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Based on observation, interview and record review the facility failed to ensure patients presenting to the ED with a suicidal risk received appropriate psychological screening, proper suicidal evaluation, and stabilizing treatment prior to discharge. This deficient practice was found in 1 of 31 sampled patients (Patient #10).

This deficient practice had the likelihood to cause harm in all patients presenting to the ED with psychological complications.

Refer to Tag A-2406, Tag A2407

Based upon record review and interview, the facility failed to provide adequate medical/psychological screening and suicidal evaluation/care. Patient was actively suicidal and was discharged to receive outpatient mental health services. This deficient practice was found in 1 of 1 sampled patients (Patient #10).

This deficient practice had the likelihood to cause harm in all patients presenting to the ED with psychological complications.




Findings include:

During an observation on 10/27/2014, after 11:30 a.m., the facility was noted to have a room called the "safe room" designated for psych patients. The room was monitored by a camera and was over a distance of 20 feet from the nursing station. The room had 2 beds, 1 chair, and 1 over bed table. Staff # 4 confirmed the room was for psych patients. The monitor for the room was at the nurses station.

Review of a nursing triage report revealed Patient #10 was a 57 year old male, who presented to the Emergency Department (ED) at 12:38 a.m. and was triaged at 12:39 a.m. Patient #10 was assessed to have an Acuity level 2 (meaning had an emergency medical condition, would be evaluated and treated in the ED by the ED physician). Review of the report revealed Patient #10 had multiple cuts and lacerations. Patient #10 was hallucinating and jumped through a window after running through the house with a machetti. The nursing triage assessment revealed the patient had an elevated blood pressure of 173/133, pain level of 10 (highest level of pain) and was classified as not being at risk for suicide.

Review of the ED suicide screen on Patient #10 revealed the following list the staff could selection from:

No positive triggers; Self-inflicted injuries present; Current suicidal/homicidal ideation; Current lethal plan; Recent suicidal/homicidal action; Current rumination; Past history of suicidal/homicidal attempts and Other.

Patient #10 had some of these triggers listed, but nursing failed to select them. With the assessment being inaccurate there was no trigger to initiate suicide precautions.

At 12:49 a.m., Patient #10 was documented as having a large laceration to the left forearm, moderate bleeding noted, laceration to 5th finger right hand, substantial bleeding; small lacerations to back of head and base of the neck minimal bleeding noted; evulsion noted to the right hand and the 4th finger on the right hand. Pressure dressing applied to laceration on the 5th finger; dressing applied to laceration on left forearm.

At 12:52 a.m., there was documentation that Patient #10 had diagnoses of hypertension, prostrate problems, anxiety disorders, bipolar disorder and alcohol abuse. At 12:53 a.m. there was documentation of a continued blood pressure elevation of 173/133.

Review of a physician procedural sheet (without a time or date) revealed Patient #10 sustained injuries to the back of his head, back of neck, left forearm, and two on the left hand. The injuries required sutures and staples.

At 4:00 a.m., Patient #10 was calm, flat affect and was unable to explain why or what caused him to have hallucinations that caused him to jump through a window trying to escape a man with a machine gun.

Review of the record revealed no continued assessment of the elevated blood pressure nor the pain level. There was no documentation of any interventions implemented to address and stabilize the blood pressure and pain level. There was no documentation of Patient #10 being put in the safe room and being placed on suicide precautions. There was no documentation of what intervention was implemented to stabilize the psychological problems.

Review of a physician emergency department record (without a time or date) revealed discharge orders which included to follow-up with MHMR. The diagnoses given on discharge were multiple lacerations (closed) and hallucinations resolved. This was documented by Staff #7 (ED physician).

At 7:30 a.m., discharge instructions were reviewed with the patient's sister.

Review of the files revealed Patient #10 returned to the ED at approximately 4 hours after being discharged.

Review of a nursing triage report revealed Patient # 10 was presented at the ED at 12:39 p.m. and was triaged at 12:49 p.m.. Patient #10 was put in the safe room. According to documentation he was there for medical clearance for a psych facility. Family states they were sent there by MHMR. States the patient was hearing voices, nervous, could not rest, and felt uneasy. States he didn't feel things were safe for himself or his family. His blood pressure was documented as being elevated at 156/101.

Review of a "Physician Emergency Department Form" dated 07/25/2014 at 1:05 p.m. revealed the patient was "feeling unsafe." The patient returned to the ED this afternoon after being seen this am for paranoid behavior. Released with family, returns now for continued paranoid and auditory hallucinations. Family member reports patient is unsafe. According to the form Patient #10 was being given diagnoses of paranoia and acute psychotic break for this visit. At 1:50 p.m. he was medically cleared for mental health.

Review of a nursing "Ambulatory Assessment/History Report" dated 07/25/2014 at 7:00 p.m.(almost 6 hours after presenting to the ED) revealed a suicide assessment by nursing on Patient #10. There was documentation he had no positive triggers on the suicide homicide lethality risk screening and family violence screen. Nursing completed the screen incorrectly. The safety measure implemented was being put into the safe room. There was no documentation of what the suicide precautions entailed or what type of monitoring he required.

During a confidential interview it was reported the safe room was not being closely monitored. While at the hospital the second time Patient #10 jumped from a chair and tried to kill himself.

Review of the record revealed documentation that report was called to a psych behaviorial unit at 9:15 p.m. and Patient #10 was discharged.

Review of the record from the psych unit revealed patient #10 was admitted there and about 5:30 a.m. (07/26/2014) Patient #10 attempted suicide by strangulation and ended up in an intensive care unit.

During an interview on 10/27/2014, after 2:00 p.m., Staff #4 reported confirmed the suicide assessments were inaccurate . There was no documented monitoring of patients placed in the safe room and no physician directive on suicide precautions. On 10/28/2014, Staff #4 reported that they kept Patient #10 the first time in the ED for an extended period until the next morning so he could go over to MHMR for a psych screening. They were having problems getting the patients screening by MHMR. Staff #4 reported they do not get physician orders for suicide precautions.

During an interview on 10/28/2014, at 9:45 a.m., Staff #6 reported remembering Patient #10. Staff #6 reported with the patient jumping through the window and causing harm to himself, this should have triggered a suicide risk and then precautions. They had no certain format for documenting monitoring and she tried to check patients as often as she could. When she had to go and check on other ED patients there was no one designated to watch the monitor.

During an interview on 10/28/2014, at 9:55 a.m., Staff #5 reported the psych patients received a screening by MHMR depending on what their payment source was. The nurses have to call around and find a private hospital to take the patients if they have insurance coverage. They have problems getting the psych patients assessed by MHMR. If the patient talks a good story the ED physicians lets them go home. Staff #5 reported he monitored his patients at least30 minutes to an hour. He was not sure if there was a policy telling them how often. When he had to leave and take care of other ED patients there was no one designated to watch the monitor. There were no suicide precaution orders.

During an interview on 10/29/2014, after 7:00 a.m., Staff #7 (ED physician) reported that he had no psych experience or training. He also knew about the problems with MHMR, but he continued to make patient referrals to them. MD #7 reported the nursing staff were suppose to perform the suicide risk assessments. He reported that they did not write orders for suicide precautions and did not provide any directive as far as monitoring by nursing staff.


Review of a facility policy named "Suicide Risk Screening, Assessment and Precautions" dated 10/2012 revealed the following:

1. Patient Safety :(Hospital name) will make every reasonable effort to provide a safe environment for patients who have expressed suicidal ideation or made a suicide attempt.

2. Screening: Screening for suicide risk will occur as follows and as appropriate to the setting and patient type:

b. Emergency Department- If a patient presents with a psychiatric, emotional or behavioral diagnosis/complaint(including self injury or overdose) the patient will be screened for suicide risk ....

3. a. If the suicide risk screening is positive, appropriate, trained personnel will conduct a comprehensive suicide assessment.

4. Notifications

a. A nurse may implement suicide precautions without a physician's order.

b. If the nurse implements suicide precautions without a physician's order the physician shall be immediately notified of potential suicidal symptoms exhibited by the patient. The nurse will obtain an order from the physician if appropriate at the time of this communication and will document in the medical record.

5. Transfer to another Facility:

a. If, after appropriate assessments are completed by trained personnel, a decision is made to transfer the patient will be transferred to an appropriate psychiatric facility when medically stabilized following all state and federal guidelines for transfer and based upon bed availability.


Procedure

1. ED Process

a. If a patient with a psychiatric, emotional, or behavioral diagnosis/complaint (including self injury or overdose) the nurse will complete the Suicide Risk Screening.

b. If the suicide risk screening is positive, the nurse will notify the physician who may complete a rapid medical assessment.

c. The patient will be placed on Suicide Precautions if the screen is positive or as needed.

d. The nurse may place the patient on suicide precautions prior to obtaining the medical screening or prior to the physician's order.

e. A mental health professional will complete a comprehensive suicide assessment if the suicide risk screening is positive.

f. The mental health professional will complete the assessment and will consult with the physician regarding the results and placement.

g. A patient may be detained to ensure immediate physical safety when less restrictive interventions have been determined to be ineffective to protect a patient or others from imminent harm. (Hospital's name) will initiate emergency detention proceedings as soon as possible .....

h. MHMR will be notified to complete an assessment when appropriate.

5. Suicide Precautions- The following interventions may be implemented when a patient is placed on Suicide Precautions:

a. General

1)Inform the patient his/she is being placed on Suicide Precautions.

2)If possible, place the patient in a room that allows for direct continuous observation by staff and/or ED rooms designated as safer rooms if possible or request a trained sitter for the room if possible and appropriate.

d. Monitoring:

1)Patients on Suicide Precautions shall be monitored at a level prescribed by the physician.

e. Documentation:

1)The nurse is responsible for documenting the initial Suicide Risk Screen initially and then as indicated.

2)Monitoring of the patient will be documented in the medical record at the level prescribed by the physician.

3) The nurse is responsible for documenting ongoing medical assessment/reassessment as medically indicated.

Based on observation, interview and record review, the facility failed to ensure patients presenting to the ED with a suicidal risk received appropriate psychologial screening and stabilizing treatment prior to discharge.

Patient #10 was actively suicidal and did not receive suicidal evaluation or care and was discharged to receive outpatient services. This deficient practice was found in 1 of 1 sampled patients (Patient #10).

This deficient practice had the likelihood to cause harm in all patients presenting to the ED with psychological complications.

Findings include:

During an observation on 10/27/2014, after 11:30 a.m., the facility was noted to have a room called the "safe room" designated for psych patients. The room was monitored by a camera and was over a distance of 20 feet from the nursing station. The room had 2 beds, 1 chair, and 1 over bed table. Staff # 4 confirmed the room was for psych patients. The monitor for the room was at the nurses station.

Review of a nursing triage report revealed Patient #10 was a 57 year old male who presented to the Emergency Department (ED) at 12:38 a.m. and was triaged at 12:39 a.m. Patient #10 was assessed to have an Acuity level 2 (meaning had an emergency medical condition, would be evaluated and treated in the ED by the ED physician). Review of the report revealed Patient #10 had multiple cuts and lacerations. Patient #10 was hallucinating and jumped through a window after running through the house with a machetti. The nursing triage assessment revealed the patient had an elevated blood pressure of 173/133, pain level of 10 (highest level of pain) and was classified as not being at a risk for suicide.

Review of the ED suicide screen on Patient #10 revealed the following list the staff could selection from:

No positive triggers; Self-inflicted injuries present; Current suicidal/homicidal ideation; Current lethal plan; Recent suicidal/homicidal action; Current rumination; Past history of suicidal/homicidal attempts and Other.

Patient #10 had some of these triggers listed, but nursing failed to select them. With the assessment being inaccurate there was no trigger to initiate suicide precautions.

At 12:49 a.m., Patient #10 was documented as having a large laceration to the left forearm, moderate bleeding noted, laceration to 5th finger right hand, substantial bleeding; small lacerations to back of head and base of the neck minimal bleeding noted; evulsion noted to the right hand and the 4th finger on the right hand. Pressure dressing applied to laceration on the 5th finger; dressing applied to laceration on left forearm.

At 12:52 a.m., there was documentation that Patient #10 had diagnoses of hypertension, prostrate problems, anxiety disorders, bipolar disorder and alcohol abuse. At 12:53 a.m. there was documentation of a continued blood pressure elevation of 173/133.

Review of a physician procedural sheet (without a time or date) revealed Patient #10 sustained injuries to the back of his head, back of neck, left forearm, and two on the left hand. The injuries required sutures and staples.

At 4:00 a.m., Patient #10 was calm, flat affect and was unable to explain why or what caused him to have hallucinations that caused him to jump through a window trying to escape a man with a machine gun.

Review of the record revealed no continued assessment of the elevated blood pressure nor the pain level. There was no documentation of any interventions implemented to address and stabilize the blood pressure and pain level. There was no documentation of Patient #10 being put in the safe room and being placed on suicide precautions. There was no documentation of what intervention was implemented to stabilize the psychological problems.

Review of a physician emergency department record (without a time or date) revealed discharge orders which included to follow-up with MHMR. The diagnoses given on discharge were multiple lacerations (closed) and hallucinations resolved. This was documented by Staff #7 (ED physician).

At 7:30 a.m., discharge instructions were reviewed with the patient's sister.

Review of the files revealed Patient #10 returned to the ED at approximately 4 hours after being discharged.

Review of a nursing triage report revealed Patient # 10 was presented at the ED at 12:39 p.m. and was triaged at 12:49 p.m.. Patient #10 was put in the safe room. According to documentation he was there for medical clearance for a psych facility. Family states they were sent there by MHMR. States the patient was hearing voices, nervous, could not rest, and felt uneasy. States he didn't feel things were safe for himself or his family. His blood pressure was documented as being elevated at 156/101.

Review of a "Physician Emergency Department Form" dated 07/25/2014, at 1:05 p.m. revealed the patient was "feeling unsafe." The patient returned to the ED this afternoon after being seen this am for paranoid behavior. Released with family, returns now for continued paranoid and auditory hallucinations. Family members reports patient is unsafe. According to the form Patient #10 was being given diagnoses of paranoia and acute psychotic break for this visit. At 1:50 p.m. he was medically cleared for mental health.

Review of a nursing "Ambulatory Assessment/History Report" dated 07/25/2014, at 7:00 p.m.(almost 6 hours after presenting to the ED) revealed a suicide assessment by nursing on Patient #10. There was documentation he had no positive triggers on the suicide homicide lethality risk screening and family violence screen. Nursing completed the screen incorrectly. The safety measure implemented was being put into the safe room. There was no documentation of what the suicide precautions entailed or what type of monitoring he required.

During a confidential interview it was reported the safe room was not being closely monitored. While at the hospital the second time Patient #10 jumped from a chair and tried to kill himself.

Review of the record revealed documentation that report was called to a psych behaviorial unit at 9:15 p.m. and Patient #10 was discharged.

Review of the record from the psych unit revealed patient #10 was admitted there and about 5:30 a.m. (07/26/2014) Patient #10 attempted suicide by strangulation and ended up in an intensive care unit.


During an interview on 10/27/2014, after 2:00 p.m., Staff #4 reported confirmed the suicide assessments were inaccurate . There was no documented monitoring of patients placed in the safe room and no physician directive on suicide precautions.

On 10/28/2014 Staff #4 reported they kept Patient #10 the first time in the ED for an extended period until the next morning so he could go over to MHMR for a psych screening. They were having problems getting the patients screening by MHMR. Staff #4 reported they do not get physician orders for suicide precautions.

During an interview on 10/28/2014, at 9:45 a.m., Staff #6 reported remembering Patient #10. Staff #6 reported with jumping through the window and causing harm to himself this should have triggered a suicide risk and then precautions. They had no certain format for documenting monitoring and she tried to check patients as often as she could. When she had to go and check on other ED patients there was no one designated to watch the monitor.

During an interview on 10/28/2014, at 9:55 a.m., Staff #5 reported the psych patients received a screening by MHMR depending on what their payment source was. The nurses have to call around and find a private hospital to take the patients if they have insurance coverage. They have problems getting the psych patients assessed by MHMR. If the patient talks a good story the ED physicians lets them go home. Staff #5 reported he monitored his patients at least30 minutes to an hour. He was not sure if there was a policy telling them how often. When he had to leave and take care of other ED patients there was no one designated to watch the monitor. There were no suicide precaution orders.

During an interview on 10/29/2014, after 7:00 a.m., Staff #7 (ED physician) reported he had no psych experience or training. He also knew about the problems with MHMR, but he continued to make patient referrals to them. MD #7 reported the nursing staff were suppose to perform the suicide risk assessments. He reported they did not write orders for suicide precautions and did not provide any directive as far as monitoring by nursing staff.


Review of a facility policy named "Suicide Risk Screening, Assessment and Precautions" dated 10/2012 revealed the following:

1. Patient Safety :(Hospital name) will make every reasonable effort to provide a safe environment for patients who have expressed suicidal ideation or made a suicide attempt.

2. Screening: Screening for suicide risk will occur as follows and as appropriate to the setting and patient type:

b. Emergency Department- If a patient presents with a psychiatric, emotional or behavioral diagnosis/complaint(including self injury or overdose) the patient will be screened for suicide risk ....

3. a. If the suicide risk screening is positive, appropriate, trained personnel will conduct a comprehensive suicide assessment.

4. Notifications

a. A nurse may implement suicide precautions without a physician's order.

b. If the nurse implements suicide precautions without a physician's order the physician shall be immediately notified of potential suicidal symptoms exhibited by the patient. The nurse will obtain an order from the physician if appropriate at the time of this communication and will document in the medical record.

5. Transfer to another Facility:

a. If, after appropriate assessments are completed by trained personnel, a decision is made to transfer the patient will be transferred to an appropriate psychiatric facility when medically stabilized following all state and federal guidelines for transfer and based upon bed availability.


Procedure

1. ED Process

a. If a patient with a psychiatric, emotional, or behavioral diagnosis/complaint (including self injury or overdose) the nurse will complete the Suicide Risk Screening.

b. If the suicide risk screening is positive, the nurse will notify the physician who may complete a rapid medical assessment.

c. The patient will be placed on Suicide Precautions if the screen is positive or as needed.

d. The nurse may place the patient on suicide precautions prior to obtaining the medical screening or prior to the physician's order.

e. A mental health professional will complete a comprehensive suicide assessment if the suicide risk screening is positive.

f. The mental health professional will complete the assessment and will consult with the physician regarding the results and placement.

g. A patient may be detained to ensure immediate physical safety when less restrictive interventions have been determined to be ineffective to protect a patient or others from imminent harm. (Hospital's name) will initiate emergency detention proceedings as soon as possible .....

h. MHMR will be notified to complete an assessment when appropriate.

5. Suicide Precautions- The following interventions may be implemented when a patient is placed on Suicide Precautions:

a. General

1)Inform the patient his/she is being placed on Suicide Precautions.

2)If possible, place the patient in a room that allows for direct continuous observation by staff and/or ED rooms designated as safer rooms if possible or request a trained sitter for the room if possible and appropriate.


d. Monitoring:

1)Patients on Suicide Precautions shall be monitored at a level prescribed by the physician.

e. Documentation:

1)The nurse is responsible for documenting the initial Suicide Risk Screen initially and then as indicated.

2)Monitoring of the patient will be documented in the medical record at the level prescribed by the physician.

3) The nurse is responsible for documenting ongoing medical assessment/reassessment as medically indicated.