HospitalInspections.org

Based on interview and record review, the facility failed to maintain inpatient medical records for 10 out of 30 sampled patients (Patients 1, 2, 4, 5, 6, 7, 8, 9, 10, 12) when:

1. The 5150 (the reference number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled.) documentation was missing from the medical record of Patients 1, 2, 5, 6.

2. The suicide DRA (Suicide Detailed Risk Assessment, a psychiatric assessment tool) was missing from the medical record of Patients 1, 2, 4, 5, 6, 7, 8, 9, 10.

3. The choice letter form for a patient to elect an outpatient hospice service was missing from the medical record of Patient 12.

These failures resulted in incomplete patient medical records.

Findings:

1a. Review of Patient 1's medical record indicated she arrived to the emergency department on 12/3/23 at 1:27 PM and had diagnoses of depression and suicidal ideation (SI, suicidal thinking).

Review of Patient 1's physician's note dated 12/3/23 at 1406 (military time for 2:06 PM) indicated, "Patient requested psych eval (psychiatric evaluation) [4] depression, SI (suicidal ideation), hopelessness.

Review of a physician's note dated 12/3/23 at 1830 (military time for 6:30 PM) indicated Patient 1, " ... met criteria for a 5150 hold."

Review of a nurse's note dated 12/4/23 at 0030 (military time for 12:30 AM) indicated, "Patient placed on a 5150 hold ... "

During an interview and concurrent record review on 9/27/24 at 3:17 PM with the Accreditation and Regulatory Manager (ARM), she confirmed a 5150 form needs to be filled out prior to putting a patient on a 5150 hold, but there was no 5150 form filled out in the clinical record for Patient 1 because the process was missed.

1b. Review of Patient 2's medical record indicated she was brought from home and placed on a 5150 hold by police prior to her emergency department arrival on 2/12/24 at 8:55 PM. She had diagnoses of depression, suicidal behavior, deliberate self cutting with forearm and wrist lacerations (cuts).

During an interview and concurrent record review on 9/30/24 at 1:30 PM with the Emergency Department Director (EDD), she confirmed there was no 5150 form in Patient 2's medical record, and there should have been.

1c. Review of Patient 5's medical record indicated she was placed on a 5150 hold by a school psychologist and arrived at the emergency department on 4/30/24 at 6:24 PM with a diagnosis of intentional self-harm by razor blade.

During an interview and concurrent record review on 10/1/24 at 11:19 AM with the ARM, she confirmed there was no 5150 form in Patient 5's medical record, and there should have been.

1d. Review of Patient 6's medical record indicated he arrived at the emergency department on 5/5/24 at 1:58 PM with diagnoses of major depression and suicidal ideation. Patient 6 was placed on a 5150 hold for danger to self and others.

During an interview and concurrent record review on 10/1/24 at 11:55 AM with the ARM, she confirmed there was no 5150 form in Patient 6's medical record, and there should have been.

2a. Review of Patient 1's physician's note dated 12/3/23 at 1406 (military time for 2:06 PM) indicated, "Patient requested psych eval (psychiatric evaluation) [4] depression, SI (suicidal ideation), hopelessness.

Review of a physician's note dated 12/3/23 at 1830 (military time for 6:30 PM) indicated Patient 1, " ... met criteria for a 5150 hold."

During an interview and concurrent record review on 9/27/24 at 2:45 PM with the ARM, she stated the suicide DRA was not filled out in the medical record for Patient 1, and should have been.

2b. Review of Patient 2's medical record indicated she was brought from home and placed on a 5150 hold by police prior to her emergency department arrival on 2/12/24 at 8:55 PM. She had diagnoses of depression, suicidal behavior, deliberate self cutting with forearm and wrist lacerations (cuts).

During an interview and concurrent record review on 10/1/24 at 10:10 AM with the ARM, she confirmed there was no suicide DRA form filled out in Patient 2's medical record, and there should have been.

2c. Review of Patient 4's medical record indicated he arrived at the emergency department on 4/13/24 at 7:59 PM with diagnoses of self injurious behavior, wrist laceration.

During an interview and concurrent record review on 10/1/24 at 10:50 AM with the ARM, she confirmed there was no suicide DRA form filled out in Patient 4's medical record, and there should have been.

2d. Review of Patient 5's medical record indicated she was placed on a 5150 hold by a school psychologist and arrived at the emergency department on 4/30/24 at 6:24 PM with diagnoses of intentional self-harm by razor blade.

During an interview and concurrent record review on 10/1/24 at 11:19 AM with the ARM, she confirmed there was no suicide DRA form filled out in Patient 5's medical record, and there should have been.

2e. Review of Patient 6's medical record indicated he arrived at the emergency department on 5/5/24 at 1:58 PM with diagnoses of major depression and suicidal ideation. Patient 6 was placed on a 5150 hold for danger to self and others.

During an interview and concurrent record review on 10/1/24 at 11:55 AM with the ARM, she confirmed there was no suicide DRA form filled out in Patient 6's medical record, and there should have been.

2f. Review of Patient 7's medical record indicated she arrived at the emergency department on 5/8/24 at 2:45 PM with diagnoses of depression and suicidal ideation. Patient 6 was placed on a 5150 hold.

During an interview and concurrent record review on 10/1/24 at 2:30 PM with the ARM, she confirmed there was no suicide DRA form filled out in Patient 7's medical record, and there should have been.

2f. Review of Patient 8's medical record indicated he arrived at the emergency department on 5/10/24 at 2:15 PM with a diagnosis of suicidal ideation. Patient was placed on a 5150 hold.

During an interview and concurrent record review on 10/1/24 at 1:55 PM with the ARM, she confirmed there was no suicide DRA form filled out in Patient 8's medical record, and there should have been.

2g. Review of Patient 9's medical record indicated he arrived at the emergency department on 5/16/24 at 3:22 PM with diagnoses of suicidal ideation, homicidal ideation, self-harming behavior. Patient was placed on a 5150 hold.

During an interview and concurrent record review on 10/1/24 at 2:13 PM with the ARM, she confirmed there was no suicide DRA form filled out in Patient 9's medical record, and there should have been.

2h. Review of Patient 10's medical record indicated he arrived at the emergency department on 5/18/24 at 11:27 PM with a diagnosis of self-harm and "wanted to kill self."

During an interview and concurrent record review on 10/1/24 at 2:19 PM with the ARM, she confirmed there was no suicide DRA form filled out in Patient 10's medical record, and there should have been.

3a. Review of Patient 12's medical record indicated he arrived to the emergency department on 9/5/24 with a diagnoses of shortness of breath, acute respiratory failure, pneumonia, acute exacerbation of chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease.

During an interview and record review on 10/2/2022 at 1:15 PM with the director of case management (DCM), she stated Patient 12 had an inpatient hospice consent in place; however, the medical record lacked a "choice letter" for the patient to elect an outpatient hospice service. The DCM stated there should have been follow-up by case management to have the choice letter filled out, since it was part of case management's process with filling out hospice paperwork to have the choice letter completed.

During an interview and concurrent record review on 10/2/24 at 1:42 PM with the ARM, she confirmed Patient 12's medical record lacked a "choice letter" for the patient to elect an outpatient hospice service.and confirmed it was part of case management's process with filling out hospice paperwork to have the choice letter filled out and signed [by the patient and/or the patient's representative].

A review of the revised 03/23 hospital's policy and procedure, "Suicide Risk Assessment and Management for Non-Behavioral Health Settings", indicated, "Ensure that patients age six (6) to eleven (11) years ..... and all patients twelve (12) years and older are assessed for risk of suicide with appropriate suicide precautions implemented as indicated.

Columbia Suicide Severity Rating Scale (C-SSRS): Initial screening tool utilized by the nurse. It will provide an auto-calculated level of no risk, low, moderate, or high risk.

Suicide Detailed Risk Assessment (suicide DRA): Subsequent assessment completed by the Provided/Practitioner. The suicide
DRA must be completed for any patient with a positive C-SSRS screen.

Overall Risk Level (ORL): Determined by the provider/practitioner's clinical judgment and suicide DRA. The provider/practitioner will assign a level of no risk, low, moderate, or high risk. This will take precedence over the C-SSRS, if the risk level differs.

Any patient with a positive, "at risk" C-SSRS screening (low, moderate or high risk) require a secondary level suicide DRA to identify activating events, protective factors, and contributing clinical factors to risk of suicide. This should be completed by a licensed or credentialed physician/practitioner/Qualified Mental Health Practitioner (QMHP).
The Provider/Practitioner will use the information collected from the suicide DRA paired with clinical judgement to determine (estimate) the patient's ORL.

A review of the 3/10 hospital's policy on, "Psychiatric Hold Policy", indicated, ... The person initiating the hold must fil out, sign and date the 5150 and/or the 1799.11 form. A front and back photocopy of the 5150 form will be retained for the medical record.