A.M. There was no evidence of a suicide screen ing assessment or a vital sign assessment performed on Patient #4 at triage. There was no evidence of a suicide screening assessment while in the EMH Pod. The EMR then indicated that patient was discharged, not transferred to South Pod for medical evaluation as ordered by Physician #

Review of the Emergency Department Care Timeline, dated 9/2/21 indicated that Physician #1 evaluated Patient #4 at 9:21 A.M. The Emergency Room Provider Notes indicated that Patient #4 is a 41 year old with a history of post traumatic stress disorder and type 1 bipoalr disorder with a report of suicidal ideation and possible suicide attempt. Nursing report received information that he/she had take Klonopin and heroine. He/she was uncooperative with Physician #1 and refused to tell him what he ingested. The record indicated that Patient #4 was very clearly somnolent, but wakes to verbal stimuli and breathing comfortably.

Review of the Emergency Departement Phsyican Progress notes, dated 9/2/21, indicated that Patient #4 comes with apparent suicidal ideation, possible suicide attempt. Report of Klonopin and heroin, but patient refuses to tell Physician #1 more. Therefore, we will need an EKG and blood work including aspirin and Tylenol level. At this time he/she is not medically appropriate for emergency mental health and requires further emergency department work-up. Alerted EMH and the will have him/her transferred to a medical bed.

Review of the Emergency Medicine (nursing) Progress Notes on 9/2/21 at 9:27 A.M. indicated that Patient was sent to EMH from triage. Patient reports taking Clonazepam (Klonopin) and heroine in a suicide attempt. Patient is slumped over and lethargic. Pateint is uncooperative with intake and answered few questions. Patient was transferred back to South Pod (SH7) for further medical clearance.

Review of the Patient Care Timeline indicated that on 9/2/21 at 10:00 A.M., Patient #4 was discharged, not transferred to South Pod

Review of the Emergency Medicine (nursing) Progress Notes addendum dated 9/2/21 at 10:45 A.M., indicated that Nurse #2 was alerted that Patient #4 left the Emergency Department without being seen.

Review of the Physician Progress Notes dated 9/2/21 at 11:09 A.M. inidcated that when Physician #1 went to inquire why labs and EKG were not done yet, he was informed that Patient #4 had been relased from the hospital by South Pod nurse and police without informing any physician. The patient had clearly indicated a suicidal overdose and therefore meets Section 12 criteria.

Review of the Hospital's Risk Management Investigative Synopsis, dated 9/2/21 indicated that and incident report was submitted on 9/2/21 when Patient #4 was sent to EMH from triage without vitals being taken. The event reporter indicated that he/she was told patient was medically stable without vitals being taken prior to transfer to EMH from triage. No further investigation or coorective measures were identified by the Hospital for this incident report.

Review of the Hospital's Risk Management Investigative Synopsis, dated 9/2/21 indicated another incident report was submitted regarding Patient #4 and indicated that Patient #4 eloped from the South Pod after being borught out from EMH from initial evaluation after reporting recent overdose with suicidal intent. Patient was seen by provider who ordered labs and an EKG. It is documented that when the provider went to ask the resource nurse why the blood work and EKG weren't done, they were told the patient was let go by the nurse and police.

The short summary of the event indicated that the risk manager started an investigation on 9/7/21 and requested an RCA to address Emergency Department elopement issues of suicidal patients. An email was sent to Emergency Department staff for contact information of EMH and South Pod RN's. On 9/8/21 the Risk Manager requested the information again for contact of EMH RN involved. On 9/8/21 the report indicated that leadership state that this is not reportable and does not require a Root Cause Analysis. The Risk Manager is getting a group together including ED leadership, legal and EMH to go over any question about section 12 or suicidal patients. The report indicated that a corrective action plan will take place. On 9/9/21 Nurse #3 was called and a message was left for her. On 9/27/21 Leadership determined this did not need a Root Cause Analysis. Meetings with legal, ED leadership, Quality and Risk to communicate and be able to ask quations about suicidal patients that do not yet have a section 12 placed. Good conversation occured between all staffon 9/15 and 9/27. We are hoping to increasepolcie presence in the ED and increase communication between ED staff and the Police. CAP (corrective action plan) was developed.

There was no evidence that the CAP was in relation to the Patient #4's lack of care and inappropriate discharge. It did not identify a lack of suicide assessment, the lack of vital sign assessment or the discharge of Patient #4 versus a transfer to South Pod for medical evaluation of intentional suicidal overdose.

During an interview on 5/10/22 at 12:54 P.M. the Lead Risk Manager said that the Hospital never found out who the South Pod nurse was. She said that a nurse was never assigned to Patient #4. The Lead Risk Manager said that they did identify who the Resource Nurse (RN #3) was but were not able to reach her for interview. She said they are not able to to identify who the security officers involved were.

During an intervew on 5/10/22 at 1:00 P.M. with the Senior Director of Emergency Medicine said that he was not made aware of this specific case so didn't have any information to give the surveyor.

The Hospital failed to investigate why the triage nurse didn't perform vital signs or a suicide assessment on Patient #4. The Hospital failed to investigate why a suicide screening assesment was not done in EMH for Patien t#4. The Hospital didn't identify why Patient #4 was discharged instead of transferred, without proper nurse to nurse communication and allowed to leave the Emergency Department without having labs and EKG ordered by Physician #1. The Hospital failed to identify who the staff members involved were in the case when they failed to perform a complete investigation, analyze and creat corrective measures as a result of this incident.

No corrective actions were taken as a result of these two incidents to prevent a like occurence from happening in the future.