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Based upon record review and interview, the facility failed to provide a psychiatric evaluation for 3 of 4 patients (P-2, P-8, P-9) presenting to the Emergency Department (ED) with suicidal ideation resulting in the potential for poor outcomes including death. Findings include:

See A-1104 - Failure to follow emergency service policies.

Based on record review and interview, the facility failed to follow policy and provide a psychiatric evaluation by CMH (Community Mental Health) for 3 of 4 patients (P-2, P-8, P-9) reviewed for presentation to the Emergency Department (ED) with suicidal ideation, resulting in the potential for poor outcomes including death. Findings include:

P-2: On 6/27/2024 at 1400 document review was conducted of P-2's medical record. P-2 was described as, "Patient is a 23-year-old female with a past medical history significant for chronic nausea/vomiting, bipolar disorder, lupus, and RA (rhematoid arthritis) who presents to the emergency department with a chief complaint of shortness of breath... "Pt (P-2) was at a f/u (follow-up) appointment at (facility) and ended up making suicidal statements. Pt is currently not having suicidal thoughts. Is just frustrated. C/O (complains of) pain where pt had a chest tube placed." P-2 arrived at the ED via ambulance on 6/4/2024 at 1239. Documentation by staff K included, "Today, she was seen her psychiatry NP (Nurse Practitioner). She was expressing to her nurse petitioner that she had worsening suicidal thoughts due to her ongoing shortness of breath and frustration."

On 6/27/2024 at 1100 an interview was conducted with staff K, ED Physician. Staff K was queried if he knew P-2 had presented to the ED with an existing petition. Staff K stated he was aware of the petition for P-2, but ED staff were unable to find the petition for P-2. Staff K was asked if a petition would have been sufficient for P-2 to stay under suicidal precautions. Staff K stated, "Yes, but I was under the impression that her medical status would have kept her and provided time to observe (P-2) for suicidal ideations ... I had no idea that the internal medicine group was not going to admit." Staff K was then queried if any staff member made an attempt to re-petition the patient or reached out to the EMS (Emergency Medical Services) squad to inquire about the petition. Staff K stated he did not know if any staff member had tried to obtain the petition.

On 6/27/2024 an interview was conducted with staff N, ED physician. Staff N was asked about his role in the care of P-2. Staff N stated that he had received report from staff K at the change of shift. Staff N was queried if he knew P-2 was brought to the facility as a petitioned patient. Staff N stated that he was aware of the patient being there as part of a petition, but the petition was not presented with the patient. Staff N was asked what the plan was when he received report from staff K. Staff N stated that staff K had ordered the patient (P-2) to be evaluated by the Internal Medicine hospitalist. Staff N stated that staff K had planned that P-2 would be admitted for low oxygenation levels. Staff N stated that staff K had stated he did not feel that the patient (P-2) was truly suicidal but depressed because of ongoing complex medical issues. Staff N stated that after the Internal Medicine hospitalist team did not feel that the patient (P-2) met the need for hospitalization that he had to tell the patient that she would be discharged home. Staff N stated that P-2 became irrational and irate. Staff N stated, "F bombs were flying from the patient's mouth ...she was irrational." Staff N was asked if the behavior would have elicited a psychiatric evaluation. Staff N stated the patient was not approachable after she found out that she would not be admitted and discharged home.

On 6/27/2024 the Patient Experience Advocate provided a copy of the grievance filed with the facility by P-2. The grievance had been filed on 6/18/2024. Documentation included in the grievance stated that she (P-2) should have been certified because a petition existed, and she was suicidal on 6/4/2024.

On 6/27/2024 an interview was conducted with Staff J, the Medical Director of the ED. Staff J was queried if the original petition had not accompanied the patient (P-2) was it possible that another petition could be initiated in lieu of the original petition. Staff J stated, "yes." Staff J stated she had spoken with staff K and questioned what had taken place. Staff J stated that staff K had assessed the patient and felt the patient was not suicidal but depressed because of her physical illnesses. Staff J further stated staff K felt the patient would be admitted for low oxygenation levels. Staff J was queried if a patient is known to have presented to the ED related to being petitioned what is the procedure for physicians. Staff J stated that all patients presenting with petition are evaluated by the community mental health (CMH) employees for a psychological evaluation. Staff J was queried if P-2 had a psychological evaluation. Staff J stated, "No."

Documentation in P-2 medical record failed to have documentation of a psychiatric evaluation by Community Mental Health (CMH). Staff C, the Director of Patient Care Services confirmed the lack of a psychiatric evaluation.

P-8: On 6/27/2024 during record review of P-8 medical record it was revealed that P-8 presented to the ED for suicidal ideation. P-8 presented to the facility ED on 4/17/2024 at 1308 with the chief complaint of, "Pt (patient, P-8) states that he wants to end his life. Pt states that his plan is to either shoot himself or to jump off a building." P-8 was triaged and assigned an ESI number 2 - emergent. P-8 diagnosis was documented as "Suicidal Ideation." P-8 CSSR (Columbia Suicide Severity Rating - a screening scale assessment tool that evaluates suicidal ideation and behavior) screened risk was documented as, "high risk." According to documentation P-8 Columbia Suicide Severity responses to screening were as follows, "Past Month Wish to be Dead - Yes, Past Month Suicidal Thoughts - Yes, Past Month Ideation with Method No Intent - Yes, Patient Month with Intent No Plan - Yes, Past Month with Intent and Plan - Yes, Columbia Screen Suicide Behavior - Yes, CSSRS Screen Suicide Behavior Timeline - Within the last 3 Months."

Further document review of P-8 medical record included the review of patient history documented by the ED physician, staff U revealed, "The patient is a 28-year-old male, past medical history significant for PTSD (post-traumatic stress disorder), anxiety, depression, presents to the ED for evaluation of suicidal ideation. He states that he has had difficulty with addiction and meth use. He has been in and out of rehabs and has had some relapses. He just left rehab 2 days ago and states that he left because he was being mistreated due to the fact he is gay. That has happened at other facilities as well and has caused him to leave other facilities. He has been having suicidal thoughts now for the past 4 days. He says that he has attempted to hurt himself in the past and feels that he may act on his feelings today and that has him concerned. He does have some low back pain and a headache. He denies any fever, chills, chest pain or SOB (shortness of breath). Further ROS (review of systems) unremarkable ... Physical exam is as documented otherwise. Will order medical screening labs. Pet/cert will likely be necessary given suicidal ideation with a plan and prior attempts. Past medical history significantly affecting the patient's presenting condition: PTSD, anxiety, depression"

P-8 was placed on "suicide precautions" on 4/17/2024 at 1311.

P-8 medical record included under the subtitle, "Management, re-evaluation and ED course," ED Physician staff U documented, "The patient was re-evaluated and is clinically stable. He denies any further suicidal ideation. He states that he was just having a hard time facing having to go to a shelter, return to rehab in a few days and upcoming court cases. He is displaying good insight. He states that he wants to continue to live and take care of all the things that he needs to take care of. He agrees to follow up with CMH (Community Mental Health) and return to the ED if he begins to have thoughts of self-harm. Will provide resources for outpatient psychiatric follow up." P-8 documented disposition was documented as, "Safe for discharge home to follow up with the PCP (primary care provider) in the next 5-7 days. The patient was informed of reasons to return to the ED. Vitals stable." The patient (P-8) received patient education for "Suicidal Feelings: How to Help Yourself" and "Managing Depression, Adult," prior to discharge. P-8 also received contact information for CMH (Community Mental Health). P-8 was discharged from the facility on 4/17/2024 at 1837.

Documentation in P-8 medical record failed to have documentation of a psychiatric evaluation by CMH. Staff C, the Director of Patient Care Services confirmed the lack of a psychiatric evaluation.

P-9: On 6/27/2024 during record review of P-9 medical record it was revealed P-9 presented to the ED on 5/5/2024 at 0717. Documentation included the diagnosis of "suicidal ideation." P-9 was assigned an ESI number of 4 - semi-urgent. P-9 CSSRS screen was as follows: "Past Month Wish to be Dead - Yes, Past Month Suicidal Thoughts - No, Columbia Screen Suicide Behavior - No, CSSRS Screened Risk: Low Risk. According to the History of Present Illness the following was documented, "The patient is a 25-year-old with history of developmental delay who presented with suicidal ideation. The patient states that she has had a new AFC (adult foster care) home for the past month. She states that since she has been at the AFC home, she has not been allowed to eat what she wants. The patient endorses suicidal ideation, but she denies any plan. The patient states that she is depressed as she does not like her AFC home. She states that she was evicted from her other AFC home."

Documentation on 5/5/2024 in the medical record by staff V, ED physician continued, "On presentation in the emergency department, the patient's vitals were notable for the patient being afebrile, normotensive and saturating well on room air. Physical exam was remarkable for endorsement of suicidal ideation. She denies any plan to harm herself. She states that if she is discharged she will not harm herself. She denies any homicidal ideation. She denies any hallucinations. She states that she would like to be moved to a new group home and is requesting to talk with CMH. CMH was not present in the emergency department at the time of presentation but will be here in a couple of hours. The patient states that she will wait to speak with them further. No workup is indicated as the patient denies any plan to harm herself. The patient was provided with food...On re-evaluation, the patient was hemodynamically stable. She states that she no longer wishes to wait to speak with CMH. She wishes to be discharged back to her group home. She denies any suicidal ideation at this time. Return precautions were discussed with the patient, who voiced understanding. The patient was advised to follow-up with their primary care provider and mental health provider. All questions were answered. The patient was discharged home."

Documentation in P-9 medical record failed to have documentation of a psychiatric evaluation by CMH. Staff C, the Director of Patient Care Services confirmed the lack of a psychiatric evaluation.

On 6/27/2024 document review of the policy titled, , "Admission of Involuntary Patients," policy number BH 105, revision date 10/23. Under the subtitle, "2.3. Petition," it states, "2.3.1. A petition may be filed by any person 18 years of age or older and is filed with the court which asserts that an individual is a person requiring treatment as defined in the criteria listed below. A petition is filed when the person is not in the custody of the hospital." Further review of the policy states under the subtitle, "2.4. Procedure for petition as follows: 2.4.1. When the petition is filed with the Probate Court it should be accompanied by the certificate of physician unless after reasonable effort the patient could not be secured for examination. If no certificate accompanies the petition, an affidavit setting forth the reasons an examination could not be secured should also be filed with the court."