HospitalInspections.org

Based on record review, interview and policy review, the facility failed to ensure a suicide screening was provided to emergency room patients. The average daily census of the emergency department was 55.

See C1006

Based on medical record review, policy review and interview, the facility failed to ensure a suicide screening was provided to emergency room patients. This affected four (Patients #9, #17, #18 and #19) of 20 medical records reviewed. The facility's average daily census in the emergency department was 55.

Findings include:

1. Patient #19 arrived at the facility's emergency department on 05/15/24 at 4:50 PM with a chief complaint of anxiety. Staff E documented Patient #19 left without being seen after triage on 05/15/24 at 6:30 PM. The facility did not perform a C-SSRS (Columbia-Suicide Severity Rating Scale) screen during triage.

The findings were shared with Staff C on 09/11/24 at 3:38 PM and confirmed. Staff C reported the C-SSRS is supposed to be done at every triage.

2. Patient #9 arrived at the facility's emergency department on 04/07/24 at 10:45 PM for a chief complaint of anxiety and was discharged on 04/07/24 at 11:31 PM. The facility did not perform a C-SSRS screen during triage.

The findings were shared with Staff B on 09/12/24 at 9:28 AM and confirmed.

3. Patient #17 arrived at the facility's emergency department on 04/25/24 at 1:06 PM for a chief complaint of Psychiatric Evaluation and left against medical advice on 04/25/24 at 6:11 PM. The facility did not perform a C-SSRS screen during triage.

The findings were shared with Staff B on 09/12/24 at 9:40 AM and confirmed.

4. Patient #18 arrived at the facility's emergency department on 08/31/24 at 7:39 PM with a chief complaint of needing a psychiatric evaluation. The patient left without being see after triage on 08/31/24 at 7:39 PM. The facility did not perform a C-SSRS screen during triage.

The findings were shared with Staff B on 09/12/24 at 9:41 AM and confirmed.

Review of the policy titled "Suicide Risk Identification and Safety Management", dated September 2023, stated adult patients will be screened for suicide risk every Emergency Department (ED) visit by the RN (registered nurse) using the Columbia-Suicide Severity Rating Scale (CSSRS) - Screen with Triage Points for Emergency Department (ED). For those patients who indicate a suicidal ideation, a level of low, moderate or high is determined based on the results of the C-SSRS. The ED provider is notified if the results of the screen indicate a moderate or high-risk level.

Review of the document titled "Guideline - Emergency Department Triage Process and Documentation", dated September 2023, stated triage is performed by registered nurses or other qualified professionals practicing within the scope of their professional license. The paramedic may work in collaboration with the registered nurse to gather data. Triage is a sorting process that determines the "order" in which individuals are seen for the Medical Screening Exam (MSE). Triage may include such factors as history, presentation of symptoms, vital signs and severity of chief complaint.

Risk Screens:

1. Suicide Risk Screen: See CP-141
2. Falls risk (adult/peds)
3. Risk of Homicide
4. Domestic Violence
5. Sepsis Screen
6. Travel or exposure history