HospitalInspections.org

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Based on medical record review, document review an interview, in one (1) of 20 medical records reviewed, nursing staff failed to notify the physician of pertinent information regarding patient's suicidal thoughts received from the patient's mother so that it contributes to the overall care of the patient. This finding was evident in MR #1.

Findings include:

The policy titled "PCS: Nursing Documentation: Assessments, Reassessments, Plan of Care and General Documentation," last reviewed 4/21/21 states, "The nurse will integrate assessment data into the patient's problem list. The nursing documentation is intended to facilitate communication within the multidisciplinary health care team. Assessments incorporate both immediate and emerging needs and the plan of care is reviewed and/or revised based on changes of the patients, to include, but not limited to physical, psychosocial, social, cultural, religious, educational, functional status, nutrition and hydration status, and high-risk concerns as applicable."

Review of MR #1 revealed this 27-year-old patient was brought to the Emergency Department (ED) from a Motel on 11/2/22 at 2:39 PM with a complaint of "multiple days of urinary retention (2-3 days) and decreased mobility in the upper arms as well as nausea, vomiting and confusion. There was abdominal distention and guarding and the patient had been COVID-19 positive for five (5) days. The patient's previous medical history included Bipolar Disorder, Schizoaffective Disorder, Kidney Stone, Leukopenia, Low Thyroid Stimulating Hormone, Lyme Disease, Neuropathy, Small Bowel Obstruction and Volvulus. Upon arrival the patient was alert to self and his vital signs were within normal limits.

A suicide screen at 3:41 PM and 10:33 PM on 11/2/22 revealed the patient did not "wish to be dead and had no suicidal thoughts." The patient was diagnosed with Urinary Retention and Encephalopathy, COVID-19, R/O Polypharmacy, and the Urine was positive for Cannabis. The impression was Encephalopathy due to medications and recommendations included follow-up with psychiatry to rule out Benzodiazepine Toxicity versus withdrawal and anticholinergic symptoms. A Foley catheter was inserted, and 1.5 L of urine drained into the bag. By 11/3/22 the patient was alert and oriented to person, place and time and the Physician Assistant documented at 2:16 PM that six (6) Liters of urine had drained in the last 24 hours.

On 11/3/22, the psychiatrist documented at 2:30 PM that the patient does not need psychiatry, he denied suicidal ideations, and that none of the patient's medications had anti-cholinergic effect. The psychiatrist also documented that the patient denied having psychiatric diagnoses and had not been taking his medications.

On 11/4/22 the following sequence of events were noted:

9:33 AM, a nursing note indicated the patient threatened to remove his Foley catheter.
Staff A, Charge nurse stated in an interview conducted on 12/1/22 at 1:15 PM, that the patient stood at his room door without a mask even though he was on isolation, requesting to have his Foley catheter removed.

Staff C, the patient's hospitalist (primary doctor) stated during an interview conducted on 12/2/22 at 11:45 AM that the patient was agitated because he wanted his catheter removed and he wanted to leave the hospital. Staff C stated he made many trips to the unit that day to see the patient.

At 11:39 AM, the Physician Assistant (Urology service) documented that the catheter was removed.

Staff A, Charge Nurse stated on 12/1/22 at 1:15 PM that she spoke to the patient's mother who "expressed concerns about the patient's suicidal thoughts." Staff A stated she did not ask the patient's mother if the patient had disclosed a suicidal plan or if he had a prior history of suicide attempts. Staff A, Charge Nurse stated she assessed the patient while the PA was in the room and the patient denied suicidal ideations. Staff A also acknowledged she did not ask the patient if he had attempted suicide in the past. Staff A, Charge Nurse also stated she shared the mother's concerns with Staff B, Assistant Nurse Manager.

Staff B, Assistant Nurse Manager stated during an interview conducted on 12/1/22 at 2:20 PM that she shared the mother's concern with Staff E, the patient's primary nurse. Staff B, Assistant Nurse Manager acknowledged she did not report the mother's concerns to any of the patient's doctors or providers.

Review of the medical record revealed none of Staff A's, B's or E's conversations with each other, nursing assessments or actions were documented in the patient's medical record. The lack of documentation was confirmed during Staff A's and B's interviews which were conducted on 12/1/22.

None of the nursing staff reported the mother's concern to a doctor or provider. This was also confirmed during their interviews conducted on 12/1/22 and on 12/2/22.

Staff C, Hospitalist stated during interview conducted on 12/2/22 at 11:45 AM, that he wanted the psychiatrist to clear the patient given the patient's medical diagnosis and to ensure that the patient had the mental capacity to make the decision to leave the hospital against medical advice.

At 12:19 PM Staff C, Hospitalist (primary doctor) documented the psychiatrist cleared the patient to sign out of the hospital against medical advice (AMA). Staff C, Hospitalist also confirmed that none of the nursing staff shared the mother's concern of the patient's suicidal ideations on 11/4/22.

At 12:37 PM, Staff E, primary nurse sent a tiger text to Staff C, Hospitalist regarding the patient's request to be discharged. Documentation in this note indicated the doctor stated the patient has mental capacity and the patient can leave against medical advice (AMA).

At 1:30 PM, the patient and staff sign the AMA form.

At 2:01 PM Staff B, Assistant Nurse Manager's documentation in the medical record revealed she escorted the patient to the lobby to take a taxi which would take him back to his motel.

Staff D, the psychiatrist stated during an interview conducted on 12/2/22 at 11:00 AM that the patient was not suicidal or psychotic when she assessed him on 11/4/22 and deemed him competent to sign himself out against medical advice. Staff D, Psychiatrist confirmed that she was not informed of the mother's concerns, but it probably would not have made a difference because of the patient's denial of suicidal ideations and the mother's desire to keep her son hospitalized.

The nursing staff failed to notify any of the medical staff of the mother's concerns that the patient had expressed suicidal thoughts.

These findings were shared with Staff F, Assistant Vice President of Quality on 12/2/22 at 2:30 PM.