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Based on interview, policy review, contract review, and clinical record review, the facility failed to provide complete social services to a homeless patient, Patient #5, to victims of suspected spouse abuse, Patient #9 and Patient #22, and failed to provide psychiatric services to Patient #1, #10, #11, #12, #14, #19, #20, and #21, and failed to have nursing conduct a self-harm risk assessment for Patient #1, #9, #10, #11, #12, #14, #17, #18, #19, #20, and #21-all of whom presented to the emergency department with psychiatric chief complaints.

Findings:

See A1103 for details.

Based on interview, policy review, contract review, and clinical record review, the facility failed to integrate nursing, psychiatric, and social services into its emergency services for Patient #1, #9, #10, #11, #12, #14, #17, #18, #19, #20, #21 and #22.

Findings:

The clinical record review for Patient #5 was completed on 01/10/12. The clinical record review revealed the patient was brought to the emergency department on 12/02/11 at 12:30 A.M. by police for lying on the ground and being unable to get up. The clinical record review revealed an emergency physician record that stated the patient stated he/she was homeless and he/she thought he/she had multiple sclerosis. The emergency physician record listed alcohol intoxication as a clinical impression.

The clinical record review revealed the patient was discharged 12/03/11 at 1:25 A.M. to be taken by police to a hotel for the night.

The clinical record review did not indicate whether the patient wanted help for alcoholism, whether materials were made available to him/her to help with his/her alcoholism, or whether social services were contacted to help him/her find community resources for food and shelter.

On 1/10/12 at 12:10 P.M. in an interview, this finding was presented to the Chief Nursing Officer, Nursing Administrator #1, and Quality Officer #1.


The clinical record review for Patient #9 was completed on 01/10/12. The clinical record review revealed the 37-year-old patient was brought to the emergency room on 12/10/11 at 11:12 P.M. by the local sheriff. The clinical record review revealed an application for emergency (involuntary) admission dated 12/10/11 and signed by the sheriff. The application for emergency (involuntary) admission stated the patient and his/her spouse "were in an argument. He/she was destroying chairs and other items in the kitchen area. He/she then went and grabbed his/her .357 revolver from the bedroom and told her/his that he/she wasn't going to like what he/she does next." The note said he/she fled the home and called police.

The clinical record review revealed an application for emergency (involuntary) admission dated 12/10/11 and signed by the emergency room physician that stated the patient was suicidal. The clinical record review revealed a nursing note dated 12/11/11 at 8:00 A.M. that stated the patient was informed he/she would be admitted to a psychiatric facility. The note stated the patient rolled his/her/his eyes then glared at his/her wife.

The clinical record review revealed a nursing note dated 12/11/11 at 10:45 A.M. that stated the patient was seen by a social worker. The clinical record review did not contain documentation of what transpired between the patient and that social worker. The clinical record review did not show evidence where the social worker educated the spouse on the facility's policy and procedure on domestic violence, on a shelter crisis hotline, a court advocate, or counseling services.


The clinical record review for Patient #22 was completed on 01/10/12. The clinical record review revealed the patient presented to the emergency department on 11/06/11 and was triaged at 7:10 P.M. The triage note stated he/she feared her/his spouse would hurt her/him, and stated the spouse was verbally and mentally abusive.

The clinical record review revealed a nursing note dated 11/06/11 at 10:30 P.M. that stated he/she was attempting to find where spouse was so he/she could go home.

The clinical record review revealed a nursing note dated 11/06/11 at 11:55 P.M. that stated he/she was discharged to home (and the spouse was with a brother).

The clinical record review did not reveal social services provided education on the facility's policy and procedure on domestic violence, on a shelter crisis hotline, a court advocate, or counseling services.


Review of the facility's policy entitled, "Domestic Violence", last reviewed on 03/10, stated a licensed social worker is to offer intervention to the victim that included education on the facility's policy and procedure on domestic violence, on a shelter crisis hotline, a court advocate, or counseling services.

On 01/05/12 at 2:15 P.M. in an interview, the Director of Nursing and Nursing Administrator #1 confirmed Patient #9 and #22's clinical record did not contain evidence they were educated by social work in accordance with the facility's policy.

The clinical record review for Patient #11 was completed on 01/10/12. The clinical record review revealed the 42-year-old patient was brought to the emergency department on 12/14/11 by local police for a psychological evaluation. The clinical record review revealed a nursing note dated 12/14/11 at 5:00 P.M. that stated while the patient was at her/his therapist's office he/she was delusional and suicidal. The note stated the patient admitted to stabbing self in hand in an attempt to harm herself.

The clinical record review revealed a physician's order dated 12/14/11 at 5:00 P.M. for a psychiatric evaluation. The clinical record review did not reveal evidence a psychiatric evaluation was performed while the patient was in the emergency department. The clinical record review did not reveal evidence nursing performed a self-harm risk assessment.


The clinical record review for Patient #12 was completed on 01/10/12. The clinical record review revealed a nursing database that contained a triage note dated 12/15/11 at 2:04 A.M. that stated the patient was brought to the emergency department for threatening to jump off a bridge.

The clinical record review revealed an emergency physician record dated 12/15/11 that stated he/she told his/her parent he/she might jump off a bridge or cut his/her wrists.

The clinical record review did reveal an order for a psychological evaluation, but did not reveal where one was done and did not reveal where nursing performed a self-harm risk assessment.


On 12/23/11 at 12:00 P.M. Patient #19 presented to the emergency department by emergency medical services. The clinical record review for that visit revealed an emergency physician record that stated the patient had suicidal and homicidal ideation. The clinical record review revealed an application for emergency (involuntary) admission that stated the patient was a threat to harm his/her spouse and him/her.

The clinical record review revealed a physician's order dated 12/14/11 at 5:00 P.M. for a psychiatric evaluation. The clinical record review did not reveal evidence a psychiatric evaluation was performed while the patient was in the emergency department. The clinical record review did not reveal where nursing performed a self-harm risk assessment.


The clinical record review for Patient #20 was completed on 01/10/12. The clinical record review revealed the patient was brought to the emergency department by a parent on 12/19/11 for three cuts to the wrist. The clinical record review revealed an emergency physician record dated 12/19/11 at 1:55 P.M. that stated the patient said he/she cut himself to relieve stress. The clinical record review revealed the physician did order a psychological evaluation.

The clinical record review did not reveal where a psychological evaluation was done or where nursing performed a self-harm risk assessment.


The clinical record review for Patient #21 was completed on 01/10/12. The clinical record review revealed a nursing data base that stated the 18-year-old patient was brought to the emergency department by police on 12/08/11 at 8:45 A.M. for wanting to hurt himself.

The clinical record review revealed an application for emergency (involuntary) admission, signed by the police, dated 12/08/11 that stated the patient attempted to cut self with kitchen knife. The application for emergency (involuntary) admission stated the patient asked to be shot in the head, and also said he/she should have just hung himself.

The clinical record review revealed a physician's order for a psychological evaluation.

The clinical record review did not reveal where a psychological evaluation was done or where nursing performed a self-harm risk assessment.


The clinical record review for Patient #1 was completed on 01/10/12. The clinical record review revealed the 16-year-old patient was brought to the emergency department on 01/11/12 at 9:32 P.M. The clinical record review revealed a nursing record that stated the patient was triaged at 9:25 P.M. and he/she stated he/she took 10 or 15 white pills. The nursing record stated the patient had a history of suicide.

The clinical record review did not reveal where the patient was ordered or received a psychological evaluation. The clinical record review did not reveal where nursing performed a self-harm risk assessment. The clinical record review did reveal the patient was discharged 10/01/11 at 11:38 P.M. to juvenile detention and to have suicide precautions until he/she could have a psychological evaluation on 10/03/11.


The clinical record review for Patient #10 was completed on 01/10/12. The clinical record review revealed the 23-year-old patient presented to the emergency department as a walk-in on 12/13/11 at 1:51 P.M. with a chief complaint of heroin withdrawal, having last used on 12/12/11. The clinical record review revealed a nursing database that stated the patient was triaged at 1:55 P.M. with pain of 10/10-10 being the worst. The clinical record review did not reveal where that pain was. "Suicidal thoughts" was listed among the triage findings.

The clinical record review did not reveal where a psychological consult was ordered or performed, or where nursing performed a self-harm risk assessment.


The clinical record review for Patient #14 was completed on 01/10/12. The clinical record review revealed the 51-year-old was brought to the emergency department via emergency medical services on 12/15/11 at 11:00 P.M. The clinical record review revealed a nursing note dated 12/15/11 at 11:00 P.M. that stated the patient had called the crisis intervention line due to feeling depressed over the loss of her/his mother. The triage note of the same time and date stated he/she had pain of 10/10.

The clinical record review revealed the only physician order to be to administer five milligrams of Valium. The clinical record review revealed this was given at 11:38 P.M.

The clinical record review did not reveal where any psychological services were consulted or implemented or where nursing performed a self-harm risk assessment.


The clinical record review for Patient #9 was completed on 01/10/12. The clinical record review revealed the 37-year-old patient was brought to the emergency room on 12/10/11 at 11:12 P.M. by the local sheriff. The clinical record review revealed an application for emergency (involuntary) admission dated 12/10/11 and signed by the sheriff. The application for emergency (involuntary) admission stated the patient and his/her spouse "were in an argument. He/she was destroying chairs and other items in the kitchen area. He/she then went and grabbed his/her .357 revolver from the bedroom and told her/his that he/she wasn't going to like what he/she does next." The note said he/she fled the home and called police.

The clinical record review did not reveal where nursing performed a self-harm risk assessment.


The clinical record review for Patient #17 was completed on 01/10/12. The clinical record review revealed the patient was brought in with spouse in private vehicle. The clinical record review revealed an emergency physician record dated 12/19/11 at 11:35 A.M. that stated the patient had a complaint of suicide thoughts and depression. The physician record stated the patient did not have a plan to commit suicide. The physician record did not list a clinical impression or medical diagnosis.

The clinical record review did not reveal where nursing performed a self-harm risk assessment.


The clinical record review for Patient #18 was completed on 01/10/12. The clinical record review revealed the 20-year-old was brought to the emergency department by private vehicle. The clinical record review revealed an emergency physician record dated 12/17/11 at 1:00 P.M. that listed suicidal thoughts and depression as chief complaints. The clinical record review revealed an application for emergency (involuntary) admission that stated the patient was a substantial suicide or self-harm risk.

The clinical record review did not reveal where nursing performed a self-harm risk assessment.


Review of the facility's policy entitled risk assessment in the emergency department, last revised on 12/22/09, stated during triage assessment a self-harm risk assessment is to be performed. This was not done for Patient #1, #9, #10, #11, #12, #14, #17, #18, #19, #20, and #21. The policy stated those patients identified as moderate or high risk for self-harm will, among other things, have a nursing psychological evaluation completed.

On 01/10/12 at 3:30 P.M. in an interview, Nursing Administrator #1 stated the self-harm assessments weren't being done because the facility was transitioning to a different charting system.

On 01/04/11 at 10:00 A.M. in an interview, Nursing Administrator #1 said the facility did not have any in-patient psychiatric units, or any in-house psychiatry. He/she said the facility relies on a community mental health agency to make psychiatric assessments and placements as needed. He/she said the community mental health agency was available to come to the emergency department 24 hours a day, seven days a week.

Review of the contract between the facility and the community mental health agency, signed on 11/01/11, stated, "Company will furnish qualified mental health care professionals ... to provide psychiatric emergency care at Hospital on a twenty-four hour per day, three hundred sixty-five (365) days a year basis. Such psychiatric emergency care shall include Mental Health Pre-Screening and/or Crisis Intervention Services ...". These services were not provided to Patient #1, #10, #11, #12, #14, #19, #20, and #21.