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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation § 482.13 Patient's Rights was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on interviews and document review, the facility failed to ensure patients were provided treatment and deemed safe before leaving the psychiatric emergency department (PED) in 5 of 6 medical records reviewed of patients who came to the PED seeking care for emergencies and had no evidence of being stabilized and deemed safe prior to discharge (Patient #6, #9, #11, #16, and #22). Additionally, the facility failed to ensure all patients who presented to the ED seeking care were evaluated for an emergency condition in 3 of 10 medical records reviewed of patients experiencing suicidal ideations (SI). (Patient #10, #18, #21).

Based on interviews and document review, the facility failed to ensure patients were provided treatment and deemed safe before leaving the psychiatric emergency department (PED) in 5 of 6 medical records reviewed of patients who came to the PED seeking care for emergencies and had no evidence of being stabilized and deemed safe prior to discharge (Patient #6, #9, #11, #16, and #22). Additionally, the facility failed to ensure all patients who presented to the ED seeking care were evaluated for an emergency condition in 3 of 10 medical records reviewed of patients experiencing suicidal ideations (SI). (Patient #10, #18, #21).

Findings include:

Facility policies:

The Medical or Behavioral Health Emergency Policy read, patients experiencing an obvious medical crisis anywhere on the Hospital campus should receive prompt medical attention and stabilization, including basic cardiovascular life support when indicated, under the supervision of a registered nurse, physician or other privileged Provider. Patients requesting or requiring further evaluations or care for a medical or behavioral health condition should be voluntarily escorted to the Psychiatric Emergency Department (PED) for further screening and stabilization. Team members should document objective and subjective information and arrive at evaluations as detailed in current version of PED medical records documentation tools. The individual(s) performing these initial assessments should contact an on-call PED Provider, who shall become responsible for implementing a plan of care or treatment, which may include hospitalization, continued observation and evaluation, and transfer to another hospital.

The Assessment and Diagnosis Policy read, if a patient refuses to be examined or is unable to be completely examined secondary to symptoms of mental illness, the provider, nurse, and/or case worker must document the attempt within the timeframe required by the specified evaluation.

1. The facility failed to ensure individuals presenting to the facility for emergency care were stabilized and deemed safe for discharge.

A. Record review revealed patients who presented to the ED with high risk psychiatric emergencies were discharged prior to being stabilized and deemed safe for discharge.

i. Medical record review revealed on 1/26/23 at 5:39 p.m., Patient #9 presented to the facility for treatment. During the initial assessment, Patient #9 reported suicidal ideations (thought process of having ideas or ruminations about the possibility of ending one's own life), depression, and anxiety. In addition, Patient #9 stated he had auditory command hallucinations (hallucinations that instruct a patient to act in specific ways) to kill himself. Patient #9 also reported having a plan and intent to kill himself. The patient was scored as a high risk on the suicide risk assessment, yet was documented as a moderate risk by the registered nurse (RN). The RN documented he spoke on the phone with a provider. There was no evidence a provider assessed the patient to determine if the patient had an emergency medical condition and required further care or was safe for discharge from the facility. In addition, there was no evidence the patient received any treatment. The patient refused to sign and receive a safety plan. The patient was documented to tell the RN he was scared to leave, he was feeling suicidal and that he had children at home. The patient then discharged from the facility on 1/27/23, a specific discharge time was not recorded in the patient's medical record.

This was in contrast with The Medical or Behavioral Health Emergency Policy, which read team members should document objective and subjective information and arrive at evaluations as detailed in current version of PED medical records documentation tools.

ii. On 1/31/23 at 5:46 a.m., Patient #6 presented to the facility for treatment. During the initial assessment, Patient #6 reported suicidal ideations, a suicide attempt (an attempt to die by suicide that results in survival) two days prior, withdrawing from methamphetamine, homicidal ideations (thought process of having ideas or ruminations about the possibility of ending someone else's life), and hearing voices. Patient #6 reported having a plan and intent to kill himself, which was the same plan attempted two days prior to presenting to the PED. The patient was scored as high risk on the suicide risk assessment.

The patient left the facility the next morning. There was no evidence the patient received any treatment. The patient refused to sign a safety plan. Documentation in the electronic health record of Patient #6 by advanced practice nurse (APN) #13 on 2/1/23 at 10:07 a.m. acknowledged the patient requested help with his depression and addiction and APN #13 had determined the patient was appropriate for an inpatient level of care. Despite the presentation of Patient #6 and the acknowledgment by APN #13 that the patient had met criteria for an inpatient level of care, Patient #6 was discharged on 2/1/23.

iii. Similar findings of patients presenting to the facility for care but were discharged prior to receiving treatment or deemed safe to discharge were found in the medical record reviews of Patients #11, #16, and #22.

B. Interviews

i. On 2/14/23 at 1:04 p.m., an interview was conducted with RN #11. RN #11 stated the assessment process for patients in the PED included an RN intake assessment with a four page suicide risk assessment. RN #11 stated RN assessment findings were presented to providers by phone call, zoom call, or in person and the provider determined if the patient met inpatient psychiatric hospitalization based on the RN assessment findings. RN #11 stated once the provider established inpatient psychiatric hospitalization criteria was met, staff then determined if the patient was voluntary or involuntary. RN #11 stated patients who did not meet criteria for inpatient psychiatric admission were provided a safety plan which included outpatient resources.

ii. On 2/15/23 at 7:28 a.m., an interview was conducted with RN #5. RN #5 stated the provider did not perform direct assessments of the patients before they were discharged from the facility if the RN intake assessment concluded inpatient psychiatric hospitalization criteria was not met. RN #5 stated homeless patients often presented to the PED and stated they had an emergency condition in an attempt to get free food and shelter. RN #5 stated the prior number of PED visits were considered in the admission decision for patients who had multiple past visits with the same presenting concern.

iii. On 2/15/23 at 9:07 a.m., an interview was conducted with nurse practitioner (NP) #6. NP #6 stated full psychiatric evaluations were provided to all patients who presented to the PED. NP #6 stated patients with SI were assessed for suicide risk, current and past SI history, and factors that may affect care after discharge. NP #6 stated if a patient left the facility prior to stabilization they were at risk of a suicide attempt which could result in death or injury.

2. The facility failed to ensure all patients who presented to the facility were assessed for an emergency medical and or psychiatric condition.

A. Review of the EMTALA log revealed medical and psychiatric emergencies were not identified and addressed for patients who presented to the PED seeking treatment.

i. Review of the EMTALA log revealed on 1/14/23 at 10:00 a.m., Patient #21 presented to the facility and requested to speak with a clinician. Patient #21 was informed evaluations were performed inside the psychiatric emergency department and to 'ring the bell if needed'. According to the EMTALA log, it was documented no evaluation was requested. No further documentation or evidence was provided to show the patient was assessed to determine if an
emergency medical or psychiatric conditions existed. Patient #21 was documented as leaving the facility at 10:03 a.m.

ii. On 1/26/23 at 1:52 a.m., Patient #10 presented to the facility stating he "took too much Fentanyl." According to the EMTALA log, no evaluation was requested. No further documentation or evidence was provided to show the patient was assessed to determine if an emergency medical or psychiatric condition existed. Patient #10 left the facility at 2:00 a.m.

iii. On 2/12/23 at 8:13 a.m., Patient #18 presented to the facility with complaints of weakness, body pain and not feeling right. Interviews with staff on 2/15/23 at 12:14 p.m., revealed the patient also stated he was experiencing chest pain. The EMTALA log read no evaluation was requested. The facility was unable to provide evidence the patient was assessed and any treatment was provided to the patient by the facility. An interview with an RN who was present on 2/12/23 stated 911 was called for Patient #18, yet was unable to verify this with any documented evidence.

B. Interviews revealed patients who presented to the PED with medical and psychiatric emergencies were not assessed and provided stabilizing treatment.

i. On 2/14/23 at 4:59 p.m., an interview with RN #12 was conducted. RN #12 stated a completed medical screening exam (MSE) ensured the facility met the patient's medical needs and provided a higher level of care when needed. RN #12 stated treatments for stabilization in the PED included medication administration, obtaining vitals, conducting laboratory testing, monitoring blood glucose levels, and utilizing the CIWA (Clinical Institute Withdrawal Assessment) protocol (a tool used to help minimize the risk of complications from alcohol withdrawal).

RN #12 stated the risk to patients who did not receive a MSE was not identifying a potentially life threatening assessment finding.

ii. On 2/15/23 at 12:14 p.m., an interview with RN #7 was conducted. RN #7 stated the facility staff told patients who presented to the PED with emergency conditions they were not allowed to leave until they were assessed by a nurse. RN #7 stated he had a discussion with Patient #18 on 2/12/23 at 8:13 a.m., when Patient #18 presented to the PED and asked for help. RN #7 stated he explained to Patient #18 he would not be allowed to leave the hospital without a nursing assessment if he crossed the hospital door threshold and entered the hospital. Additionally, RN #7 stated Patient #18 decided to sit on the ground outside the PED rather than enter the PED after being informed he would not be able to leave the facility if he entered the hospital doors. RN #7 stated a brief nursing assessment was provided to Patient #18 outside the hospital doors and an ambulance was called.

The facility was unable to to provide evidence Patient #18 was assessed, received stabilizing treatment, or that an ambulance was called.

This was in contrast to The Medical or Behavioral Health Emergency Policy, which read, patients requesting or requiring further evaluations or care for a medical or behavioral health condition should be voluntarily escorted to the Psychiatric Emergency Department for further screening and stabilization.

iii. On 2/15/23 at 5:25 p.m.,. an interview with director of nursing (DON) #2 was conducted. DON #2 stated Patient #10 who presented to the PED on 1/26/23 at 1:52 a.m., was at risk for harm because he did not receive an assessment when he arrived at the PED and asked for an evaluation. Additionally, DON #2 stated documentation including a nursing assessment was not completed for patients who were treated on hospital property but did not enter the PED doors or for patients who staff did not collect completed demographic information for. DON #2 stated staff was not able to create documentation or medical records for patients who did not have a complete demographic profile due to limitations of the electronic health record (EHR) and therefore care was not documented for those patients.

The facility was unable to to provide evidence Patient #10 was assessed or received stabilizing treatment.

This was in contrast to The Assessment and Diagnosis Policy, which read if a patient refused to be examined or was unable to be completely examined secondary to symptoms of mental illness, the provider, nurse, and/or case worker must document the attempt within the timeframe required by the specified evaluation.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A-395 - (b)(3) RN SUPERVISION OF NURSING CARE A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol, policy, and national guidelines. Specifically, the facility failed to ensure registered nurses (RN) followed the Clinical Institute Withdrawal Assessment (CIWA) protocols (clinical assessment used to diagnose the severity of alcohol withdrawal) when ordered to assess withdrawal from alcohol in eight of nine patients reviewed who were ordered to be on the CIWA protocol. (Patients #3, #7, #8, #12, #13, #14 #15, and Patient #19)

Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol, policy, and national guidelines. Specifically, the facility failed to ensure registered nurses (RN) followed the Clinical Institute Withdrawal Assessment (CIWA) protocols (clinical assessment used to diagnose the severity of alcohol withdrawal) when ordered to assess withdrawal from alcohol in eight of nine patients reviewed who were ordered to be on the CIWA protocol. (Patients #3, #7, #8, #12, #13, #14 #15, and Patient #19)

Findings include:

Facility policies:

The CIWA Orders - First 72 Hours policy read, the purpose of CIWA is used to provide assessment guidelines specific to the care and safety of individuals who may experience alcohol withdrawal. The assessment creates a rubric for the determination of the necessary pharmacological interventions. Signs and symptoms of alcohol withdrawal peak on to three days post ingestion. Alcohol withdrawal seizures may occur in one-third of alcoholics when they abruptly reduce or stop alcohol intake.

When a patient is admitted and may be experiencing alcohol withdrawal symptoms, a provider will order the CIWA protocol for nursing to implement. Nursing will assess and monitor vital signs and symptoms assigning a score after each assessment. Based on the score, nursing will determine if additional protocol interventions are required.

Nurses are to assess symptoms according to the appropriate time frames listed on the CIWA scoring tools. Signs of alcohol withdrawal include: elevated blood pressure, elevated temperature, agitation, reddening skin, elevated pulse, hyper arousal, restlessness, tremors, sweating, uncoordinated movements, dilated pupils and disorientation. An additional symptom of alcohol withdrawal includes delirium tremens (DTs), a sometimes fatal episode of delirium.

References:

The CIWA Scoring Guidelines document read, initial vital signs should be obtained along with an initial CIWA score. If the initial score is greater than or equal to eight or if vital signs are out of range, repeat every hour, then if stable, complete assessment and vital signs every four hours for 72 hours or until the assessment is discontinued. If the score is greater than or equal to eight at any time, repeat assessment and vital signs every hour. If indicated, administer medications per CIWA instructions.

According to the Indications for PRN medication/Interventions section: PRN medication should be administered with a score of or greater than eight.

The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management read, for inpatient management of alcohol withdrawal, patients with moderate to severe withdrawal or those
requiring pharmacotherapy, reassess every one to four hours for 24 hours, as clinically indicated. Once stabilized (e.g CIWA-Ar score<10 for 24 hours), monitoring can be extended to every 4-8 hours for 24 hours, as clinically indicated. Patients with mild withdrawal and low risk of complicated withdrawal may be observed for up to 36 hours, after which more severe withdrawal is unlikely to develop. Monitor patients ' vital signs, hydration, orientation, sleep, and emotional status including suicidal thoughts. Monitor patients receiving pharmacotherapy for alcohol withdrawal for signs of oversedation and respiratory depression.

1. The facility failed to ensure patients who were withdrawing from alcohol were assessed per facility protocol, policy, and national guidelines.

A. Record Review

i. A review of Patient #3's medical record revealed Patient #3 was admitted on 1/31/23 for disorganized behavior, severe anxiety and alcohol or drug withdrawal. CIWA assessment was ordered on 1/31/23 at 3:59 p.m. to be completed per CIWA protocol.

a. Review of Patient #3's medical record revealed the first inpatient CIWA score was completed on 2/4/23 at 9:44 p.m., four days after Patient #3 was admitted and CIWA orders were placed. Patient #3's CIWA score was 13 and the patient was administered 50 milligrams (mg) of Librium (a medication used to treat withdrawal symptoms).

ii. A review of Patient #12's record revealed the patient presented to the facility's emergency department (ED) looking for detox. The outpatient detox facility did not have available beds and Patient #12 was observed in the ED. Patient #12 reported he had a history of DTs and he drank a six pack of beer and ½ pint of vodka daily.

a. A review of Patient #12's CIWA Assessment revealed at 8:00 p.m., his CIWA score was 8. At that time, Patient #12 was administered 50 mg of Librium. Patient #8 was not reassessed until 3:30 a.m. the following morning, seven and a half hours after the initial CIWA assessment.

This was in contrast to the CIWA protocol which read if a patient scored an eight or higher, the patient was to be reassessed every hour.

b. Further review of Patient #8's medical record revealed at 6:30 a.m., the patient's CIWA score was 14. At 6:57 a.m. the patient was administered 50 mg of Librium. Patient #8 was then discharged at 11:50 a.m. There was no evidence Patient #12 was reassessed an hour after the score of 14 or was reassessed for medication effectiveness.

iii. A review of Patient #15's medical record revealed the patient was admitted on 2/4/23 for bipolar disorder and alcohol abuse. A CIWA order was placed on 2/5/23 at 12:51 p.m., for CIWA protocols to be followed.

a. A review of Patient #15's CIWA score sheet revealed on 2/5/23 at 8:30 a.m. Patient #15's CIWA score was 6. Later the same day at 12:30 p.m., Patient #15 scored a 9. At 5:30 p.m., Patient #15's CIWA score was 14. At that time, 25 mg of Librium was administered to Patient #15. On 2/5/23 at 9:30 p.m., Patient #15's CIWA score was 9. The next CIWA assessment was not completed until 2/6/23 at 11:00 a.m., over 13 hours later.

This was in contrast to the CIWA protocol which read if a patient scored an eight or higher, the patient was to be reassessed every hour.

iv. Similar examples of CIWA assessments and vital signs not being completed per CIWA protocol, facility policy, and national guidelines were found during medical record review for Patients #7, #8, #13, #14, and Patient #19.

B. Interviews

i. On 2/16/23 at 2:15 p.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated the CIWA protocol was used to monitor patients for symptoms of alcohol withdrawal. RN #1 stated if a patient scored an eight or higher on the CIWA assessment, the patient would need to be reassessed every hour and often provided medication. RN #1 stated it was important to follow the protocol to prevent the patient from going through severe withdrawal.

ii. On 2/21/23 at 9:29 a.m., psychiatric nurse practitioner (NP) #4 was interviewed. NP #4 stated the CIWA protocol was used to assess and manage a patient who was in withdrawal for alcohol. NP #4 stated if a patient was scoring high or was more acute, the patient would need to be assessed more frequently. NP #4 further stated if a patient was not assessed and treated per the CIWA protocol, the patient was at risk for experiencing withdrawal symptoms to include seizures.

iii. On 2/21/23 at 10:24 a.m., an interview was conducted with the director of nursing (DON) #2. DON #2 stated when a patient came in and was at risk for alcohol withdrawal, the patient would need to be started on the CIWA protocol to assess and determine the severity of the withdrawal. DON #2 stated if a patient was not assessed and treated for withdrawal symptoms, the patient was at risk for DTs, vomiting, diarrhea, electrolyte imbalances and hallucinations.

Interviews were in contrast to medical record review which revealed patients were not assessed according to the CIWA protocol and reassessed and treated based on the patient's CIWA score.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.55 Emergency Services was out of compliance.

A-1101 If emergency services are provided at the hospital. Based on interviews and record review, the facility failed to ensure emergency services in the Psychiatric Emergency Department (PED) were provided under the direction of a qualified member of the medical staff. (Cross reference A-0144)

Based on interviews and record review, the facility failed to ensure emergency services in the Psychiatric Emergency Department (PED) were provided under the direction of a qualified member of the medical staff. (Cross reference A-0144)

Findings include:

References:

According to the Facility Organizational Chart dated 1/16/23, the director of nursing (DON) #2 and operations manager (Manager) #6 supervise the Emergency Department. The chief medical officer (CMO) #3's role with oversight of the medical staff, encompassed and directly linked, to his Medical Director role.

The DON job description read, Qualifications: Master's degree from an accredited school of Nursing and licensed as a Registered Nurse (RN) in the State of Colorado preferred; Four years previous nursing experience in a hospital setting required, to include minimum two years of progressive, responsible experience as a leader in a psychiatric hospital or other mental health-related field required. Comprehensive nursing theory and practice with administrative and leadership abilities.

Job Purpose: provides management direction, strategic planning, organizational goals, process and procedures, budgets, evaluation of nursing care, quality improvement, risk management, hiring and supervision of nursing staff and reporting.

The CMO job description, last modified 10/24/22 read, Qualifications: Board Certified in Psychiatry; Colorado licensed physician required. Minimum five years experience in hospital or mental health setting including two years of management experience.

Purpose: Responsible for all medical services including the scheduling for medical coverage, medical policies, integration with clinical services, as well as participating in program reviews and staff selection. Responsible for supporting the facility's quality assurance mechanisms, service coordination with other agencies, crisis and emergency coverage, and medical community relations. This is both a Clinical and Management position. Hence, this position requires expertise in the formulation of policy and management of programs through the implementation of business acumen. Exercises independent judgment and action within the context of the program(s) and goals, recognizing that they represent the facility and its mission at all times.

The Medical Staff By-Laws, revised on 12/1/22, read, the Medical Director functions as the administrative officer of the Medical Staff organization. The Medical Director is appointed by the Governing Body to oversee the medical operations of the Hospital. Specific functions and tasks in each of these roles are detailed in the job description.

Responsibilities and Authority of the Medical Director: Transmitting the views and recommendations of the Medical Staff and the Medical Executive Committee (MEC), to the Hospital Administrator and to the Chief Executive Officer (CEO) on matters of Hospital policy, planning, operations, governance, and relationships with external entities, and transmitting the views and decisions of the Governing Body, Hospital Administrator, CEO, and Medical Staff membership; Communicating the opinions of the Medical Staff and individual members on organizational and individual staff matters affecting Hospital operations to the Hospital Administrator and the CEO; Overseeing compliance of the Medical Staff with the procedural safeguards and rights of individual physicians in all stages of the credentialing process;
Directing the operation of the Medical Staff organization; Assisting in coordinating Medical Staff functions and responsibilities with Hospital administration, nursing, and other support staff;
Enforcing compliance with the provisions of these bylaws, and the rules and regulations, and policies and procedures of the Hospital; Presiding over all general and special meetings of the Medical Staff and of the MEC, including responsibility for the agenda; Appointing Medical Staff members to chair and serve on Medical Staff committees; Serving as chair of the MEC and serving as a member without vote on all other standing Medical Staff committees, unless otherwise provided in the Hospital or Medical Staff bylaws; Reviewing and enforcing compliance with standards of ethical conduct and professional demeanor by the Medical Staff in their relations with each other, the Governing Body, Hospital administration, support staff, and the community the Hospital serves; Directing the development and implementation of the Medical Staff components of the performance improvement programs and overseeing processes consistent with any accrediting agency requirements; Appointing Medical Staff members to chair and serve on committees formed to accomplish Medical Staff performance improvement and monitoring functions, unless otherwise provided in these bylaws; and Performing such additional duties as may be assigned by the MEC, the CEO, or the Governing Body.

1. The facility failed to ensure emergency services in the PED were organized and received direction from a qualified member of the medical staff in order to provide safe patient care.

A. Document review revealed no position was created for the organization and direction of the PED. Without oversight, processes were not established or overseen by a qualified staff member to ensure patients received safe care.

i. Job Descriptions

a. The CMO job description, last modified 10/24/22, required CMO #3 to be a physician trained in psychiatric health. It mentioned his responsibility to support all medical services and crisis and emergency coverage. The job description was not updated to include oversight of the PED after its creation and open date of 1/3/23.

b. The DON job description, signed by DON #2 on 11/23/22, required DON #2 to be an RN with previous nursing experience in the mental health field. It mentioned his responsibility to provide management direction and supervise nursing staff. The job description was not updated to include oversight of the PED after its creation and open date of 1/3/23. Additionally, as an RN, DON #2 was not able to manage or supervise physicians who worked in the PED.

ii. The organizational chart dated 1/16/23 revealed DON #2 and Manager #6 were in charge of the Emergency Department.

iii. The Medical Staff By-Laws did not list oversight of the PED as part of CMO #3's assigned roles whether as CMO or Medical Director.

iv. Review of medical records revealed processes were not established or overseen by a qualified staff member to ensure patients received safe care.

a. Review of Patient #13's medical record revealed on 1/14/23 at 5:39 p.m., he presented as a walk-in patient to the PED to receive treatment. Review of the medical record revealed the patient reported depression, anxiety, thoughts of self-harm, anger, mood swings, and desired to hurt or kill someone. Patient #13 reported suicidal ideation (thought process of having ideas or ruminations about the possibility of ending one's own life) with intent and plan to commit suicide. Patient #13 was marked as moderate suicide risk by nursing staff. Record review of the PED Staffing Note revealed an advanced practice nurse (APN) #10 met with Patient #13, although no provider assessment was documented, and the patient was documented as "appropriate for care in a non-hospital setting." He was provided with a safety plan and discharged on 1/14/23 at 3:23 p.m. Additionally, Patient #13 reported 10/10 back pain and there was no documentation of an assessment or intervention for these physical symptoms.

There was no evidence of an assessment which documented changes in Patient #13's condition or any treatment provided which would have led to a change resulting in readiness for discharge.

b. Review of Patient #6's medical record revealed on 1/31/23 at 5:46 a.m., he presented as a walk-in patient to the PED to receive treatment. Review of the medical record revealed the patient reported suicidal ideations, a suicide attempt (an attempt to die by suicide that results in survival) two days prior, withdrawing from methamphetamine, homicidal ideations (thought process of having ideas or ruminations about the possibility of ending someone else's life), and hearing voices. The Medical Screening Exam (MSE) was completed on 2/1/23 at 8:30 a.m., more than 24 hours after Patient #6 presented to the PED. The MSE reported Patient #6 was a high suicide risk by RN #5.

The patient left the facility the next morning. There was no evidence the patient received any treatment. The patient refused to sign a safety plan. Documentation in the electronic health record of Patient #6 by advanced practice nurse (APN) #13 on 2/1/23 at 10:07 a.m. acknowledged the patient requested help with his depression and addiction and APN #13 had determined the patient was appropriate for an inpatient level of care. Despite the presentation of Patient #6 and the acknowledgment by APN #13 that the patient had met criteria for an inpatient level of care, Patient #6 was discharged on 2/1/23.

There was no evidence of an assessment which documented changes in Patient #6's condition or any treatment provided which would have led to a change resulting in readiness for discharge.

c. Review of Patient #16's medical record revealed on 12/27/22 at 5:15 p.m., he presented as a walk-in patient to the PED to receive treatment. Review of the medical record revealed he was tired and wanted to hang himself. Patient #16 stated he wanted to be taken to a bed. He scored in the severe risk category for suicidal ideation intensity, yet he was documented as a moderate risk for suicide. The discharge notes stated that Patient #16 was appropriate for non-hospital services as he just needed a place to sleep and had passive suicidal ideation (SI). The patient chose to discharge himself before the hospital discharge was completed. A nursing note revealed Patient #16 remained outside the facility where he screamed and threatened staff.

There was no evidence of an assessment which documented changes in Patient #6's condition or any treatment provided which would have led to a change resulting in readiness for discharge.

B. Interviews

i. An interview with CMO #3 was conducted on 2/21/23 at 9:59 a.m. CMO #3 stated all medical care fell under his domain across the organization but oversight of the PED was a layered responsibility amongst various staff members. His primary responsibilities were to supervise the providers and coordinate oversight and responsibilities with other supervisors in the facility.

ii. An interview with DON #2 was conducted on 2/21/23 at 10:25 a.m. DON #2 stated oversight of the PED prior to the survey was done by auditing five chart audits per week by nursing supervisors, who sent the information to the Quality Improvement Committee (QIC), the medical providers who worked in the PED and the on-call providers who provided assistance after hours.

Additionally, DON #2 stated it was important to have oversight of the PED to ensure patients were safe and the facility abided by the statutes.

Interviews and document review showed processes and procedures were not being followed in the PED to ensure the safe care of patients. Neither CMO #3 nor DON #2 had directed or managed the PED since its creation and considered it a joint responsibility amongst the facility's supervisors and providers. As a physician, CMO #3 had the qualifications to direct care in the PED, but neither the guidelines in the bylaws nor the job description were updated to include this role. DON #2, although in charge of the PED along with Manager #6 per the Organization Chart, would not have been able to direct care in the PED with a nursing background as a nurse could not manage physician care of patients.