HospitalInspections.org

Based on record review and interview, the facility failed to have a registered nurse supervise and evaluate the nursing care for each patient. This deficient practice is evidenced by the registered nurse failing to screen 1 (#1) of 3 (#1 - #3) patients for the risk of elopement upon admission to the facility per facility policy.
Findings:

A review of facility policy, "Elopements," policy #CS-34, with an effective date of 01/11/2016 and last revised on 12/01/2023, reveal in part, Purpose: To identify those at risk for elopement and to prevent the occurrence. Procedure: 1. Upon admissions to the inpatient facility, all patients are screened for the risk of elopement.

An electronic medical record (EMR) review of Patient #1's record did not reveal a screening for the risk of elopement upon admission to the facility.

In an interview on 06/03/2024 at 3:42 p.m. S2IDON/QD confirmed the above mentioned findings.

Based on record review and interview, the facility failed to ensure each patient had an individualized, comprehensive treatment plan based on an inventory of the patient's strengths and disabilities. This deficient practice is evidenced by the facility failing to include the patient's risk for self-harm in the nursing care plan of 1 (#1) of 3 (#1 - #3) patient care plans reviewed for the inclusion of all medical and psychological needs of a patient.

A review of facility policy, "Suicide/Homicide Risk Assessment," Policy #AS-19 with an effective date of 01/11/2016 and last revised on 11/01/2023, revealed in part, Policy: All patients admitted will be screened for the risk of suicide using a validated tool ... Procedure: Inpatient: 2. The RN will complete the Suicide & Homicide/Violence Risk Assessment as a part of the Admit Nursing Assessment. Suicide/Homicide/Violence risk level will be determined and appropriate precautions are implemented and incorporated into the treatment plan if applicable. 5. Levels of Risk Stratification and appropriate interventions will be used in the assessment and to mitigate any suicide/homicide/violence risk. Suicidal ideation with intent or intent with plan in past month would indicate a HIGH Suicide Risk Stratification with one of the corresponding inventions, "Initiate a 'Potential for Self-Harm' treatment plan." 6. Multidisciplinary team members will assess patient, update treatment plan, and individualize goals and interventions.

An electronic medical record (EMR) review of Patient #1's record revealed an admissions of 05/02/2024 at 5:15 a.m. An Inpatient Psychiatric Evaluation from 05/02/2024 at 3:20 p.m. by S4PMHNP indicated the patient was on a Physician Emergency Certificate (PEC) after an intentional overdose of fentanyl today. Physician orders initiated upon admissions included a Precaution level: Suicide/Self Harm Precautions. A review of the Plan of Care did not reveal a problem associated with the Potential for Self-Harm.

In an interview on 06/04/2024 at 3:42 p.m. S2IDON/DQ confirmed the above mentioned findings.