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Based on observation, record review, and interviews, the Governing Body of the hospital failed to ensure that the hospital has systems and processes in place to ensure compliance with the requirements set forth in the regulations at 42 CFR 489.24.


The hospital failed to appropriately transfer psychiatric patients in crisis to a safe environment where qualified staff can provide safe and appropriate care for their psychiatric conditions. This failure resulted in 7 (P# 1, 5, 7, 9, 11, 14, and 21) of 23 sampled patients that presented to the Emergency Room (ER) being discharged in unstable condition and sent to a facility with no capability in providing safe and appropriate care for their psychiatric condition. Further, this failure has the likelihood of harm to all individuals presenting to the hospital for examination of a medical condition.


When a patient in psychiatric crisis was discharged to jail from the ER of this hospital and the jail subsequently released him, the patient successfully killed himself at home the following day after release. The hospital conducted a Root Cause Analysis (RCA) of the adverse event but failed to immediately and effectively implement corrective actions to ensure the protection and safety of all patients in psychiatric crisis.


See A-Tag 2409.

Based on observation, record review, and interviews, the hospital failed to transfer psychiatric patients in crisis to a safe environment where qualified staff can provide appropriate care.

The failure to appropriately transfer psychiatric patients placed 7 of 23 sampled patient (P# 1, 5, 7, 9, 11, 14, and 21) at great risk for harming themselves and one (P#11) ended his life by suicide, and poses a likelihood of harm to any patients presenting to the hospital with psychiatric condition.


Findings:

On June 7, 2021, at 9:50 AM, an observation was made of the hospital Emergency Room (ER). The ER has one orthopedic private room, one obstetric private room for precipitate deliveries, one isolation private room, one trauma private room, and five beds separated by curtains. The nurses station is located in front of the five beds. It was confirmed by the ER staff that there is no room for psychiatric patients.


Patient #11

This patient was seen in the Emergency Room on 04/24/2021 and died on 04/25/2021 by suicide. The hospital leadership conducted two Root Cause Analysis (RCA) and identified areas that needed immediate attention.

Record review indicated that the patient was an 18-year old male who was brought to the ER by the police at 6:53 PM after being found throwing himself into moving traffic with the intent of killing himself. Presenting complaints was suicidal ideation. He has a medical history of depressive disorder and suicidal ideations.

Record review revealed that the staff was not able to complete the PHQ 9 assessment due to the patient being agitated, repeatedly saying, " I am going to kill myself call my grandmother."

Review of the patient medical record, root cause analysis (RCA) including the timeline revealed the following actions by the ER nursing and medical staff:

a) 7:00 PM, the Emergency Room placed the patient on 1:1 observation. The patient was continually calling his grandmother yelling he wanted to die

b) 7:00 PM, the patient was taken off metal handcuffs (police cuff) and bilateral soft wrist restraints were applied per medical provider orders. The police left the ER.

c) Medical provider orders included the recording of patient's behavior every 30 minutes

d) 7:10 PM, the patient refused to change his clothing into hospital paper scrubs. The medical provider at bedside encouraged patient to change into paper scrubs and patient complied

e) 7:20 PM, Patient #11 walked to the bathroom with the observer (certified nurse aide). The RN observer was also the evening supervisor and was processing a transfer.

f) 7:35 PM, the medical provider ordered Lorazepam 1 mg Intramuscularly. Observation: Patient agitated. Medication was given

g) 7:35 PM, police were called to come back to the ER.

h) 7:50 PM to 7:55 PM, peripheral intravenous (IV) access was started as medical order. 8:02 PM, a second dose of Lorazepam 1 mg's was administered IV.

i) 8:05 PM, nurse reported the patient was calmer

j) 8:30 PM, nurse reported the patient stated he was sorry about everything, "I am just not in a good place".

k) 8:50 PM, nurse reported the patient removed the soft restraints.

l) 9:45 PM, the patient tried to run away from the hospital ER

m) 9:50 PM, police back in the ER. The patient was agitated and aggressive towards the police. Police alerted the patient and ER staff the patient was under arrest and they will be taking him to jail.

n) 10:10 PM, The medical provider at the ER medically cleared the patient to go to jail. The patient was awaiting transfer to a Mental Health facility.


Review of the medical record revealed that on April 24, 2021, Rosebud Indian Hospital Emergency Room had submitted a court petition for the judge to sign declaring the patient mentally ill and he was a danger to himself or others. In the petition it was described that Patient #11 was suicidal, had inflicted cuts to his anterior neck, exhibited minor intoxication, and depression. The court petition was signed.

Record review showed that the patient was taken by correctional officers to the jail. Record review revealed that Patient #11 was prescribed Lorazepam 1 mg by mouth for discharge medication. The correctional officers did not wait for the medication that the medical provider prescribed to be dispensed by hospital pharmacy. When the transfer to a metal health facility was ready, the medical provider called the jail but the jail officers refused to bring the patient back because he was under arrest. The medical provider medically cleared the patient to be transferred to the jail and placed him on suicidal watch. In less than 24-hours, his grandmother posted a bond to get him out of jail. The patient went home and killed himself.


The hospital leadership conducted a RCA on Patient #11 and identified several areas in which needed immediate attention:

1. Patient #11 did not have a PHQ 9 assessment completed,

2. Inappropriate discharge, 3.1:1 observation without knowing how the correctional facility conduct 1:1 observations,

4. Hospital Medical Clearance was not found in the patient record,

5. Removal of the restraints without a medical evaluation or order,

6. Inconsistent use of chemical restraints,

7. ER staff did not de-escalate the situation,

8. ER staff did not call leadership for assistance (per hospital policy),

9. ER staff did not activate Code Green (per hospital policy) ,

10. The presence of the Police increased stress to the patient,

11. ER staff needed training on de-escalation of volatile situations involving suicidal patients and staff sensitivity to suicidal patients coming to the ER.


Patient #1:

Record review indicated that she was brought to the Emergency Room (ER) in police custody on 03/02/2021 at 4:32 am. The patient had a diagnosis that included depression, alcohol abuse, drug addiction, and suicidal attempts; the presenting complaint was suicidal ideation (SI). According to the medical examination recorded, the patient tried to hang herself while in jail. The patient used her brassiere and wrapped it around her neck.

The ER provider noted bruising to neck and fingers with petechiae around the neck, face, and hands, and ligature marks on the neck. Additional information: the ER provider indicated the patient was crying, angry, talking about being homeless, and making plans for her family after she kills herself.

Record review of the visit note revealed that she is a veteran with a history of PTSD (post traumatic stress disorder). The patient complained of minor pain around the neck. The Medical Decision Making Clinical Course/Differential Diagnosis Note indicated, "Patient likely have some minor discomfort to her neck but does not appears to have an acute injury that requires intervention in the ER." "Tribal Hold in place." "Approval for Transport Order for Involuntary Commitment."

Review of the court request document for involuntary seclusion declared her as "unstable mentally". A court order was signed for the patient to be placed on involuntary seclusion on March 2, 2021.

Record review of the Certificate of Qualified Mental Health Professional noted the findings of the patient's physical condition to be 'stable". "Mental Condition: Suicide Attempt. "

Record review of the PHQ 9 (Patient Health Questionnaire) completed March 2, 2021, at 04:32 am question 9: " Thought: "Would be better off dead or hurting yourself?" Answer: "For several days" " . Total score of 14 (moderately severe depression).

While in the ER the patient was placed on 1:1 observation. The patient was to be discharged to a psychiatric facility or to the jail until the transfer arrives. On 03/02/2021 at 10:25 am, Patient #1 was placed on medical hold. The care plan revealed the patient was to be transferred to a psychiatric facility for advance psychiatric care. The ER log revealed that she was transferred by police. The medical record did not indicate whether the patient was taken to jail or to a psychiatric facility.


Patient #5

Record review indicated that this patient was a 13-year old female, brought to the Emergency Room (ER) by her mother on March 3, 2021, at 6:38 PM. The presenting complaint was suicidal ideation. The patient had a diagnoses that included self-harm, depression, suicidal thoughts, and history of sexual abuse. .

Record review of Patient #5 ER physical examination indicated that the patient was in school talking with other students about shooting sports/target practice. The patient was asked by a student, "If she is to shoot someone, who would it be?" Patient stated "she" as herself. The patient mentioned to the classmate's the names of the individuals she was going to kill. The patient stated, "This is not a hit list but a hate list." The school principal contacted the patient's mother and her mother brought her to the ER.

Record review of the ER History of Present Illness revealed that the patient's mother told the ER provider that the patient had increased self-cutting events in the last two weeks and she was struggling at school. The school teachers also complained of the patient talking back to them.

The physical examination conducted on March 3, 2021, at 6:38 PM, indicated that the patient's skin showed signs of cutting on the left arm.

The patient is under mental health care for depression and currently is taking Zoloft 50 milligrams (MG) daily. The ER provider placed the patient on 1:1 observation.

Record review of the PHQ 9 " (Thoughts that you would be better off dead or hurting yourself in some way.") Patient answered, "Several Days, More than half a day."
Total score of the PHQ 9 was 19. The PHQ 9 revealed the patient had moderately severe depression.

Record review indicated that the patient was assessed by telemedicine behavioral consultant on March 3, 2021. The consultant stated, "The patient was at the shooting range today when someone asked her if she wanted to shoot someone who would she shoot, patient responded myself".

Review of the Medical Decision Making Clinical Course/Differential Diagnosis Note completed on March 3, 2021, the provider indicated, "I am unsure if the patient actually has a hit list or hate list. Patient states it is a hate list. She does not have suicidal ideation's. The consultant has assessed the patient and based on my conversation with her, we feel it is safe for the patient to go home."

Discharge Planning from the ER provider indicated that she is to see Behavioral Health before returning to school. Discharge education was provided to the patient's mother. The patient was discharged home on March 3, 2021 at 11:48 PM.

On March 10, 2021, at 4:33 PM, the patient was brought back to the ER from the Indian Health Counselor. During therapy the patient stated, "I'm going to take all my Zoloft 50 mg's." in an attempt to kill herself. The patient was placed on 1:1 observation. The PHQ 9 assessment was 17 (Moderate Severe Depression). Patient #5 was not discharged home. The patient was in the ER for 24 hours until the transfer to a mental health facility was completed March 11, 2021, at 11:17 am.


Patient #7

Record review indicated that the patient was brought to the ER by police on March 4, 2021, at 3:52 PM. The presenting complaint was Suicidal Ideation. She has a history of Hallucinations, Pain, Depression, Insomnia, Bipolar Disorder, and Hypocalcemia

Record review of the ER Visit Details indicated that the patient was in the jail and was found hanging in her cell. According to the medical provider notes, the correctional officers found the patient with a ripped blanket tied around her neck. Marks on neck found.

Review of the patient PHQ 9 completed on March 4, 2021, at 3:54 PM indicated a score of 19. Question number 9: Thoughts that you will be better off dead, or hurting yourself in some way. The patient answered, "Nearly every day". A PHQ 9 score higher that 19 signifies Moderate Severe Depression.

The patient stated to the ER medical provider that, "She cuts or attempts suicide when alone, the more alone she is the more likely she is to attempt things like this". The patient was placed on 1:1 observation in the Emergency Room.

Review of the Nursing Assessment conducted in the ER on March 4, 2021, at 3:52 PM indicated the patient had petechiae around the neck.

ER documentation review of the Critical Care Flowsheet revealed that the ER providers called telemedicine behavioral consultant at 4:47 PM. At 5:50 PM, the consultant called back to the ER provider and indicated "Might take the patient later when a spot opens."

Record review of the ER History of Present Illness written on March 4, 2021, at 3:52 PM, indicated that the patient told the ER provider, "She's been thinking about harming herself for a long time. Stated whether she was in jail or out of jail, would probably have done it."

Record Review of ER Medical Decision Making/Clinical Course/Differential Diagnosis note written on March 4, 2021, at 6:23 PM the provider indicated," Medically Cleared, COVID positive". Provider indicated, "I'm concerned about her history, her imbalance of her Trazadone and Wellbutrin, and suicide attempt. "Pending acceptance into HSC/Yankton." "Will discharge back to jail pending acceptance by HSC."

Review of the Discharge Instructions completed on March 4, 2021 at 7:38 PM indicated, "The behavioral health facility will call if/when you are accepted". The patient was discharged to the jail on March 4, 2021 at 8:15 PM.


Patient #9.

Record review indicated that the patient was brought to the ER by the police on April 16, 2021, at 4:06 PM., the presenting complaint was Suicidal Attempt. He has a history of Depression, Anxiety, Auditory hallucinations, Left hand fracture, Mood Disorder, Pain, and Insomnia.

Record review of the Chief Complaint written on April 16, 2021, at 4:06 PM, revealed, Suicide Attempt. Patient has abrasion on the right forearm that is self-inflicted in a suicide attempt. Patient had a plaster cast on his hand and was using that to cause the injury. Patient has a history of suicidal ideation and previous attempts."

Review of the PHQ 9 conducted at the ER on April 16, 2021, at 7:53 PM. PHQ 9 score: 27 (Severe Depression).

The pain assessment conducted in the ER on April 16, 2021, at 4:10 PM, was 10/10 (Score from 0 to 10, 10 being the worst). Patient stated that the pain is in the right arm where the cut was self-inflicted.

Review of the patient History of Present Illness completed on April 16, 2021, at 4:07 PM, indicated, "Patient presents from jail due to suicide attempt. Patient stated he has this type of thought before, voices urging him to harm himself." "The patient told the medical provider that he wanted to kill himself."

Behavioral Health Assessment was completed on April 16, 2021, at 4:16 PM, by Telemedicine. The consultation indicated that the patient was in a behavioral program in March 2021. The patient continued to state, "I hear voices to kill myself every day." Suicidal behavior: Yes. Clinical Status: Command Hallucinations to hurt self. Recommendations from the Telemedicine consultant: "You have been selected for inpatient care and treatment but you must return to jail until a bed is available."

Review of the Discharge Instructions revealed the ER medical provider agree with the Telemedicine Mental Health provider as: "You have been selected for inpatient care and treatment but you must return to jail until bed is available.

The ER Medical Clearance form completed on April 16, 2021, for the patient indicated with a check mark: "I have examined the prisoner and find him/her acceptable for admission into the RST Adult Correctional facility (jail). I have no specific suggestions regarding the care of this prisoner for the condition for which I have examined him/her." Physician/Nurse Remarks: "Patient requires suicide watch-based on recent attempt." The patient returned to the jail on April 16, 2021 at 7:05 PM.


Patient #14

Record review indicated a 15-year old patient came to the ER as a walk-in on 06/08/2021 at 12:31 am. The patient had a diagnoses that included Adjustment Disorder with depressed Mood, Post-traumatic Stress Disorder, Suicidal Ideation, Alcohol/Substance Abuse Disorder.

The patient presented to the ER with the Chief Complaint (C/O) of laceration of the right hand sustained by putting hand through a window. The mother reported that the patient was trying to break up a fight and put his hand through a window. Additional information obtained from the ED Nurse Triage Note revealed that the patient indicated on the PHQ-9 that "He feels he would be better off dead, or of hurting himself."

PHQ 9 (Patient Health Questionnaire) completed June 8, 2021 at 4:32 am, Question 9: "Thought that you would be better off dead, or hurting yourself in some way, scored 3-Nearly Everyday." Total score of 5 (5-9 moderate depression). Actions based on PHQ-9 Score revealed patient has Suicidal Ideation.

Record review of the ED Provider Note revealed that the PHQ-9 Screening was reviewed and documented a BH (Behavioral Health) consult would be required. Further record review of ED Provider Note under Psychiatric revealed the following statement: "C/O: states he doesn't want to be here anymore ..."

Social History revealed that the last Alcohol Screen results obtained 12/02/2020 was positive. Last Alcohol Screen on 06/08/2021 results: Positive. Ethanol Blood. Lab specimen collected at 01:44 am screen, result 197 mg/dl (.08 percent legal blood alcohol limit).Review of the Tele-Psych Consult revealed that the patient was evasive during the interview, was not forthcoming with information and the interviewer spoke with patient's mother regarding suicidal ideation. Per the tele-psych note, recommendation for inpatient psychiatric care was determined.

The ED Provider Assessment revealed the following in part, Suicidal Ideation - (P); the patient was accepted to Monument Health-Rapid City on 06/08/2021. Transportation arrangement was pending.

Review of the Risk Assessment note revealed that based on the nursing assessment documented the "Observer was required." At 02:16 am 1:1 observation initiated immediately.

Review of the Telemedicine BHS Nurse Assessment note revealed the patient reported thoughts about hurting himself once in the last two weeks and denied hurting his hand was intentional after a fight with a friend. The nurse assessment further revealed that the patient stated, he was actually having suicidal thoughts that night, the patient had a history of "Self-Harm: Cutting" and he cut himself a few weeks ago. The patient has received inpatient mental health services in Rapid City two months ago.

Review of the MSE (mental status exam) note conducted by the Registered Nurse revealed the patient reported experiencing auditory hallucinations, stating that he hears, "Someone calling my name." The patient also reported having SI earlier that day.

Review of the ER provider addendum note revealed, the patient was placed on 1:1 observation with staff and his mother at the bedside. The patient was to be discharged to a psychiatric facility but was pending transportation. At 09:15 am, the "patient became aggressive and stated "You guys can't fucking keep me here, I have my rights." Patient continued to rip off all his monitor leads and left at this time in a hurry attempting to push through staff. Patient eloped at this time."

The ER log revealed at 09:15 am, "Pt. left facility AMA."


Patient #21

Record review indicated an 18-year old female patient came to the ER on 01/25/2021 at 08:11 am with the Chief Complaint (C/O) of Suicidal Ideation. The patient had diagnoses that included Adjustment Disorder, Child Sexual Abuse, Depressive Disorder, Suicidal, snd Alcohol Abuse.

Record Review of the EMS (Emergency Medical Services) and Interventions on Arrival Report note revealed that the patient presented to the ER accompanied by EMS staff. EMS reported patient tried to hang herself this morning with a cell phone charging cord in her bathroom, the patient had been drinking a large amount of vodka and there was vodka near the patient.

Record review of the ER History Past Medical History note revealed in the psychologic ROS (review of systems): "depression, suicidal thoughts, one prior mental health admission for a week or two about four years ago". The psychiatric assessment indicated the patient had a flat affect and admitted frequent suicidal thoughts. The patient had a PHQ 9 score of 13 (10-14 moderate depression). The patient was discharged home.


Interviews:

On June 7, 2021, at 11:23 am, an interview was conducted with the ER Contract Staff Nursing Supervisor. The Supervisor stated that he is responsible for training the contract nursing staff in all new policies and procedures in the ER. The Supervisor indicated that 90% of the nursing staff is contract employees, and he supervises and ensures that the staff is proficient in administering care for all patients that come for any emergency. The ER Supervisor further stated that the hospital leadership is changing the policy governing the transfer of psychiatric patients to the jail for suicidal watch. The Supervisor indicated that as soon as the policy is official he would be training the contract nurses on the procedures to follow in the care of psychiatric patients, especially suicidal attempt or ideation. He also stated that the contract nurses rotate every three weeks but no contract nurse will be assigned a patient until they are trained


On June 7, 2021, at 12:01 PM, an interview was conducted with the Chief Nurse (CN) Great Plains Area Office. The CN stated that the RCA was completed and some updates were made after all the investigations were completed by the hospital leadership. The CN stated that the patient (Patient #11) died at home by suicide and not in the jail. When asked if she knew what the process is for suicidal patients that are sent from the hospital ER to the jail for suicidal watch, the CN responded, "The process is for the ER provider to evaluate the suicidal patient, get a court order for involuntary seclusion, complete the Medical Clearance and transfer the patient to a Behavioral Health Care facility or to the jail. Once they get to the jail, I don't know what the process was until Patient #11 incident. We will not send any suicidal patients to the jail until they are stable or transfer out to another facility for mental health care."


On June 7, 2021, at 12:30 PM, an interview with the hospital Chief Operating Officer (COO) was conducted. During the interview the COO stated, "According to our investigation the ER doctor medically cleared the patient (Patient #11) to be transferred to jail with instructions to have the patient on suicidal watch." "We did not find the Medical Clearance form for this patient nor did the jail." During the interview, the COO stated, "before this incident (Patient #11), we have always sent the suicidal patients to the jail for suicidal watch. "The ER medical provider will evaluate the suicidal patient, they will get a court order for involuntary seclusion, and then the patient will be transferred to the jail. That was our process." When asked if the hospital leadership has ever been in the jail where the correctional officers keep the suicidal patients on suicide watch, the COO stated, "We never visited the jail until this incident." "There is no medical staff in the jail, no nurses, the patients were without clothes, no bedding, nothing in the jail cell." "The suicide watch in the jail is the Correctional Officer who will go to the suicidal patient and observe him/her every 30 minutes." "The patient was not mentally stable at the time of the transfer." "We don't know how the judge ordered bail for him in less than 24 hours of being in jail." When asked if the patient was waiting to be transferred to a Mental Health facility, the COO stated, "Yes." The COO stated, "When the medical provider called the jail so they can bring the patient back to the hospital for transfer, the Correctional Officer stated that the patient was under arrest for assaulting a Police Officer and they can't un-arrest him. Nor can he go to the facility the hospital was transferring him to because it was not a correctional facility." The COO stated that the ER medical provider or the evening supervisor failed to call leadership and alert them of this incident.


On June 7, 2021, at 2:15 PM, an interview was conducted with a hospital Pharmacist. The Pharmacist stated that the hospital pharmacy dispensed Lorazepam injectable (PYXIS medication machine) twice on the evening of April 24, 2021. The doctor's order was for Lorazepam 1 mg's Intramuscularly at 7:35 PM and Lorazepam 1 mg intravenous at 8:02 pmt Pharmacist stated the discharge order for Lorazepam was never picked up by the Correctional Officers before taking the patient to the jail. The Pharmacist stated, "Lorazepam order was discontinued because nobody from the correctional facility (jail) picked it up for the patient.


June 7, 2021, at 2:56 PM, an interview was conducted with the hospital Chief Nurse Officer (CNO). When asked about the process for suicidal attempt/Ideation patients that come from the jail or the street, the CNO stated, "We are changing the process. For years the process was to evaluate the patient in the ER. If the patient is unstable, the providers can request for the patient to be transferred to a Mental Health facility or the provider will ask for a court involuntary seclusion order. Once the judge signed the order, the patient was taken to the jail for suicidal watch." The CNO stated that the medical provider has to sign a Medical Clearance for the patient to be taken to the jail. When asked if the Medical Clearance gave any recommendations for the Correctional Officer to follow, the CNO stated, "Some do." The CNO stated that the patient was not ready to be sent to the jail because he was out of control, aggressive, not following any commands, and had not been completely evaluated. The CNO stated, "He was not mentally stable". "The ER staff failed to control the situation by not de-escalating the situation. The Police should have never come because we believe this made it worse." "This is should not have happened, this was a young man that needed help, this is very sad for us and the community". The CNO stated the hospital policy and procedure for the suicidal patient coming to the ER is going to change. The CNO also stated that the new policy went out to be signed and approved by leadership. "After it is signed, we are all going to be trained, especially the ER staff and all the hospital workers that assist as 1:1 observers."


On June 8, 2021, at 8:50 am, the hospital Deputy Clinical Director was interviewed. The Director indicated that the incident with the patient was sad and that she is expecting changes in the process governing the ER handling of suicidal patients. When asked if she believed Patient # 11 was Medically Clear to be transferred to the jail for suicidal watch by Correctional Officers, the Director responded. "No". "He was not mentally stable. The medication administered twice did not work for him. The 1:1 observer released the restraints too early without the doctor orders. The Police being call twice did not help the situation. The ER staff failed to activate Code Green, and the medical provider allowing the Police to take the patient to jail after the arrest was unnecessary." The Director indicated that the situation was not handled well by her staff and she was very disappointed. When asked, what she wanted to see changed after this event, the Director stated, "Everything". "We have to become more sensitive and understanding when we address suicidal ideation's."


On June 8, 2021, at 9:10 am, the ER Manager was interviewed. The ER Manager stated that the hospital does not have any contract or agreement with the local jail to send suicidal patients to be monitored at the jail. The Manager also stated there are five Mental Health facilities that they can transfer their active suicidal patients to. However, they are full most of the time. She stated that she is responsible for the day by day operations in the ER and she ensures that there is sufficient staff (Nurses and Medical Providers) each shift. When asked who is responsible for ensuring that the ER nursing staff is familiar with the hospital policies and procedures, the manager stated that "she is responsible for the permanent staff nurses ". "There is a new verbal order from leadership that instructs us not to send suicidal patients to the jail. We are to keep them until they get discharged to a safe location." The Manager was asked if she was familiar with the type of care the jail was providing to the ER patients on suicidal watch. The Manager stated, "We recently learned that they are only doing observations every 30 minutes, until Mental Health goes to visit them at the jail." The Manager confirmed that the transfer of Patient #11 to the jail was the wrong thing to do. The ER manager stated, "once the patient is out of their hospital there is no way to know how they are doing or if they have been seen by Mental Health Services, or if they have been transferred to a Mental Health facility." The ER Manager further stated that Patient #11 was not mentally stable and was waiting to be transferred to a Mental Health facility until his aggression towards the Police got him arrested. The Manager confirmed that the RCA was very specific in the areas that the ER staff needs improvement. The ER manager mentioned de-escalation of disruptive behaviors, restraints, Code Green activation and caring for the suicidal patient.


June 8, 2021, at 11:47 am, an interview was conducted with the hospital Quality Assurance and Performance Improvement (QAPI) Coordinator. During the interview, the Coordinator stated that the QAPI team meets every morning for morning reports and updates. The QAPI Coordinator stated that every month they have a formal meeting with all the department managers and leaders. In the meetings, they discuss any new plans for quality improvement of the departments. They also discuss the existing projects that the teams are working on. They revise policies and procedures with the opportunity to improve practices involving patient care. Every discussion in QAPI is taken to the Governing Body, including minutes of all the different departments. When asked about the Root Cost Analysis for Patient #11's negative outcome, the Coordinator stated that leadership and all the members from QAPI were seriously involved with the RCA report. In doing a RCA, the hospital leadership determined that they failed in several critical areas and they were already taking action. The Coordinator stated that the completion of the RCA revealed that the ER staff (medical providers and nurses) needed training in the use of restraints, Code Green activation, how to de-escalate an agitated patient, how and when to call the Police, recognizing signs of a suicidal attempt in the ER, the completion of PHQ 9 in all suicidal patients, identifying when a medical provider can declare a suicidal attempt/ideation patient is "Medically Cleared" to be taken to jail, when to tell the Police that the patient is not ready to be transferred to jail, when ER staff needs to call leadership and notify a difficult situation and the possibility of staff burn -out.
When asked if the hospital has an agreement with the jail on how to perform suicidal watch on a patient awaiting transfer to a Mental Health facility, the Coordinator stated, "No." When asked if the nursing staff or leadership has visited the jail where suicidal patients were being discharged to, the Coordinator stated, "No, when we started this RCA it was the first time we went to the jail and it was an eye opener." "The conditions in the suicidal watch jail cell are depressing; no covers for the bed, no clothing, no bathroom, and no body to talk to." The Correctional Officer goes to the cell every 15-30 minutes." She stated that it is just not the place for a patient that attempted to take his/her life." The Coordinator stated that leadership went to the ER and informed the medical providers that the suicidal patients will not be taken to the jail for suicidal watch, but will stay in the ER until a bed is available in a transferring facility. When asked if the new policy has been developed, the Coordinator stated, "Yes, we are waiting for signatures and then we will begin an all staff training."


On June 9, 2021, at 9:00 am, an interview was conducted with Evening Nursing Supervisor. The Supervisor stated that she is a RN federal employee and she is also a bed coordin