HospitalInspections.org

Based on staff interview, medical record review, and review of facility documents, it was determined the facility failed to ensure: 1.) policies and procedures for incident reporting are followed by all staff; and 2.) a suicide screening is completed accurately for all patients in the ED in one of seven medical records reviewed (Patient (P) 1).

Findings include:

1. Facility policy titled, "Incident Investigation Reports" (Last Revised 06/2024) stated, "Policy: Reporting is essential to the identification and evaluation of incidents for the purpose of improving processes, patient care and safety issues. The purpose of such documentation is to identify patterns of risk to patients, visitors, and/or the organization, conduct further investigations as needed, and provide a foundation for education to reduce risks. incidents involving patients and visitors are documented according to the procedure specified below. ... Definition: .. .b. Near Miss: an occurrence that could have resulted in an adverse event, but the adverse event was prevented. ... Procedure: 1. The person discovering the error/near miss communicates the incident to the supervisor for the purpose of taking action to mitigate harm to involved parties. 2. The person discovering the incident completes a Healthcare Event Report, no later than by the end of their shift, using the electronic tool located on the [name of facility] Intranet. ... c. Provide a brief, objective, factual narrative description of the event. d. Review all information and submit. ... When notified of an error or near miss in their area, the manager/supervisor is responsible for performing an investigation and documenting follow-up and corrective action in the electronic reporting system ..."

Facility document titled, "Behavioral Health: [Name of facility] ED Environmental Assessment (May-August 2024)," stated, " ... This Self-Assessment Questionnaire (SAQ) highlights areas of risk management and patient safety unique to behavioral health treatment facilities or units, with particular emphasis on policies and procedures for the safe environment of care, use of restraints and seclusion, and suicide risk assessment and prevention ..."

An incident report was requested for the 08/08/24 incident, when P1 attempted to jump over the rail outside the ED. The facility failed to provide an Incident Report from the event on 08/08/24, when security officers de-escalated P1 from the railing and brought him/her into the ED for a psychiatric evaluation.

Review of an email titled, "[Name of facility] Last 24 hr (hour) Incident Reports" that was sent to facility administration on 08/09/24, stated, "Statistics from Occurred Date 8/8/24 6:00 am to 8/9/24 6:00 am ... 6 Searches; 6 Returns; 1 Room Search---3rd floor; 1 Fire Drill; No other Issues." This document did not contain evidence of P1 attempting to jump over the rail.

On 08/30/24 at 12:45 PM, S3 confirmed an incident should have been generated and that no incident report was filed for the 'near miss' event that occurred at the ED railing on 08/08/24 as per facility policy.

2. Facility policy titled, "Suicide Risk Assessment & Prevention, S-8" (Last Revised: 02/2024) stated, " ... Policy: ... 2. The Columbia Suicide Severity Rating Scale (C-SSRS) is utilized to screen for a patient's risk for suicide upon arrival to the ED [emergency department] ... The determined level of risk identified through screening aids the licensed provider and clinical nurse in determining clinical management and interventions to prevent patient self-harm (see Appendix A). ... 4. The provider, clinical nurse, and other members of the health care team utilize the C-SSRS identified levels of risk ... to make clinical decisions when addressing the care needs of the patient. Documentation of such clinical decision making must be documented in the patient's medical record ... Appendix A: Columbia-Suicide Severity Rating Scale Screen Version-Recent ... Suicide Ideation Definitions and Prompts ... Past Month ... Ask questions 1 and 2. 1) Have you wished you were dead or wished you could go to sleep and not wake up? Yes (Yellow)/ No (Blank) ... 2) Have you actually had any thoughts of killing yourself? Yes (Yellow)/ No (Blank) ... If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6) ... 3) Have you been thinking about how you might do this? Yes (Orange)/ No (Blank) ... 4) Have you had these thoughts and had some intention of acting on them? Yes (Red)/ No (Blank) ... 5) Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Yes (Red)/ No (Blank) ...6) Have you ever done anything, started to do anything, or prepared to do anything to end your life? If yes, ask: 'Was this in the past three months?': Yes (Red)/ No (Orange) ... Key: Low Risk (Yellow); Moderate Risk (Orange); High Risk (Red) ... ."

Upon review of the medical record for P1 on 08/28/24, the following was noted:

P1 arrived at the ED on 08/20/24 at 3:24 AM with complaints of suicidal ideation and shoulder pain.

The triage note written by S32, an RN, at 3:25 AM, stated, "Pt arrives ambulatory c/o [complaint of] SI [suicidal ideation]. States 'the only reason I didn't do it was because I didn't have anything sharp.' 1:1 maintained ..."

Review of the patient's Columbia Severity Rating Scale (C-SSRS Short Version) completed 8/20/24 at 3:28 AM, indicated that for Question #1: 'Wish to be dead', the nurse documented "No"; Question #2: 'Suicidal thoughts', the nurse documented "No"; Question #6: 'Suicide Behavior Question', the nurse documented "No." The C-SSRS Risk Level indicated there was 'No Risk identified.'

The nurse's documentation on the C-SSRS did not indicate that the patient had presented to the ED with a chief complaint of suicidal ideation, as per facility policy.