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Item #1 - Suicide Risk Assessment

Based on interview, policy review, and record review, the hospital failed to develop and implement written policies and procedures that clearly outlined the discharge planning process for patients that included a consistent process for reassessing suicide risk prior to discharge, as demonstrated by 3 of 6 records reviewed (Patient #1501, #1503, and #1504).

Failure to development and implement policies and procedures to guide staff in the discharge planning process evaluate, assess, identify all patients who are at an increased risk for suicide prior to discharge, puts patient at risk for negative outcomes and/or harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Suicide Assessment and Intervention," policy number 8676227, last revised 10/20, showed the following:

a. All patients are assessed for suicide risk at pre-admission, admission, and at regular intervals throughout the hospital stay.

b. All staff assessing the suicide risk using the C-SSRS tool are trained and determined to be competent annually.

c. The Columbia-Suicide Severity Rating Scale (C-SSRS) (a short questionnaire used for suicide assessment) to gather information needed to classify a patient's suicidal ideation and behavior, determine levels of risk and aid in making clinical decisions about care.

d. All patients receive a suicide risk screen during pre-admission and the findings are communicated to the psychiatric provider.

e. All patients are screened using the C-SSRS once per shift by the nursing staff.

f. Response Protocols to C-SSRS Screenings are as follow:

i. Very Low Risk of Harming Self: Level 1 - Patients with no suicidal ideation or suicidal ideation with an intensity score of 8 or less within last 30 days are considered at very low risk for suicide. Interventions include: C-SSRS each shift and mental health referral at discharge.

ii. Low to Moderate Risk of Harming Self: Level 2 - Patients with active suicidal ideation without a plan within the last 30 days and no active intentions and details to the suicide plan within the past 30 days. Interventions include: Precautions elevated as patient's condition warrants and mental health referral at discharge.

iii. Heightened Risk of Harming Self: Level 3 - Patients with active suicidal ideation with intent or yes to suicidal behaviors in the past 90 days. Interventions: Patient is always within assigned staff's line of sight and mental health referral and resources at discharge.

iv. Imminent Risk of Harming Self: Level 4 - Patient has attempted suicide in the past week by a particularly lethal method or verbalizing clear intent of self-harm with viable means available. Interventions include: Patient is always within arm's length of staff at all times and mental health referral and resources at discharge.

g. During the comprehensive Psychiatric Evaluation, the psychiatric provider assesses the risk of suicide for each patient within 24 hours of admission and ongoing throughout the patient's admission. The psychiatric provider reviews the plan of care, ensures that the interventions are aligned with the risks and informs the nursing staff when modifications are made.

h. The Psychosocial Assessment is completed by a qualified social worker within 72 hours of admission and includes an evaluation of the patient's suicide risk using the SAFE-T assessment (a five step suicide assessment performed by mental health professionals that identifies risk factors, identifies protective factors, conducts suicide inquiry, determines risk level, and documents).

i. If a patient has endorsed suicide ideation or behavior during their inpatient stay, their Discharge/After Visit Summary contains suicide prevention information (such as the National Suicide Prevention Hotline Number or their local mental health crisis number) and/or a referral to an appropriate outpatient mental health provider.

Patient #1501

2. On 12/10/21 at 10:30 AM, Investigator #15 reviewed the medical record for Patient #1501, a 19-year-old male, admitted voluntarily on 09/29/21 at 4:26 PM, with a psychiatric history of Depression and Anxiety. The Patient endorsed Suicidal Ideation with a plan and reported that the thoughts of suicide had been worsening for months. Review of the Patient's medical record showed the following:

a. On 09/29/21 at 4:48 PM, the Intake Nurse screened the Patient using the C-SSRS Suicidal Ideation Screening Tool, assessing for suicidal ideation within the past 30 days. The Patient answered yes to all five of the questions, scoring 5/5. Patient #1501 endorsed "wishing he was dead, thoughts of killing self, thoughts about how to kill self, thoughts of acting on the plan, and started to work out the details of the plan."

b. On the Initial Psychiatric Evaluation, dated 09/30/21 at 6:42 AM, the provider documented that the patient stated several times throughout the interview in a matter-of-fact way about how severely depressed he was and that he was now planning on committing suicide by stabbing himself in the wrists." The psychiatric provider assessed the Patient's suicidal risks using the Columbia C-SSRS. The Patient answered yes to all five of the questions, scoring 5/5.

c. The psychiatric provider assessed the Patient's suicide risk to be Low to Moderate.

d. On the Psychosocial Assessment, dated 09/30/21 at 5:56 PM, the social worker documented that the Patient stated "there was no point in meeting because nothing will change my mind. I do not want to live." The social worker noted in the assessment that patient was untruthful regarding a previous suicide attempt by drowning and had not actually had a single episode of self-harm. The Patient reported that he "absolutely wants to die and has every intention of killing himself." The social worker noted that the Patient does not have the appearance of one who is profoundly depressed and suicidal.

e. On 10/01/21 at 11:23 AM, the psychiatric provider documented on the Discharge Summary that Patient #1501 denied thoughts of suicide and requested to discharge. The provider documented that given the "inconsistencies in the presentation and several recent hospitalizations, it appeared that the patient had sought out hospitalization for secondary gain. At the time of the discharge the Patient did not represent an imminent threat to himself or others and was not gravely disabled and appropriate to discharge to a less restrictive environment." The psychiatric provider assessed the Patient's suicidal risks using the Columbia C-SSRS. The provider did not refer the Patient to the DCR for an evaluation prior to discharge. The provider documented that Patient #1501's discharge was a planned/routine discharge and the discharge diagnosis was Malingering.

f. On 10/01/21 at 1:35 PM, the Patient was discharged home. The hospital was notified that the Patient committed suicide later that night by stabbing himself in his upper extremities.

3. On 12/16/21 at 10:30 AM, during an interview with Investigator #15, psychiatric provider (Staff #1508) stated that when Patient #1501 requested to discharge on 10/01/21, Staff #1508 reviewed the Patient's chart from the previous admission (08/31/21 to 09/03/21) where it was documented that staff believed that the Patient was admitted for secondary gains. The provider stated that the Patient's mother also believed that the Patient was seeking secondary gains to achieve SSI disability. The provider noted that the current admission "felt similar to the previous stay." The provider stated that the Patient was assessed for suicide risk prior to discharge (C-SSRS), but suicide screenings are only a component of his clinical decision to discharge the patient. The provider reported that he "believed that Patient #1501 was discharged routinely/planned and his symptoms were just not adding up at discharge." Staff #1508 stated that he based the Patient's discharge diagnosis on the previous chart review and the Patient's reported desire to seek disability for depression.

Investigator #15 asked Staff #1508 about the interventions provided to Patient #1501 related to the reported suicidal ideation with a plan to stab himself as reported upon admission and the provider's documented "very low" suicide risk formulation. Staff #1508 stated that he uses his "clinical judgement" to make those determinations and could not speak to his colleague's practices. Staff #1508 stated that "he believed there was no formal process or protocol" to guide staff making those decisions or guidance in the hospital's policy (Suicide Prevention and Intervention) for re-assessment prior to discharge.

4. On 12/16/21 at 11:30 AM, during an interview with Investigator #15, social worker (Staff #1509) stated that she spoke with the Patient to conduct the Psychosocial Assessment. Staff #1509 reported the Patient was telling staff different things, such as "I am going to stab myself" and "When I leave here, I am going to kill myself." Investigator #15 asked the social worker if this was documented, and Staff #1509 stated that the information didn't get into the medical record. Staff #1509 stated that he "didn't present like a person that was depressed."

Patient #1503

5. On 12/16/21 at 3:00 PM, Investigator #15 reviewed the medical record for Patient #1503, a 29-year-old male, admitted voluntarily on 11/15/21 at 7:29 AM, with a psychiatric history of Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), and Substance Use Disorder (SUD). The Patient presented with psychotic symptoms and the toxicology screen was positive for amphetamines and morphine. The Patient denied suicidal ideation, stating "sometimes I am suicidal." Review of the Patient's medical record showed the following:

a. On the Initial Psychiatric Evaluation, dated 11/15/21 at the provider assessed the Patient's suicidal risks using the Columbia C-SSRS. The Patient answered yes to one of five questions (Have you ever wished you were dead or could go to sleep without waking up?), scoring 1/5. The provider documented that they were unable to assess the Patient's suicide history based on the Patient's psychosis

b. On 11/24/21 at 12:39 PM, the psychiatric provider documented on the Discharge Summary that Patient #1503 requested to discharge. The provider's risk assessment revealed no suicidal ideation. The provider advised the patient that if the patient discharged, it would be against medical advice (AMA) and noted that the Patient would have benefited from more alignment of outpatient services. The provider referred Patient #1503 to a DCR for evaluation. The DCR evaluated the Patient on 11/24/21 and did not detain the Patient.

c. On 11/24/21 at 1:00 PM, the Patient was discharged against medical advice to a shelter.

Patient #1504

6. On 12/16/21, Investigator #15 reviewed the medical record for Patient #1504, a 36-year-old male, admitted voluntarily on 11/08/21 at 9:15 AM, with a psychiatric history of Depression. The Patient presented with increased auditory command hallucinations to kill himself and his toxicology screen was positive for amphetamines and opiates. The Patient had previously been admitted in October and September with similar presentation and left against medical advice (AMA) both times. Review of the Patient's medical record showed the following:

a. On 11/08/21 at 9:17 AM, the Intake Nurse screened the Patient using the C-SSRS Suicidal Ideation Screening Tool, assessing for suicidal ideation within the past 30 days. The Patient answered yes to all five of the questions, scoring 5/5. Patient #1504 endorsed "wishing he was dead, thoughts of killing self, thoughts about how to kill self, thoughts of acting on the plan, and started to work out the details of the plan."

b. On the Initial Psychiatric Evaluation, dated 11/08/21 at 4:11 PM, the provider documented that the Patient had a history of a prior suicide attempt. The provider documented that the Patient endorsed suicidal ideation, with a plan to jump off a bridge. The provider screened the Patient using the C-SSRS Suicidal Ideation Screening Tool, assessing for suicidal ideation within the past 30 days. The Patient answered yes to three of five questions, scoring 5/5. Patient #1504 endorsed "wishing he was dead, thoughts of killing self, and thoughts about how to kill self."

c. Nursing staff performed C-SSRS assessments for Patient 1504 on 11/08 at 8:08 PM, on 11/09 at 6:00 PM and 8:00 PM, and 11/10 at 10:00 AM. Patient #1504 denied any suicidal ideation and scored 0/5 on all C-SSRS assessments performed after the intake suicide assessment.

d. On 11/09/21 at 2:27 PM, the psychiatric provider documented that Patient #1504 demanded immediate discharge. The Patient denied any suicidal ideation and stated he had "made it up in order to get a bed and a meal." The provider advised the Patient that a DCR would be consulted for a referral for evaluation.

e. On 11/10/21 at 1:45 PM, the psychiatric provider documented in the Discharge Summary that the DCR was contacted because the Patient presents frequently with the same complaint and is often complaining of psychosis. The DCR evaluated the Patient on 11/10 and did not detain the Patient. Prior to discharge, the psychiatric provider screened the Patient using the C-SSRS Suicidal Ideation Screening Tool, assessing for suicidal ideation within the past 30 days. The Patient answered no to five of five questions, scoring 0/5. The provider documented making a number of appeals to the Patient to stay, but the Patient refused. The Patient denied suicidal or homicidal ideation. The provider documented that he reviewed the case with the Chief Medical Officer and hospital administration.

f. The Patient discharged against medical advice (AMA) on 11/10/21 at 2:45 PM.

7. Review of the medical records for Patient #1501, #1503, and #1504 showed the following incongruencies between their C-SSRS scores and the risk mitigation for suicide, based on the response protocols to C-SSRS screening defined in hospital policy:

a. Patient #1501 - Based on C-SSRS scores and medical record review, the Patient met the criteria for Level 3 - Heightened Risk of Harming Self. The Initial Psychiatric Evaluation documented the Patient's risk mitigation as "Level 1 - Very Low."

b. Patient #1503 - Based on C-SSRS scores and medical record review, the Patient met the criteria for Level 1 - Very Low Risk of Harming Self. The Initial Psychiatric Evaluation documented the Patient's risk mitigation as "Level 2 - Low to Moderate."

c. Patient #1504 - Based on C-SSRS scores and medical record review, the Patient met the criteria for Level 3 - Heightened Risk of Harming Self. The Initial Psychiatric Evaluation documented the Patient's risk mitigation as "Level 1 - Very Low."

8. Review of the hospital's policy titled, "Suicide Prevention and Intervention," found no evidence of a clearly outlined process to ensure that all patients that endorsed suicidal ideation or behaviors during their admission received a thorough suicide risk assessment prior to discharge other than the C-SSRS completed by nursing staff each shift.

Item #2 - Referral to Designated Crisis Responder (DCR) Process

Based on interview, policy review, and record review, the hospital failed to develop and implement written policies and procedures that clearly outlined the discharge process for patients requesting to leave against medical advice (AMA) that included consistent guidelines for referral to a Designated Crisis Responder (DCR) for evaluation prior to discharge, as demonstrated by 6 of 6 records reviewed (Patient #1501, #1502, #1503, #1504, #1505, and #1506).

Failure to development and implement policies and procedures to guide staff in the discharge process for patients requesting to leave AMA that included consistent guidelines for referral to a DCR for evaluation puts patient at risk for negative outcomes and/or harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Detainment Referral to Designated Crisis Responder (DCR)," policy number 8665226, last revised 04/21, showed the following:

a. Washington State law has created a unified involuntary commitment law that allows those that are assessed by a qualified mental health provider to be at imminent likelihood of serious harm to self, to others and/or assessed to be gravely disabled due to mental health or substance use disorder get the necessary treatment. See Revised Code of Washington (RCW) 71.05.050 and RCW 71.05.153.

b. At the time a patient requests an unplanned release from the hospital, a provider or qualified mental health professional should assess to determine if the patient is believed to be a danger to themselves or others, or is gravely disabled, based on mental health.

c. In instances where the patient is assessed to be a danger and requests to be released, the qualified mental health provider should initiate a referral to the DCR for further evaluation of the need for involuntary commitment.

2. Document review of the hospital's policy and procedure titled, "Leaving Against Medical Advice/Leaving Without Being Seen/Elopement," policy number 8665266, last revised 10/20, showed the following:

a. If a voluntary patient seeks to leave against medical advice (AMA), the provider will inform the patient of the medical consequences of leaving the hospital against medical advice.

b. If any questions exists regarding the patient's capacity to make informed decisions regarding his/her healthcare, the provider should request a competency evaluation and the patient should not be discharged until capacity has been determined.

Patient #1501

3. On 12/10/21 at 10:30 AM, Investigator #15 and the Director of Quality (Staff #1507) reviewed the medical record for Patient #1501, a 19-year-old male, admitted voluntarily on 09/29/21 at 4:26 PM, with a psychiatric history of Depression and Anxiety. The Patient endorsed Suicidal Ideation with a plan and reported that the thoughts of suicide had been worsening for months. Review of the Patient's medical record showed the following:

a. On 09/29/21 at 4:48 PM, the Intake Nurse screened the Patient using the C-SSRS Suicidal Ideation Screening Tool, assessing for suicidal ideation within the past 30 days. The Patient answered yes to all five of the questions, scoring 5/5. Patient #1501 endorsed "wishing he was dead, thoughts of killing self, thoughts about how to kill self, thoughts of acting on the plan, and started to work out the details of the plan."

b. On the Initial Psychiatric Evaluation, dated 09/30/21 at 6:42 AM, the provider documented that the patient stated several times throughout the interview about how severely depressed he was and that he was now planning on committing suicide by stabbing himself in the wrists." The psychiatric provider assessed the Patient's suicidal risks using the Columbia C-SSRS. The Patient answered yes to all five of the questions, scoring 5/5.

c. On the Psychosocial Assessment, dated 09/30/21 at 5:56 PM, the social worker documented that the Patient stated "there was no point in meeting because nothing will change my mind. I do not want to live." The social worker documented that the Patient stated that he absolutely wants to die and has every intention of killing himself.

d. On 10/01/21 at 11:23 AM, the psychiatric provider documented on the Discharge Summary that Patient #1501 denied thought of suicide and requested to discharge. The provider documented that given the "inconsistencies in the presentation and several recent hospitalizations, it appeared that the patient had sought out hospitalization for secondary gain. At the time of the discharge the Patient did not represent an imminent threat to himself or others and was not gravely disabled and appropriate to discharge to a less restrictive environment." The provider did not refer the Patient to the DCR for an evaluation prior to discharge. The provider documented that Patient #1501's discharge was a planned/routine discharge and the discharge diagnosis was Malingering. The Patient was discharged to his home on 10/01/21 at 1:35 PM.

e. On 10/05/21, family notified the hospital that Patient #1501 had died on 10/01/21. The cause of death according to the King County Coroner's Office was ruled a Suicide - due to sharp force injuries to upper bilateral extremities.

Patient #1502

4. On 12/10/21 at 4:30 PM, Investigator #15 and a Registered Nurse (Staff #1510), reviewed the medical record for Patient #1502, a 60-year-old female, admitted voluntarily on 10/23/21 at 4:00 PM, with a psychiatric history of Depression and Anxiety. The Patient endorsed Suicidal Ideation which had been worsening for the past 3 months. Review of the Patient's medical record showed the following:

a. On 10/23/21 at 3:56 PM, the Intake Nurse screened the Patient using the C-SSRS Suicidal Ideation Screening Tool, assessing for suicidal ideation within the past 30 days. The Patient answered yes to two of five of the questions, scoring 2/5. Patient #1502 endorsed "wishing she was dead and had thoughts of killing self."

b. On 10/23/21 at 4:41 PM, the intake social worker assessed Patient #1502. The social worker documented that Patient #1502 denied suicidal ideation but stated that "her current mental health makes her feel like wanting to go to sleep and not wake up." Review of the clinical assessment found no evidence of the C-SSRS or SAFE-T assessments for Patient #1502.

c. On the Initial Psychiatric Evaluation, dated 10/23/21 at 7:42 PM, the provider documented that the Patient took 4 times her prescribed dose of Ambien, Restoril, and Xanax in an attempt to sleep, but not to attempt suicide. The provider documented that Patient #1502 endorsed suicidal thoughts without a plan. Patient #1502 reported that her family psychiatric history included a brother who committed suicide after being diagnosed with Stage 4 Cancer.

d. The psychiatric provider's assessment/formulation noted that Patient #1502 needed inpatient treatment for acute stabilization in a safe environment to have her psychotropic medication titrated under the supervision of a psychiatric provider. Patient #1502 was unable to contract for safety and a danger to self with suicidal ideation.

e. On 10/24/21, Patient #1502 demanded to be discharged, stating she was not suicidal and would be able to keep safe at home.

f. The provider determined that a referral to a DCR was not appropriate, as the Patient denied suicidal ideation and on 10/24/21 at 10:02 AM, the Patient was discharged home.

5. On 12/10/21 at 4:30 PM, during an interview with Investigator #15, the Director of Quality (Staff #1507), stated that on 10/24/21 at 1:30 PM (3 ½ hours after AMA discharge), Patient #1502's family called to notify the hospital that the Patient had reportedly taken a gun, walked into the woods, and committed suicide.

6. Investigator #15's review of the medical records for Patient #1501, #1502, #1503, #1504, #1505, and #1506 showed the following incongruencies between the interventions provided and protocols followed for voluntary patients that requested unplanned discharges:

a. Patient #1501 reported a plan to commit suicide by stabbing himself in the wrists. The Patient endorsed suicide up until the request to discharge against medical advice (less than 48 hours after admission). The Patient was screened for suicide risk prior to discharge by the provider and the Patient denied suicidal ideation. The provider did not refer the Patient to the DCR for evaluation. The Patient was discharged routinely/planned.

b. During the intake screening, Patient #1502 reported worsening suicidal ideation (without a plan) and difficultly sleeping. The Patient requested to discharge less than 24 hours after admission. The Patient denied suicidal ideation at discharge, so the provider did not refer the Patient to the DCR for evaluation. The provider asked the Patient to stay to taper and discontinue benzodiazepines, but the Patient refused. The Patient was discharged against medical advice.

c. Patient #1503 presented with psychotic symptoms and a toxicology screen that was positive for amphetamines and morphine and stated, "sometimes I am suicidal." When the Patient requested to discharge (9 days after admission), the provider's risk assessment found no suicidal ideation. The provider requested the Patient stay to for alignment of outpatient services. The provider referred Patient #1503 to a DCR for evaluation. The DCR evaluated the Patient and did not detain them.The Patient was discharged against medical advice.

d. Patient #1504 presented with increased auditory command hallucinations to kill himself and his toxicology screen was positive for amphetamines and opiates. During intake, the Patient endorsed suicidal ideation with a plan. After the initial suicide screening, the Patient denied any suicidal ideation currently or historically throughout the rest of his admission. The Patient requested to discharge 48 hours after admission and the provider documented making several appeals to the Patient to stay, but the Patient refused. The provider referred Patient #1504 to the DCR for evaluation. The DCR evaluated the Patient and did not detain them. The Patient was discharged against medical advice.

e. During intake, Patient #1505 reported a history of depression, but stated he was feeling better over the last few days. Two days after admission, the Patient requested to leave. The provider documented that the Patient denied suicidal ideation. The provider notified the DCR for evaluation prior to discharge. The DCR did not detain the Patient and was he discharged against medical advice.

f. Patient #1506 presented with increasing symptoms of nightmares and anxiety, worsening within the past 30 days. The Patient endorsed suicidal ideation and had a history of a suicide attempt. Less than 6 hours after admission, the Patient denied suicidal ideation or a history of a suicide attempt and requested to leave. Provider documented that Patient does not meet criteria for DCR referral and was discharged against medical advice.

7. On 12/15/21 at 10:30 AM, during an interview with Investigator #15, psychiatric provider (Staff #1508) responded to questions regarding the hospital's policy titled, "Leaving Against Medical Advice/Leaving Without Being Seen/Elopement." Investigator #15 asked Staff #1508 about how the policy and protocol addresses risk assessments, criteria/protocol for referral to a DCR and Staff #1508 stated that he has a process he uses to respond to a patient's request to leave AMA and was unsure how the policy addresses the process. Investigator #15 asked Staff #1508 about the noted incongruencies between the psychiatric providers response to a patient's request to discharge AMA for the 6 medical records reviewed. Staff #1508 stated that he uses his "clinical judgement" to make those determinations and could not speak to his colleague's practices. Staff #1508 stated that "he believed there was no formal process or protocol" to guide staff making those decisions.

8. On 12/16/21 at 8:45 AM, during an interview with Investigator #15, the Chief Nursing Officer (Staff #1510) and Chief Executive Officer (Staff #1501) stated that the decision to call a DCR is considered within the psychiatric providers clinical judgement.

9. On 12/16/21 at 9:45 AM, during an interview with Registered Nurse (Staff #1511) reported that during the intake process, if the nursing staff feels that the patient meets the criteria, and declines to stay voluntarily, they will contact the DCR. Staff #1511 stated she did not know where a list of the "criteria for detention" was, and verified it was not in the hospital's policy (Detainment Referral to Designated Crisis Responder).

10. Review of the hospital's policy titled, "Detainment Referral to Designated Crisis Responder," found no evidence of guidelines that outlined the process for referral to DCR's, giving staff clear, consistent criteria and protocols so that all appropriate patient's receive the potentially life-saving assessments prior to discharge.

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