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Based on staff interviews, review of medical records, and review of facility documents, it was determined the facility failed to ensure the emergency needs of all patients arriving via ambulance with an emergency psychiatric condition are addressed in accordance with facility documentation and acceptable standards of practice.

Findings include:

1. The facility failed to ensure all patients identified during triage with an emergency psychiatric condition are secured for safety and addressed as a top priority. (Cross-refer to Tag 1104-A)

2. The facility failed to ensure a policy and procedure is established for the care of patients who arrive in the access area with an emergency psychiatric condition. (Cross-refer to Tag 1104-B)

A. Based on staff interviews, review of three (3) of ten (10) medical records (Medical Records #1, #3, and #9), and review of facility documents, it was determined the facility failed to ensure all patients identified during triage with an emergency psychiatric condition are secured for safety and addressed as a top priority.

Findings include:

Reference: Facility document titled, "Initial Assessment Triage Section:" states, "Are you here for a mental health condition and/or substance abuse such as drug or alcohol problems? Yes - CONTINUE below ...
a. Yes No - Do you feel like you could kill yourself or someone else RIGHT NOW
b. Yes No - Do you feel as if someone is commanding you to hurt yourself or someone else
If YES to any of the above go to EMERGENCY CONDITION ...EMERGENCY CONDITION ...If PSYCHIATRIC, the Access Clinician will secure the safety of the patient and alert LIP (Licensed Independent Practitioner). The Access Clinician will proceed with their assessment and pass it on to the LIP as a top priority. ..."

1. On 8/11/21 at 12:50 PM, a review of Medical Record #1 revealed the following:

a. The patient arrived at the facility on 6/4/21 at 9:39 PM and was triaged at 9:50 PM. On the "Initial Assessment Triage Section" form, question #2 asks: "Are you here for a mental health condition and/or substance abuse such as drug or alcohol problems?"

(i) The form was marked "YES" to question #2.

b. Question #2(b) asks: "Do you feel as if someone is commanding you to hurt yourself or someone else? (If YES to any of the above go to EMERGENCY CONDITION, otherwise go to question 3)."

(i) The form was marked "YES" to question #2(b).

c. The section labeled "Emergency Condition" states, "If PSYCHIATRIC, the Access Clinician will secure the safety of the patient and alert LIP. The Access Clinician will proceed with their assessment and pass it on to the LIP as a top priority."

d. Review of the facility's "Access Log" for 6/4/21 revealed the patient arrived via ambulance to the access area at 9:39 PM and remained in the ambulance until 11:40 PM, when the patient was brought to the unit for admission. This was two (2) hours and one (1) minute after the initial triage determined the patient may have a psychiatric emergency condition.

e. There was no evidence in the medical record that the patient's safety was secured.

f. There was no evidence in the medical record that the LIP was notified the patient was a top priority.

2. On 8/11/21 at 1:20 PM, review of Medical Record #3 revealed the following:

a. The patient arrived at the facility on 6/16/21 at 5:18 PM and was triaged at 6:00 PM. The "Initial Assessment Triage Section" form states, "Presenting Complaint: (In patient's own words): I had thoughts to just end it once and for all."

b. Question #2 asks: "Are you here for a mental health condition and/or substance abuse such as drug or alcohol problems?"

(i) The form was marked "YES" to question #2.

c. Question #2(a) asks: "Do you feel like you could kill yourself or someone else RIGHT NOW? (If YES to any of the above go to EMERGENCY CONDITION, otherwise go to question 3)."

(i) The form was marked "YES" to question #2(a).

d. The section labeled "Emergency Condition" states, "If PSYCHIATRIC, the Access Clinician will secure the safety of the patient and alert LIP. The Access Clinician will proceed with their assessment and pass it on to the LIP as a top priority."

e. There was no evidence in the medical record that the patient's safety was secured.

f. There was no evidence in the medical record that the LIP was notified the patient was a top priority.

3. On 8/11/21 at 1:20 PM, a review of Medical Record #9 revealed the following:

a. The patient arrived to the facility on 5/14/21 at 7:49 PM and was triaged at 8:31 PM. The "Initial Assessment Triage Section" form states, "Presenting Complaint: (In patient's own words): Extreme Suicide Ideation."

b. Question #2 asks: "Are you here for a mental health condition and/or substance abuse such as drug or alcohol problems?"

(i) The form was marked "YES" to question #2.

c. Question #2(a) asks: "Do you feel like you could kill yourself or someone else RIGHT NOW? (If YES to any of the above go to EMERGENCY CONDITION, otherwise go to question 3)."

(i) The form was marked "YES" to question #2(a).

d. The section labeled "Emergency Condition" states, "If PSYCHIATRIC, the Access Clinician will secure the safety of the patient and alert LIP. The Access Clinician will proceed with their assessment and pass it on to the LIP as a top priority."

e. Review of the facility's "Access Log" for 5/14/21 revealed Patient #9 arrived via ambulance to the access area at 7:49 PM and remained in the ambulance until 11:00 PM, when the patient was brought to the unit for admission, approximately two (2) hours and twenty-nine (29) minutes after the initial triage determined the patient may have a psychiatric emergency condition.

f. There was no evidence in the medical record that the patient's safety was secured.

g. There was no evidence in the medical record that the LIP was notified the patient was a top priority.

2. The above findings were confirmed with Staff #1 during the exit conference.

B. Based on staff interviews and review of facility documentation, it was determined the facility failed to ensure a policy and procedure is developed and implemented for the care of patients arriving via ambulance in the access area with an emergency psychiatric condition.

Findings include:

1. On 8/10/21 at 9:57 AM, Staff #2 stated that prior to 8/3/21, all patients arriving via ambulance to the Access Area would remain in the ambulance for triage by an Admissions Counselor or Nurse, and an assessment by an LIP, and then the ambulance would bring the patient to their unit for admission.

a. During Medical Record review, the following was determined:

(i) On 5/14/21, Patient #9 arrived in the Access Center via ambulance, and it was determined during triage the patient may have an emergency psychiatric condition. Documentation of the facility's Access Log revealed the patient arrived to the access area at 7:49 PM and remained on the ambulance until admission at 11:00 PM. This was two (2) hours and twenty-nine (29) minutes after the initial triage determined the patient may have a psychiatric emergency condition.

(ii) On 6/4/21, Patient #1 arrived in the Access Center via ambulance and it was determined during triage the patient may have an emergency psychiatric condition. Documentation of the facility's "Access Log revealed the patient arrived to the access area at 9:39 PM and remained in the ambulance until admission at 11:40 PM. This was two (2) hours and one (1) minute after the initial triage determined the patient may have a psychiatric emergency condition.

b. Upon interview, Staff #1 stated that patients undergoing triage and assessment screening in the ambulance, while awaiting admission, are monitored by the ambulance staff and are not monitored by facility staff. Staff #1 stated the ambulance staff follow their own protocols while monitoring the patient.

c. Upon request, Staff #1 stated there is no policy and procedure to ensure conditions are being safely managed in the ambulance for patients with an emergency psychiatric condition.

2. The above findings were confirmed by Staff #1 during the exit conference.