HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 (Pt #1) patients who presented to the Hospital's emergency department (ED) with psychiatric issues, the Hospital failed to ensure that policies were in place to provide an appropriate psychiatric assessment.

Findings include:

1. The ED record for Pt #1 was reviewed and included that this was a 37 year old female brought to the Hospital's Emergency Department (ED) via ambulance on 2/21/12 at 8:21pm for a psychiatric evaluation after violent behavior at a residential facility (TK) where Pt #1 was a resident. The nurse's (E #1) triage note dated 2/21/12 at 8:25pm included that Pt #1 was assigned an acuity level of 3-urgent. The EMS (Emergency Medical Services) report included, "Patient's past medical history-suicidal tendencies".

Pt #1 was seen by the ED physician (MD #1) at 8:50pm and MD #1's note included, "Pt #1 presents with anxiety and 37 year old with past medical history of anxiety/depression presents to the ER via EMS from TK after she became angry and punched a door after she was not allowed outside to smoke. Denies homicidal ideation/suicidal ideation, delusions, hallucinations, drug or ETOH (alcohol) abuse. One prior suicide attempt but denies any current ideation. The onset was just prior to arrival...."

A suicide risk assessment tool (SAD) was completed by E #1 and included a score of 4.5 (a score greater than 5 requires a consult with a Behavioral Health Team Expert-social worker, A&R, Psychiatrist, etc).

E #2's Behavioral Health Counselor (BHC) Intake Assessment dated 2/21/12 included, "8:11pm: Pt #1 stated she has been at TK for a week and a half due to depression and anxiety... She stated that therapy brought up old memories that triggered anxiety. Pt #1 reported her anxiety built every day and continued getting worse ... Pt #1 said she was going to go outside to smoke a cigarette because she wanted to reduce her anxiety and they refused to let her so she broke the door down ...Pt #1 admits to having SI (suicidal ideation) prior to admission at TK. She stated she has not had any since admission.

At no point did the E #1, E #2, or MD #1 request clinical records from TK, contact the psychiatrist at TK or on-call, or speak with Pt #1's family or significant other to obtain Pt #1's history and ensure a safe discharge plan. Pt #1 was discharged and left the Hospital by taxi at approximately 11:00 pm on 2/21/12. Pt #1 committed suicide by overdose on 2/22/12. Pt #1 was only in the ED for 3 hours and did not receive a complete psychiatric evaluation before being discharged.

2. An interview was conducted with the ED Medical Director (MD #2) on 1/9/13 at approximately 1:15pm. MD #2 stated that the normal process when a patient presents to the ED with psychiatric issues is they are seen by the ED physician, medically cleared, and a referral is sent to the social worker (SW) or behavioral health counselor (BHC). The SW or BHC then speaks with the patient in person or by telephone to assess whether the patient meets the criteria for psychiatric admission [although requested, no written criteria was presented to the surveyor] or wants to go home with outpatient follow up and treatment. The SW or BHC then discusses the assessment and plan with the ED physician. The SW or BHC also talks to the patient's family if they are present or by phone if indicated. The ED physician then determines the plan for admission or discharge and the SW or BHC makes the appropriate arrangements/referrals.

3. On 1/9/13 at approximately 11:00am, the surveyor requested from the Director of Quality (E #4) the criteria/requirements for admission of a patient to an inpatient psychiatric facility and the Hospital's policy and/or procedure on the assessment of a psychiatric patient in the ED by the SW/BHC. E #4 stated that there was not written criteria, it is based on assessment and if the physician determines the need. E #4 stated that the Hospital does not have a policy or written procedure for the assessment of a patient by the SW or BHC.