HospitalInspections.org

Based on document review and interview, the nurse executive failed to ensure that nursing staff followed the facility's policy/procedure on suicide screening and intervention for 3 of 4 mental health medical records (MR) reviewed (Patient #3, 4 and 6).

Findings include:

I. Review of policy/procedure NUR 829, Suicide Screening & Intervention, indicated the following on page 1:
"Suicide Screening
1. A licensed healthcare professional - Physician, Registered Nurse (RN), or Licensed Practical Nurse (LPN) will screen for suicide risk by identifying those being treated for the following emotional or behavioral disorders:
A. Mood Disorders
B. Mental Disorders
F. History of suicidal attempts or current suicidal ideation
G. Recent history of perceived loss (loss of spouse or close family member, terminal medical condition)
III. After identification of a patient who is receiving treatment for the emotional or behavioral disorders listed above, the licensed healthcare professional will then screen patient for suicide risk by questioning and observing the patient utilizing the sample "Yes or No" question listed below:
A. Have you ever had thoughts of harming yourself?
B. Do you have a plan?

Suicide Lethality Risk Assessment
I. If the answer is "yes" to either of the 2 above questions (section III), the licensed healthcare professional will then screen the patient utilizing the Suicide Lethality Risk Assessment form and rate the categories on the scale, which most closely apply to the patient's situation or behavior, from low to high risk for suicide."
This policy/procedure was last reviewed/revised on 08/10.

2. Review of patient #3's MR indicated the patient presented to the facility on 02-11-11 and Nursing Note indicated the following:
I've been sad for about 3 weeks, can't sleep, eat, lots of pain. I want to go to sleep and not wake up. Sometimes I would like to open the door and jump out of the car.
The patient's MR lacks documentation that the patient was asked; Have you ever had thoughts of harming yourself? Do you have a plan? The MR lacked documentation of the Suicide Lethality Risk Assessment form being completed.

3. Review of patient #4's MR indicated the patient presented to the facility on 03-13-11 and the MR indicated the following: I'm depressed. Did you know my husband died? The MR indicated the patient has had a past history of suicidal ideation with a plan of hanging self. The patient's MR lacked documentation that the patient was asked; Have you ever had thoughts of harming yourself? Do you have a plan? The MR lacked documentation of the Suicide Lethality Risk Assessment form being completed.

4. Review of patient #6's MR indicated the patient presented to the facility on 03-01-11 and the MR indicated the following: But now he was brought in mainly because the patient is making suicidal threats, asking his wife to get a gun. The patient's MR lacked documentation that the patient was asked: Have you ever had thoughts of harming yourself? Do you have a plan? The MR lacked documentation of the Suicide Lethality Risk Assessment form being completed.

5. On 05-26-11 at 1455, staff #41 confirmed that staff should have asked patient #3, 4 and 6, Have you ever had thoughts of harming yourself? Do you have a plan? and complete the Suicide Lethality Risk Assessment form if answers to either question was yes.