HospitalInspections.org

This CONDITION is not met as evidenced by:

Based on observations, video review, medical record review, policy review, document review, and interview, it was determined that emergency department nursing staff did not utilize screening tools correctly to assess a patient's suicide risk, which lead to staff not implementing the appropriate safety precautions for suicidal patients; and the psychiatric assessment officer failed to recommend an observation status and/or included the justification for the use of 15-minute checks for high risk suicidal patients (A1104). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients identified on 03/13/24 at 02:02 PM.

On 03/13/24 at 09:20 PM, the facility provided an acceptable corrective action plan. The facility immediately began to implement the corrective action plan that included policy revision and staff education related to suicide risk assessment, precautions, and 1:1 constant observation requirement for high-risk suicidal patients.

On 03/13/24 at 09:50 PM, the Immediate Jeopardy was removed based on the onsite surveyor's observations, policy review, document review, and interviews with staff, which verified that the corrective action plan was fully implemented.

Additionally, emergency department staff did not follow hospital policy for the use of 1:1 in-person constant observation (A1104) and the hospital does not ensure all clinical staff are qualified in emergency care to meet the written emergency procedures and anticipated needs for one of three psychiatric assessment officers (A1112).

Cross Reference:
482.55 (a)(3)- Emergency Services Policies
482.55 (b)(2)- Qualified Emergency Services Personnel

Based on policy review, medical record review, document review, video review, and interviews, the facility failed to establish and implement policies to ensure the appropriate assessment and care of high-risk suicide patients is provided in the emergency department as evidenced by:
1. The nursing staff did not utilize screening tools correctly to assess a patient's suicide risk, which led to the implementation of less restrictive monitoring (15-minute safety checks instead of 1:1 constant, in-person observation) for four of four high risk suicidal patients (Patient #16, #17, #19, and #20); and emergency department staff did not follow hospital policy for the use of 1:1 in-person constant observation for Patient #19.
2. The psychiatric assessment officer failed to recommend an observation status (15-minute checks or 1:1 constant observation) and/or included the justification for the use of 15-minute checks for high-risk suicidal patients (Patient #17, #19, and #20).
3. From 03/13/23 to 03/12/24, seven emergency department patient registrations were cancelled by staff. This action cancelled the registration, the generation of a medical record, and removed these patients from the central log.
4. Emergency department staff failed to notify the provider that Patient #1 was leaving and/or document the reason for leaving in the medical record.

Findings #1:

Review of the policy "Triage", revised 02/2022 indicated that the triage registered nurse will complete a focused assessment of the patient and assign the appropriate triage level 1-5 based upon the emergency severity index (ESI) scale. A patient that has an immediate or life-threatening issue will be scored a 1 on the emergency severity index scale and will be assessed by the triage nurse or designated nursing personnel within 15 minutes of arrival. A patient that has an emergency issue will be scored a "2" on the emergency severity index scale and will be assessed by the triage nurse or designated nursing personnel within 30 minutes of arrival. A patient that has an urgent issue will be scored a "3" on the emergency severity index scale and will be assessed by the triage nurse or designated nursing personnel within 45 minutes of arrival. A patient that has a semi-urgent issue will be scored a "4" on the emergency severity index scale and will be assessed by the triage nurse or designated nursing personnel within 60 minutes of arrival. A patient that has a non-urgent issue will be scored a "5" on the emergency severity index scale and will be assessed by the triage nurse or designated nursing personnel within 90 minutes of arrival.

Review of the policy "Care and Management of Patients Presenting to the Emergency Department for Psychiatric Care/Crisis," revised 05/20/22 included that upon arrival to the emergency department, the triage nurse will assess and evaluate the patient according to the triage categories (emergency severity index). Suicidal behaviors would score the patient as an emergency severity index level two. A suicide screen is completed by the nurse and precautions are put into place if necessary.

Review of the policy "Suicidal Ideation Screening, Assessment, Precautions, Observation Guidelines," revised 06/07/23 included that every patient over the age of twelve that are being evaluated for a behavioral health condition will be screened for risk of suicide using the Patient Safety Screener-PSS-3 tool. If the screen is positive, the nurse will complete the Safe Secondary Screener-ESS-6 tool. A score of five or six will classify a patient at high risk; suicide precautions will be implemented, and the provider will be notified. The high-risk suicide patient will be monitored with a continuous 1:1 (in-person) observations by designated staff who will always sit with the patient and will document observations at least every fifteen minutes. A score of zero through four will classify a patient to be at mild/moderate risk; fifteen-minute documented safety checks will be completed. A referral will be for a made to mental health for a psychiatric assessment officer evaluation.

Review on 03/11/24 of the medical record for Patient #16 revealed that on 02/02/24 at 09:01 PM, Patient #16 was brought to the emergency department with police for a 9.41 mental health evaluation (police officer may take a person into custody for psychiatric evaluation if the person is conducting themselves in a manner that is likely to result in serious harm to self or others). At 09:05 PM, Patient #16 was triaged with the chief complaint of suicide ideation and a plan to hang themself stating that if law enforcement was not called, they would have acted on their thoughts. An emergency severity index score of "2" was assigned. The registered nurse assessed Patient #16' at low risk (no current attempt, no suicide plan or intent) using the "Patient Safety Screener-ESS-3 tool." The "Safe Secondary Screener-ESS-6 tool," was not used. As a result, the registered nurse implemented 15-minute safety checks to monitor Patient #16. At 09:39 PM, the psychiatric assessment officer evaluated Patient #16 at high-risk for suicide. 1:1 constant (in-person) observation was never implemented. On 02/04/24 at 07:00 AM, Patient #16 was transferred to another hospital for an inpatient mental health admission.

Review on 03/11/24 of the medical record for Patient #17 revealed that on 01/21/24 at 01:36 PM Patient #17 was brought to the emergency department with police for a 9.41 mental health evaluation. At 01:38 PM, Patient #17 was triaged with the chief complaint of suicide ideation with a plan to shoot themself with their ex-spouse's rifle. An emergency severity index score of "2" was assigned. The registered nurse assessed Patient #17 at low risk (no current attempt, no suicide plan or intent) using the "Patient Safety Screener-ESS-3 tool," and the "Safe Secondary Screener-ESS-6 tool." As a result, the registered nurse implemented 15-minute safety checks to monitor Patient #17. At 02:32 PM, the psychiatric assessment officer evaluated Patient #17 at high-risk for suicide. At 08:30 PM, Patient #17 was transferred to another hospital for an inpatient mental health admission.

Observation on 03/11/24 at 09:53 AM in the emergency department revealed Patient Staff (S), Patient Care Technician, sitting outside of the room #10. Interview with Staff (S) revealed that Patient #19 in room #10 was a "mental health transfer and needed to have a sitter present." Staff (S) stated that it was appropriate to sit outside of the room if direct visualization was maintained. Staff (S) had a documentation sheet for fifteen-minute checks but stated that because Patient #19 was on a 1:1 in-person observation, the charting did not need to be completed. The form was blank. (Staff S did not understand how to perform 1:1 observation and documentation according to hospital policy).

Medical record review for Patient #19 revealed that Patient #19 was brought to the emergency department for a mental health evaluation via ambulance. At 09:40 AM, Patient #19 was triaged with the chief complaint of a suicide attempt with intentional overdose and an attempt to drown self. An emergency severity index score of "2" was assigned. The registered nurse assessed Patient #19's suicide risk as "moderate risk" for suicide (no current attempt, no suicide plan or intent) using the "Patient Safety Screener-ESS-3 tool," and the "Safe Secondary Screener-ESS-6 tool." As a result, the registered nurse implemented 15-minute safety checks, two hours after Patient #19's arrival (delay in documented safety checks). At 02:58 PM, the psychiatric assessment officer evaluated Patient #19 at high-risk for suicide. On 03/12/24 at 11:00 AM, Patient #19 was admitted to the hospital's inpatient mental health unit.

Review on 03/11/24 of the medical record for Patient # 20 revealed on 03/11/24 at 12:50 AM, Patient #20 was brought to the emergency department with police for a 9.41 mental health evaluation. At 12:55 AM, Patient #20 was triaged with the chief complaint of suicide ideation with a plan to cut self with a knife. An emergency severity index score of "2" was assigned. The registered nurse assessed Patient #20 at low risk (no current attempt, no suicide plan or intent) using the "Patient Safety Screener-ESS-3 tool," and the "Safe Secondary Screener-ESS-6 tool." As a result, the registered nurse implemented 15-minute safety checks, two hours after Patient #20's arrival (a delay in documenting safety checks). At 08:35 AM, the psychiatric assessment officer evaluated Patient #20 at high-risk for suicide. At 09:45 PM, Patient #20 was transferred to another hospital for an inpatient mental health admission.

Interview on 03/12/24 at 10:40 AM with Staff (D), Director of Informatics and Nursing Education, revealed that while reviewing the emergency department medical records for Patients #16, #17, #19 and #20, the initial suicide screening by the registered nurse was completed incorrectly. All four patients should have been classified as at high risk for suicide and a 1:1 constant (in-person) sitter should have been implemented.

Findings #2:

Review of the electronic medical record "Behavioral Health Interdisciplinary Assessment Form" section revealed the assessment that the psychiatric assessment officer uses to assess a suicidal patient as low, moderate, or high risk. If the patient scores low suicide risk, a discretionary outpatient referral is recommended. If the patient scores a moderate suicide risk, the assessment addresses the suicide risk by the implementation of suicide prevention strategies and the development of a plan. If the patient scores a high suicide risk, the assessment directs the psychiatric assessment officer to consult with the provider for admission status and patient care options while in the emergency department, documenting the date and time of the conversation. The psychiatric assessment officer has the option to recommend 1:1 (in-person) constant observation or fifteen-minute checks for high-risk suicidal patients. If fifteen-minute checks are recommended, a justification for why 1:1 observation is not needed will be documented. The justification section includes documentation options of "no intent and/or no plan available in the setting," and a free text box.

Review of the emergency department medical record for Patient #17 revealed that on 01/21/24 at 02:32 PM, the psychiatric assessment officer initiated the "Behavioral Health Interdisciplinary Assessment Form," for Patient #17, evaluated them as high-risk for suicide, and determined that they met the criteria for inpatient psychiatric admission due to suicidal ideation with a plan. The psychiatric assessment officer failed to document a recommended observation status (15-minute checks or 1:1 constant observation). On 01/21/24 at 08:45 PM, Patient #17 was transferred to another hospital for an inpatient mental health admission.

Review of the emergency department medical record for Patient #19 revealed on 03/11/24 at 02:58 PM, the psychiatric assessment officer initiated the "Behavioral Health Interdisciplinary Assessment Form," for Patient #19, evaluated them as high-risk for suicide, and determined that they met the criteria for inpatient psychiatric admission due to a suicide attempt. The psychiatric assessment officer determined that Patient #19 required fifteen-minute safety checks but did not document the justification. On 03/12/24 at 11:00 AM, Patient #19 was transferred to the hospital's inpatient mental health unit.

Review of the emergency department medical record for Patient #20 revealed on 03/11/24 at 08:35 AM, the psychiatric assessment officer initiated the "Behavioral Health Interdisciplinary Assessment Form," for Patient #20, evaluated them as high-risk for suicide, and determined that they met the criteria for inpatient psychiatric admission due to suicide ideation with a plan, and previous attempts. The psychiatric assessment officer failed to document a recommended an observation status (15-minute checks or 1:1 constant observation). On 03/11/24 at 11:20 PM, Patient #20 was transferred to another hospital for an inpatient mental health admission.

Interview on 03/13/24 at 01:30 PM with Staff (B), Director of Nursing verified the findings.

Findings #3:

Review of the policy "Triage" with an effective date of 02/22 indicates that all patients presenting to the emergency department will be greeted by the registration clerk who will obtain the patients first and last name, date of birth, arrival time and chief complaint. The registration clerk will notify the designated triage nurse that a patient has arrived, enter their information into electronic health record, and place the patient on the emergency department tracking board. When the situation arises that a patient requests to leave before treatment, the emergency department provider must be notified immediately, and it must be documented in the patient's electronic health record the time the provider was notified. If the patient decided to leave the reason for leaving and date and time is to be documented in the electronic health record.

Review on 03/11/24 at 04:15 PM of video surveillance with Staff (M), Director of Healthcare Information Systems, revealed that on 02/19/24 at 06:10 PM, Patient #1 and their mother walked into the emergency department and was observed speaking with Staff (K), Patient Information Specialist (registration staff). At 06:13 PM, Staff (K), Patient Information Specialist, placed a band (identification bracelet per Staff M) on Patient #1's wrist. At 06:14 PM, Staff (K), is seen speaking on the phone. At 06:14 PM, Patient #1 and their mother walked into the waiting room. At 06:18 PM, Staff (L), and Staff (R), Registered Nurses were observed walking to the waiting room and spoke to Patient #1's mother. At 06:22 PM, Staff (L) and Staff (R) were observed walking back into the emergency department. At 06:23 PM, Staff (L) was observed bringing something out to the waiting room and giving it to Patient #1's mother (medical supplies per Staff M). Staff (L) walked back into the emergency department. At 06:25 PM, Patient #1 and their mother walked out of the facility.

Review of the document "Wyoming County Community Health System - Event (Incident) Reporting Form," revealed Patient #1 was brought to the emergency department by their mother. The investigation revealed that emergency department staff called registration staff and asked for the check in of Patient #1 to be reversed. Review of the electronic medical record computer screen shots indicated that Patient #1 was initially registered as a "3-emergency department (patient in the emergency department) but was changed to a "2-outpatient/canceled (registration was cancelled). The dates of service were changed from 02/19/24 to 01/01/01 at 01:01.

Interview on 03/11/24 at 02:22 PM with Staff (H), Patient Information Specialist indicated that Staff (H), Patient Information Specialist recalled that Patient #1 came in with their mom, was registered, and went to the waiting room. The nurse went to the waiting room to talk to the mom and brought them supplies. Patient #1 left with the mother. They (registration staff) were then told by someone in the emergency department to cancel the account out as Patient #1 was not treated. Staff (H) stated that they can cancel a chart if needed.

Interview on 03/11/24 at 03:05 PM with Staff (K), Patient Information Specialist indicated that Staff (K), Patient Information Specialist recalled that Patient #1 came into the emergency department on 02/19/24 with their mother for treatment. Staff (K) registered the patient, placed the wrist band on Patient #1, called back to the triage nurse to make aware of the patient ' s arrival, and told Patient #1 ' s mother to wait in the waiting room for treatment. Staff (K) stated the triage nurse asked for details as to why they arrived for treatment. Two nurses went to the waiting room and spoke to Patient #1 ' s mother and brought them supplies. Then Patient #1 and the mother left the facility. A nurse called Staff (K) and asked for the registration to be reversed and to cancel the account, which was completed by Staff (K).

Interview on 03/12/24 at 10:26 AM with Staff (P), Quality and Risk Manager Coordinator, indicated Patient #1 was registered as a "3- emergency department" that was changed to a "2- outpatient or cancel." The date was changed from 02/19/24 to 01/01/01 at 01:01. Staff (P) felt that the registration staff were just doing what they were told.

Interview on 03/13/24 at 10:30 AM with Staff (M), Director of Health Care Information, indicated that data was collected to confirm if any other registrations were reversed or cancelled for the emergency department like what occurred on 02/19/24 with Patient #1. A report was run from 03/13/23 through 03/12/24 of the electronic medical record system that resulted in seven occurrences for the emergency department. Staff (M) provided the documents from the seven occurrences that were found. The investigation is still ongoing.

Review on 03/13/24 of the electronic medical record system extracted report for all patients classified with a service code of 03 (emergency department) from 03/13/23 to 03/12/24 revealed seven emergency department patient registrations were reversed or cancelled (Patient #1 on 02/19/24 at 06:30 PM, Patient #21 on 06/12/23 at 04:39 PM, Patient #22 on 08/08/23 at 07:13 AM, Patient #23 on 11/21/23 at 01:12 PM, Patient #24 on 12/07/23 at 09:37 AM, Patient #25 on 08/01/23 at 07:52 AM, and Patient #26 on 09/21/23 at 02:32 PM).

Interview on 03/13/24 at 01:30 PM with Staff (B), Director of Nursing, verified the findings.

Findings #4:

Review of the policy "Triage," effective 02/2022 indicated that all patients presenting to the emergency department will be greeted by the emergency department registration clerk who will notify the designated triage nurse that a patient has arrived. The triage registered nurse will complete a focused assessment on the patient, assign the appropriate triage level, and complete the emergency department triage document in the electronic health record. After triage, the patient will either be directed to the waiting room or be placed into an emergency department designated room or hallway area. When a situation arise that a patient decides to leave from the waiting room before being seen by an emergency department provider, nursing staff while attempt to encourage the patient to stay. They will notify the emergency department provider who will attempt to encourage the patient to stay. If the patient decided to leave, the reason for leaving and date/time is to be documented in the electronic health record.

Review of the policy "Leaving Against Medical Advice," revised 07/27/20 indicated that upon becoming aware of a patient's refusal of treatment or plan to leave against medical advice, the provider shall be notified of the patient's refusal or intent to leave. All pertinent sections of the leaving against medical advice/refusal of treatment form are to be completed and witnessed by a licensed physician, nurse practitioner, or physician assistant. Documentation of the refusal shall be recorded in the patient's chart, including the reason. All risks to be explained and understood, including a worsening illness, chronic pain, permanent disability, and death. If the patient refuses to sign the leaving against medical advice/refusal of treatment form, a notation in the chart will be documented with all applicable witnesses noting the refusal and/or decision to leave against medical advice.

Review on 03/11/24 at 04:15 PM of video surveillance with Staff (M), Director of Healthcare Information Systems, revealed that on 02/19/24 at 06:10 PM, Patient #1 and their mother walked into the emergency department and was observed speaking with Staff (K), Patient Information Specialist (registration staff). At 06:13 PM, Staff (K), Patient Information Specialist, placed a band (identification bracelet per Staff M) on Patient #1's wrist. At 06:14 PM, Staff (K), is seen speaking on the phone. At 06:14 PM, Patient #1 and their mother walked into the waiting room. At 06:18 PM, Staff (L), and Staff (R), Registered Nurses were observed walking to the waiting room and spoke to Patient #1's mother. At 06:22 PM, Staff (L) and Staff (R) were observed walking back into the emergency department. At 06:23 PM, Staff (L) was observed bringing something out to the waiting room and giving it to Patient #1's mother (medical supplies per Staff M). Staff (L) walked back into the emergency department. At 06:25 PM, Patient #1 and their mother walked out of the facility.

Review 03/11/24 of the document "Wyoming County Community Hospital Emergency Department Log," for 02/19/24 revealed no evidence Patient #1 presented to the hospital's emergency department.

Medical record review on 03/11/24 revealed no evidence that a medical record was generated for Patient #1 on 02/19/24. No documenation was found to indicate that a provider was notified that Patient #1 and their mother presented to the emergency department but decided to leave.

Interview on 03/12/24 at 11:50 AM with Staff (G), Nurse Practitioner revealed that registration came in the emergency department to notify staff regarding a mom with a child that was here with E. coli (bacterial infection), wanting some intravenous fluids, and was then going to another facility. Patient #1 was not seen here. Staff (G) never spoke to Patient #1 ' s mom. Patient #1 ' s mom elected to leave.

Based on document, policy review, medical record review, and interview, the hospital does not ensure all clinical staff are qualified in emergency care to meet the written emergency procedures and anticipated needs for one of three psychiatric assessment officers (Staff AA). Failure to have qualified staff performing assessments has the potential for inaccurate assessments and inadequate treatment and could contribute to an adverse patient event.

Finding include:

Review of the document "New York State Department of Health Dear Chief Executive Officer letter 08-01," dated 04/25/08 indicated that if a psychiatric assessment is an appropriate part of a medical screening examination and a psychiatrist/physician with the appropriate skills and training is not immediately available to assess the patient, such assessment may be conducted by other appropriately credentialed licensed staff such as a registered professional nurse, nurse practitioner, physician assistant, psychologist, clinical social worker, and/or a master degree social workers. When the assessment is not carried out by a psychiatrist or other appropriately qualified physician, the licensed staff assessing the patient for a psychiatric emergency must directly consult with a psychiatrist or other appropriately credentialed physician (credentialed on the staff of the hospital) regarding disposition of the patient. The conversation with the psychiatrist or appropriately credentialed physician must be documented on the patient record including the name of the psychiatrist/physician and the time of the consultation.

Review on 03/12/24 of the document "Psychiatric Assessment Officer Job Description," last revised 07/07/16 indicated the individual must have graduated from a regionally accredited or New York State registered college or university with a master's degree in social work, sociology, psychology, human services, or a closely related field with some experience working in a mental health setting. A certified substance abuse counselor will be considered with a minimum of five years working in an inpatient behavioral health unit. Every psychiatric assessment officer must obtain a New York State license as a mental health counselor, mental social worker, or certified social worker within twelve months of appointment.

Review of the policy "Suicidal Ideation Screening, Assessment, Precautions, Observation Guidelines," revised 06/07/23 included that every patient over the age of twelve that are being evaluated for a behavioral health condition will be screened for risk of suicide using the Patient Safety Screener-PSS-3 tool. A referral will be for a made to the mental health team for a psychiatric assessment officer evaluation.

Medical record review on 03/12/24 revealed Staff (AA), Psychiatric Assessment Officer performed an assessment for the following suicidal patient: on 01/21/24 at 02:32 PM for Patient #17.

Review on 03/12/24 of the personnel file for Staff (AA), Psychiatric Assessment Officer revealed a hire date of 03/2011. Staff (AA) had a master's degree in education and was a credentialed as alcohol and substance abuse counselor by the state of New Yorks office of alcoholism and substance abuse services that expired in 2015. Staff (AA) had mental health work experience however, it was not in the inpatient setting. No evidence was found to indicate that Staff (AA) has a New York State license as a mental health counselor, mental social worker, or certified social worker.

Interview on 03/13/24 at 02:55 PM with Staff (X), Human Resource Assistant, confirmed that Staff (AA), does not meet the minimum qualifications to hold a position as a psychiatric assessment officer.