HospitalInspections.org

Based on record reviews and interviews the facility failed to:

1. Implement or execute recomendations based on the Suicide Lethality Scale for 4 (P2, P7, P8, & P10) of 10 patients sampled for having concerns of suicidal ideation based on presentation.

2. Provide continuous 1:1 care for 2 (P2 and P8) of 10 patients sampled for having concerns of suicidal ideation based on presentation.

3. Provide care in a safe setting by not following the hospital Suicide Precautions policy & not providing supervision.

This failed practice has the likelihood to result in patients not receiving the optimal care to maintain their highest practical well being which could lead to an increased risk for adverse events, and negative clinical outcomes, including death. See tag 144

Based on record reviews and interviews the facility failed to:

1. Implement or execute recommendations based on the Suicide Lethality Scale for 4 (P2, P7, P8, & P10) of 10 patients sampled for having concerns of suicidal ideation based on presentation.

2. Provide continuous 1:1 care for 2 (P2 and P8) of 10 patients sampled for having concerns ideation based on presentation.

3. Provide care in a safe setting by not following the hospital Suicide Precautions policy & not providing supervision.

This failed practice has the likelihood to result in patients not receiving the optimal care to maintain their highest practical well being which could lead to an increased risk for adverse events, and negative clinical outcomes, including death.

The findings are:

A. Record review of facility's policy, "Suicide Precautions," dated 02/2020, revealed:

1. "Patients admitted to the hospital with suicidal ideation will be screened for risk of suicide utilizing the Suicide Lethality Scale. If a patient is identified to be at risk for suicide, then suicide precaution interventions will be implemented including referral to a behavioral health professional. At discharge suicide prevention information will be provided.

2. "Facility Name Identifier will minimize the risk by placing any patient with a high risk for suicide either in ICU (Intensive Care Unit provides the critical care and life support for acutely ill and injured patients) or an area where they can receive 1:1 by a trained observer at all times. Once medically stabilized, the patient may be transferred to a secure behavioral health facility as soon as possible if criteria indicate the need.

B. Record review of facility's policy, "Lethality Scale," dated 02/2020, revealed:
1. " Patients with High Risk Score will have the following safety measures implemented:
A. Suicide Risk screening (Suicide Lethality Scale) will be documented upon admission by nursing.
C. Patients will be monitored in ER, admitted to an ICU bed (depending on acuity and medical need) or admitted to a regular patient room where 1:1 monitoring there continuous direct observation can be maintained to ensure safety.
E. Patient is restricted to unit unless accompanied by nursing staff.

C. Record review of the "Initial Suicide Lethality Scale", undated, revealed:
1. Score is 0-39 = Suicide Risk: Low. Occasional or fleeting suicidal ideation, no plan, will contract for safety.
2. Score is 40-125 = Suicide Risk: High. Ongoing suicidal ideation, command hallucinations, or clear intent with concrete plan.

D. Record review of P8's medical chart from 12/15/2020 revealed:

1. At 12:54 am, P8 was admitted to the Emergency Department with a documented Chief Complaint of "anxious, self injury, and suicidal thoughts, (took several unknown dose of street Xanax, (medication which acts on the brain and nerves to produce a calming effect) in an attempt to kill herself, due to situational problems with her father who is verbally abusive.) and agitated, delusional and paranoid."

2. On 12/15/2020 at 2:17 am P8 was asked questions by S12 (Registered Nurse) on the Initial Suicide Lethality Scale, P8 scored a 41, which scores in High Suicide rate according to scale. Refers to ongoing suicidal ideation, command hallucinations (auditory commands to perform a specific act), or clear intent with concrete plan.

3. Record review of physician orders, S12(Medical Doctor) placed orders for suicide precaution on 12/15/2020, which were initiated at 1:08 am.

4. Record review pf physician orders, S12 placed orders for elopement precaution (when a patient leaves a facility without authorization, or appropriate supervision) on 12/15/2020 which were acknowledged by S13 (Registered Nurse) at 1:08 am.

5. No evidence P8 was placed on 1:1 suicidal monitoring.

6. Record review of, "Suicide Observation and Plan Of Care," revealed no documentation or observation at times of 10:15 am, and 10:30 am and no documentation the room that P8 was in was clear of any ligature (Materials used to tie or bind tightly), on 12/15/2020

7. Record review of P8's medical chart revealed that the patient was transferred to a Behavioral Health Facility on 12/16/2020 at 10:30 am.

E. On 08/03/21 at 9:46 am during interview with S4 (Lead Security Officer) stated, he was called at 11:03 am from the Emergency Department, and was told P8 kept coming out of her room. "She was awaiting transfer to a behavioral facility. She didn't have a sitter, security was not asked to watch the patient."

F. On 08/03/21 at 10:13 am during interview with S5 (ED Tech) stated, "there was no sitter with the patient that day."

G. Record review of P2's medical chart from 04/06/2021 revealed:

1. At 3:43 pm, P2 arrived in Emergency Department with a documented Chief Complaint, (a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter) of depression, suicidal thoughts, and cutting of wrist.

2. No documentation of Initial Suicide Lethality Scale (tool which gives clinicians a rapid, accurate, and empirically validated measure of suicide risk in adults and adolescents.)

3. No documentation of Facility Suicide Risk Assessment (to help establish a person's immediate risk of suicide in a specific environment.)

4. Record review of physician orders, S(Staff)10 (Medical Doctor) placed orders for suicide precaution (Process to keep a patient that has suicidal thoughts) on 04/06/2021 which were initiated at 4:55 pm.

5. No documentation of 1:1 (plan ensuring the safe and sensitive monitoring of the patients physical and psychological well-being) observation by a trained observer.

6. No documentation from 8:15 pm to 8:45 am, of 15 minute safety check (verbal and visual quick assessment/monitoring of the patient location, and the environment for possible unsafe conditions) performed.


H. Record review of P7's medical chart from 04/20/2021 revealed:

1. School Counselor performed Columbia-Suicide Severity Rating Scale (a 6-question assessment of suicidal thinking and behavior to help first responders, faculty and staff identify students in psychological crisis that might need immediate intervention,) referred P7 to ED for disclosing information to him about "hurting herself," and concern of ongoing suicidal ideation and comments.

2. No documentation of Initial Suicide Lethality Scale.

3. No documentation of Facility Suicide Risk Assessment.


I. Record review of P10's medical chart from 04/22/2021 revealed:

1. On 04/22/2021, at 11:30 am, P10 arrived in Emergency Department with a documented Chief Complain of "Suicidal Thoughts, (Patient states she expressed suicidal intentions to her counselor today, she states she has had suicidal thoughts for a year now but today is worse. She denies a plan at this time.)"

2. No documentation of Initial Suicide Lethality Scale.

3. No documentation of Facility Suicide Risk Assessment.

4. Record review of physician orders, S11 (Medical Doctor) placed orders for suicide precaution on 4/22/2021 which were initiated at 12:40 pm.

J. On 8/2/2021 at 1:00pm during interview with S1 (Human Resource Director) the surveyors requested to interview S12 (Medical Doctor) and S13 Registered Nurse), S1 stated that S12 and S13 were no longer employed at the facility and would not be able to arrange an interview with either former staff member.

Based on record review and interview, the hospital failed to ensure:

1. To report adverse events (An unexpected medical problem that happens during treatment with a drug or other therapy).

2. Care is provided in accordance with hospital's policy of the "Chaperone use by providers", last revised dated 07/2018 revealed "Examinations that may require the presence of a chaperone include: Pediatric examinations." See tag 286.

This failed practice has the likelihood to result in negative outcomes by not resolving adverse events and expose patients to ineffective or unsafe care.

The findings are:

A. On 08/02/2021 at 2:00 pm during interview with (Staff) S9 (Chief Nursing Officer) confirmed that the previous director of quality did not report the incident between the pediatric patient and the provider that happened (Allegation of inappropriate conduct) on 12/15/2020 to the quality committee.

B. On 08/03/2021 at 11:00 am during interview with S3 (Quality and Risk) confirmed that the previous director of quality did a report (Sequence of events) on the incident on 12/15/2020 but did not report the incident to the quality committee.

C. Record review of the "Sequence of events", dated 12/15/2020 revealed that the provider examined the Pediatric patient alone, without a chaperone present.

D. Record review of the "Chaperone use by providers", last revised dated 07/2018 revealed "Examinations that may require the presence of a chaperone include: Pediatric examinations."

Based upon record review and interview the facility failed to ensure that the Quality Assessment Process Improvement (QAPI) committee report to the governing body any adverse events. This failed practice of not reporting adverse events to the organized committee is likely to result in patients not getting the necessary care needed.

The findings are:

A. Record review of the "Quality steering committee agenda" (a group of people that reviews incidents and recommends how the quality department handles the incident) revealed:

1. No documentation of a quality committee meeting from 01/01/2021 to 03/01/2021.

2. Dated 03/18/2021 revealed no documentation of the incident that happened on 12/15/2020.

B. On 08/04/2021 at 2:00 pm during the exit conference (Staff) S14 (Chief Executive Officer - CEO) confirmed that the facility did not have a governing body from 01/01/2021 to 04/01/2021 because of the reorganization of the governing body. S14 also confirmed that the new governing body was not informed of the incident that happened on 12/15/2020.