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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 RIGHTS was out of compliance.

A0144- §482.13 (c)(2) PATIENT RIGHTS: CARE IN SAFE SETTING. The patient has the right to receive care in a safe setting. Based on document reviews and interviews, the facility failed to conduct suicide screening risk assessments in accordance with national guidelines and facility policy to ensure patients received care in a safe setting. This failure was identified in three of three patients with behavioral health concerns who received care in the emergency department (ED). (Patients #1, #2, and #3)

Based on document reviews and interviews, the facility failed to conduct suicide screening risk assessments in accordance with national guidelines and facility policy to ensure patients received care in a safe setting. This failure was identified in three of three patients with behavioral health concerns who received care in the emergency department (ED). (Patients #1, #2, and #3)

Findings include:

Facility policy:

The Suicide Risk Assessment for Non-Behavioral Health (BH) Settings policy read, the purpose is to assist with the identification of patients in non-BH settings who are at risk for suicide, ensuring a safe environment for the provision of care. The Columbia Suicide Severity Rating Scale (C-SSRS) is the initial screening tool utilized by the nurse. It will provide an auto-calculated level of no risk, low, moderate or high risk. It is the policy of the facility to create an environment of care that will foster the assessment, identification, and management of patients who are at increased risk for suicide or self-harming behaviors. Patients who are at an increased risk for suicide or self-harming behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well-being. The scope of this plan begins at triage, prior to admission to the hospital, and continues until the patient is discharged.

Minimum requirement: Patients in non-psychiatric areas (e.g., Emergency Room (ER) and non-BH inpatient units), ages 12 years and older, who are being evaluated or treated for BH conditions as their primary reason for care should be screened using the C-SSRS. The Provider/Practitioner will be notified of positive screens (i.e., at-risk patients). The at-risk patient's (low, moderate, or high) environment will be made safe by implementing the checklist and observation precautions.

Reference:

According to the Columbia Lighthouse Project, About the Protocol, retrieved from https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/, the first step in effective suicide prevention is to identify everyone who needs help. The Columbia Protocol was the first scale to address the full range of suicidal thoughts and behaviors that point to heightened risk. That means it identifies risk not only if someone has previously attempted suicide, but also if he or she has considered suicide, prepared for an attempt (for example, buying a gun, collecting pills, or writing a suicide note), or aborted plans for suicide because of a last-minute change of mind or someone ' s intervention.

The Columbia Protocol screens for this wide range of risk factors without becoming unwieldy or overwhelming, because it includes the most essential, evidence-supported questions required for a thorough screening. Use of the protocol redirects resources to where they are needed most. It reduces unnecessary referrals and interventions by more accurately identifying who needs help and it makes it easier to correctly determine the level of support a person needs, such as patient safety monitoring procedures, counseling, or emergency room care.

1. The facility failed to conduct suicide screening risk assessments in accordance with national guidelines and facility policy to ensure patients received care in a safe setting.

A. Document Review

i. Medical record review revealed Patient #1 was a 17 year old who was transferred to the ED from a psychiatric facility on 5/21/24 at 9:25 p.m. with a chief complaint of hand injury. Patient #1's record revealed they were admitted to the psychiatric facility for suicidal ideations with intent. Patient #1 eloped from the ED on 5/21/24 at 9:41 p.m. There was no evidence a suicide screening risk assessment (C-SSRS) had been completed for Patient #1.

ii. Review of the Suicide Risk Assessment for Non-Behavioral Health (BH) Settings policy revealed suicide risk assessments were only completed for patients who were being evaluated or treated for BH conditions as their primary reason for care.

This was in contrast to the Columbia Lighthouse Project guidelines which read, the first step in effective suicide prevention was to identify everyone who needed help.

iii. Medical record review revealed Patient #2 was a 39 year old who presented to the ED on 12/14/24 at 2:40 p.m. with a chief complaint of hearing voices. Patient #2 eloped from the ED at 3:43 p.m. There was no evidence a C-SSRS had been completed for Patient #2.

iv. Medical record review revealed Patient #2 returned to the ED on 12/14/24 at 3:58 p.m. with a chief complaint of hearing voices. Patient #2 again eloped from the ED at 5:10 p.m. There was no evidence a C-SSRS had been completed for Patient #2.

v. Medical record review revealed Patient #3 was a 15 year old who presented to the ED on 10/23/24 at 4:53 p.m. with a chief complaint of intentional overdose and suicidal ideation. Nursing documentation at 5:12 p.m. revealed Patient #3 would not respond verbally, and at 5:17 p.m., nursing staff were unable to assess Patient #3's suicide risk. Between 5:36 p.m. and 8:17 p.m., provider documentation revealed Patient #3 was able to answer questions. There was no evidence a C-SSRS had been completed for Patient #3 while they were in the ED.

Medical record reviews for Patients #2 and #3 were in contrast to the Suicide Risk Assessment for Non-Behavioral Health (BH) Settings policy which read, the C-SSRS was the initial screening tool that should have been utilized by the nurse. At a minimum, patients who were being evaluated or treated for BH conditions as their primary reason for care should have been screened using the C-SSRS.

B. Interviews

i. On 12/18/24 at 1:52 p.m., an interview was conducted with registered nurse (RN) #1, who provided care to Patient #2 during their second ED visit on 12/14/24. RN #1 stated the C-SSRS was supposed to be completed any time a patient came to the ED with psychiatric related issues, such as depression, anxiety, if they wanted to harm themselves or had a recent attempt, or if they heard voices. RN #1 stated they never reported the C-SSRS scores to providers and nurses were not required to notify the patient's provider of what the suicide risk assessment scores were because providers completed their own assessments to determine if patients needed to be placed on M1 holds (a 72 hour psychiatric hold).

Additionally, RN #1 stated they used their best judgement and did not complete the C-SSRS on patients if they did not feel like the patients were at risk of suicide. RN #1 stated it was up to nurses to make a judgement call of whether the patient could benefit from further psychiatric interventions. RN #1 stated Patient #2 muttered under their breath but did not seem like they were talking to someone who was not there. RN #1 stated they did not feel Patient #2 was a candidate for a C-SSRS because they were alert and oriented, talking, did not want to be in the hospital, and asked to let them leave the facility. Furthermore, RN #1 stated it was important to know if a patient was at risk for suicide because it was the facility's responsibility to ensure patients were mentally and physically safe.

This was in contrast to the Suicide Risk Assessment for Non-Behavioral Health (BH) Settings policy which read, the purpose was to assist with the identification of patients in non-BH settings who were at risk for suicide and ensured a safe environment for the provision of care. The C-SSRS was the initial screening tool utilized by the nurse. It was the policy of the facility to create an environment of care that fostered the assessment, identification, and management of patients who were at increased risk for suicide or self-harming behaviors. Patients who were at an increased risk for suicide or self-harming behaviors required intensive support, close observation, and frequent reassessment for their emotional and physical well-being. The scope of this plan began at triage, prior to admission to the hospital, and continued until the patient was discharged.

At a minimum, patients in the ED, ages 12 years and older, who were being evaluated or treated for BH conditions as their primary reason for care should have been screened using the C-SSRS. The Provider/Practitioner would be notified of positive screens (i.e., at risk patients).

This was also in contrast to the Columbia Lighthouse Project guidelines which read, the first step in effective suicide prevention was to identify everyone who needed help.

ii. On 12/19/24 at 2:43 p.m., an interview was conducted with ED manager (Manager) #2. Manager #2 stated the C-SSRS was used to identify individuals at a high risk for suicide and should have been completed for Patients #1, #2, and #3. Manager #2 stated Patient #3's C-SSRS should have been completed as early as possible, once the patient was able to complete the assessment. Manager #2 stated staff were trained during the orientation process that suicide screenings were a safety measure which needed to be completed. Manager #2 stated staff could miss an opportunity to intervene if suicidal patients were not screened when they were being seen for a different complaint. Manager #2 stated every ED patient should have been screened for suicide risk, regardless of their chief complaint. Additionally, Manager #2 stated patients could be at risk of harming themselves if suicide screening risk assessments were not completed. Manager #2 stated staff needed to assess suicide risk to ensure the correct safety measures were implemented if patients were suicidal.

This was in contrast to the medical record reviews for Patients #1, #2, and #3 which revealed the C-SSRS was not completed during their ED visits. This was also in contrast to the interview with RN #1 who stated they used their best judgement and did not complete the C-SSRS on patients if they did not feel like the patients were at risk of suicide, and it was up to nurses to make a judgement call of whether patients could benefit from further psychiatric interventions.

iii. On 12/19/24 at 3:42 p.m., an interview was conducted with the director of patient safety (Director) #3. Director #3 stated it was a corporate decision to only screen patients for suicide if they presented with a BH diagnosis or gave a reason to be screened. Director #3 stated unnecessary interventions were put into place when all patients were screened for suicide risk.

This was in contrast to the Columbia Lighthouse Project guidelines which read, the first step in effective suicide prevention was to identify everyone who needed help. The Columbia Protocol screened for a wide range of risk factors without becoming unwieldy or overwhelming because it included the most essential, evidence-supported questions required for a thorough screening. Use of the protocol redirected resources to where they were needed most. It reduced unnecessary referrals and interventions by more accurately identifying who needed help, and made it easier to correctly determine the level of support a person needed, such as patient safety monitoring procedures, counseling, or emergency room care.