HospitalInspections.org

Based on record review and interview the facility failed to ensure staff followed policy in place for suicide assessments and interventions for 1 (P[patient] 8) out of 4 (P2, P8, P9, and P14) patients reviewed for presenting to the hospital with psychiatric complaints. This deficient practice could lead to patients presenting with psychiatric complaints being at increased risk for self-harm while in a hospital setting.

The findings are:

A. Record review of the facility's Policy titled, "Suicide Assessments and Interventions," dated 05/27/2025 stated, If the patient has a positive screen (suicidal), the clinical staff will assess suicide ideation (thinking about or planning suicide) and risk with the Columbia Suicide Severity Rating Scale (C-SSRS). There are 3 levels to this assessment Low Risk, Medium Risk and High Risk. High risk level is a patient that attempts suicide and requires continuous one on one observation (a person that sits with the patients and always watches the person to ensure the patient is safe and not self-harming). With documentation of what the patient is doing or where the patient is every 15 minutes and requires an inpatient behavioral health admission.

B. Record review of P8's chart revealed P8 came to the Emergency Department (ED) on 05/19/2025 at 6:52 pm with chief complaint, "Suicide Attempt." There was no Columbia Suicide Severity Rating Scale assessment completed in the chart, there was no documentation of one-on-one observations, or every 15-minute documentation. P8 was transferred out via air to a higher level of care for the chief complaint of suicide attempt.

C. During an interview on 07/28/2025 at 2:15 pm with S[staff] 4 (clinical) it was confirmed that P8 came to the ED with chief complaint, "Suicide Attempt." S4 confirmed there was no Columbia Suicide Severity Rating Scale completed to assess the patients risk for suicide, there was no suicide precautions ordered such as one-on-one for patient monitoring or documentation every 15 minutes of the patients activity or suicide risk to keep the patient safe with no self-harming activity occurring. S4 confirmed that the staff did not put in place the intervention that would keep P8 safe from harm.

D. During an interview on 07/30/2025 at 10:30 am with S6 (clinical) it was confirmed that patients that come into the ED with a Chief Complaint of suicide ideation or attempt were placed in the room in front of the nurse's station, there is not a staff member assigned to the patient for one-on-one watch. The staff will watch the patients as they work, and S6 did confirm that a suicidal patient will be left unattended to care for other patients.

Based on interview the facility failed to have a discharge planning process in place for any patient that presents to the hospital. This deficient practice could lead to increased hospital visits because patients don't have access to discharge planning.

The findings are:

A. During an interview on 07/29/2025 at 12:45 pm with S(staff)3, clinical, they explained that discharge planning is managed by the nursing staff and the provider.

B. During an interview on 07/29/2025 at 1:00 pm with S4, clinical, they explained that the facility does not have a discharge planner.

C. During an interview on 07/30/2025 at 1:00 pm with S4, clinical, it was confirmed that the facility did not have a policy regarding discharge planning.