HospitalInspections.org

Based on record review and interview the facility failed to follow policy to assure a safe environment at discharge for 1 of 1 patients discharged to home with a high suicide risk rating in a total of 10 medical records reviewed.

Findings include:

Review of the facility policy titled, "Suicide/Self Harm Precautions for Acute Care (System)" #14400249 dated 09/2023 revealed, "Policy: Patients presenting for behavioral or mental health issue will be screened with the C-SSRS (Columbia-Suicide Severity Rating Scale assesses severity and intensity of suicidal ideation) Screener for ages 18 and greater. The RSQ-4 (Risk of Suicide Questionnaire - a brief 4-item screening tool tool used for ages 12 up to age 18)...A positive answer on the RSQ-4 tool will be considered a high-risk screen. High risk patients will have a Suicide Risk Assessment, i.e. SAFE-T (a five-step assessment that includes identification of risk and protective factors; conducting an inquiry about suicidality; determining level of risk and selecting an appropriate intervention; and documenting the process, including a follow-up plan) with C-SSRS completed by the physician or mental health professional. ED (Emergency Department) Procedure: During triage note in the EHR (electronic medical record) that the patient is being evaluated for behavioral or mental health issues. This will trigger the C-SSRS Screener or RSQ-4 Tool based on age...C. Disposition: Ensure the SAFE-T with C-SSRS is completed prior to discharge..."

Medical record review of Pt. (patient) #4 revealed a 15 year old admitted to the ED on 7/10/2023 with presenting complaint of "cutting on her legs and wanting to die". The record revealed a RSQ-4 was performed in triage with the result indicating high risk. Pt. was seen and evaluated by the provider who noted, "...he/she was medically screened from triage for suicidal ideations, worsening over the last few weeks...Did have a long discussion with mother, she feels safe taking the patient home and continue to monitor..." The pt was discharged to home with the mother at 5:33 PM.

There was no evidence in the medical record of a SAFE-T tool being completed.

In an interview with Quality Director F on 11/1/2023 at 1:50 PM, Director F confirmed that a SAFE-T had not been completed and stated, "According to our policy it should have been."