HospitalInspections.org

Based on record review and interview the hospital failed to reassess a patient for suicidal ideation on the day of discharge, in 1 of 1 inpatient records reviewed (Patient #1) in a total sample of 20 medical records reviewed.

Findings include:

Per policy titled "Care of the Patient with Suicidal Ideation Policy" last revised on 10/2019, revealed in part "IV. Discharge; i. Patients that screen as low, moderate, or high risk for suicide at any time during their hospitalization will be reassessed on the day of discharge."

Review of Patient #1's medical record revealed Patient #1 was admitted to the hospital on 11/7/2019 at 9:33 PM with diagnosis of depression with suicidal ideation with plan, past suicidal attempt. Admission orders include: Suicide Precautions with every 15 minute checks. Behavioral Med Progress note-RN (registered nurse) dated 11/10/2019 at 10:29 AM revealed in part "Pt (patient) was discharged due to not participating with treatment plan, accusing staff of being racist and his mistreatment of staff. Pt was irate over not receiving narcotic pain reliever. Pt has a pain management program with [agency], however when Pt was admitted his UA (urine) only tested positive for cocaine. Pt reported being treated at [Facility] before admit here, writer contacted [facility] with Pt consent and learned, in spite of Pt statement he did not receive any narcotics or benzo's (sic) while there. Writer informed Pt that due to his breaking his contract with pain management by use of cocaine we would not provide narcotics. Pt was told that if he chooses not to participate he may d/c (discharge). Pt initially agreed, then became threatening to staff after telling staff that other patients were receiving narcotics and it was because they were white. Pt threatened to tear RN head off due to not wanting to comply with plan. Security was called and the Pt was d/c and escorted off the unit by security with all of his belongings and with discharge paperwork." Behavioral Medicine Discharge Summary dated 11/10/2019 at 4:44 PM revealed in part "Mental Status Exam: Taken from admit note of 11/8/2019. He was not personally seen by me on discharge. He is a normally developed, healthy appearing black male. He is alert, fully oriented. Mood is irritable, with restricted affect. No overt psychosis. Attention and concentration as well as memory are all grossly intact. He is estimated to have normal intelligence. He was threatening to staff and discharged....."

During an interview with Behavioral Health Manager G, on 11/17/2019 at 2:15 PM stated "The staff didn't follow our policy on documenting on suicidal ideation at discharge. The patient was given the discharge papers and instructions but he refused to review them with staff."

Based on record review, observation and interview, staff failed to ensure appropriate documentation was completed for 3 of 3 patients (Patients's #2, 7, and 11) who left against medical advice (AMA); failed to provide and document stabilizing treatment for 1 patient who presented to the Emergency Department (ED) with a psychiatric emergency condition (Patient #19); failed to ensure that all areas where emergency patients or patients in labor are treated had EMTALA signs regarding their rights in 2 departments observed (Obstetrical/Labor and Delivery Department); and failed to ensure that transfer documents were completed with patient risks and benefits specific to the patient's condition explained to them for 2 of 7 patients who were transferred (Patient #'s 13, and 16) in a total sample of 20 records reviewed.

Findings include:

Facility staff failed to provide stabilizing treatment prior to discharge . See tag A2407

Facility staff failed to provide appropriate transfer. See tag A2409

Based on observation and interview, staff failed to ensure that all areas where emergency patients or patients in Labor are treated had Emergency Medical Treatment and Labor Act (EMTALA) signs regarding their rights posted in all areas emergency patients or patients in labor would be treated in 1 of 2 departments observed (Obstetrical (OB)/Labor and Delivery (L&D) Department.)

Findings include:

An observational tour of the Obstetrical (OB)/Labor and Delivery (L&D) unit was conducted on 12/17/2019 at 9:45 AM accompanied by Executive Director of Nursing A, Quality and Patient Safety B, OB supervisor D and OB Clinical Nurse Specialist (CNS) E. There were no EMTALA signs observed in 3 Triage rooms, 8 antepartum ( before birth) room and 9 L&D rooms.

During an interview with OB/CNS E and OB supervisor D on 12/17/2019 at 9:45 AM, E stated "I didn't know we needed to have the signage in patient rooms since it is at the registration desk." D stated "If a patient is in active labor they will bypass registration and go right to a room."

Based on record review and interview, facility failed to provide and document stabilizing treatment for 1 patient, who presented to the Emergency Department (ED) with a psychiatric emergency condition (Patient #19); and staff failed to ensure the appropriate documentation was completed for 3 of 3 patients (Patients #2, 7, and 11) who left against medical advice (AMA) in a total sample of 20 medical records reviewed.

Findings include:

A.. Review of the facility's policy 7129286 "Care of the Patient with Suicidal Ideation - AW" dated 10/2019 reveals, IV Discharge 1. ED, Inpatient and Behavioral Health i. Patients that screen as low, moderate or high for suicide at any time during their hospitalization will be reassessed on the day of discharge...11. Upon discharge, patients who have been on suicide precautions at any time during their hospitalization will be provided information and education regarding the National Suicide Prevention Lifeline...for crisis situations. iii education provided to patients will be documented in the medical record."

ED Medical record review of Patient # 19 on 12/17/2019 revealed a 26 year old who presented to the Emergency Department on 8/19/2019 at 4:13 AM with suicidal ideation. A Columbia-Suicide Severity Rating Scale (a questionnaire used for suicide assessment) completed at 4:15 AM revealed a high risk score for suicide and the patient was placed on 1:1 observation. The "Emergency Department Note-Physician" at 4:18 AM revealed, "...presents to the ED requesting admission to BHU (Behavioral Health Unit) for suicidal ideation...it appears patient was seen earlier this month and was declared to be in appropriate [sic] for admission to the care of her [sic] health unit. Patient states he has an intention to overdose on pills." ED medical record review reveals blood work was done and an EKG (electrocardiogram) performed. "Case Management Progress Note" in the Emergency Department medical record at 12:26 PM revealeds, "...he states if he is not admitted to the hospital there is a 75% chance he will kill himself...CMS-M BHU (Columbia St Mary's-Milwaukee) has current bed availability and are willing to consider the patient for admission. Writer to staff case with [psychiatrist name]." "Addendum Case Management" note at 12:50 PM reveals, "Pt is not a candidate for admission at this facility...Per ED provider patient is to be discharged." "Emergency Department Note-Physician" at 12:55 PM reveals, "...He'll be seen by case management. Ultimate disposition will be based on their evaluation. There are no beds available in the city for this individual...I had a discussion with him...He states that he is comfortable going home. He doesn't have any present thoughts or [sic] hurting himself." Patient was discharged to home at 1:00 PM. There was no assessment at discharge of suicidality and no documentation in the discharge instructions of education or provision of the number for the National Suicide Prevention Lifeline per the faciloity's policy.

In interview with Staff B on 12/18/2019 at 9:10 AM when asked about reassessing suicidal patients at discharge stated, "I guess we just take the word of the doctor that they are safe to go home."

B. Review of facility policy 5956713 "Patients Leaving Against Medical Advice/Elopement, AW" dated 2/2019 revealed the following, "...4. Request the patient sign the AMA form a) if the patient refuses to sign the AMA form, the form should be completed, read to the patient (if possible) and witnessed by the facility personnel present. The statement "refused to sign" or "signature refused" should be written on the form."

Review of Patient #2's ED medical record on 12/17/2019 revealed a 30 year old who presented to the Emergency Department on 9/21/2019 at 12:09 PM by ambulance with complaints of abdominal and low back pain after a fall the night before. "ED Note - Physician" revealed that the patient was 18 weeks pregnant. "ED Nursing Progress Note" on 9/22/2019 at 00:29 AM reveals, "...pt req [request] to d/c [discharge];explained to pt dc orders not in & she must speak c [sic] the MD (Medical Doctor), MD notified, police district 1 notified that pt is leaving AMA...MD to bedside to explain to pt importance of staying...pt ambulatory & left AMA x [sic] signing AMA paperwork." There was no AMA form in the patient's medical record.

Review of Patient #7's ED medical record on 12/17/2019 revealed a 32 year old who was dropped off at the Emergency Department by law enforcement on 11/12/2019 at 9:27 AM with complaints of suicidal ideation. ""ED Nursing Progress note" at 11:58 AM revealed, "patient left the department AMA. Refused to sign paperwork." There was no AMA form or indication of risks and benefits being explained to the patient in the medical record.

Review of Patient #11's ED medical record on 12/17/2019 revealed a 54 year old who presented via ambulance to the Emergency Department on 8/21/2019 at 2:33 PM with suicidal and homicidal ideation. ED Medical record reveals that the patient was triaged at 2:37 PM. Triage note reveals, "no specific plan for suicidal ideation." For homicidal ideation, "burn house down of his ex." "ED Nursing Progress note" reveals the patient was triaged to the waiting room and moved to an exam room at 4:35 PM. "ED Note - Physician" at 4:40 PM on 12/17/2019 reveals, "patient was very upset, would not answer my questions...patient left without being seen. Police were called." There was no AMA form or indication of risks and benefits being explained to the patient in the medical record.

During an interview with Staff B on 12/17/2019 at 9:00 AM, Staff B was asked about completing the AMA paperwork when patients refused to sign and responded, "it is our policy to have the nurse sign the form and include it with the medical record indicating that the patient refused to do so. We obviously didn't do that in any of these three cases."


















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Based on record review and interview the facility failed to ensure that transfer documents are completed with patient risks and benefits specific to the patient's condition explained to them for 2 of 7 patients who were transferred (Patient #'s 13, and 16) in a total sample of 20 records reviewed.

Findings include:

Review of the facility "Hospital to Hospital Transfer Form" on 12/17/2019 revealed a 3 part form; part one "To Be Completed by Nursing, part 2 To Be Completed by Physician and part 3 To Be Completed by Patient." Part 2 contained the following statement, "I do hereby certify that based upon the information available at the time of the transfer that the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweighed the increased risks to the individual (and in case of a woman in labor to the unborn child) from effecting the transfer." The form continued with the heading, "Risks associated with Transfer" and a blank for the provider to write.

Emergency Department Medical Record review of Patient #13 on 12/17/2019 revealed a 17 year old who admitted to the Emergency Department on 7/5/2019 at 00:51 AM with shortness of breath and chest pain. The patient was transferred to a Children's Hospital (Hospital A) at 5:02 AM. On the "Hospital to Hospital Transfer Form" under the "Risks of Transfer" heading, the provider documented, "none anticipated."

Emergency Department Medical Record review of Patient #16 on 12/17/2019 revealed a 65 year old who admitted to the Emergency Department on 7/28/2010 at 1:15 AM with complaints of suicidal ideation. The patient was transferred to a Mental Health Center (Hospital B) at 12:33 PM. On the "Hospital to Hospital Transfer Form" under the "Risks of Transfer" heading, the provider documented, "none expected."

An interview with Staff B on 12/18/2019 at 9:10 AM revealed the following when asked why the risks specific to the patient were not documented on the transfer form, "It really should list what risks could happen."