HospitalInspections.org

Based on record review and interview the facility staff failed to accurately complete the discharge suicide risk assessment for 1 of 5 (Patient #1) discharged patients in a sample of 10 records reviewed.

Findings include:

A review of the facility policy, titled "Suicide Risk Assessment (SRA), Prevention and Precautions", last reviewed on 5/31/2022, revealed: "Risk Assessment: At time of discharge, or any change in environmental setting (i.e. hospital, residential or PHP [partial hospital program]/IOP [intensive outpatient]) within [facility name] the licensed clinician will complete the SRA."

A review of Patient #1's Suicide Risk Assessment (SRA) (Discharged), completed on 4/8/2022 at 2:48 PM, revealed: "CSSRS [Columbia Suicide Severity Rating Scale] Inpatient Discharge Screener:
CSSRS IP (inpatient): Wish to be dead: No
CSSRS IP: Suicidal thoughts: No
CSSRS IP: Suicidal thoughts with method [without specific plan or intent]: No
CSSRS IP: Suicidal intent [without specific plan]: No
CSSRS IP: Suicidal intent with specific plan: No
CSSRS IP: Made preparations to end life: No
CSSRS Final Consideration and Risk Determination:
[This portion of the Suicide Risk Assessment was completed on 6/1/2022 at 11:35 AM] CSSRS: Moderate, Provider Response: Provider agrees with patient being moderate risk. Rationale for Final Risk Determination: Patient denies all safety concerns at this time. Patient states they feel safe to discharge at this time."

During an interview on 6/1/2022 at 3:00 PM, Psychiatrist H stated, "Patient #1 was stabilized and it was no longer beneficial for her to remain here."

During an interview on 6/3/2022 at 9:00 AM, when asked why the CSSRS Final Consideration and Risk Determination portion of the SRA was dated 6/1/2022, RN L stated, "I had forgotten to complete that portion of the SRA, so Psychiatrist H and I discussed it today and came up with moderate risk." When asked if Patient #1 was safe to discharge, RN L stated, "yes".

During an interview on 6/3/2022 at 3:00 PM, Nurse manager J stated, "We discovered that the SRA was missing information on 6/1/2022 so we had the nurse do an addendum. The rest of the SRA was there, just the rating was missing. Patient #1 was ready and safe to discharge on 4/8/2022." When asked what is the expectation regarding completion of the discharge SRA, Nurse Manager J stated, "It should be complete on the day of discharge."