HospitalInspections.org

The Condition of Participation: Patient's Rights was out of compliance.

The Hospital failed for five patients (Patients #1, #7, 8, 9, & 10) in a sample of ten patients to ensure patient privacy and patient safety.

Refer to TAG: A-0142 Safety & Privacy.

The Hospital failed for one patient (Patient #1) in a sample of ten patients to ensure they required appropriate staff, the Medical Staff physicians and other Licensed Independent Practitioners (LIP) authorized to order restraint or seclusion by Hospital policy to have a working knowledge of Hospital policy regarding the use of restraint and seclusion based on the specific needs of the patient population.

Refer to TAG: A-0199 Patient Rights Training.

Based on records observations, records reviewed and interview the Hospital failed for five patients (Patients #1, #7, 8, 9, & 10) in a sample of ten patients to ensure patient privacy and patient safety.

Findings included:

Hospital Policy titled Patients' Rights and Responsibilities, dated 7/2020, indicated patients had the right to receive care in a safe environment.

Regarding Section 12 Procedures:

During the interview, at 9:10 A.M. on 12/15/2021, the ED Nurse Manager said the ED had several faxe machineds at nursing stations that received faxes. The ED Charge Nurse said there was no clear process where faxes [Section 12 Forms, Commonwealth of Massachusetts Department of Mental Health Application for an Authorization of Temporary Involuntary (psychiatric) Hospitalization] arrived at the ED nor was there a person responsible (to retrieve and provide to the Provider).

Regarding Elopement in the Emergency Department:

The document titled ED Hospital Reports, dated from 7/23/2021 to 19/5/2021, indicated seven of forty-two (17% of) patients (Patients #7, #8, #9, & #10 and three Unsampled Patients) eloped or attempted to elope form the ED.

Regarding Patient Care in ED Hallways:

During observations of the ED, on 12/16/2021, the Surveyor observed a seriously crowded ED, with every patient room occupied, patients on hallway stretchers on both sides of the hallway, one after the other as staff provided hallway care. There we no curtains separating hallway beds and a patient on a hallway stretcher in a Hospital gown required a sheet for privacy.

During the observations, at 3:00 P.M. on 12/16/2021, the VP Chief Nursing Officer said the ED had 150 visits per day, with forty beds and presently there were one-hundred and three ED Patients, with sixty-two patients cared for on hallway stretchers. VP Chief Nursing Officer said patient rights were a concern.

Refer to Emergency Services Condition of Participation TAG A-1103.

Based on records reviewed and interview the Hospital failed to ensure they (the Hospital) required appropriate staff, the Medical Staff physicians and other Licensed Independent Practitioners (LIP) authorized to order restraint or seclusion by Hospital policy to have a working knowledge of Hospital policy regarding the use of restraint and seclusion based on the specific needs of the patient population.

Findings included:

The Hospital policy titled Restraint and Seclusion, dated 3/2020, indicated restraints may be ordered by an LIP after evaluation of the patient. The Restraint and Seclusion policy indicated Medical Staff members ascribed duties in this policy shall receive training. The Restraint and Seclusion policy indicated Physicians and other LIPs who ordered restraints would have a working knowledge of this policy.

During the interview, at 11:00 A.M. on 12/16/2021, the Medical Staff Coordinator said that the Hospital did not have a method to document training (in accordance with the Restraint and Seclusion policy that indicated Physicians and other LIPs who ordered restraints would have a working knowledge of this policy).

Physician #1, Physician #2 and Allied Health Professional #1's (an LIP) Credential Files indicated no documentation of use of restraint and seclusion based on the specific needs of the patient population.

The Hospital provided no documentation to indicated Physicians and LIPs who ordered restraints had a working knowledge restraint and seclusion in accordance with the Hospital Restraint and Seclusion policy.

The Condition of Participation: Quality Assessment and Performance Improvement Program was not met.

Findings included:

1.) The Hospital's Quality Assessment and Performance Program failed for five patients (Patients #1, #7, #8, #9 & #10) in a sample of ten patients to ensure data collection, analysis of Emergency Services processes of care were used and monitored (audited) the effectiveness and safety of services and quality of care.

Refer to TAG: A-0273.

2.) The Hospital Quality Assessment & Performance activities failed for nine patients (Patients #1, #2, #3, #4, #5, #6, #8, #9 & #10) in a sample of ten patients to ensure actions aimed at performance improvement were identified, (corrective action plans were) implemented, and measured (monitored, audited) for compliance to ensure that improvements were sustained, and opportunities for improvement were identified and implemented.

Refer to TAG: A-0283.

3.) The Hospital's Governing Body (Board of Trustees), Hospital Executives and Medical Staff failed for ten patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, & #10) in a sample of ten patients to ensure they assumed full authority, responsibility and accountability for Hospital operations regarding efforts that improved quality of care, patient safety and that all improvement actions were evaluated.

Refer to TAG: A-Executives.

Based on records reviewed and interviews, the Hospital's Quality Assessment and Performance Program failed for five patients (Patients #1, #7, #8, #9, & 10) in a sample of ten patients to ensure data collection, analysis of Emergency Services processes of care were used and monitored (audited) the effectiveness and safety of services and quality of care.

Findings included:

Regarding Patient #1:

During the interview, at 10:15 A.M. on 12/10/2021, with the Vice President (VP) Chief Nursing Officer, Associate Vice President for Nursing and the Vice President Chief Quality Officer, the VP Chief Quality Officer said Patient #1 presented to Patient #1's Primary Care Provider (PCP, at the Brockton Neighborhood Health Center, BNHC) requesting prescription refills for psychiatric medications and the Primary Care Provider would not prescribe Patient #1's psychiatric medications because Patient #1 had not stopped drinking alcohol. The VP Chief Quality Officer said Patient #1's PCP initiated the Section 12 (Commonwealth of Massachusetts Department of Mental Health Application for an Authorization of Temporary Involuntary Hospitalization) (for suicidal ideation), the PCP called (voice-message) the ED to notify the ED that Patient #1 was self-presenting to the ED on a Section 12; however, the Hospital had not received the Section 12 Form. The VP Chief Quality Officer said the Section 12 was to get Patient #1 here (transport Patient #1 to the ED) and if Patient #1 was determined to require inpatient psychiatric level of the Hospital would renew the Section 12. The VP Chief Quality Officer said the Hospital had never seen before a patient self-present to the ED on a Section 12 and that patients on Section 12 were brought to the ED by ambulance.

The Emergency Department Note, dated at 5:14 P.M. on 12/7/2021, indicated Patient #1 was triaged.

The Emergency Department Note, dated at 5:57 P.M. on 12/7/2021, indicated Patient #1 was seen by a Provider.

The Section 12 Form, dated at 5:57 P.M. on 12/7/2021, indicated Patient #1 was seen by a Provider.

During the interview, at 10:15 A.M. on 12/14/2021, the ED Chief said Patient #1 came in (presented to the ED) on a Section 12, was not off the Section we (the Section 12 was not discontinued) and was stopped (discontinued) when the psychiatric evaluation determined Patient #1 did not meet the criteria for an inpatient psychiatric level of care.

Patient #1's medical record indicated no documentation that Patient #1's Section 12 was discontinued.

The VP Chief Quality Officer said Patient #1 self-presented to the Hospital's Emergency Department (ED), was triaged at a low risk for suicide and an ESI of 3.

The Hospital policy titled Management of the Patient Requiring Behavioral Health Evaluation, dated 6/2021, indicated an evaluation included an Emergency Severity Index (ESI) level;

- ESI of 1 indicated the patient's symptoms required life-saving resuscitation,

-ESI of 2 indicated the patient's symptoms required emergent interventions,

-ESI of 3 indicated the patient's symptoms were Urgent and the patient could safely wait in the waiting room [(for example the patient required a medical clearance (determined symptoms appearing to be psychiatric were not due to a serious underlying medical condition)].

-ESI of 4 indicated the patient's symptoms were less urgent, and

-ESI of 5 indicated the patient's symptoms were non-urgent.

The VP Chief Quality Officer said the Emergency Service Program (ESP) Clinician conducted the psychiatric evaluation, consulted with the ESP Supervisor, determined Patient #1 did not meet inpatient level of care criteria, was to be discharged and brought this information to the ED Physician. The VP Chief Quality Officer said a video recording showed a person (Patient #1) caring a bag, walking across a Hospital parking lot, then with a rope was hanging from a tree; the Hospital did not know if the rope was in Patient #1's bag as it was Hospital policy not to search patient bags. The VP Chief Quality Officer said the Hospital had not made any changes (implemented immediate corrective actions) because the event was still under investigation (three days following Patient #1's suicide).

During the interview, at 8:30 A.M. on 12/14/2021, the VP Chief Quality Officer said that the Hospital had made no new changes (seven days following Patient #1's suicide).

During the interview, at 10:15 A.M. on 12/14/2021, the ED Chief (an ED physician) said Patient #1 was brought to the ED by Patient #1's family.

During the interview at 12:50 P.M. on 12/14/2021, the VP Chief Quality Officer said if a serious event required immediate action, we (the Hospital) would take immediate action and that the Hospital investigation (regarding Patient #1's death) was being scheduled.

During the interview, at 1:00 P.M. on 12/14/2021, the ED Triage Nurse [a specially trained ED Registered Nurse who is responsible for evaluating patients and establishing the level of care that they require (the ESI) to rapidly identify patients with urgent life-threatening conditions] said that she was not aware that Patient #1 was on a Section 12, they (BNHC) did not send it here. The Triage Nurse said when a Patient presented to the ED on a Section 12, she gave the Section 12 Form to the ED Provider. The Triage Nurse said that to her knowledge the Hospital had not changed anything (implemented corrective actions one week following the Patient #1's death).

During the interview, at 9:10 A.M. on 12/15/2021, the ED Nurse Manager said there were no changes (corrective actions were implemented) yet and that the Hospital still needed to review with all the parties and did not know if the ED Behavioral Health Nurse Manager had scheduled a date for the review

The ED Psychiatric Triage Note, dated at 4:31 P.M. on 12/7/2021 by a Hospital Psychiatric Social Worker, indicated a message received from the Brockton Neighborhood Health Center (BNHC, Patient #1's Primary Care Provider) stated that they were referring Patient #1 to the ED for Suicidal ideation with a plan to drink himself, herself to death and relayed that they (BNHC) faxed a Section 12 to the Hospital however Patient #1 was to self-present to the ED with the assistance of family and did not want to come by ambulance. The ED Psychiatric Triage Note indicated the Hospital Psychiatric Social Worker placed a call to the BNHC to let BNHC know Patient #1 would be seen by an ESP Clinician. The ED Psychiatric Triage Note indicated the Psychiatric Triage Social Worker informed the ED Charge Nurse that Patient #1 was in the waiting room, that the BNHC wanted Patient #1 evaluated and Patient #1 was on a Section 12. The ED Psychiatric Triage Note did not indicate that the message from the BNHC was a person to person call or a voice message nor did the ED Psychiatric Triage Note clarify that the call back to the BNHC was a person to person call or a voice message.

The Hospital provided no documentation to indicate that they implemented immediate corrective actions prior to the Survey to:

-analyze their processes for voice-mail communications regarding psychiatric patients arriving to the Hospital ED on a Section 12.

-analyze ED care processes of care in accordance with the Hospital policy titled Management of the Patient Requiring Behavioral Health Evaluation, dated 6/2021, that indicated a.) Patients who were determined suicidal were detained in the ED even if this was against the patient's wishes, b.) The patient remained in the ED until and appropriate disposition was determined by the ED Physician, c.) Immediate actions for managing the patient at moderate and high-risk included initiating a Section 12A (Commonwealth of Massachusetts Department of Mental Health Application for an Authorization of Temporary Involuntary Hospitalization) as appropriate, d.) Instructions to staff to not open patient bags (gym bags, back packs duffel bags, suitcases, etc.).

Regarding Emergency Department Elopement:

The document titled ED Hospital Reports, dated from 7/23/2021 to 19/5/2021, indicated seven of forty-two (17% of) patients (Patients #7, #8, #9, & #10 and three Unsampled Patients) eloped or attempted to elope form the ED. Refer to Emergency Services Condition of Participation.

During the interview, at 9:10 A.M. on 12/15/2021, the Emergency Department Nurse Manager said elopements were just reported, every elopement was a failure and every elopement should be reviewed. The ED Nurse Manager said they were proactive with medicating patients because being in the hallway for days was stressful and overwhelming for psychiatric patients. The ED Nurse Manager said elopements were just reported (to the Hospital), every elopement was a failure and every elopement should be reviewed.

During the Medical Record Review and interview with the ED Behavioral Health Nurse Manager, at 11:30 A.M. on 12/16/2021, regarding ED patient elopement, the ED Behavioral Health Nurse Manager said he reviewed all cases of elopement and evaluated if the patient was properly medicated. The ED Behavioral Health Nurse said that the Hospital did not have a formal process for tracing the numbers of patients that eloped from the ED. The ED Behavioral Health Nurse said there was not a lot of diversional activities, or space for behavioral health patients.

Regarding Patient #10:

The Triage Note, dated at 1:53 P.M. on 12/3/2021, indicated Patient #10 presented to the ED by ambulance, on a Section 12, had visual hallucinations, paranoia. The Triage Note, dated at 11:11 A.M. on 12/5/2021, indicated Patient #10 was waiting in the ED for an inpatient psychiatric admission and Patient #10 eloped from the ED at approximately 9:45 AM this morning, was located and returned to the ED, by the Brockton Police. The Triage Note indicated Patient #10 was minimally communicative, answering few questions, followed directions with intense eye contact and demonstrated suicidal ideation; Patient #10 presented by ambulance, on a Section 12 and Patient #10 was assigned an ESI Score of 2.

The ED Psychiatric Nurse Manager said the Hospital conducted a Root Cause Analysis (RCA, an investigation), however there was no documentation of the investigation, internal reviews were conducted for all elopements as far as he knew and it was beyond what he knew.

The Hospital provided no documentation to indicate analysis nor a corrective action plan to manage ED elopements of behavioral health patients.

Based on observations, records reviewed and interviews the Hospital Quality Assessment & Performance activities failed for ten patients (Patients #1, #2, #3, #4, #5 #6, #7, #8, #9 & #10) in a sample of ten patients to ensure actions aimed at performance improvement were identified, (corrective action plans were) implemented, and measured (monitored, audited) for compliance to ensure that improvements were sustained, and opportunities for improvement were identified and implemented.

Findings included:

Regarding Patient #1:

The Hospital failed to identify immediate corrective actions following Patient #1's death.

During the interview, at 10:15 A.M. on 12/10/2021, the VP Chief Quality Officer said Patient #1 presented to Patient #1's Primary Care Provider (PCP, at the Brockton Neighborhood Health Center, BNHC) who initiated a Section 12 (Commonwealth of Massachusetts Department of Mental Health Application for an Authorization of Temporary Involuntary Hospitalization) (for suicidal ideation); an Emergency Service Program (ESP) Clinician conducted the psychiatric evaluation and determined Patient #1 did not meet inpatient level of care criteria, was to be discharged. The VP Chief Quality Officer said a video recording showed a person (Patient #1) walking across a Hospital parking lot, then with a rope was hanging from a tree. The VP Chief Quality Officer said the Hospital had not made any changes (implemented immediate corrective actions) because the event was still under investigation (three days following Patient #1's suicide).

Regarding ED not knowing BNHC initiated a Section 12 for Patient #1:

The ED Attending Physician and three Registered Nurses said they did not know BNHC initiated a Section 12 for Patient #1.

During the interviews, at 1:00 P.M. on 12/14/2021 with the ED Triage Nurse, at 8:45 A.M. on 12/15/2021 with the ED Charge Nurse, at 10:00 A.M. on 12/15/2021 with Patient #1's ED Patient Care Nurse, and at 2:00 P.M. on 12/15/2021 with the ED Attending Physician, said they did not know BNHC initiated a Section 12 for Patient #1.

Regarding Section 12 faxes:

During the interview, at 8:45 A.M. on 12/15/2021, the Charge Nurse on duty the evening Patient #1 self-presented to the ED, said Section 12 Forms were faxed to various facsimile machines in the ED and the secretaries go through the faxes.

During the interview, at 9:10 A.M. on 12/15/2021, the ED Nurse Manager said the ED had several faxes at nursing stations that received faxes. The ED Charge Nurse said there was no clear process where faxes (Section 12 Forms) arrive at the ED nor was there a person responsible (to retrieve, provide to the Provider).

Regarding elopement in the Emergency Department and ESI evaluations:

The document titled ED Hospital Reports, dated from 7/23/2021 to 19/5/2021, indicated seven of forty-two (17% of) patients (Patients #7, #8, #9, & #10 and three Unsampled Patients) eloped or attempted to elope form the ED. Refer to Emergency Services Condition of Participation.

During the interview, at 9:10 A.M. on 12/15/2021, the ED Nurse Manager said elopements were just reported, every elopement was a failure and every elopement should be reviewed. The ED Nurse Manager said they were proactive with medicating patients because being in the hallway for days was stressful and overwhelming for psychiatric patients.

During the Medical Record Review and interview with the ED Behavioral Health Nurse Manager, at 11:30 A.M. on 12/16/2021, regarding ED patient elopement, the ED Behavioral Health Nurse Manager said he reviewed all cases of elopement and evaluated if the patient was properly medicated. The ED Behavioral Health Nurse said that the Hospital did not have a formal process for tracing the numbers of patients that eloped from the ED. The ED Behavioral Health Nurse said there was not a lot of diversional activities, or space for behavioral health patients.

Patient #7:

The Medical Screening Examination, dated 8/30/2021, indicated Patient #7 presented to the ED with psychiatric symptoms, had a history of multiple drug overdosed and serious suicide attempts. The ED Provider Note, dated 8/31/2021, indicated Patient #7 was transferred from the ED to the Intensive Care Unit because Patient #7 required ketamine (an anesthetic medication for behavioral control and side effects include respiratory depression).

The Hospital Report, dated 8/23/2021, indicated Patient #7 was able to get to the area outside of the Admitting Office (attempted elopement).

Patient #8:

The Triage Note, dated at 7:51 P.M. on 7/23/2021, indicated Patient #8 was assigned an ESI Score of 3 (Urgent). The Triage Note indicated Patient #8 had suicidal ideation with a plan to crash a car.

ED Nursing Note, dated at 8:59 P.M. on 7/23/2021, indicated Patient #8 arrived at the hallway from triage, refused to change into hospital attire, demanding a doctor come to see him/her now because he/she was not going to stay in this hallway like yesterday; the nurse went to check for a room in the heightened secured area when a sitter stated the patient was seen walking out of the hallway toward the exit. Security was notified to take the patient inside (the ED); Security went outside to stop Patient #8; however, Patient #8 was already gone. Brockton Police was notified, given Patient #8's description. Patient #8 was not yet on a Section 12.

The Hospital policy titled Management of the Patient Requiring Behavioral Health Evaluation, dated 6/2021, indicated an evaluation included an Emergency Severity Index (ESI) level;

- ESI of 1 indicated the patient's symptoms required life-saving resuscitation,

-ESI of 2 indicated the patient's symptoms required emergent interventions,

-ESI of 3 indicated the patient's symptoms were Urgent and the patient could safely wait in the waiting room [(for example the patient required a medical clearance (determined symptoms appearing to be psychiatric were not due to a serious underlying medical condition)].

-ESI of 4 indicated the patient's symptoms were less urgent, and

-ESI of 5 indicated the patient's symptoms were non-urgent.

ED Behavioral Health Nurse Manager said Patient #8 should have been assigned an ESI of 2.

Patient #9:

The Triage Note, dated at 12:27 P.M. on 8/29/2021, indicated Patient #9 was assigned an ESI Score of 3.

The Medical Screening Examination, dated at 12:26 P.M. on 8/29/2021, indicated Patient #9 required a psychiatric evaluation because the devil was trying to kill himself/herself.

ED Behavioral Health Nurse Manager said Patient #9 should have been assigned an ESI of 2.

The Hospital Report, dated at, 12:55 A.M. on 8/31/2021, indicated Patient #9 eloped from the Emergency Department. The Hospital Report indicated Patient #9 was on a Section 12, while on a watch with a sitter; eloped through the ambulance bay doors. Brockton police were able to bring Patient #9 back to the ED for management within one hour. The ED physicians attempted to keep Patient #9's behavior and agitation under control with medication. The Hospital Report indicated elopements were a continued concern with a high behavioral health census as there were less spaces available to place patients away from doors or in the security area.

Patient #10:

The Triage Note, dated at 1:53 P.M. on 12/3/2021, indicated Patient #10 presented to the ED by ambulance, on a Section 12, had visual hallucinations, paranoia, and assigned an ESI Score of 2. The Triage Note, dated at 11:11 A.M. on 12/5/2021, indicated Patient #10 was waiting in the ED for an inpatient psychiatric admission. Patient #10 eloped from the ED at approximately 9:45 AM this morning located and returned to the ED, by the Brockton Police. The Triage Note indicated Patient #10 was minimally communicative, answering few questions, followed directions with intense eye contact and demonstrated suicidal ideation; Patient #10 presented by ambulance, on a Section 12 and Patient #10 was assigned an ESI Score of 2.

The Hospital Report, dated at 9:30 A.M. on 12/5/2021, indicated Patient #10 was assigned to a hallway space.

Regarding Patient #2:

The Complaint Report, dated 7/1/2021, indicated the Complainant alleged Patient #2 died, in the Hospital, one day after birth of a healthy baby. The Complainant alleged that the Hospital did not control Patient #2's bleeding after the birth.

The Discharge Summary, dated 2/21/2021, indicated presented to the Hospital on 2/20/2021, had a normal spontaneous vaginal delivery and following the delivery of the placenta there was significant post-partum hemorrhage; Patient #2 was treated with medications, blood and transferred to the Intensive Care Unit (ICU). The Discharge Summary indicated after admission to the ICU Patient #2 received the massive transfusion protocol, an emergency hysterectomy to control bleeding. The Discharge Summary indicated Patient #2 coded (had a cardiac arrest) and was pounced dead at 9:19 A.M. on 2/21/2021.

1.) The Hospital failed to ensure they conducted a thorough investigation regarding Certified Nurse Midwife (CNM) and Obstetrician consultation, collaboration, and referral processes were analyzed to identify possible actions aimed at performance improvement.

The Bylaws of Signature Healthcare Brockton Hospital Medical Staff, dated 1/28/2021, indicated the Medical Staff indicated all Midwives with Hospital privileges would function in accordance with the Midwifery Protocol; the CNM would assume responsibility and management of medically uncomplicated, low-risk, full-term labor patients throughout the labor and delivery process; when there was a variation form normal the CNM would consult, collaborate and refer (transfer) to the (Obstetrician) Physician according to the Midwifery Protocol.

The Brockton Hospital Midwifery Protocol, undated, indicated Conditions Requiring Collaboration / Referral; with a definition of collaborative management indicated that the CNM and physician team jointly managed patient care.

The documents titled Meeting titled Root Cause Analysis (RCA) Maternal Mortality, dated 3/17/2021 and the document titled Safety and Quality Review, dated 6/21/2021, indicated no indication that Midwifery-Obstetrician consultation, collaboration nor referral (transfer of care) to an Obstetrician according to the Bylaws and Midwifery Protocol were analyzed. The documents titled Meeting titled Root Cause Analysis (RCA) Maternal Mortality and the document titled Safety and Quality Review, indicated no analysis of consultation, collaboration nor referral for a patient with a post-partum hemorrhage.

During the interview, at on 12/15/2021, the Chief of Obstetrics (a Physician) said he needed to look at the Bylaws (of Signature Healthcare Brockton Hospital Medical Staff) regarding CNM and Obstetrician consultation and transfer (referral) to ensure the Bylaws were clear.

Medical Record review, indicated no clear documentation when Patient #2 care was referred (transferred) to an Obstetrician.

2.) The Hospital failed to ensure they implemented the Modified Early Warning Score in accordance with their Corrective Action Plan, following Patient #2's death on 2/21/2021 and by the time of the Survey approximately ten months following Patient #2's death.

The document titled Safety and Quality Review, dated 6/21/2021, indicated a corrective action to implement the utilization of the Modified Early Warning Score.

The document titled Safety and Quality Review, dated 6/21/2021, indicated the MEWS corrective action was completed on 4/30/2021.

The Meeting titled Root Cause Analysis (RCA) Maternal Mortality, dated 3/17/2021, indicated the Modified Early Warning Score (MEWS) was a calculation utilized to assist in determining if the patient required more medication attention (most likely medical attention was intended) than a patient was currently receiving; this score likely would have been beneficial in determining at which pointy the Patient #2 required escalation of care or additional resources available. The RCA Maternal Mortality indicated there would be implementation of MEWS for all Obstetric patients with orders sets reflecting when a provider needed to come to the bedside to evaluate patients at risk. The RCA Maternal Mortality identified the former Chief of Obstetrics as the responsible. The RCA Maternal Mortality indicated no documentation of an expected date of completion, nor monitoring (audits) of compliance to ensure that improvements were sustained.

The RCA Maternal Mortality, indicated Patient #2's cumulative blood loss was under appreciated. The Hospital provided no documentation to indicate a corrective action to tally (provide a current amount of) cumulative blood loss.

The article titled Incidence of Uterine Tachysystole in Women Induced with Oxytocin, dated 2013 https://www.jognn.org/action/showPdf?pii=S0884-2175%2815%2931251-X, indicated Uterine Tachysystole can result in life-long consequences for the mother and fetus. Maternal complications include placental abruption and/or uterine rupture, either of which can be fatal, an emergent sequelae that can result from tachysystole (ACOG, 2009b; Simpson, 2008).
The article titled Implementation of a Maternal Early Warning Trigger (MEWT) System, dated 6/1/2018, https://doi.org/10.1016/j.jogn.2018.04.054, indicated Maternal early warning systems were endorsed by the American College of Obstetricians and Gynecologists, the Society of Maternal Fetal Medicine, and the Association of Women's Health, Obstetric and Neonatal Nurses.

The article titled Implementing Obstetric Early Warning Systems, dated 4/8/2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5910060/, indicated Severe maternal morbidity and mortality are often preventable and obstetric early warning systems that alert care providers of potential impending critical illness may improve maternal safety. The Modified Early Obstetric Warning System (MEOWS) evaluated respiration rate (breaths per minute); oxygen saturation (%); temperature (°C); systolic blood pressure (mm HG); heart rate (beats per minute); level of consciousness each with an evaluation identified as yellow or red; a single red score or two yellow scores triggers an evaluation.

During an interview, at 2:15 P.M. on 2/14/2021, the Maternity Nurse Manager said Patient #2 presented to the Hospital for an Induction of Labor and her risk (factor) was Advanced Maternal Age (AMA); had uterine tachysystole (an abnormally rapid rate of muscle contraction) and received terbutaline (a medication) to relax the uterine muscles. The Maternity Nurse Manager said the Hospital conducted a Root Cause Analysis (RCA, Hospital investigation) that identified Modified Early Warning Score (as actions aimed at performance improvement, corrective action). The Maternity Nurse Manager said that the Modified Early Warning Score was not implemented at this time, still kind of training and that it (MEWS, the performance improvement action) was not mandatory to complete in the computer.

During the interview, at on 12/15/2021, the Chief of Obstetrics (a Physician) said the implementation of the (Modified) Early Warning Signs was a nursing responsibility.

During the interview, at 1:40 P.M. on 12/15/2021, the Obstetric Charge Nurse said they were still learning the MEWS process. The Obstetric Charge Nurse said that their "Pink Sheet" could serve as a trigger to remind Obstetric Nurses to complete the MEWS.

The Labor Worksheet (Pink Sheet), undated, indicated a worksheet for Obstetric Nurses. The Labor Worksheet indicated no documentation (trigger) to remind Obstetric Nurses to complete the MEWS.

Regarding cumulative output:

The document titled 2021 Department of Obstetrics Case Reports, indicated four obstetric patients transferred to the Intensive Care Unit for a higher level of care. The 2021 Department of Obstetrics Case Report indicated Patient #3 was transferred to the ICU for a postpartum hemorrhage.

Medical Record reviews, regarding Patient's #3, #4, #5, & #6, indicated no indication that the cumulative output function in the Electronic Medical Record (EMR) was utilized to appreciate cumulative blood loss.

Medical Record reviews, regarding Patients #4, #5, #6, indicated no documentation that the hemorrhage risk screening was completed.


3.) The Hospital failed to monitor for the requirement for Attending Physician to Attending Physician communication regarding OBGYN patient transfer to the Intensive Care Unit in accordance with the (RCA) Maternal Mortality corrective action.

The documents titled Meeting titled Root Cause Analysis (RCA) Maternal Mortality, dated 3/17/2021, indicated the acuity of a patient requiring transfer to a higher level of care should be conducted from Attending Physician to Attending Physician. A requirement that all OBGYN patients that were transferred to the Intensive Care Unit would require a discussion between the Obstetrician Attending Physician and the Intensive Care Unit Attending Physician to facilitate transfer and provide all relevant clinical information.

During the interview, at on 12/15/2021, the Chief of Obstetrics (a Physician) said the face to face, attending to attending (requirement of the RCA) was through communication review.

The Hospital provided no documentation to indicate monitoring the Attending Physician to Attending Physician (face to face) communication in accordance with the RCA corrective action.

4.) The Hospital failed to ensure the used data collected to identify an opportunity for improvement regarding maternal opioid screening consistent with evidence based obstetric care.

ACOG Committee Opinion, dated 8/2017, indicated routine screening should rely on validated screening tools, these tools that have been well studied and demonstrated high sensitivity for detecting substance use and missus. These tools can be used in direct interview by physicians as well as non-physician and can be streamlined into clinical practice by using computer-based approaches.

The article titled Optimizing Outcomes for Women With Substance Use Disorders (SUD) in Pregnancy and the Postpartum Period, dated 2019, https://www.jognn.org/article/S0884-2175(19)30392-2/pdf, indicated nurses should be competent in screening approaches to identify the use of legal and illegal substances and SUD in pregnant women and women who may become pregnant. Early and universal, verbal screening is recommended in pregnancy (ACOG, 2017). The purpose of screening is to identify substance use and initiate a referral to treatment, if indicated, that will benefit the woman and fetus rather than to report use. Validated screening tools for assessment of alcohol, tobacco, and other drugs should be used (ACOG, 2017). Evidence-based approaches include motivational interviewing and the Screening, Brief Intervention and Referral to Treatment model (American Society of Addiction Medicine, 2017).

The Commonwealth of Massachusetts Department of Public Health, Guidelines for Community Standard for Maternal/Newborn Screening, For Alcohol/Substance Use, Massachusetts Department of Public Health (the Department) recommended: Screening all pregnant women through interviews using a standard tool at the beginning of pregnancy, as well as at 28 weeks and at the time the woman presents for delivery.

Medical Record review for Patients #2, #3, #4, & #6 indicated no documentation of validated screening tools for assessment of alcohol, tobacco, and other drugs in accordance with be used (ACOG, 2017).

Based on records reviewed The Hospital's Governing Body (Board of Trustees), Hospital Executives and Medical Staff failed for ten patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, & #10) in a sample of ten patients to ensure they assumed full authority, responsibility and accountability for Hospital operations regarding efforts that improved quality of care, patient safety and that all improvement actions were evaluated.

Findings included:

The Hospital failed to ensure they (the Hospital):

1.) Provided patient privacy and patient safety.

2.) Required appropriate staff, the Medical Staff physicians and other Licensed Independent Practitioners (LIP) authorized to order restraint or seclusion to have a working knowledge of Hospital policy regarding restraint and seclusion.

3.) Collected, analyzed and monitored data for effectiveness and safety of services and quality of care.

4.) Identified actions aimed at performance improvement, (corrective action plans were) implemented, and measured (monitored, audited) for compliance to ensure that improvements were sustained.

5.) Organized the Emergency Department.

6.) Integrated the Emergency Department with other departments of the Hospital to decompress patient over-crowding the Emergency.

7.) Utilized qualified clinicians to perform psychiatric evaluations in the Emergency Department.

The Condition of Participation: Emergency Services was not met.

Findings included:

1.) The Hospital failed for one patient (Patient #1) in a sample of ten patients to ensure that Emergency services as organized under the direction of a qualified member of the Medical Staff was responsible for the Hospital's Emergency Services regarding psychiatric evaluations and Section 12 (Commonwealth of Massachusetts Department of Mental Health Application for an Authorization of Temporary Involuntary Hospitalization) procedures.

Refer to TAG: A-1102 Organization.

2.) The Hospital failed for five patients (Patient #1, #7, #8, #9, & #10) in a sample of ten patients to ensure Emergency Services were integrated with other departments of the Hospital to decompress patient over-crowding the Emergency Department (ED)and immediately make available the full extent of its patient care resources to assess and render appropriate care for an ED patient including personnel.

Refer to TAG: A-1103 Integration.

3.) Based on records reviewed and interviews the Hospital Medical Staff failed for four patients (Patients #7, #8, #9, & #10) in a sample of ten patients to ensure they determined Emergency Service Program (ESP) personnel (Clinicians) delineated qualifications (skills, education, certifications, specialized training and experience) in emergency care to meet the needs of psychiatric patients in accordance with Medical Staff Bylaws.

Refer to TAG: 1112 Qualified Personnel.

Based on records reviewed and interviews the Hospital failed for five patient (Patient #1, #7, #8, #9, & #10) in a sample of ten patients to ensure that Emergency services as organized under the direction of a qualified member of the Medical Staff was responsible for the Hospital's Emergency Services regarding psychiatric evaluations and Section 12 (Commonwealth of Massachusetts Department of Mental Health Application for an Authorization of Temporary Involuntary Hospitalization) procedures.

Findings included;

1.) Bylaws of Signature Healthcare Brockton Hospital Medical Staff, dated 1/28/2021, indicated the Medical Staff was organized in separate clinical departments, each with a chief who was responsible for the overall supervision of patient care within the department (ED). The Bylaws indicated responsibilities of the ED Chief included providing recommendations and suggestions regarding the ED in connection with policies of the Hospital, and develop and implement policies and procedures that guide and support the provision of care, treatment and services.

Patient #1:

The Nursing Note, dated at 7:30 P.M. on 12/7/2021 by an ESP Clinician) indicated Patient #1 was help-seeking and looking to get back on his/her (psychiatric) medications. The Nursing Note indicated Patient #1 presented in the Behavioral Health ED hallway in person.

During the interview, at 10:15 A.M. on 12/10/2021, with the Vice President (VP) Chief Nursing Officer, Associate Vice President for Nursing and the Vice President Chief Quality Officer, the VP Chief Quality Officer said Patient #1's PCP initiated the Section 12 (Commonwealth of Massachusetts Department of Mental Health Application for an Authorization of Temporary Involuntary Hospitalization) (for suicidal ideation), the PCP called (voice-message) the ED to notify the ED that Patient #1 was self-presenting to the ED on a Section 12; however, the Hospital had not received the Section 12 Form.

During the interviews, at 1:00 P.M. on 12/14/2021 with the ED Triage Nurse, at 8:45 A.M. on 12/15/2021 with the ED Charge Nurse, at 10:00 A.M. on 12/15/2021 with Patient #1's ED Patient Care Nurse, and at 2:00 P.M. on 12/15/2021 with the ED Attending Physician, said they did not know BNHC initiated a Section 12 for Patient #1.

During the interview, at 9:10 A.M. on 12/15/2021, the ED Nurse Manager said the ED had several faxes at nursing stations that received faxes and there was no clear process where faxes (that received Section 12 Forms) arrived at the ED nor was there a person responsible (to retrieve and provide to the Provider).

Patient #7:

The Medical Screening Examination, dated 8/30/2021, indicated Patient #7 presented to the ED with psychiatric symptoms, had a history of multiple drug overdosed and serious suicide attempts.

The Hospital Report, dated 8/23/2021, indicated Patient #7 was able to get to the area outside of the Admitting Office (attempted elopement).

Regarding Patients #8:

The Triage Note indicated Patient #8 had suicidal ideation with a plan to crash a car.

ED Nursing Note, dated at 8:59 P.M. on 7/23/2021, indicated Patient #8 was not yet on a Section 12 (Commonwealth of Massachusetts Department of Mental Health Application for an Authorization of Temporary Involuntary Hospitalization).

The Hospital Report, dated 7/23/2021, indicated the Police were unable to locate Patient #8.

Patient #9:

The Hospital policy titled Patient Sitter Guidelines, dated 7/2018, indicated the Patient Observation Assistant, also known as sitters or one-to-one observers) were assigned to provide continuous observation for patients that presented as a risk to themselves or others, suicidal patients, cognitively unable patients.

The Medical Screening Examination, dated at 12:26 P.M. on 8/29/2021, indicated Patient #9 required a psychiatric evaluation because the devil was trying to kill himself/herself.

The Hospital Report, dated at, 12:55 A.M. on 8/31/2021, indicated Patient #9 eloped from the ED, on a Section 12, while on a watch with a sitter.

Patient #10:

The Triage Note, dated at 1:53 P.M. on 12/3/2021, indicated Patient #10 presented to the ED by ambulance, on a Section 12, had visual hallucinations and paranoia. The Triage Note, dated at 11:11 A.M. on 12/5/2021, indicated Patient #10 was waiting in the ED for an inpatient psychiatric admission and eloped.

The Hospital provided no documentation to indicate management of Section 12 procedures following Patients #1, #7, #8, #9 and #10's adverse patient events.

Based on observations, records reviewed and interview the Hospital failed for four patients (Patients #7, #8, #9, & #10) in a sample of ten patients to ensure Emergency Services were integrated with other departments of the Hospital to decompress patient over-growing in the Emergency Department (ED) and immediately make available the full extent of its patient care resources to assess and render appropriate care for an ED patient including personnel.

Findings included:

The article titled Overcrowding in emergency departments: A review of strategies to decrease future challenges, dated 2017 Feb 16: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5377968/, indicated overcrowding in hospitals is a complex phenomenon. The quality of services in EDs depends on coordinated efforts between emergency physicians, on-call specialists, emergency nurses, other health professionals, laboratory, diagnostic imaging services, and inpatient units. If any of these interdependent components disrupts the processes, health care would counter with difficulty. ED leaders can control some of these components. However, many components are controlled by stakeholders outside the ED whose priority may not be optimizing patient care in the ED. Thus, the ED may experience poor communication with laboratory and imaging services, restricted access to inpatient beds. ED leaders must focus on discussion meeting with institutional executives, internal and external stakeholders, and public policymakers to implement initiatives to ease ED crowding. In addition, economic incentives of high occupancy, aging population phenomenon in developed countries, and not predicting emergency demands to optimize capacity may cause overcrowding. Solutions could be a realignment of financial incentives, considering misuse and overuse of health services, and improved chronic disease management to reduce hospital bed demand. Although various models of care have been invented these days, understanding how and which models could be implemented in which organization requires further research. Keeping challenges and advantages of each model help us choose the correct way.

Bylaws of Signature Healthcare Brockton Hospital Medical Staff, dated 1/28/2021, indicated the Medical Staff was organized in separate clinical departments, each with a chief who was responsible for the overall supervision of patient care within the department (ED). The Bylaws indicated responsibilities of the ED Chief included recommendations on space and other resources needed by the ED, assistance in the integration of the ED into primary functions of the organization and coordination of interdepartmental and intradepartmental services, recommendations to the Medical Executive Committee off-site sources for needed patient care, treatment, and services not provided by the ED or the Hospital.

Regarding Patient Care in ED Hallways:

During the interview, at 9:10 A.M. on 12/15/2021, the ED Nurse Manager said the ED had forty-four beds and Hallway beds were countless.

The Medical Screening Examination, dated 8/30/2021, indicated Patient #7 presented to the ED with psychiatric symptoms, had a history of multiple drug overdosed and serious suicide attempts. The ED Provider Note, dated 8/31/2021, indicated Patient #7 was transferred from the ED to the Intensive Care Unit because Patient #7 required ketamine (an anesthetic medication for behavioral control and side effects include respiratory depression).

The Hospital Report, dated 8/23/2021, indicated Patient #7 was assigned to a hallway space in the ED.

ED Nursing Note, dated at 8:59 P.M. on 7/23/2021, indicated Patient #8 was not going to stay in this hallway.

The Hospital Report, dated at 9:30 A.M. on 12/5/2021, indicated Patient #10 was assigned to a hallway space.

The Hospital provided no documentation to indicate a plan to explore options for ESP psychiatric evaluations conducted in a space that provided improved patient confidentiality the ED.

During observations of the ED, on 12/16/2021, the Surveyor observed a seriously crowded ED, with every patient room occupied, patients on hallway stretchers on both sides of the hallway, one after the other as staff provided hallway care. During the observations, at 3:00 P.M. on 12/16/2021, the VP Chief Nursing Officer said the ED had 150 visits per day, with forty beds and presently there were one-hundred and three ED Patients, with sixty-two patients cared for on hallway stretchers.

Regarding Emergency Department Elopements and ESI Evaluations:

The Hospital policy titled Patient Sitter Guidelines, dated 7/2018, indicated the Patient Observation Assistant, also known as sitters or one-to-one observers) were assigned to provide continuous observation for patients that presented as a risk to themselves or others, suicidal patients, cognitively unable patients.

The document titled ED Hospital Reports, dated from 7/23/2021 to 19/5/2021, indicated seven of forty-two (17% of) patients eloped or attempted to elope form the ED.

During the interview, at 9:10 A.M. on 12/15/2021, the Emergency Department Nurse Manager said being in the hallway for days was stressful and overwhelming for psychiatric patients.

Patient #7:

The Hospital Report, dated 8/23/2021, indicated Patient #7 was able to get to the area outside of the Admitting Office (attempted elopement).

The Medical Screening Examination, dated 8/30/2021, indicated Patient #7 presented to the ED with psychiatric symptoms, had a history of multiple drug overdosed and serious suicide attempts. The ED Provider Note, dated 8/31/2021, indicated Patient #7 was transferred from the ED to the Intensive Care Unit because Patient #7 required ketamine (an anesthetic medication for behavioral control and side effects include respiratory depression).

Patient #8:

The Triage Note, dated at 7:51 P.M. on 2021, indicated Patient #8 was assigned an ESI Score of 3 (Urgent). The Triage Note indicated Patient #8 had suicidal ideation with a plan to crash a car.

ED Nursing Note, dated at 8:59 P.M. on 7/23/2021, indicated Patient #8 arrived at the hallway from triage, refused to change into hospital attire, demanding a doctor come to see him/her now because he/she was not going to stay in this hallway like yesterday; the nurse went to check for a room in the heightened secured area when a sitter stated the patient was seen walking out of the hallway toward the exit. Security was notified to take the patient inside (the ED); Security went outside to stop Patient #8; however, Patient #8 was already gone. Brockton Police was notified, given Patient #8's description. Patient #8 was not yet on a Section 12.

The Hospital policy titled Management of the Patient Requiring Behavioral Health Evaluation, dated 6/2021, indicated an evaluation included an Emergency Severity Index (ESI) level;

- ESI of 1 indicated the patient's symptoms required life-saving resuscitation,

-ESI of 2 indicated the patient's symptoms required emergent interventions,

-ESI of 3 indicated the patient's symptoms were Urgent and the patient could safely wait in the waiting room [(for example the patient required a medical clearance (determined symptoms appearing to be psychiatric were not due to a serious underlying medical condition)].

-ESI of 4 indicated the patient's symptoms were less urgent, and

-ESI of 5 indicated the patient's symptoms were non-urgent.

ED Behavioral Health Nurse Manager said Patient #8 should have been assigned an ESI of 2.

Patient #9:

The Triage Note, dated at 12:27 P.M. on 8/29/2021, indicated Patient #9 was assigned an ESI Score of 3.

The Medical Screening Examination, dated at 12:26 P.M. on 8/29/2021, indicated Patient #9 required a psychiatric evaluation because the devil was trying to kill himself/herself.

ED Behavioral Health Nurse Manager said Patient #9 should have been assigned an ESI of 2.

The Hospital Report, dated at, 12:55 A.M. on 8/31/2021, indicated Patient #9 eloped from the Emergency Department. The Hospital Report indicated Patient #9 was on a Section 12, while on a watch with a sitter; eloped through the ambulance bay doors. Brockton police were able to bring Patient #9 back to the ED for management within one hour. The ED physicians attempted to keep Patient #9's behavior and agitation under control with medication. The Hospital Report indicated elopements were a continued concern with a high behavioral health census as there were less spaces available to place patients away from doors or in the security area.

Patient #10:

The Hospital Report, dated at 9:30 A.M. on 12/5/2021, indicated Patient #10 was assigned to a hallway space.

The Triage Note, dated at 1:53 P.M. on 12/3/2021, indicated Patient #10 presented to the ED by ambulance, on a Section 12, had visual hallucinations, paranoia, and assigned an ESI Score of 2. The Triage Note, dated at 11:11 A.M. on 12/5/2021, indicated Patient #10 was waiting in the ED for an inpatient psychiatric admission. Patient #10 eloped from the ED at approximately 9:45 AM this morning located and returned to the ED, by the Brockton Police. The Triage Note indicated Patient #10 was minimally communicative, answering few questions, followed directions with intense eye contact and demonstrated suicidal ideation; Patient #10 presented by ambulance, on a Section 12 and Patient #10 was assigned an ESI Score of 2.

Regarding Code Help.

During the observations, at 3:00 P.M. on 12/16/2021, the VP Chief Nursing Officer the Hospital had been in a Code Help since 8/2021.

The Hospital policy titled Code Help, dated 11/2019, indicated The purpose of this policy is to implement a plan to address hospital and Emergency Department boarding and crowding by implementing a formalized Code Help Plan. A Code Help will be implemented when: 1.) The ED is at capacity and is unable to care for existing patients in a licensed treatment space/area, 2.) or the ED is unable to accept new patients into a licensed treatment space/area, and 3.) there are admitted patients waiting in the ED for an inpatient bed. A Code Help will be initiated with the goal of moving all admitted patients out of the ED within 30 minutes of activation. In the event that the Code Help does not eliminate the burden of admitted patients in the ED within 2 hours, or if the severity of the initial situation warrants, then the Disaster Plan must be activated. The disaster plan will be activated by the Administrator on Call or his or her designee.

The Emergency Operations Plan, dated 2021-2022, indicated the Hospitals Disaster Plan.

The Emergency Operations Plan indicated During events where the Emergency Operations Plan (EOP) is activated, Emergency Operations Plan should be initiated when the Hospital was impacted by unusual conditions. Signature Healthcare has developed an "all hazards" approach to address a range of emergencies by planning for responding to emergencies impacting critical areas. The decision whether or not to invoke the Emergency Operations Plan will be made co-jointly by the Administrator On-Call (AOC) and, depending upon the nature of the event, additional, appropriate hospital representatives knowledgeable regarding the type of incident being responded to.

The Hospital provided no documentation to indicate the Emergency Services:

1.) Made recommendations to the Hospital regarding an immediate plan to decompress patient overcrowding in the ED.

2.) Was evaluating their Code Help Policy for effectiveness. (Code Help plans are put in place by hospitals to eliminate ED (ED) crowding and ensure that they can maintain their ability to accept and manage new patients for emergency care. All acute care hospitals licensed by the Department of Public Health (DPH) must have a Code Help policy in place.)

Based on records reviewed and interviews the Hospital Medical Staff failed for one patient (Patient #1) in a sample of ten patients to ensure they determined Emergency Service Program (ESP) personnel (Clinicians) delineated qualifications (skills, education, certifications, specialized training and experience) in emergency care to meet the needs of psychiatric patients in accordance with Medical Staff Bylaws.

Findings included:

Bylaws of Signature Healthcare Brockton Hospital Medical Staff, dated 1/28/2021, indicated the Medical Staff was organized in separate clinical departments, each with a chief who was responsible for the overall supervision of patient care within the Emergency Department (ED). The Chief of Emergency Medicine shall adopt a method of staffing the ED, in accordance with the Hospital's basic plan for the delivery of such services including the delineation of clinical privileges for all practitioners who render emergency care. The Bylaws indicated responsibilities of the ED Chief included recommending criteria for clinical privileges to the Medical Executive Committee.

The ED Psychiatric Triage Note, dated at 4:31 P.M. on 12/7/2021 by a Hospital Psychiatric Social Worker, indicated a message received from the Brockton Neighborhood Health Center (BNHC, Patient #1's Primary Care Provider) stated that BNHC were referring Patient #1 to the ED for suicidal ideation with a plan to drink to death and relayed that they (BNHC) faxed a Section 12 to the Hospital.

The Nursing Note, dated at 7:30 P.M. on 12/7/2021 documented by an ESP Clinician) indicated Patient #1 was help-seeking and looking to get back on his/her (psychiatric) medications. The Nursing Note documented by ESP Clinician indicated Patient #1 denied no plan or intent of Suicidal Ideation, but stated sometimes it would be better if I wasn't here; I cannot go back home without my meds (medications). The Nursing Note documented by ESP Clinician indicated collateral information gathered revealed that Patient #1 had a suicide attempt approximately ten years ago. The Nursing Note documented by ESP Clinician indicated no documentation gathered from the BNHC as collateral information. The Nursing Note documented by ESP Clinician indicated the ESP Clinician evaluated Patient #1's insight as moderate, judgement as fair, impulsivity as moderate risk, mood and affect as irritable. The Nursing Note documented by ESP Clinician indicated the ESP Clinician evaluated Patient #1's risk as: Client has a suicide history and inpatient level of care history, endorsing depression, anxiety, low self-esteem and without medication for the past year. The Nursing Note documented by ESP Clinician indicated the ESP Clinician consulted with the ESP Supervisor, client is nor currently a harm to self or others at this time, is help-seeking and cooperative, does not meet inpatient level of care criteria and would benefit from Community Crisis Stabilization (CCS) for immediate stabilization and medication evaluation and Patient #1 would be discharge. The Nursing Note documented by ESP Clinician indicated no documentation of review of information gathered shared with the ED Provider.

During the interview, at 10:15 A.M. on 12/10/2021, the VP Chief Quality Officer said the role of the ESP Clinicians provided psychiatric evaluations to determine inpatient or outpatient level of care; ESP Clinicians conducted a psychiatric bed search for inpatient level of care. The VP Chief Quality Officer said Patient #1 presented to Patient #1's Primary Care Provider (PCP) requesting prescription refills for psychiatric medications. The VP Chief Quality Officer said the ESP Clinician conducted the psychiatric evaluation, consulted with the ESP supervisor, determined Patient #1 did not meet inpatient level of care criteria, was to be discharged and brought this information to the ED Physician. The VP Chief Quality Officer said a video recording showed a person (Patient #1) caring a bag, walked across a Hospital parking lot, then with a rope was hanging from a tree. The Vice President Chief Quality Officer said ESP Clinicians were not credentialed by the Hospital.

The agreement titled Emergency Services Program (ESP) Consultation Agreement, dated 6/1/2017, indicated a contract between Community Counseling of Bristol County and Signature Healthcare Brockton Hospital. The ESP Consultation Agreement indicated all licensed mental health professionals would be credentialed as members of the allied clinical staff of the medical staff.

During the interview, at 8:30 A.M. on 12/14/2021, the Vice president Chief Quality Officer said that changed, on 7/12/2017, (the agreement) and the Hospital decided not to credential the ESP Clinicians.

During the interview, at 10:15 A.M. on 12/14/2021, the ED Chief (an ED physician) said it was the main job (for ED Providers) to medically clear patients for psychiatric evaluation and order the psychiatric evaluation. The ED Chief said they (ED Providers) were out of the process for the psychiatric evaluations; the psychiatric evaluations were conducted by either the Hospital Social Workers or the ESP depending on the patients insurance. The ED Chief said Patient #1 was medically cleared and referred for psychiatric evaluation.

During the interview, at 11:00 A.M. on 11/14/2021, the VP Chief Nursing Officer said the State (Commonwealth of Massachusetts) designated the Community Counseling of Bristol County (CCBC) to do the Hospital psychiatric evaluations and that the Hospital had an agreement with the CCBC. The VP Chief nursing Officer said ESP Clinician #1 was one of the ESP Consultants (Clinicians) that did (psychiatric) evaluations for Medicare behavioral health evaluations and mental health status determination for inpatient (psychiatric level of care) determination. The VP Chief Nursing Officer said the ESP Clinicians were Master's (degree) Level Social Workers. The VP Chief Nursing Officer said ESP Clinician #1 referred to his supervisor and determination Inpatient Level of care, referral to a crisis center (for outpatient care) or discharge to home. The VP Chief Nursing Officer said they (ESP) determined Patient #1 was at no risk and they made the recommendation to the ED Provider.

During the interview, at 10:00 A.M. on 12/15/2021, the Patient Care Nurse said Patient #1 said if I go, I'm just going to get drunk and figured the family was picking Patient #1 up; she never questioned the (ESP) evaluators, and she had never called them (ESP Clinicians) before, she saw that Patient #1 was not a hospital level of care and could go home to family.

During the interview, at 1:15 P.M. on 12/15/2021, Psychiatric Social Worker #1 said she was employed by the Hospital as a Psychiatric Clinician and her role was to perform psychiatric evaluations in the ED. Psychiatric Social Worker #1 she received a voice mail message, later in the day at approximately 4:00 P.M., on the Psychiatric triage (telephone) line, from a Social Worker at BNHC; BNHC was sending Patient #1 (to the ED), as Patient #1 needed an evaluation, was on a Section 12, because Patient #1 had a plan to drink to death; Patient #1 did not want to arrive by ambulance and would arrive on his/her own. Psychiatric Social Worker #1 said it was unlikely that the voice mail message was still on the recording and was able to be retrieved. Psychiatric Social Worker #1 said this was a run of the mill phone call for our department. (The Hospital provided no information regarding retrieving the voice mail message regarding Patient #1 arriving to the ED on a Section 12 following Surveyor request.) Psychiatric Social Worker #1 said she questioned insurance coverage and called BNHC that we (the Hospital Psychiatric Clinicians) cannot see (provide the psychiatric evaluation) because of insurance coverage. Psychiatric Social Worker #1 said she called the ESP Clinician for evaluation as Patient #1 was now in the waiting room. Psychiatric Social Worker #1 said she spoke with the ED Charge Nurse, informed her that Patient #1 was in the waiting room, on a Section 12 and BNHC would fax the Section 12. Psychiatric Social Worker #1 said Patient #1 was on a Section 12; she was told Patient #1 was not on Section 12; it was unclear if Patient #1 was on a Section 12; unless we have the Section 12 in form (hand) Patient #1 was not on a Section 12. Psychiatric Social Worker #1 said the Hospital did not interview her, she had a small part, the main part was with the ESP Social Worker for the crisis (psychiatric) evaluation.

The Hospital provided no documentation to indicate that the ESP Clinicians, the ESP Supervisors nor the Hospital Behavioral Health Social Workers that provided psychiatric evaluations were credentialed in accordance with the Hospital Medical Staff Bylaws to provide psychiatric evaluations as determined qualified by the Medical Staff and recommended to the Governing Body (Board of Trustees) to grant clinical privileges to provide psychiatric examinations to Hospital patients.

The Hospital provided no documentation to indicate that the ED recommended criteria for ESP Clinicians or Hospital Social Workers who provide psychiatric evaluations, to the Medical Executive Committee for consideration as qualified and competent persons to provide psychiatric evaluations.