HospitalInspections.org

The Condition of Participation of Quality Assessment & Performance Improvement Program was not met.

Findings included:

The Hospital failed to identify opportunities for improvement, consider the incidence, prevalence, and severity of problems and implement changes that will lead to improvement for 1 (Patient #1) of 10 patient records reviewed.

Refer to TAG: A-0286.

Based on interviews and records reviewed the Hospital failed for 1 (Patient #1) of 10 patient's records reviewed to investigate and implement corrective actions after Patient #1, a suicidal patient who was boarding in the Emergency Department while awaiting an inpatient psychiatric bed, was discharged without a safe and integrated discharge plan.

Findings include:

Review of the Hospital's Performance Improvement and Patient Safety Plan, fiscal year 2022 indicated that the Risk Management Department in collaboration with the involved physicians and staff is responsible for developing and implementing a comprehensive corrective action plan.

The Performance Improvement Department is responsible for conducting a review of critical variances that are determine not to be SREs (serious reportable events). The review is conducted in collaboration with the involved physicians, staff and unit or department managers who then develop and implement an action plan.

Action plans and monitoring results will be presented to the appropriate oversite committee which may include, but is not limited to, local department committees, Risk Management Committee, Performance Improvement/Patient Safety Committee, Board of Quality/Patient Experience and Care assessment Committee.

Patient #1 was admitted to the ED (Emergency Department) in 1/2022 with diagnoses of depression with suicidal ideation, Asperger's syndrome, depressive disorder, SARS-Co V-2 positive (COVID -19 positive) and hypokalemia.

Review of the ED Provider Note dated 1/21/22 at 2:12 P.M. indicated that Patient #1 presented complaining of severe depression and suicidal ideation with a plan. Patient #1 denied taking medications for 6 months. Patient #1 last saw his/her counselor 2 weeks ago. Physical exam significant for profoundly depressed male. Patient placed on a section 12 and cleared for mental health evaluation. Patient requires inpatient treatment at this time. Bed search underway.

Review of the Emergency Psychiatric Services (EPS) note dated 1/21/22 at 5:49 P.M. indicated that Patient #1 said he/she is here because "I am suicidal, and I can't endure my life any longer." Patient #1 reported he/she is practically agoraphobic (an anxiety disorder where a person has a fear of places and situations that might cause panic, helplessness, or embarrassment) and doesn't leave the house except to go to work because of the intense anxiety associated with driving. Patient #1 reported he/she wanted to die. Patient #1's medical record reflects history of one prior psychiatric hospitalization in 2000 for suicide attempt by CO2 poisoning by driving into the woods and connecting a hose from the exhaust to the window. Patient reports bi-weekly therapy with today's appointment being cancelled, and he/she won't have another until sometime next week. Patient #1 reported that he/she lives at home with his/her parents, but they were in Florida, currently on their way home from visiting his/her sibling. The EPS note indicated that they spoke with Patient #1's mother who said Patient #1 called her today to disclose that Patient #1 hadn't been taking his/her medications, despite previously telling her that he/she was. Patient #1's mother said that she is concerned for Patient #1's safety. Patient #1's mother said that Patient #1 had a social worker through his/her union that Patient #1 talks with. The ESP screener spoke with the Social Worker who expressed concern for Patient #1 as she was aware Patient #1 stopped taking medications, but thought it was only 3 weeks ago. The note identified that the patient's mood is depressed, affect flat and tearful. Patient calm and cooperative, help seeking. Recommended for inpatient level of care at this time.

Review of the ED Psychiatric Progress Note dated 1/21/22 at 4:43 P.M. indicated that Patient #1 had been seen by a mental health clinician. Requires inpatient level psychiatric care, however, has tested positive for COVID-19. Will board in ED until a COVID positive inpatient psych bed is available of until his/her 5-day quarantine has completed.

Review of the Emergency Psychiatric Services note dated 1/24/22 at 8:09 P.M. indicated that Patient #1 was evaluated on 1/21/22 and deemed to be appropriate for inpatient level of care. Re-evaluation noted that Patient #1 continued to present with suicidal thoughts; was hopeless and helpless. Today, he/she is resting, awakens easily when clinician enters the room. Patient is lying flat on his/her back, eye contact limited, looking at ceiling during evaluation. He/she is irritable, stating he/she is feeling angry because of "solitary confinement" in the emergency department. He/she denies suicidal thoughts but cannot or will not talk about what has changed and to further make a safety plan. He/she has no supports at this time as his/her parents whom he lives with are out of town. Medication compliance noted as a precipitant to worsening depression. Patient declines to talk about medications with this clinician during evaluation, stating "I don't know." Continued to meet criteria for inpatient level of care: unable to effectively safety plan for a lower level of care at this time.

Review of the ED Psychiatric Progress Note dated 1/25/22 at 2:54 P.M. indicated that Patient #1 was evaluated by the screener today who noted Patient #1 is irritable and still angry, but more about being in "solitary confinement" for so long. Patient #1 was not able to make a safety plan, has limited supports and parents are out of town. Still felt to require inpatient level of care.

Review of the Behavioral Health Initial Consult Report dated 1/26/22 at 12:09 A.M. indicated that Patient #1 reports feeling a little overwhelmed at work and admits to being inconsistent with his/her psychiatric medications. Patient #1 notes that he/she was having thoughts of suicide but doesn't want to die so self-presented to the Emergency Department. Since Patient #1 has been in the Emergency Department he/she has been noted to be COVID-19 positive. Patient #1 noted that he/she has felt better and more hopeful since he/she has been taking his/her psychiatric medications again. Patient #1 has a noted history of suicide attempt in 2000. Patient, however, states he had thoughts of suicide and never attempted in the past.

Review of the Peer Review document dated 2/28/2022 indicated that it was identified that there was no contact with Patient #1's social worker or parents prior to the discharge. The Conclusion indicated that opportunities exist to standardize greater documentation of outpatient management and discharge plans into the medical record.

During an interview on 5/18/22 at 10:18 A.M. the Director of Performance Improvement and Quality and the Manager of Regional Compliance and Patient Safety indicated that this case did not get investigated by the Hospital's QAPI team. They said that incident came in as a complaint from the Patient's mother after he was not heard from or seen since discharge from the Emergency Room on 1/26/22. They said it was not an SRE so the Emergency Department and Chief Medical Officer did a peer review to determine if the discharge was safe. The Quality Department was not involved in the review or with implementation of corrective action. The multidisciplinary peer review took place on 2/28/22.

During an interview on 5/18/22 at 11:33 A.M. the Chief Medical Officer (CMO) said that the peer review of the case determined it was a safe discharge, but there were opportunities for improvement. The CMO said that it was identified that the nurse responsible for the discharge was a travel nurse who didn't document a discharge note. They also identified that there should be a standardized safe discharge process, individualized discharge plans and have a better outpatient game plan. He said that documentation of how a patient is getting home and who they should follow up with needs to be completed. The CMO said that case management doesn't get involved with behavioral health patient's discharge plans. The CMO said that the peer review team has been working on an algorithm for safe discharge plans. He said that the algorithm was approved by the behavioral health Psychiatrist yesterday, 5/17/22, but no education has been done to begin utilizing it.

During an interview on 5/18/22 at 12:45 P.M. the Assistant Chief Nursing Officer said that the nurse didn't do a disposition note for the Patient. She also said that there will be an algorithm for safe discharge planning of patients with behavioral health concerns starting next week. She said they also will start using a safety plan that they have adopted from their inpatient psychiatric units and that patients will not be able to be discharged without a safety plan.

During an interview on 5/19/22 at 9:30 A.M. the Chief of Emergency Services said that during the peer review they determined that there needed to be a creation of a safe discharge plan. He said that the plan was rolled out yesterday, but not fully disseminated. The Chief of Emergency Services said that it is very difficult to roll out in the Emergency Department. The algorithm will address situations where there could be disagreement between the consulting psychiatry team and the Emergency Psychiatry Services team. It would result in a doctor-to-doctor discussion between the Hospital's consultant psychiatrist and the behavioral health team psychiatrist. The Chief of Emergency Services said he will roll out the formal education for this updated safety discharge plan at the end of the month in his staff meeting.

During an interview on 5/19/22 at 10:00 A.M. the Psychiatric Nurse Practitioner said that he was called to evaluate the patient for disposition purposes. He stated that he does not read the medical record ahead of time. He said that the peer review team is working on an algorithm, but he isn't aware of the outcome yet.

Although the Hospital was in contact with Patient #1's Mother and Social Worker from work throughout his Emergency Room stay from 1/21/22 through 1/26/22, and were aware of the discharge plan to transfer Patient #1 to inpatient level of psychiatric care when an appropriate bed became available, there is no documentation either support person was contacted and notified that the discharge plan changed.

When asked why the Patient's mother or social worker weren't informed of the change in discharge plan from inpatient level of care to discharge home, even though the Social Work notes state that patient lacked supports at home, was not medication compliant and required stabilization in an inpatient psychiatric setting, the Hospital was unable to answer this question.

The Hospital failed to investigate and implement corrective measures to prevent a suicidal patient who had limited social supports with his/her parents being out of town, was not medication compliant at home and required stabilization in an inpatient setting from being unsafely discharged.

The Condition of Participation of Discharge Planning was not met.

Findings included:

The Hospital failed to implement adequate discharge planning for a suicidal patient who was boarding in the Emergency Department while awaiting an inpatient psychiatric bedfor 1 (Patient #1) of 10 patient records reviewed.

Refer to TAG: A-0800.

Based on record review and interviews, the Hospital failed for 1 (Patient #1) of 10 patient's records reviewed to implement adequate discharge planning for a suicidal patient who was boarding in the Emergency Department while awaiting an inpatient psychiatric bed, was likely to suffer adverse health consequences upon discharge, and was never heard from or seen again after discharge.

Findings include:

Review of the Hospital policy titled "Inpatient Discharge Planning", reviewed on 9/13/19 indicated the following:
-In order to assess a patient's capability for post-discharge self-care, the Care Coordinator actively solicits information from the patient, the patient's representative and family, friends, support persons and outpatient providers.
-Referrals will be made to the appropriate agencies and/or facilities.

Patient #1 presented to the Hospital Emergency Department on 1/21/22 with a diagnosis of depression with suicidal ideation.

Review of Patient #1's Emergency Department progress notes dated 1/21/22 indicated he/she arrived with very anxious pressured speech and stated he/she feels suicidal all the time. Patient #1 presented to the Emergency Department complaining of severe depression and suicidal ideation with a plan (walk in front of an 18-wheeler truck in the early morning). Patient #1's judgement and insight were assessed to be limited. Patient #1 denied taking his/her prescribed medications for 6 months as he/she felt they were not working any longer. Patient #1 reported living with his/her parents, who were currently away in another state; the Patient's mother provided history over the phone and stated she was concerned for the Patient's safety. Patient #1 reported having a therapist in the community, however, the Hospital was unable to reach his/her therapist on 1/21/22. Patient #1 reported his/her appointment with his/her therapist was cancelled on 1/21/22, the day he/she presented to the Emergency Department. Patient #1 had attempted suicide once in the past in 2000. Patient #1 was determined to require inpatient treatment at the time he/she presented to the Emergency Department. Patient #1 was placed on a section 12 and search for an inpatient psychiatric bed was initiated. Patient #1 tested positive for COVID-19 and was placed in quarantine in the Emergency Department; Patient #1 was to be boarded in the Emergency Department and a search for a COVID positive inpatient psych bed was then initiated.

Patient #1 was assessed on 1/21/22 to be at a high-risk level for self-harm on the Columbia Suicide Severity Rating Scale (C-SSRS) but was assessed to have a low suicide risk level because his/her plan was not accessible from the Emergency Department. Further assessment conducted on 1/21/22 indicated Patient #1's risk factors for self-harm included suicidal ideation with a plan, hopelessness, impaired judgement, and lack of social supports. Patient #1's protective factors from self-harm included strong family supports, supervised living, and supportive therapeutic relationships.

Review of Patient #1's Emergency Department progress notes dated 1/22/22 indicated he/she continued to endorse vague suicidal ideation without a specific plan to carry out any suicidal actions at that time. A comprehensive assessment was also conducted by the Emergency Psychiatric Service (ESP) on 1/22/22. The comprehensive assessment indicated Patient #1 endorsed suicidal ideation but would not disclose his/her plan during the ESP assessment on 1/22/22. The patient reported being agoraphobic with worsening anxiety and only leaving his/her house for work, however, did not like his/her current job. The EPS comprehensive assessment failed to indicate any identified needs and goals for treatment, nor did it include a safety plan for discharge.

Review of Patient #1's Emergency Department progress notes dated 1/23/22 indicated he/she continued to endorse vague suicidal ideation. Patient #1 stated to a Registered Nurse (RN) that he/she was sick of being cooped up in a room.

Review of Patient #1's suicide risk level assessment conducted on 1/24/22 indicated the Patient had a low suicide risk level because his/her plan was not accessible from the Emergency Department. Patient #1 was evaluated by the ESP on 1/24/22. Patient #1 stated he/she was angry on 1/24/22 because he/she was in solitary confinement in the Emergency Department. Patient #1 denied suicidal thoughts, however, would not talk about what had changed to further make a safety plan. Patient #1 had no supports to return home to at that time. Patient #1 declined to discuss his/her medications despite medication compliance being noted as a precipitant to his/her worsening depression. Patient #1 was assessed to have poor insight and impaired judgement. Patient #1 denied suicidal ideation, however, the ESP Behavioral Health Clinician had concerns for his/her change in suicidal ideation, possibly due to having tested positive for COVID and being placed in quarantine. The ESP Behavioral Health Clinician recommended to continue inpatient level of care, Patient #1 required stabilization and assistance from his/her family was needed, however, they were not available at that time.

Patient #1 was evaluated again by another ESP Behavioral Health Clinician on 1/25/22. Patient #1 continued to deny suicidal ideation, however, the Behavioral Health Clinician documented given the Patient's initial presentation there continue to be safety concerns. A psychiatric consult was requested to assist with disposition for Patient #1. The Behavioral Health Clinician assessed Patient #1 to have impaired insight and judgement. Patient #1 denied suicidal ideation, however, the ESP Behavioral Health Clinician had concerns for his/her change in suicidal ideation, possibly due to having tested positive for COVID and being placed in quarantine. The ESP Behavioral Health Clinician recommended to continue inpatient level of care, Patient #1 required stabilization, and assistance from his/her family was needed, however, they were not available at that time.

Review of Patient #1's Behavioral Health Initial Consult Report dated 1/26/22 indicated he/she was evaluated by the Psychiatric Nurse Practitioner (NP) on 1/26/22. Patient #1 denied suicidal ideation and reportedly had regularly denied suicidal ideation. Patient #1 had a noted history of a suicide attempt in 2000, however, Patient #1 reported he had thoughts of suicide and never attempted in the past. Patient #1 requested to be discharged home to get back to work. The consult also indicated Patient #1 lived at home with his/her parents, however, they were currently in another state; the consult failed to indicate any attempts were made to obtain permission from Patient #1 reach out to his/her family. The consult also failed to indicate any attempt to reach out to Patient #1's community therapist. The consult failed to indicate any acknowledgement of the assessments conducted by the ESP Behavioral Health Clinicians on 1/22/22, 1/24/22 nor 1/25/22.

Review of Patient #1's After Visit Summary (AVS) dated 1/26/22 failed to indicate any follow-up appointments had been arranged with Patient #1's community therapist nor were there any instructions for the Patient to follow-up with his/her community therapist.

During an interview on 5/18/22 at 10:38 A.M., The Director of Performance Improvement and Quality said Patient #1's mother had reported his/her discharge and subsequently being found dead as a complaint to the Hospital. She said the peer review of the event was managed by the Emergency Department, and an algorithm was developed from the peer review. She said opportunities to improve documentation were identified from the peer review conducted by the Emergency Department.

During an interview on 5/18/22 at 11:33 A.M., the Chief Medical Officer (CMO) said Patient #1 was discharged on 1/26/22 after being evaluated by the Psychiatric NP. He said the RN discharging Patient #1 said she had offered to book transportation for the Patient but had not documented this. He said Patient #1 was discharged with recommendations to follow up with his own provider, no appointment had been set. The CMO said he was not sure if there was a safety plan developed for Patient #1 upon his/her discharge on 1/26/22.

During an interview on 5/18/22 at The Associate Chief Nursing Officer (CNO) said an algorithm was developed for safe discharge planning for patients in the Emergency Department. She said the plan had just been approved and education for staff and providers would be starting within the week.

During an interview on 5/19/22 at 9:30 A.M., the Chief of Emergency Services said the algorithm from the peer review was rolled out on 5/18/22. He said it had not been formally rolled out though, and he will be presenting the algorithm and plan at his next staff meeting on 5/31/22. He said a root cause analysis was not performed because the discharge of Patient #1 on 1/26/22 was not a Serious Reportable Event (SRE). He said the peer review identified the need for the Hospital to do better to address differences in opinion between providers and EPS clinicians; he said the algorithm was developed to address disagreements on discharge dispositions between providers and the EPS. He said in terms of documentation, a checklist with prompts would make cases clearer and help review inpatient discharge plans, however, he was not sure where that was in development.

During an interview on 5/19/22 at 10:00 A.M., the Psychiatric NP said he was asked to evaluate Patient #1 for a discharge disposition. He said he did not review Patient #1's medical records before interviewing the Patient. He said he was aware Patient #1 had been denying suicidal ideation, the Patient was future-oriented, and had self-presented to the Emergency Department. He said he felt Patient #1 was ready for discharge on 1/26/22 and spoke with the Emergency Department Physician Assistant (PA) and the EPS Behavioral Health Clinician. He said he had requested the EPS set up a follow up post discharge with Patient #1; he said the Behavioral Health Clinician did not communicate the concerns identified in the assessments conducted by the EPS on 1/24/22 and 1/25/22. He did not speak with Patient #1's community therapist nor parents/support system. He said he was aware of an algorithm was being developed, however, was not fully aware of what the algorithm addressed.

The Hospital failed to effectively plan and implement an adequate discharge plan for Patient #1 prior to his/her discharge on 1/26/22 to the community; Patient #1 was never heard from or seen again after his/her discharge from the Hospital on 1/26/22.