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as edvidenced by lack of written policies related to patient safety as it pertains to patients with intent to harm self or harm others.

Based on record review and interview, the hospital failed to implement policies to protect the health and safety of patients for 1 (patient #16) of 20 patients reviewed.

This failed practice had the likelihood of putting patients at risk of self harm.

Findings:

During an investigation of complaint OK00058687 (regarding a different facility), OSDH reviewed documentation that suggested noncompliance with Provision of Services during an encounter with this hospital.

On 04/22/22, patient #16 was diagnosed with suicidal ideation after prior suicide attempt. While in the Emergency Department (ED) no suicide precautions were in place and patient was able to leave the ED unaccompanied.

On 05/05/22 staff D stated that a patient at risk for suicide in the ED would be placed on suicide precautions and have a staff member at bedside at all times to protect the patient from self harm. Staff D also stated that the patient on suicide precautions should be with the staff member as they moved through the facility.

On 05/06/22, the surveyors requested a copy of facility policy that addresses suicide precautions for patients in the ED. Staff C stated in part that there were no suicide precautions in place for patient #16 and there are currently no policies specific to suicide precautions in the ED.

Based on record reviews and interviews, the hospital failed to ensure a MSE was performed for all patients presenting to the ED requesting a MSE. This failed practice had the potential to result in a delay of treatment and deterioration of the patient's condition for 1 (Patient #20) of 20 patients reviewed that presented to the ED for a MSE.

Findings:

The surveyor reviewed an Emergency Department policy titled "Emergency Order of Detention (EOD)" which read in part:

"Any patient presenting to the Emergency Department with complaints of a psychiatric nature shall receive an appropriate medical screening by the Emergency Department provider to determine if they are at risk of being harmful to themselves or others. This screening shall include: an evaluation of the patient's physical condition and all necessary measures available at this hospital to stabilize the patient."

The surveyor reviewed the complaint and incident logs for the prior 6 months and noted the following in the description of incident #OC-22-14161 on 04/20/22 at 9:00 PM:

"Mother brought 14 year old patient to the ER due to suicidal thoughts. Mother was told we cannot treat the patient and even if we could, there are no police to provide transport. She was not allowed to check into the ER."

The surveyor reviewed a document titled "Quality Investigative Log" dated 04/22/22 at 11:44 AM, which read in part:

"I spoke with (Staff F)...the mother walked up and said what they needed seen [sic] for, so (Staff F) called the back. (Staff G) answered the phone...stating it will be a 6 hour process, but to bring the patient back..."

"Evidently (Staff H) overheard and said we did not have police on duty to stay with or transport the patient and they should try Seminole (a different hospital). (Staff F) told the mother this...the mother was angry and left."

During an interview on 05/05/22, the surveyor asked staff D under what circumstances a patient presenting to the ED would not receive a MSE. Staff D stated "You see everybody."

During an interview on 05/05/22, the surveyor asked Staff E under what circumstances a patient presenting to the ED would not receive a MSE. Staff E stated "There are no conditions to skip a MSE."