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Based on record review and interviews, the facility failed to ensure 1 of 1 patients on an mental health hold received a mental health evaluation prior to discontinuing the mental health hold (Patient #2).

Findings include:

The policy, Behavioral Health Suicide Risk Assessment and Care of the Suicidal Patient read, disposition of a patient will be determined by the Psychiatrist and/or LCSW in consultation with the medical team. A patient at risk for self-harm will be reassessed and this assessment will be documented once per shift by the registered nurse. Patients who are no longer deemed at risk for self-harm will be evaluated by a physician who will provide the appropriate orders to decrease protective measures.

The policy, Mental Health Hold read, discontinuation of a M-1 hold read, in order to discontinue a M-1 hold, the physician must place an order to do so in the medical record. There must be accompanying documentation by the physician that stated the reason the hold has been discontinued. Without this order and documentation, the M-1 hold remains active.

1. The facility failed to ensure a patient deemed an imminent danger to himself and placed on a mental health hold was evaluated by a physician prior to discontinuing the mental health hold.

a. Review of the medical record revealed Patient #2, was brought in to the emergency department on 3/10/18 at 10:35 a.m. by emergency medical services after an attempted suicide.

At 12:15 p.m., Patient #2 was placed on a mental health hold (M1 hold) by the emergency department physician after it was determined the patient was an imminent danger to himself. According to the M1 Hold documentation, Patient #2 jumped off a second level tier (15 feet) with the intent to kill himself.

At 3:50 p.m., Patient #2 was transferred to the Intensive Care Unit (ICU) with the M-1 hold still in place.

At 3:55 p.m., the critical care physician documented in the progress note, Patient #2 reported stress but denied suicidal ideations (SI). The physician then documented in the diagnosis, assessment and plan section of the progress note under SI: M1 hold and psychiatry consulted.

At 8:34 p.m., a verbal order, by a Registered Nurse (RN), was documented to discontinue the M-1 hold and signed by Physician #2.

On review of the medical record for Patient #2, there was no documentation of an evaluation by a physician as to the reason the hold had been discontinued, to include Physician #2, prior to discontinuing the M-1 hold. This was in contrast to facility policy.

On 3/11/18 at 7:30 a.m., 11 hours after the M1 hold was discontinued via a verbal order, Physician #1 completed a psychiatric examination.

On 3/11/18 at 10:02 a.m. in an addendum to the psychiatric progress note, Physician #1 discontinued the M-1 hold.

b. On 3/14/18 at 4:00 p.m. an interview was conducted with the ICU manager (Manager #3). Manager #3 stated a M1 Hold was a psychiatric hold placed if a patient was deemed as harmful to themselves or the community. Manager #3 stated a M1 hold was for the safety of a patient who was deemed incapable to make decisions for themselves. Once placed on a M1 hold, the patient must be observed by staff until the patient was evaluated by appropriate personnel and deemed capable to make decisions for themselves.

c. On 03/14/2018 at 11:41 a.m. an interview was conducted with the Physician #1. Physician #1 stated he was unaware a RN had placed a verbal order in Patient #2's medical record to discontinue the M-1 hold. Physician #1 stated a verbal order to discontinue a M1 hold was not appropriate as a face to face, by a licensed professional qualified to evaluate the patient, was required prior to discontinuing the hold. The evaluation, according to Physician #1 would include an assessment of what measures were in place to maintain the patient's safety and an evaluation of the patient, including evaluation for psychosis (a mental disorder in which thought and emotions are impaired), needed to be present.

d. On 03/14/18 at 5:04 p.m., a joint interview was conducted with Chief Medical Officer (CMO) #4 and Physician #2 (via telephone). Physician #2 who signed the verbal order to discontinue the M1 hold, confirmed he was not involved in Patient #2's care and did not conduct a face to face evaluation of Patient #2 prior to the discontinuation of the M1 hold.

Based on the onsite validation suirvey, completed March 13 through March 20, 2018, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code tags K0161, K0211, K0222, K0300, K0324, K0325, K0341, K0345, K0347, K0351, K0363, K0372, K0374, K0521, K0911, K0918, K0920, and on Bldg A-3 deficiencies K0131, K0161, K0323, and K0363. See survey event ID #SKFC21 for full details of the cited deficiencies.