HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled patient (7) with suicidal ideations had been thoroughly assessed to ensure a safe and appropriate discharge had occurred from the hospital to her desired destination. Findings include:

1. Review of patient 7's medical record revealed she had been admitted to the emergency department (ED) on five separate occasions during July 2017.

Review of patient 7's 7/2/17 ED medical record revealed:
*She was admitted into the ED for right upper quadrant (abdomen) pain and shortness of breath that had started one day prior.
*The attending physician's chart indicated she had:
-A mass removed from her bile duct two days ago.
-A complete physical assessment was completed with orders for laboratory (lab) work and CT Scan of her abdomen and pelvis were given.
-The lab work and CT scan results revealed no postprocedural complications.
-She had been discharged to home in a stable condition.
-She had been provided with discharge instructions to follow-up with the gastroenterologist and take the prescribed pain medications as directed.
*The nursing documentation revealed she had a diagnosis of anxiety.

Review of patient 7's 7/7/17 ED medical record revealed:
*She was admitted into the ED for major depression, dehydration, suicidal ideations, headache, nausea, and abdominal pain.
*The attending physician's chart indicated:
-"Patient is a 73 year old female presenting with suicidal ideations for the past 3 weeks. She has increased stressors related to family lawsuit with hospital and monetary stress."
-"She had been a counselor in inpatient psychiatry for 20 plus years and has been on Ativan for the past 3 years. She notes increased confusion, difficulty sleeping, urinary incontinence, and diarrhea."
-"She had talked to [doctors name] yesterday and she states he was going to wean her off Ativan."
-She was given intravenous (IV) fluids for dehydration, pain medications for headache and abdominal pain, and antiemetics for nausea.
-"She agrees for voluntary inpatient psychiatric care. The case was discussed with psychiatry who states patient is not allowed to be admitted to our inpatient psychiatry due to previous lawsuits filed by her family with the hospital."
-"Patient is accepted as a voluntary admission to [facility name]. Family will drive patient to Sioux Falls."
*The nursing documentation from that ED visit revealed:
--"Patient complaining of worsening depression x 2 months. States 'I want to kill myself.' States she is also withdrawing from Ativan."
-"Precautions: suicidal/homicidal ideation."
-She was discharged to home with family and instructions for voluntary inpatient psychiatry provided.

Review of patient 7's 7/17/17 ED medical record revealed:
*She was admitted into the ED for depression, mild hypokalemia, possible urinary tract infection, decreased fluid and food intake, and weakness.
-That ED admission had been two days after her discharge from the mental health hospitalization in Sioux Falls and ten days after the previous ED visit.
*The attending phsycian's visit indicated:
-"She was discharged from [facility name] psychiatric hospital on Saturday and returned home where she lives with her daughter. Since then she states she has just been lying in bed because she is weak and depressed. She states she is eating and drinking essentially nothing. Her daughter says she offers frequently to get food and fluids for her mother who declines. Patient denies any suicidal ideation. She states she was given a prescription for Xanax when she left the hospital but has not filled the prescription. There had been discussion regarding patient going to assisted living and daughter has picked up a packet of papers from the Department of Social Services but they have not yet contacted any facilities and outpatient [the patient] is changing her mind about going to assisted living. She has felt as if she may have a fever and chills. She has not measured her temperature. She complains of dry mouth and eyes. She states she does not get up to get fluids or help herself because she is afraid of falling even though she has her daughter to assist her."
-They had been unable to find nursing home placement for her.
-She was discharged to home with family and a home health referral.
*The nursing documentation from that ED visit revealed:
-Chief complaint: "Weakness. PT [patient] was discharged from [facility name] on Saturday, PT states she thinks she is withdrawing from Xanax, PT states has been weak the past two days."
-Safety Screening:
--"Have you ever been emotionally physically or sexually hurt by your partner or someone close to you? 'No.'"
--"Do you feel afraid in any of your relationships? 'No.'"
--Suicidal: Nothing had been documented in that area.
-Precautions: "Universal."
-General: "PT has the shakes. Alert, Anxious, Well developed. PT states feeling dizzy at times, PT states generalized weakness, Alert, Oriented x3. Skin is diaphoretic [wet]."
-At 11:30 a.m. RN case manager A documented: "Asked by physician to round on the pt. Pt's daughter is having difficulty caring for her at home and would like SNF [skilled nursing facility] placement. Pt is 'confused, weak, and not eating per daughter. Pt states she has not been taking her medications. Pt was just inpt [inpatient] at the mental health unit in Sioux Falls for 'withdrawal from Ativan.' Talked to the pt and her daughter and about SNF placement and they were both agreeable to this. Spoke with [staff name] at [facility name] about possible admission and faxed over the pt's face sheet for her to review. Awaiting return call."
-At 1:20 p.m. the case manager called [facility name] for request for medical records to be faxed to RCRH per physician's request."
-At 1:50 p.m. the case manager received those documents and faxed them to the potential SNF.
--The patient had still been in the ED when those documents had been received and faxed to the potential SNF.
-At 2:53 p.m. the case manager had received notification from the SNF that they were unable to accept the patient.
-At 2:58 p.m. the case manager contacted the personal care provider regarding home health services. She assisted the patient to pick a home health agency and faxed the information to that agency.
-At 3:30 p.m. "Patient resting quietly, states that she feels much better and is ready to go home. Daughter at bedside."
-At 4:02 p.m. the patient was discharged to home with her family.
-No documentation to support:
--More than one SNF had been contacted for potential nursing home placement.
--The social service department had been notified to assist with nursing home placement per the facilities policy.
--The document that was received from the mental health hospital had been reviewed by the case manager to ensure no further issues or concerns should have been reviewed with the patient prior to discharging her back into the same living environment.
--The Department of Social Services (DSS) had been informed within twenty-four hours of the patient's discharge from the facility and back into the same living environment with her son and daughter.

Review of patient 7's 7/8/17 admission documentation from her mental health hospitalization revealed:
*History of present illness:
-"Admitted on voluntary status for failure of outpatient management, and deterioration of function. Patient states 'I have always had depression,' but states that for the last 2 months her symptoms of depression have been significantly worsening. She notes several stressors."
-The patient reported a recent stressor was all the current medical problems along with losing her current job.
-"Patient states that she has some financial stressors. She tells me that her son has moved in with her, and he has not been working for a while. He, according to the patient, is 'verbally abusive,' and very impatient, will snap his fingers at her. She reports he has PTSD [post traumatic stress disorder] after being assault while he was working as an behavioral health check [technician] on the same unit where the patient works. She states that he was hit again, and subsequently filed a lawsuit against the hospital. Patient reports that she is refinance [refinancing] her home to help her son pay for his legal flows [fees], and when specifically asked, states that there is potential danger that she might lose her home. On top of this, the patient states that she was also supporting her daughter and granddaughter. She says that she was no longer able to afford supporting them, and they moved back into her home in Rapid City. Patient states that she, her daughter, and her granddaughter are living in the basement of her home. Patient states that no one else living in the home is employed."
-"She says that her suicidal ideation goes only so far as a passive wish to be dead. She says 'I would not provoke it,' but states that if something were to happen to end her life, she would not be upset."
-She denied being a vulnerable adult that might be suffering from maltreatment or theft.
-"She does acknowledge is some emotional abuse from her son, for whom she has refinanced her home to pay his legal fees. She denies homicidal ideation. States that anxiety is 'terrible, terrible.'"
*Psychiatric history, Abuse: "Reports that currently her son, who lives in her home with her, is verbally and emotionally abusive."
*Social:
-"Serious concern that the patient is vulnerable adult."
-"Sounds like 3 adult children/grandchildren in her home, possibly taking advantage of her financially."
-"It sounds as if she is at serious risk of losing her home."

Review of the provider's 5/11/17 Skilled Nursing Facility Preference list revealed:
*There were fifteen potential nursing homes in the surrounding area the patient could have chosen from on that list.
*Seven out of those fifteen had been located in Rapid City.

Review of patient 7's 7/21/17 ED medical record review:
*She was admitted into the ED for depression, anxiety, confusion, and suicidal thoughts.
-That ED admission had been four days after the previous ED visit and one day after an ED visit to another facility in the surrounding area.
*The attending physician's chart indicated:
-Patient arrives to the emergency department by ambulance. Originally sheriff's department [had] been called to the place. Patient had anxiety and significant feelings of depression. She admits that most of what is going on with her including some mild confusion earlier today is secondary to psychiatric issues including depression, anxiety and family discord. She has had suicidal thoughts but no direct plan. She openly states that she [would] like to go to the West unit. She will do this voluntarily."
-She was unable to be admitted to the West unit related to past employment in that area.
-She was admitted to the hospitalist service area with a mental health consult.
*The nursing documentation from that ED visit revealed:
-"Patient brought in by medics for confusion that began this AM at 7:30. Patient slowly started becoming oriented while en route. discharged [facility name] yesterday for weakness/confusion. Was observed. Then discharged."
-She had felt afraid in some of her relationships and was considered an adult suicide risk.
-The patient was transferred to 10th floor in stable condition and placed on suicide precautions for one-to-one observation.

Review of patient 7's 7/21/17 patient notes documented by RN case manager G revealed:
*She had been referred by the physician to review with the patient her current social situation.
*The patient's daughter had been with her during the interview by the case manager.
*The daughter voiced multiple concerns regarding her mother's discharge during that interview.
*The daughter stated her brother had multiple lawsuits against the hospital and was not allowed on the property.
*The patient "Reported that she is scared of him, he has never hit her but he becomes very angry with her. Then went on to say that his name is on all of her belongings (house, car, bank account). Patient states he has been in control of her finances and does what he wants with them. She is fearful that he is going to empty her bank account while she is in house. She states that she has been bed bound for quite some time due to not wanting to live and feels she is going to need rehab."
*The case manager updated SW B on the patient's above status "Pt. reports history of verbal and financial abuse from her son. Police have been involved and SW will report as appropriate. Pt. may need placement. Will assess and discuss preferences."

Further review of patient 7's medical record of her observation stay from 7/21/17 through 7/22/17 revealed:
*She had been admitted to the 10th floor on suicidal observation.
*She was monitored per suicidal risk precautions and assessed appropriately.
*She had been anxious to get home and look for a job as she needed to be working.
*Her mental health status was reviewed on 7/22/17 and the hold was discontinued.
*She was discharged back to her home under the same living environment and social situation as documented above on 7/22/17.
*No documentation to support the social services department had been notified of her discharge from the facility.
-That documentation did not support the DSS had been notified of that discharge.

Review of patient 7's patient notes documented by SW B revealed:
*On 7/24/17:
-At 2:04 p.m. she had left a message for the DSS to return her call.
-At 3:41 p.m. DSS had returned her call. "Provided report to her regarding pt's expressed safety concerns and the mental hold which was lifted and pt. was discharged home on Saturday. Contact information for pt. and her daughter [provided]. [Staff name] took down the information."
--That documentation supported DSS had not been notified of the patient's discharge until two days after her discharge from the facility and back into the same social and living environment with her son and daughter.

Further review of patient 7's 7/2/17 through 7/21/17 medical record revealed there was no:
*Referral made to the SW department regarding any concerns for her until 7/21/17.
*Documentation to support DSS had been notified of any concerns regarding her current social and living situation until 7/24/17.
-That had been two days after she was discharged from being on a mental hold.

Review of patient 7's 7/26/17 ED medical record revealed:
*The attending physician's chart indicated:
-"Patient is brought here by ambulance with CPR in progress. Approximately 9 PM call to EMS because patient was not breathing. Patient's daughter was not there at the time but states her brother contacted her about the patient's condition. Patient's daughter does have some concern this may have been a suicide attempt. She states she does have access to a lot of pills but police officer looked at home and did not find any empty bottles. She recently had a stay at psychiatric hospital in Sioux Falls. There was plan for nursing home placement as soon as one became available daughter relates that home situation has been difficult because of arguing between them and patient's son. She denies any physical abuse by family members. She does relate that she is having difficulty getting patient to eat and drink. She was recently admitted to medical hospital last weekend."
-"On arrival of medics tonight they found her with asystole. After intubating and administering epinephrine she had a brief period of ventricular fibrillation. She received a total of 6 doses of epinephrine. She remains unresponsive, pulseless and apneic."
-"Cause of death is not known and this is referred to coroner."
*That arrival to the ED department had been four days after she had been discharged from the hospital for being a suicidal risk.

Interview and review of patient 7's medical record for July 2017 on 9/12/17 at 2:12 p.m. with registered nurse (RN) case manager A, social worker (SW) B, and RN nurse manager C revealed:
*SW B:
-Had not personally met patient 7 but had heard of her. She did not clarify how she heard of the patient.
-Had some contact with DSS but the patient had been discharged before another type of placement could be made.
-Had not covered weekends and would not have known what patients they had over the weekend.
-When a patient was admitted into the ED with suicidal ideation the SW in ED at that time should have completed a psychological evaluation.
-She would have helped with patient placement after a mental health hold had been discontinued.
-Had not recalled being involved with the patient until 7/24/17.
-Stated "SW see's patient on a consultative basis. General process is social services isn't involved on 100% of patient's through ED."
*RN A:
-Recalled patient 7 and her 7/17/17 admission to the ED.
-Recalled the patient had not been eating or taking her pills as prescribed.
-The patient was tearful and had not wanted to go to a nursing home.
-Attempted to seek nursing home placement, but the facility she had contacted declined to take her.
-Stated "I think there were certain places she did not want to go to."
-Had obtained the information from the hospital where the patient had been admitted for mental health concerns.
-She stated:
--"She was really nice and tearful. She didn't want to go to a nursing home and was discharged back home with her daughter and home health services."
--"I was not aware of the verbal abuse and the son living with them. That is why I didn't contact SS."
-Confirmed she had:
--Not reviewed the information she had received from the mental health hospital in SF prior to faxing it to the potential SNF nor at anytime during the patient's stay in the ED.
--Not contacted SW for assistance with SNF placement.
-She agreed she should have reviewed the documentation the mental health hospital in SF had faxed to her prior to sharing that information with the SNF and to ensure her social situation was safe.
*RN C:
-Would have expected the hospitalization report to have been reviewed by the case manager or someone prior to:
--Contacting nursing homes for potential placement.
--Discharging her from the ED to ensure her desired destination had been safe and with no risk of harm.
-Would have expected the SS department to have been notified and involved with proper placement for the patient.

Interview and review of patient 7's medical record for July 2017 on 9/13/17 at 9:20 a.m. with the director of nursing revealed:
*Confirmed RN R's interview.
*The SS department would have staff working over the weekends.
*The SW would not have reviewed the case if the patient was on observation or admitted for less than twenty-four hours.
*She agreed:
-There had been a breakdown in the care for this patient and stated "It is a communication problem."
-DSS should have been notified about her and her current social situation after her discharge from the ED on 7/17/17.

Interview and review of patient 7's medical record for July 2017 on 9/13/17 at 10:05 a.m. with RN E revealed:
*She had been the director for the case management department.
*She would have expected a SW to have been involved with patients who were at risk for abuse or neglect.
-That SW would have been responsible to ensure DSS had been notified.
*She confirmed RN C's above interview.

Review of the provider's 9/13/17 case manager job description revealed the nurse manager:
*"Facilitates planning for patient/family needs to ensure a smooth transition for the patient across the continuum of care"
*Evaluated current treatment plan to identify barriers.
*Coordinated team efforts with support services departments to ensure appropriate care and smooth discharge.

Review of the provider's 9/13/17 Social Worker BSW job description revealed the social worker:
*"Completes accurate and complete psycho-social and bereavement assessments and reassessments."
*Participated in admissions, discharges, and transfers.
*Created and updates the plan of care to include patient/family-centered goals with interventions.

Review of the 9/13/17 Social Worker MSW job description revealed the social worker:
*Developed and implemented an individualized treatment approach.
*Collaborated with patient/family, multidisciplinary team, and physician to formulate a realistic plan that identified goals, specific interventions, and resources to meet the patient's needs.
*Assessed the patient's progress and modified treatment plan accordingly.

Review of the provider's March 2015 Suicide Risk Assessment, Care Management, and Precautions policy revealed:
*"This policy assesses patients at risk for harming themselves and implements proactive measures if determined to be at risk for suicide."
*"The nurse will implement the precautions to protect the patient from self-inflicted injury."
*"Suicide assessment and precautions are actions taken to identify patients at risk for suicide and to implement precautions to prevent opportunities for suicidal behavior by a patient exhibiting these tendencies."
*The SW was to have been notified for an acute admission."
*No documentation to support the SW should have been notified:
-When a patient was placed on a mental health hold and requiring one-to-one observation.
-When that mental health hold was removed and the patient had been discharged from the facility.

Review of the provider's July 2016 Discharge Planning Process policy revealed:
*[Facility name] provides RN Care Managers and SW/Discharge Planners to assist patients and families with planning for patient's post acute hospital health care needs in the Resource Management Department."
*"Discharge planning is an interdisciplinary process that is started upon admission with the initial assessment of the patient performed by the physician and the staff nurse as documented in the history and physical and the initial assessment."
*"These services include early assessment of patient needs, utilization of community resources, emotional support to patients and families and procedures to ensure appropriate utilization of health care resources."
*Guidelines "In accordance with regulations of acute care hospitals, the following guidelines are met: Early identification of patients who are likely to suffer adverse health consequences upon discharge if there is inadequate discharge planning."
*"The medical staff recognizes and supports the need for assessment, development, and coordination of patient specific discharge planning services in order to promote optimal patient outcomes and avoid unnecessary delays in discharge."
*"Complete reassessments of the patient's needs based on response to treatment, change in diagnosis or condition, or change in psychosocial aspects of care to determine if the discharge plan meets the patient's post hospital needs."
*"Patients identified as high risk will be referred to the CM [case manager] or SW/DCP to determine post hospital needs by physician's orders or a referral from any member of the healthcare team."
*"The assessments are completed by patient and family/significant other interviews, medical record review and consultation with the patient's physician(s) and primary nurse. The results of this evaluation will include but is not limited to:
-"Evaluation of the patient's need for post hospital services such as following:
--"Family situation including contact persons/decision maker."
--"Living environment (type of resident layout, occupants, etc.)."
*"Ongoing consultation and coordination with the physician, patient, patient's family and interdisciplinary team to develop a discharge plan, including involved external providers as appropriate is necessary to ensure positive outcomes."
*"The SW/DCP is responsible to work with the patient and family in collaboration with the CM, to coordinate services for care after discharge, provide short-term counseling and utilize crisis intervention techniques."

Review of the provider's June 2017 Interdisciplinary Assessment/Reassessment for Suspected Abuse or Neglect policy revealed:
*"The scope and intensity of any further assessment are based on the patient's diagnosis, the care setting, the patient's desire for care."
"The goal of the assessment/reassessment process is to provide safe care and treatment."
*Suspected Abuse or Neglect of Elderly or Disabled Adults:
-"If caregivers know or have reasonable cause to suspect an elder or disabled adult has been or is being abused or neglected, then it must be reported within 24 hours."
-"The social worker/care manager will make the report to Adult Services, Department of Social Services [their phone number], the state's attorney of the county in which the elder or disabled adult resides or is present, or to a law enforcement officer."
-"The social worker/care manager will coordinate with the Department of Social Services, the state attorney's office or law enforcement during the investigative process."