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Based on document reviews and interviews, it was determined the CoP for Governing Body was not met as evidenced by the Governing Body's failure to provide oversight of the hospital by ensuring the medical staff was accountable, for the quality of care provided for one (1) of ten (10) patients reviewed (Patient #1).

Finding:

The Governing Body has failed to provide oversight of the hospital as evidenced by the following:

Standard: §482.12(a)(5) Medical Staff also known as A-0049 - Based on document reviews and interviews, the hospital failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to one (1) of ten (10) patients reviewed (Patient #1). This failure was demonstrated by the failure of the medical staff to evaluate a patient who presented to the outpatient location with bandages on his/her left wrist, stated he/she had made a suicide attempt and had cut his/her wrist, and was seeking medical attention for active suicidal ideations. The patient was told to return later that day, which the patient did. Upon the second presentation to the outpatient location, the medical staff failed to evaluate the the patient's wrist or his/her suicidal ideations and the patient returned home. The next day, the patient was admitted to the hospital's Emergency Department ("ED") with a self-inflicted gunshot wound to his/her head and later died. The Medical Staff failed to conduct a peer review of this adverse event. See A-0049 for details.

The cumulative effect of this deficient practice resulted in noncompliance with this CoP.

Based on document reviews and interviews, the hospital failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to one (1) of ten (10) patients reviewed (Patient #1). This failure was demonstrated by the failure of the medical staff to evaluate a patient who presented to the outpatient location with bandages on his/her left wrist, stated he/she had made a suicide attempt and had cut his/her wrist, and was seeking medical attention for active suicidal ideations. The patient was told to return later that day, which the patient did. Upon the second presentation to the outpatient location, the medical staff failed to evaluate the the patient's wrist or his/her suicidal ideations and the patient returned home. The next day, the patient was admitted to the hospital's Emergency Department ("ED") with a self-inflicted gunshot wound to his/her head and later died. The Medical Staff failed to conduct a peer review of this adverse event.

Finding:

The "Inland Hospital Medical Staff Bylaws", last reviewed 10/2019 states, in part, "The purpose of the medical staff is intended: to serve as the primary means for accountability to the Governing Board for the appropriateness of the professional performance and ethical conduct of its members and to strive toward the continual upgrading of the quality and efficiency of patient care delivered in the Hospital consistent with the state of the healing arts and the resources locally available..." and "...Section 2. The Responsibilities of the Medical Staff. The Medical Staff shall: A. Account to the Governing Board for the quality, appropriateness, and efficiency of patient care provided by all practitioners authorized to practice in the Hospital including Allied Health Practitioners and Contractors through the following measures: i. maintain an organizational structure and mechanisms that allow continuous systematic monitoring and evaluation of patient care practices and provide opportunity to improve patient care and resolve identified problems".

Documentation in Patient #1's medical record contained an email, dated 8/2/2021 at 9:58 AM, between Patient Service Representative ("PSR") #2 and RN #3. The email stated, in part: "I called the patient to schedule [him/her] an appointment...and I offered Thursday 8/12 and [he/she] said, "If I have to make it that long, I am considering suicide and ending it all". I asked if [he/she] had a plan and [he/she] said, "Yes, I have a big knife and slit my throat"...I transferred call to RN #3".

Documentation in Patient #1's medical record contained an email, dated 8/2/2021 at 9:58 AM, between RN #3 and the Co-President of the Medical Group, who is Patient #1's Primary Care Physician. In part, the email stated the following: "I spoke with [Patient #1] this morning as [he/she] expressed suicidal ideation thoughts when scheduling [his/her] appointment...Sleep is [his/her] biggest concern at this time...[He/She] expressed thoughts of suicidal ideation with a knife...did not reiterate those to me, but did say [he/she] felt [he/she] could not take things much longer with the lack of sleep".

On 8/3/2021 at approximately 9:30 AM, Patient #1 presented to his/her Primary Care Physician's office. According to an interview with PSR #1 on 10/7/2021 at 9:57 AM, the patient stated, on 8/3/2021, "I need to talk to a doctor because I attempted suicide by cutting my wrist". I asked the other check in lady to check on [him/her] while I went to check with [PA #1] and pulled him out of a patient visit. [PA #1] stated he didn't have the availability right then and maybe we could call crisis...I went to RN #1 and RN #2...they got [him/her] on the schedule for 3:15 PM that day. I explained this to [him/her] and [he/she] had already called Crisis and they suggested going to the ED but [he/she] declined. At that point, [he/she] stated, "If I had a gun, I would shoot myself with it". Again, I went back to [PA #1] and explained what was just said...he said, "Well, [he/she] is on the schedule for 3:15 PM and we will see [him/her] then".

On 8/3/2021 at 9:56 AM, PSR #1 sent an email to the Co-President of the Medical Group and PA #1. The email stated, "Patient showed up today...When patient went to sit down - [he/she] grabbed the inside of my counter top - I touched [his/hers] hands and they were ice cold. Patient states [he/she] attempted suicide (there was a bandage on [his/her] wrist) - stated that if I had a gun I would have shot myself with it..."

On 8/3/2021 at 3:15 PM, Patient #1 returned to the Primary Care Physician's office for the appointment with PA #1. There was no evidence in the patient's medical record that PA #1 discussed and assessed the patient's suicidal ideation or that a physical exam was completed to assess Patient #1's bandaged wrist before the patient left the office.

On 8/4/2021 at approximately 11:50 AM, Patient #1 arrived at this hospital's ED, via ambulance, with a self-inflicted gunshot wound to the head. He/She was assessed, treated, and then transported at 1:04 PM, via air transportation, to another hospital. The air ambulance's RN documented that the patient had a "deep horizontal laceration noted to left wrist with bandage applied".

On 8/11/2021, Patient #1 died as a result of his/her self-inflicted injury.

On 10/6/2021 at 1:59 PM, a phone interview was conducted with PA #1 regarding the care of Patient #1 on 8/3/2021. He stated the following:
- "I was pulled out of a visit to see if we could see [him/her], [PSR #1] explained that [he/she] was at the window, having suicidal ideation and feels like [he/she] needs to be seen. My recommendation is something that would require an elevated level of care and they should be seen by crisis or go to the ED...so I told [PSR #1] to offer that information. [He/She] was the major reason they came back to get me...[Patient #1] wanted to be seen immediately. They were not able to convince [Patient #1] to go to crisis or ED...but agreed to end of day with me";
- In relation to the 3:15 PM visit: "Based on my history of working with [Patient #1], [he/she] appeared manic, appeared to be at baseline mania in that it was not out of the abnormal. I asked [Patient#1] about suicidal ideation...he did report that he was having significant suicidal ideation but did not have a plan. I did not examine his body because he was agitated due to a delay in being seen. I did a general assessment but not a physical assessment. There were no bandages noted from general examination. No, I was not aware of the information regarding suicidal ideation...no details provided by [PSR #1]. Suicidal ideation is very common for this individual and previously, we have sent to the ED. I don't recall at any point that the suicidal ideation had any form or plan"; and
- When asked about screening patients with suicidal ideation: "Suicidal ideation would need to be presented with intent and have the patient quantify the suicidal ideation. I would ask them how likely or not likely are they to act on that. I would ask them, on a scale of 1-10, where do you feel you are at? I did not ask that this time around. I tried to loop around and ask but due to [his/her] agitation and demeanor I was not able to ask that. After I reviewed the plan again...[his/her] mood and agitation had lifted, I was under the assessment that [he/she] was doing really good. I had very little to no concerns. I never looped back to ask about [his/her] mood".

On 10/7/2021 at 9:57 AM, a phone interview was conducted with PSR #1 regarding Patient #1. She stated "... Later that day, I checked [Patient #1] in at 3:15 PM. [Patient #1] still had bandages on and were visible...bandages were definitely on the left wrist...".

On 10/7/2021 at 11:34 AM, a phone interview was again conducted with PA #1. He stated, "I was aware of [Patient #1's] suicidal ideation but not aware of the plan. I only recall her [meaning PSR #1] coming back once. There may have been two (2)knocks, but there was communication only once".

A review of the Medical Staff Quality Improvement Committee minutes, dated 9/3/2021, were reviewed, which contained documentation of records that were reviewed. There was no evidence that Patient #1's case was reviewed.

On 10/12/2021 at 12:50 PM, an interview was conducted with the Senior Physician Executive. The Senior Physician Executive confirmed that a medical review had not been done for this case.

On 10/12/2021 at 2:35 PM, an interview was conducted with the Co-President of the Medical Group regarding the care of Patient #1 on 8/3/2021. He stated the following:
- This case needs to go through medical review;
- Our case review began eight weeks later;
- My expectations were that it should be conducted within 2 weeks;
- There are some pretty major documentation issues; and
- I was a bit shocked that the patient was allowed to leave (in the morning with suicidal ideation)...and that the suicidal intent was not addressed at the appointment with PA #1.

On 10/14/2021 at 10:04 AM, an interview was conducted with the hospital's President, who is a member of the Governing Body, regarding the adverse event of 8/3/2021. She stated the following:
- She was made aware of the event on 8/4/2021;
- She was unaware of any issues occurring at the Primary Care Physician's office;
- "I was told a Root Cause Analysis and Medical Peer Review would be done concerning the event, but I then failed to appropriately monitor the progress of the investigations. I checked in a few times to see how it was going and was basically told it was in process..."; and
- The event has not been presented to the full Governing Body.

Based on document reviews and interviews, the hospital failed to conduct a case review of Patient #1's presentation to the office and subsequent office visit of 8/3/2021. This failure demonstrated the medical staff has failed to be accountable to the governing body for the quality of the medical care provided to Patient #1.

Based on document reviews and interviews, the CoP for Quality Assessment and Performance Improvement Program ("QAPI") was not met. The hospital failed to conduct a review of a serious adverse event to analyze its causes and implement preventive actions for one (1) of ten (10) patients reviewed (Patient #1). In addition the hospital failed to follow its own policy related to root cause analysis completion for this event.

Finding:

Standard §482.21(a)(1); 482.21(a)(2); 482.21(c)(2); and 482.21(e)(3) Patient Safety also known as A-0286. Based on document reviews and interviews, the hospital failed to conduct a review of a serious adverse event to analyze its causes and implement preventive actions for one (1) of ten (10) patients reviewed (Patient #1). In addition, the hospital failed to follow its own policy related to root cause analysis completion for this event. See A-0286 for details.

The cumulative effect of this deficient practice resulted in noncompliance with this CoP.

Based on document reviews and interviews, the hospital failed to conduct a review of a serious adverse event to analyze its causes and to implement preventive actions for one (1) of ten (10) patients reviewed (Patient #1). In addition, the hospital failed to follow its own policy related to root cause analysis completion for this event.

Finding:

The Northern Light Inland Hospital policy titled, "Safety Event Reporting Management", last updated on 7/28/2021, states, in part, - "All members of leadership and the Risk Management/Quality/Patient Safety functions are responsible for the review, investigation, and remediation of all Reportable Events in their respective departments or areas. They are also responsible for the education of staff from such events...Determination of the appropriate severity is made in concert with review by Risk Management/Patient Safety. The level of review/investigation will depend on the actual severity of the event...Events that have been categorized as having seriously Harmed the patient and all Sentinel Events will require an RCA [Root Cause Analysis] be conducted. All RCAs will be facilitated by a member of the Risk Management/Quality /Patient Safety team. RCAs shall commence as soon as possible after the event and be completed within the Member Organization specific requirements, but no later than 45 days...Additionally, Risk Management will schedule a 10-day follow-up with the team members to review all action items and will complete an assessment of action plans at 30, 60, 90 days post RCA. Risk Management will notify previously identified senior leaders of all Sentinel Events immediately when discovered. The RCA must be thorough: Proximate causes and related processes shall be identified; Underlying processes and causes analyzed through a series of "why" questions; Potential improvements to risk identified; Plans for implementation and evaluation of improvement actions developed. The RCA must be credible: Participation by leadership and those closest to the event or process; Analysis must be standard and consistent (see RCA tools/forms to be used); Provide an explanation for all findings considered "non-applicable" or "not a problem"; Review of current literature will be completed and included."

In addition, the policy defined Sentinel Event as "A type of a Safety Event that causes major permanent Harm or death, or has a high likelihood if repeated...". It also defined root cause analysis as "A systematic process for identifying causal factors that underlie variations in performance, which have resulted in actual or Near Miss significant Reportable Event. The RCA shall identify opportunities for improvement which will result in decreasing and or eliminating the risk of future variation."

Documentation in Patient #1's medical record contained an email, dated 8/2/2021 at 9:58 AM, between RN #3 and the Co-President of the Medical Group, who is Patient #1's Primary Care Physician. In part, the email stated the following: "I spoke with [Patient #1] this morning as [he/she] expressed suicidal ideation thoughts when scheduling [his/her] appointment...Sleep is [his/her] biggest concern at this time...[He/She] expressed thoughts of suicidal ideation with a knife...did not reiterate those to me, but did say [he/she] felt [he/she] could not take things much longer with the lack of sleep".

On 8/3/2021 at approximately 9:30 AM, Patient #1 presented to his/her Primary Care Physician's office. According to an interview with PSR #1 on 10/7/2021 at 9:57 AM, the patient stated, on 8/3/2021, "I need to talk to a doctor because I attempted suicide by cutting my wrist". I asked the other check in lady to check on [him/her] while I went to check with [PA #1] and pulled him out of a patient visit. [PA #1] stated he didn't have the availability right then and maybe we could call crisis...I went to RN #1 and RN #2...they got [him/her] on the schedule for 3:15 PM that day. I explained this to [him/her] and [he/she] had already called Crisis and they suggested going to the ED but [he/she] declined. At that point, [he/she] stated, "If I had a gun, I would shoot myself with it". Again, I went back to [PA #1] and explained what was just said...he said, "Well, [he/she] is on the schedule for 3:15 PM and we will see [him/her] then".

On 8/3/2021 at 9:56 AM, PSR #1 sent an email to the Co-President of the Medical Group and PA #1. The email stated, "Patient showed up today...When patient went to sit down - [he/she] grabbed the inside of my counter top - I touched [his/hers] hands and they were ice cold. Patient states [he/she] attempted suicide (there was a bandage on [his/her] wrist) - stated that if I had a gun I would have shot myself with it..."

On 8/3/2021 at 3:15 PM, Patient #1 returned to the Primary Care Physician's office for the appointment with PA #1. There was no evidence in the patient's medical record that PA #1 discussed and assessed the patient's suicidal ideation or that a physical exam was completed to assess Patient #1's bandaged wrist before the patient left the office.

On 8/4/2021 at approximately 11:50 AM, Patient #1 arrived at this hospital's ED, via ambulance, with a self-inflicted gunshot wound to the head. He/She was assessed, treated, and then transported at 1:04 PM, via air transportation, to another hospital. The air ambulance's RN documented that the patient had a "deep horizontal laceration noted to left wrist with bandage applied".

On 8/11/2021, Patient #1 died as a result of his/her self-inflicted injury.

On 10/6/2021 at 9:46 AM, the Director of Quality and Risk Management approached the surveyors to discusses events related to Patient #1. She stated the following:
- a sentinel event was identified and she reported it as an sentinel event;
- we conducted a RCA;
- we did not identify a root cause for this event.

On 10/6/2021 at 10:54 AM, an interview was conducted with the Risk Manager. She stated the following: "We have not completed a RCA, but I have completed the investigation. We are meeting on the 19th of October. We concluded that there may be some policy improvements...we have policies and we did follow them, but it may have room for improvement and communication between practices....Also, there are things that may have happened but weren't documented".

On 10/6/2021 at 1:59 PM, an interview was conducted with PA #1. He confirmed that he had not been part of any any RCA or an analysis of Patient #1's care on 8/3/2021.

On 10/8/2021 at 8:09 AM, an interview was conducted with RN #2. She confirmed that she had not been part of any any RCA or an analysis of Patient #1's care on 8/3/2021

On 10/8/2021 at 8:47 AM, an interview was again conducted with the Director of Quality and Risk Management. She was asked about the RCA process that she had indicated previously that had been completed for the event involving Patient #1 on 8/3/2021 and stated the following: "We started with interviews...well, emails...I know [the Risk Manager] had interactions with [RN #2]...I believe the interview happened via email...I do not know specifically".

On 10/12/2021 at 12:56 PM, an interview was conducted with the Senior Physician Executive in regard to the RCA for Patient #1's care on 8/3/2021. He stated the following: "We had an RCA this morning...I wasn't involved in any RCA until today...I should be involved in all RCA's...and if I was on vacation, it could be a Chief of Staff...I didn't speak with [PA #1], after the incident. [PA #1] joined the meeting today for the RCA".

On 10/13/2021 at 8:58 AM, an interview was again conducted with the Risk Manager. She stated the following in relation to the steps that had been taken following Patient #1's care on 8/3/2021. She stated the following:
- After discussing with the Director of Quality and Risk Management after the report of Patient #1's death, she conducted a chart review and looked at the correspondence between the provider and different staff members;
- We planned to review this incident as a a sentinel event;
- She is the only individual involved in a RCA;
- Emails were sent out to different staff members involved in the patient's care;
- Normally interviews would be conducted immediately;
- She did not contact the Senior Physician Executive or the Co-President of the Medical Group;
- A RCA meeting took place on 10/12/2021; and
- PA#1 was not going to be part of the RCA.

On 10/14/2021 at 10:04 AM, an interview was conducted with the hospital's President regarding the adverse event of 8/3/2021. She stated the following:
- She was made aware of the event on 8/4/2021;
- She was unaware of any issues occurring at the Primary Care Physician's office;
- "I was told a Root Cause Analysis and Medical Peer Review would be done concerning the event, but I then failed to appropriately monitor the progress of the investigations. I checked in a few times to see how it was going and was basically told it was in process..."

Based on the above information, as of 10/12/2021, the hospital failed to conduct a root cause analysis of Patient #1's care on 8/3/2021 to determine the root cause and to develop any potential improvement plans. In addition, the hospital failed to conduct a root cause analysis, per their policy, within forty-five (45) days.

Based on document reviews and interviews, it was determined the CoP for Medical Staff was not met as evidenced by the hospital's failure to ensure that the medical staff was accountable to the governing body for the quality of care provided to one (1) (one) of ten (1) patients reviewed (Patient #1).

Finding:

Standard - §482.22(b) Standard: Medical Staff Organization and Accountability also known as A-0347 - Based on record review and interview, the hospital failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to one (1) of ten (10) patients reviewed (Patient #1). This failure was demonstrated by the failure of the medical staff to evaluate a patient who presented to the outpatient location with bandages on his/her left wrist, stated he/she had made a suicide attempt and had cut his/her wrist, and was seeking medical attention for active suicidal ideations. The patient was told to return later that day, which the patient did. Upon the second presentation to the outpatient location, the medical staff failed to evaluate the the patient's wrist or his/her suicidal ideations and the patient returned home. The next day, the patient was admitted to the hospital's Emergency Department ("ED") with a self-inflicted gunshot wound to his/her head and later died. The Medical Staff failed to conduct a peer review of this adverse event. See A-0347 for details.

The cumulative effect of this deficient practice resulted in noncompliance with this CoP.

Based on document reviews and interviews, the hospital failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to one (1) of ten (10) patients reviewed (Patient #1). This failure was demonstrated by the failure of the medical staff to evaluate a patient who presented to the outpatient location with bandages on his/her left wrist, stated he/she had made a suicide attempt and had cut his/her wrist, and was seeking medical attention for active suicidal ideations. The patient was told to return later that day, which the patient did. Upon the second presentation to the outpatient location, the medical staff failed to evaluate the the patient's wrist or his/her suicidal ideations and the patient returned home. The next day, the patient was admitted to the hospital's Emergency Department ("ED") with a self-inflicted gunshot wound to his/her head and later died. The Medical Staff failed to conduct a peer review of this adverse event.

Finding:

The "Inland Hospital Medical Staff Bylaws", last reviewed 10/2019 states, in part, "The purpose of the medical staff is intended: to serve as the primary means for accountability to the Governing Board for the appropriateness of the professional performance and ethical conduct of its members and to strive toward the continual upgrading of the quality and efficiency of patient care delivered in the Hospital consistent with the state of the healing arts and the resources locally available..." and "...Section 2. The Responsibilities of the Medical Staff. The Medical Staff shall: A. Account to the Governing Board for the quality, appropriateness, and efficiency of patient care provided by all practitioners authorized to practice in the Hospital including Allied Health Practitioners and Contractors through the following measures: i. maintain an organizational structure and mechanisms that allow continuous systematic monitoring and evaluation of patient care practices and provide opportunity to improve patient care and resolve identified problems".

Documentation in Patient #1's medical record contained an email, dated 8/2/2021 at 9:58 AM, between Patient Service Representative ("PSR") #2 and RN #3. The email stated, in part: "I called the patient to schedule [him/her] an appointment...and I offered Thursday 8/12 and [he/she] said, "If I have to make it that long, I am considering suicide and ending it all". I asked if [he/she] had a plan and [he/she] said, "Yes, I have a big knife and slit my throat"...I transferred call to RN #3".

Documentation in Patient #1's medical record contained an email, dated 8/2/2021 at 9:58 AM, between RN #3 and the Co-President of the Medical Group, who is Patient #1's Primary Care Physician. In part, the email stated the following: "I spoke with [Patient #1] this morning as [he/she] expressed suicidal ideation thoughts when scheduling [his/her] appointment...Sleep is [his/her] biggest concern at this time...[He/She] expressed thoughts of suicidal ideation with a knife...did not reiterate those to me, but did say [he/she] felt [he/she] could not take things much longer with the lack of sleep".

On 8/3/2021 at approximately 9:30 AM, Patient #1 presented to his/her Primary Care Physician's office. According to an interview with PSR #1 on 10/7/2021 at 9:57 AM, the patient stated, on 8/3/2021, "I need to talk to a doctor because I attempted suicide by cutting my wrist". I asked the other check in lady to check on [him/her] while I went to check with [PA #1] and pulled him out of a patient visit. [PA #1] stated he didn't have the availability right then and maybe we could call crisis...I went to RN #1 and RN #2...they got [him/her] on the schedule for 3:15 PM that day. I explained this to [him/her] and [he/she] had already called Crisis and they suggested going to the ED but [he/she] declined. At that point, [he/she] stated, "If I had a gun, I would shoot myself with it". Again, I went back to [PA #1] and explained what was just said...he said, "Well, [he/she] is on the schedule for 3:15 PM and we will see [him/her] then".

On 8/3/2021 at 9:56 AM, PSR #1 sent an email to the Co-President of the Medical Group and PA #1. The email stated, "Patient showed up today...When patient went to sit down - [he/she] grabbed the inside of my counter top - I touched [his/hers] hands and they were ice cold. Patient states [he/she] attempted suicide (there was a bandage on [his/her] wrist) - stated that if I had a gun I would have shot myself with it..."

On 8/3/2021 at 3:15 PM, Patient #1 returned to the Primary Care Physician's office for the appointment with PA #1. There was no evidence in the patient's medical record that PA #1 discussed and assessed the patient's suicidal ideation or that a physical exam was completed to assess Patient #1's bandaged wrist before the patient left the office.

On 8/4/2021 at approximately 11:50 AM, Patient #1 arrived at this hospital's ED, via ambulance, with a self-inflicted gunshot wound to the head. He/She was assessed, treated, and then transported at 1:04 PM, via air transportation, to another hospital. The air ambulance's RN documented that the patient had a "deep horizontal laceration noted to left wrist with bandage applied".

On 8/11/2021, Patient #1 died as a result of his/her self-inflicted injury.

On 10/6/2021 at 1:59 PM, a phone interview was conducted with PA #1 regarding the care of Patient #1 on 8/3/2021. He stated the following:
- "I was pulled out of a visit to see if we could see [him/her], [PSR #1] explained that [he/she] was at the window, having suicidal ideation and feels like [he/she] needs to be seen. My recommendation is something that would require an elevated level of care and they should be seen by crisis or go to the ED...so I told [PSR #1] to offer that information. [He/She] was the major reason they came back to get me...[Patient #1] wanted to be seen immediately. They were not able to convince [Patient #1] to go to crisis or ED...but agreed to end of day with me";
- In relation to the 3:15 PM visit: "Based on my history of working with [Patient #1], [he/she] appeared manic, appeared to be at baseline mania in that it was not out of the abnormal. I asked [Patient#1] about suicidal ideation...he did report that he was having significant suicidal ideation but did not have a plan. I did not examine his body because he was agitated due to a delay in being seen. I did a general assessment but not a physical assessment. There were no bandages noted from general examination. No, I was not aware of the information regarding suicidal ideation...no details provided by [PSR #1]. Suicidal ideation is very common for this individual and previously, we have sent to the ED. I don't recall at any point that the suicidal ideation had any form or plan"; and
- When asked about screening patients with suicidal ideation: "Suicidal ideation would need to be presented with intent and have the patient quantify the suicidal ideation. I would ask them how likely or not likely are they to act on that. I would ask them, on a scale of 1-10, where do you feel you are at? I did not ask that this time around. I tried to loop around and ask but due to [his/her] agitation and demeanor I was not able to ask that. After I reviewed the plan again...[his/her] mood and agitation had lifted, I was under the assessment that [he/she] was doing really good. I had very little to no concerns. I never looped back to ask about [his/her] mood".

On 10/7/2021 at 9:57 AM, a phone interview was conducted with PSR #1 regarding Patient #1. She stated "... Later that day, I checked [Patient #1] in at 3:15 PM. [Patient #1] still had bandages on and were visible...bandages were definitely on the left wrist...".

On 10/7/2021 at 11:34 AM, a phone interview was again conducted with PA #1. He stated, "I was aware of [Patient #1's] suicidal ideation but not aware of the plan. I only recall her [meaning PSR #1] coming back once. There may have been two (2) knocks, but there was communication only once".

A review of the Medical Staff Quality Improvement Committee minutes, dated 9/3/2021, were reviewed, which contained documentation of records that were reviewed. There was no evidence that Patient #1's case was reviewed.

On 10/12/2021 at 12:50 PM, an interview was conducted with the Senior Physician Executive. The Senior Physician Executive confirmed that a medical review had not been done for this case.

On 10/12/2021 at 2:35 PM, an interview was conducted with the Co-President of the Medical Group regarding the care of Patient #1 on 8/3/2021. He stated the following:
- This case needs to go through medical review;
- Our case review began eight weeks later;
- My expectations were that it should be conducted within 2 weeks;
- There are some pretty major documentation issues; and
- I was a bit shocked that the patient was allowed to leave (in the morning with suicidal ideation)...and that the suicidal intent was not addressed at the appointment with PA #1.

On 10/14/2021 at 10:04 AM, an interview was conducted with the hospital's President regarding the adverse event of 8/3/2021. She stated the following:
- She was made aware of the event on 8/4/2021;
- She was unaware of any issues occurring at the Primary Care Physician's office;
- "I was told a Root Cause Analysis and Medical Peer Review would be done concerning the event, but I then failed to appropriately monitor the progress of the investigations. I checked in a few times to see how it was going and was basically told it was in process..."; and
- The event has not been presented to the full Governing Body.

Based on document reviews and interviews, the hospital failed to conduct a case review of Patient #1's presentation to the office and subsequent office visit of 8/3/2021. This failure demonstrated the medical staff has failed to be accountable to the governing body for the quality of the medical care provided to Patient #1.

Based on document reviews and interviews, it was determined the CoP for Outpatient Services was not met as evidenced by the hospital's outpatient department's failure to provide services that met the need of one (1) of ten (10) patients (Patient #1). On 8/3/2021 in the morning, the patient presented to the outpatient location with bandages on his/her left wrist, stated he/she had made a suicide attempt and had cut his/her wrist, and was seeking medical attention for active suicidal ideations. The patient was not assessed and was told by staff to return later that day, which the patient did. Upon the second presentation to the outpatient location, the patient was seen by a Physician Assistant ("PA"); however, the patient's wrist or his/her suicidal ideations were not assessed and the patient returned home. The next day, Patient #1 was admitted into the hospital's Emergency Department ("ED") with a self-inflicted gunshot wound to his/her head. The failure to provide this patient with needed services constituted an immediate jeopardy ("IJ") situation. IJ is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health and safety requirements.

Finding:

The Division of Licensing and Certification was made aware of the following: On 8/2/2021, Patient #1 called an outpatient clinic requesting an appointment due to suicidal ideation - cutting his/her throat due to not sleeping. On 8/3/2021, he/she presented to the clinic with bandages on his/her wrists from cutting; expressed he/she was going to shoot himself/herself; and was seen by the Provider. The patient refused to go to the ED or work with Crisis and the Provider did not complete a crisis assessment. The patient went home and committed suicide.

The Northern Light Inland Hospital policy titled, "Patients Requiring Immediate Assessment", dated 3/27/2020, stated, in part, "When a patient enters or calls the practice and is complaining of the symptoms listed below the staff person receiving the patient or call will notify the RN [Registered Nurse] by pager for immediate assistance. The symptoms are:...suicidal or homicidal...When a patient presents to the practice with the symptoms listed above the staff person speaking with the patient notifies a fellow staff person to get "RN Help". He/she initiates the RN pager for your department and indicates RN help needed and location...The patient at NO time is left alone. The RN...responds to the location...he/she performs an acute assessment and identifies the appropriate care needed. This may include EMS and transfer to an acute setting. Seek expert consultation by a provider if needed".

Documentation in Patient #1's medical record stated he/she was seen three (3) times (6/6/2021, 6/13/2021, and 7/23/2021) in an outpatient clinic/office setting. At each of these visits, the patient had expressed suicidal ideations.

On 7/23/2021, the patient presented at another hospital's ED and remained at this hospital until 7/26/2021. During this time, the patient had expressed suicidal ideations; was "blue papered" which means that the patient had expressed plans to harm self or others and must remain at the hospital involuntarily; and, on 7/26/2021, was reassessed and was determined he/she was no longer a threat to himself/herself and was safe to be discharged home.

On 7/30/2021, the patient was seen in the outpatient office and documentation stated "Seen in ED at [other hospital] after I saw [him/her] last week, suicidal, there for 3 (three) days, seen by crisis, feeling alright now, already under the care of [a psychiatrist], seeing [him/her] again 8/30/2021..."

Documentation in Patient #1's medical record contained an email, dated 8/2/2021 at 9:58 AM, between Patient Service Representative ("PSR") #2 and RN #3. The email stated, in part: "I called the patient to schedule [him/her] an appointment...and I offered Thursday 8/12 and [he/she] said, "If I have to make it that long, I am considering suicide and ending it all". I asked if [he/she] had a plan and [he/she] said, "Yes, I have a big knife and slit my throat"...I transferred call to RN #3".

Documentation in Patient #1's medical record contained an email, dated 8/2/2021 at 9:58 AM, between RN #3 and the Co-President of the Medical Group, who is Patient #1's Primary Care Physician. In part, the email stated the following: "I spoke with [Patient #1] this morning as [he/she] expressed suicidal ideation thoughts when scheduling [his/her] appointment...Sleep is [his/her] biggest concern at this time...[He/She] expressed thoughts of suicidal ideation with a knife...did not reiterate those to me, but did say [he/she] felt [he/she] could not take things much longer with the lack of sleep".

On 8/3/2021 at approximately 9:30 AM, Patient #1 presented to his/her Primary Care Physician's office. According to an interview with PSR #1 on 10/7/2021 at 9:57 AM, the patient stated, on 8/3/2021, "I need to talk to a doctor because I attempted suicide by cutting my wrist". I asked the other check in lady to check on [him/her] while I went to check with [PA #1] and pulled him out of a patient visit. [PA #1] stated he didn't have the availability right then and maybe we could call crisis...I went to RN #1 and RN #2...they got [him/her] on the schedule for 3:15 PM that day. I explained this to [him/her] and [he/she] had already called Crisis and they suggested going to the ED but [he/she] declined. At that point, [he/she] stated, "If I had a gun, I would shoot myself with it". Again, I went back to [PA #1] and explained what was just said...he said, "Well, [he/she] is on the schedule for 3:15 PM and we will see [him/her] then".

On 8/3/2021 at 9:56 AM, PSR #1 sent an email to the Co-President of the Medical Group and PA #1. The email stated, "Patient showed up today...When patient went to sit down - [he/she] grabbed the inside of my counter top - I touched [his/hers] hands and they were ice cold. Patient states [he/she] attempted suicide (there was a bandage on [his/her] wrist) - stated that if I had a gun I would have shot myself with it..."

On 8/3/2021 at 3:15 PM, Patient #1 returned to the Primary Care Physician's office for the appointment with PA #1. There was no evidence in the patient's medical record that PA #1 discussed and assessed the patient's suicidal ideation or that a physical exam was completed to assess Patient #1's bandaged wrist before the patient left the office.

On 8/4/2021 at approximately 11:50 AM, Patient #1 arrived at this hospital's ED, via ambulance, with a self-inflicted gunshot wound to the head. He/She was assessed, treated, and then transported at 1:04 PM, via air transportation, to another hospital. The air ambulance's RN documented that the patient had a "deep horizontal laceration noted to left wrist with bandage applied".

On 8/11/2021, Patient #1 died as a result of his/her self-inflicted injury.

On 10/6/2021 at 1:59 PM, a phone interview was conducted with PA #1 regarding the care of Patient #1 on 8/3/2021. He stated the following:
- "I was pulled out of a visit to see if we could see [him/her], [PSR #1] explained that [he/she] was at the window, having suicidal ideation and feels like [he/she] needs to be seen. My recommendation is something that would require an elevated level of care and they should be seen by crisis or go to the ED...so I told [PSR #1] to offer that information. [He/She] was the major reason they came back to get me...[Patient #1] wanted to be seen immediately. They were not able to convince [Patient #1] to go to crisis or ED...but agreed to end of day with me";
- In relation to the 3:15 PM visit: "Based on my history of working with [Patient #1], [he/she] appeared manic, appeared to be at baseline mania in that it was not out of the abnormal. I asked [Patient#1] about suicidal ideation...he did report that he was having significant suicidal ideation but did not have a plan. I did not examine his body because he was agitated due to a delay in being seen. I did a general assessment but not a physical assessment. There were no bandages noted from general examination. No, I was not aware of the information regarding suicidal ideation...no details provided by [PSR #1]. Suicidal ideation is very common for this individual and previously, we have sent to the ED. I don't recall at any point that the suicidal ideation had any form or plan"; and
- When asked about screening patients with suicidal ideation: "Suicidal ideation would need to be presented with intent and have the patient quantify the suicidal ideation. I would ask them how likely or not likely are they to act on that. I would ask them, on a scale of 1-10, where do you feel you are at? I did not ask that this time around. I tried to loop around and ask but due to [his/her] agitation and demeanor I was not able to ask that. After I reviewed the plan again...[his/her] mood and agitation had lifted, I was under the assessment that [he/she] was doing really good. I had very little to no concerns. I never looped back to ask about [his/her] mood".

On 10/7/2021 at 9:57 AM, a phone interview was conducted with PSR #1 regarding Patient #1. She stated "... Later that day, I checked [Patient #1] in at 3:15 PM. [Patient #1] still had bandages on and were visible...bandages were definitely on the left wrist...".

On 10/7/2021 at 11:34 AM, a phone interview was again conducted with PA #1. He stated, "I was aware of [Patient #1's] suicidal ideation but not aware of the plan. I only recall her [meaning PSR #1] coming back once. There may have been two (2)knocks, but there was communication only once".

On 10/8/2021 at 8:09 AM, an interview with RN #2 was conducted. She confirmed that PSR #1 came to her on the morning of 8/3/2021 in relation to Patient #1's suicidal ideation and she did not see the patient to conduct an assessment. She stated, "Correct, there is a requirement for an assessment, and it did not happen that day".

On 10/12/2021 at 2:35 PM, an interview was conducted with the Co-President of the Medical Group. After reviewing the medical record for Patient #1, he stated, "There are some pretty major documentation issues. I was a bit shocked that the patient was allowed to leave (in the morning with suicidal ideation)...and that the suicidal intent was not addressed at the appointment (with PA #1)".

On 10/14/2021 at 10:04 AM, the President of Northern Light Inland Hospital was interviewed. She confirmed the patient arrived at an office seeking help for suicidal ideation and attempted suicide, was not evaluated per hospital policy, and was not evaluated for suicidal ideation at 3:15 PM on 8/3/2021 with the Provider.

Based on the above, Patient #1 presented on the morning of 8/3/2021 with a bandage on his/her left wrist as a result of intentionally cutting his/her wrist, expressed suicidal ideations with a plan, the PSR interrupted the PA who did not assess the patient, the PSR contacted RNs who did not assess the patient, and the patient was given an appointment to return later that day at 3:15 PM. The hospital failed to follow their own policy and failed to provide services to this patient when he/she presented with suicidal ideations on the morning of 8/3/2021. Upon return at 3:15 PM, the patient was seen by the PA; however, there was no evidence in the patient's record that the PA assessed the patient's suicidal ideations and suicide intent. The patient shot himself/herself the next day and died seven (7) days later. The hospital's failure to provide services in this outpatient setting constituted an immediate jeopardy situation.

Please see A-0000 Initial Comments for details related to the IJ template, removal plan, and abatement of the IJ.

The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.