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Based on review of the hospital policies and procedures, Medical Staff Bylaws, Rules and Regulations, Medical Record (MR), Emergency Medical Services Prehospital Care Report, and interviews with staff it was determined Providence Hospital failed to ensure Patient Identifier (PI) # 13 who presented with suicide ideations and an identified risk of harm to himself/herself received/completed a Medical Screening Examination (MSE) and; failed to offer and inform (PI) #3 of the risks and benefits of completing the medical screening examination, and receive further evaluation and treatment for his/her suicidal ideations.

Refer to tags A2406 and A2407

Based on review of the facility policies and procedures, Medical Record (MR), EMS (Emergency Medical Services) Prehospital Care Report, and interviews with staff it was determined the facility failed to ensure an appropriate Medical Screening Examination (MSE) was performed for a patient who presented to the Emergency Department (ED) with suicide ideations and to determine if an emergency medical condition existed.

This deficient practice affected one of three MRs reviewed of patients presenting with Suicide Ideations including Patient Identifier (PI) # 13 and had the potential to negatively affect all patients presenting with suicide ideations.

Findings include:

Facility Policy: EMTALA
Policy Number: 2.01.72
Effective Date: 9/9/22

Policy:

It is the policy of Providence Hospital that any individual who comes to the Hospital...and who is in need of or requests emergency medical services will be provided necessary emergency medical services as described...

1. Medical Screen Examination (MSE) by a physician or Qualified Medical Person (QMP) to determine if the individual has an Emergency Medical Condition (EMC).

2. Patients with psychiatric symptoms must receive a Medical Screening Examination sufficient to assure that a medical condition that mimics a psychiatric condition is not present.

3. If an Emergency Medical Condition exists, the QMP provides further medical examination and treatment as required to stabilize the Emergency Medical Condition within the capability of the facility...

4. There shall be no delay with the provisions of a Medical Screening Examination, stabilizing treatment or the appropriate transfer...

Procedure:

A. Medical Screening Examination:

1. The hospital shall provide a Medical Screening Examination for every individual who comes to the emergency department seeking medical treatment...

7. The Medical Screening Examination is an ongoing process. The medical record must reflect continued monitoring, according to the individuals condition, which must continue until he is stabilized or appropriately admitted for transferred...

Facility Policy: Suicide Risk Assessment and Precautions
Policy Number: 5.01.247
Effective Date: 9/29/22

Policy:

A. An RN (Registered Nurse) will perform a suicide risk screen utilizing the Columbia Suicide Severity Rating Scales. (CSSRS) during the initial assessment at the point of entry to the organization (e.g. Emergency Department...)

...D. Based on the patient's response to the screening questions, the level of risk and actions to be taken will be determined. Suicide precautions to include 1:1 direct supervision will be implemented when the patient is identified at high risk for suicide...

Guidelines for Care for the Suicidal Patient:

C. High Risk. Suicide precautions will be maintained on patients who are identified as exhibiting suicidal behavior with a specific plan for suicide based on the risk screen.

This process will include:

1. Notify the attending physician for suicide precaution order and psychiatric consultation.

2. Admit patient to private room...any doors and blinds should remain open...

6. Provide 1:1 continuous monitoring by a qualified staff member or a trained sitter...Observation of the high risk patients behavior should be documented every 15 minutes in the individuals Observation Record...

Documentation:

A. CSSRS screening responses.

B. Observations of patient behavior and retaliated nursing interventions. Observations of patient behavior should be documented at a time interval according to risk level.

Facility Policy: Electronic Documentation in ED
Policy Number: 5.07.100
Effective Date: 10/11/22

Policy:

...2. The Emergency Department nurse should document patient assessments, interventions...and all other patient related information within the medical record utilizing the appropriate electronic and/or paper forms...

6. All patients presenting to the Emergency Department will be assessed for... Psychiatric complaints regardless of presenting complaint, age and/or gender.

7. Patients presenting with suicidal/homicidal complaints will be assessed for potential suicidal/homicidal risk...

VII. Disposition of patient - Left before Triage or Left Without Being Seen:

C. Patients who register, are triaged, have orders entered by the triage nurse per protocol and leave prior to MSE (LWBS) will also be entered as "Left without being seen" on the Disposition screen.

1. PI # 13 presented to the ED on 8/31/22 via ambulance.

Review of the EMS Prehospital Care Report dated 8/31/22 revealed the EMS arrived on the scene at 9:23 PM, PI # 13 was in police custody complaining of chest pain, headache, and suicide ideation and had a previous suicide attempt. PI # 13 was transported by EMS at 9:30 PM and arrived at Providence Hospital at 10:02 PM. The vital signs enroute were blood pressure 172/100, pulse 87, respirations 16, and oxygen saturation was 99%.

Review of the ED Triage and Nursing Assessment dated 8/31/22 at 10:32 PM revealed the chief complaint of chest pain, suicidal ideation and headache times one month. The blood pressure was 159/90, heart rate 79, respirations 18 and temperature 98.0. No ED rooms were available at the time of PI # 13's arrival so the patient remained on the EMS stretcher in front of the nurses station for the duration of the ED visit which was from 10:02 PM until 12:34 AM on 9/1/22.

Review of the Columbia-Suicide Severity Rating Scale (C-SSRS) assessment documented on 8/31/22 at 10:32 PM revealed PI # 13's risk level was calculated as a High Risk.

Review of the physician orders dated 8/31/22 revealed orders for suicide precautions, laboratory studies.

There was no documentation the laboratory tests were collected or resulted.

Review of the nurse note dated 9/1/22 at 12:33 AM revealed the nurse documented the PI # 13 stated he/she no longer had suicidal ideations and he/she was leaving because a patient was placed in a room before him/her.

Further review of the EMS Prehospital Care Report Narrative section dated 8/31/22 revealed the Paramedic documented "...the patient got angry that a room was given to a STEMI (ST Elevation Myocardial Infarction) patient so (he/she) stated that (he/she) wanted to leave...the patient pulled all of the ECG (Electrocardiogram) cables off...we lowered the stretcher so that (he/she) could get up...the patient then left the ER (Emergency Room)." The EMS was back in service on 9/1/22 at 12:43 AM.

There was no documentation an appropriate MSE was performed to determine whether an emergency medical condition existed.

There was no documentation PI # 13 was monitored by 1:1 observation as directed per facility policy for high risk suicidal patients, and there was no documentation the facility staff informed PI # 13 of the risks of leaving without the completion of the MSE.

An interview conducted on 10/20/22 at 9:28 AM with Employee Identifier (EI) # 1, Vice President of Patient Care who confirmed there was no documentation an appropriate MSE was performed to determined whether an emergency medical condition existed.

An interview was conducted on 10/20/22 at 3:20 PM with Employee Identifier (EI) # 6. During the interview EI # 6 was asked about patients with suicidal ideation's and where they are placed in the ED and what is done for them. EI # 6 stated that someone would observe the patient and if no beds were available they are placed in front of the nurses station and the nurse would observe them. EI # 6 stated on 8/31/22 the patient was brought to the ED by ambulance and kept on the stretcher in front of the nurses station. EI # 6 stated there were two EMT's (Emergency Medical Technicians) and his/herself observing the patient 1:1.

Based on Medical Record (MR) review, facility policy and procedure, and interviews, it was determined the hospital failed to ensure that staff offered the individual further medical evaluation, and treatment and informed the individual of the risks and benefits to the individual of completing the medical evaluation and further evaluation and treatment of the patient's presenting signs and symptoms of suicide ideations.

This deficient practice affected 1 of 3 MR's reviewed with Suicidal Ideations (SI), including Patient Identifier # 13 and had the potential to negatively affect all patients presenting to the Emergency Department (ED) with SI.

Findings include:

Facility Policy: EMTALA
Policy Number: 2.01.72
Effective Date: 9/9/22

Policy:

It is the policy of Providence Hospital that any individual who comes to the Hospital...and who is in need of or requests emergency medical services will be provided necessary emergency medical services as described...

3. If an Emergency Medical Condition exists, the QMP provides further medical examination and treatment as required to stabilize the Emergency Medical Condition within the capability of the facility...

Procedure:

B. Individuals who have an Emergency Medical Condition

When it is determined that the individual has an Emergency Medical Condition the Hospital shall:

Within the capability of the staff and facilities available at the Hospital, stabilize the individual to the point where the individual is either "stable for discharge" of "stable for transfer"...

C. Individuals who have an Emergency Medical Condition but refuses to consent to treatment or to transfer

If the individual refuses the examination or treatment, advise the individual or legally responsible person of the risks of refusal. Document the refusal and risks in the medical record...

1. PI # 13 presented to the ED on 8/31/22 via ambulance.

Review of the EMS Prehospital Care Report dated 8/31/22 revealed the EMS arrived on the scene at 9:23 PM, PI # 13 was in police custody complaining of chest pain, headache, and suicide ideation and had a previous suicide attempt. PI # 13 was transported by EMS at 9:30 PM and arrived at Providence Hospital at 10:02 PM.

Review of the ED Triage and Nursing Assessment dated 8/31/22 at 10:32 PM revealed the chief complaint of chest pain, suicidal ideation and headache times one month. The blood pressure was 159/90, heart rate 79, respirations 18 and temperature 98.0. PI # 13 remained on the EMS stretcher for the duration of the ED visit due to no ED bed availability.

Review of the Columbia-Suicide Severity Rating Scale (C-SSRS) assessment documented on 8/31/22 at 10:32 PM revealed PI # 13's risk level was calculated as a High Risk.

Review of the physician orders dated 8/31/22 revealed orders for suicide precautions and laboratory studies.

There was no documentation the laboratory tests were collected or resulted.

Review of the nurse note dated 9/1/22 at 12:33 AM revealed the nurse documented PI # 13 stated he/she no longer had suicidal ideations and he/she was leaving because a patient was placed in a room before him/her.

There was no documentation the physician was notified PI # 13 was leaving and there was no documentation PI # 13 was offered further medical examination and or treatment as stated in the facility's policy.

An interview conducted on 10/20/22 at 9:28 AM with Employee Identifier (EI) # 1, Vice President of Patient Care who confirmed there was no documentation necessary stabilizing treatment was performed.