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Based on review of facility policy, untitled document of a telephone conversation from Patient Identifier (PI) # 1's sibling and interview, it was determined the facility failed to follow their policy for complaints / grievances for 1 of 3 complaints / grievances reviewed. This affected PI # 1 and had the potential to affect all patients who receive care at this facility.

Findings include:

Facility Policy: Patient Complaint / Grievance
Policy / Procedure #: DK-RI-112.00
Effective Date: 10/1/06

Definitions:

1. A "patient grievance" is defined as a "a written or verbal complaint (when the verbal complaint is not resolved at the time of the complaint by staff present) by a patient or the patient's representative regarding the patient's care, abuse or neglect, alleged discrimination, issues related to the hospital's compliance with CMS (Centers for Medicare & Medicaid) Hospital COPs (Conditions of Participation)...

2. A verbal complaint is a patient grievance is:
a. It cannot be resolved at the time of the complaint by staff present;
b. Is postponed for later resolution;
c. Is referred to other staff for later resolution; or
d. Requires investigation and/or requires further actions for resolution...

... 6. A grievance may include a situation where the patient or his or her representative phones the hospital with a concern that constitutes a grievance (i.e. the care provided to the patient... or the Hospital's compliance with the COPs)...

Purpose

The purpose of this policy is to:

1. Provide a standardized process to manage and resolve complaints and/or grievances received by the hospital.

2. Provide a process to review, investigate and resolve a patient's / patient's representative's complaint/grievance within a reasonable timeframe...

Policy

1. Patients have the right to express concerns and expect resolution in a timely manner.

2. The Governing Board has delegated the Complaint and Grievance process to the Hospital Quality Improvement Committee...

3. Complaints or grievances may be in written or verbal form...

6. The hospital Quality Improvement Committee ensures the patient is provided written notice of receipt, investigation and outcomes regarding a complaint/grievance within 7 days of the hospital's receipt of the grievance, even though the hospital's resolution need not be complete within the seven-day limit...

7. If the grievance is not yet resolved within the initial, written response of 7 days, the written response will indicate that the hospital is working towards a resolution of the grievance and that a follow-up written response will be provided within a specified time period but not to exceed 30 days until the grievance is resolved. If the grievance remains unresolved after 30 days, additional written follow-up would be indicated within a specified time period but not to exceed an additional 30 days...

Procedure

1. In the event a patient or the patient's family or representative have a comment, complaint or grievance he/she is encouraged to do one or more of the following:
Inform or ask any staff member
Speak to the department director or manager of the area involved
Request to speak with someone in Administration...

Procedure for using the Event Report - Complaints and Grievances Form (ERS):

2. When a complaint/grievance is initiated, the Event Report - Complaints and Grievances (RM-3306), is utilized by staff receiving a complaint/grievance. The form is initiated by the person receiving the complaint/grievance and is then forwarded to Risk Manager who enters the reported information into the ERS, as with any other event type...

4. The complaint and grievance reporting includes demographic information, who initiated the complaint of grievance, the method, received by, nature of the complaint or grievance, resolution, severity, root causes and corrective actions.

5. The person documenting receipt of the complaint/grievance describes/summarizes the complaint in the patient/patient representative's words as best as possible, places the date, the time and the signature of the person completing the form as indicated...

14. The response letter shall be forwarded to the patient or patient's representative within 7 business days after receipt of the grievance even though the hospital's resolution need not be complete within the seven-day limit...

An interview was conducted on 9/26/18 at 10:08 AM with Employee Identifier (EI) # 4, Risk Manager / Facility Compliance Officer. The surveyor asked if she had received a complaint regarding the care PI # 1 received at the facility. EI # 4 stated she had received a call from PI # 1's sibling about a week ago, who wanted to arrange a conference with administration. She stated the caller wanted to know if the facility had followed their policy in regards to the care provided to PI # 1. EI # 4 stated that she informed the caller the facility would not be able to talk about specific care provided to the patient as the caller was not the patient's spouse. EI # 4 stated she emailed the Chief Executive Officer (CEO) and EI # 2, Chief Quality Officer (CQO) about setting up a meeting. When questioned if a meeting had been arranged or had there been any follow up in regards to the caller's requests, EI # 4 stated there had not been a meeting and she had not talked back with the caller. EI # 4 stated she did not consider this call a complaint and it was not included as part of the complaint process, including sending the caller a letter acknowledging the receipt of the caller's concerns and requests for meeting with administration. EI # 4 verified she had documented this conversation and provided a copy to the surveyors.

Review of the untitled typed document dated 9/12/18 revealed PI # 1's sibling had called and "... requested to set up a meeting with hospital representatives to discuss our policy related to suicide patients... indicated (he/she) wanted to know if our policy was followed and learn more about the care provided to (PI # 1)... just told (him/her) we would get back with (him/her) in the next few days... CEO & CQO notified of request..."

There was no documentation an acknowledgement letter had been sent to the caller, no documentation the above concerns were included as part of the grievance process, no documentation there was follow up with the caller related to his/her concerns and request for a meeting with administration.

Based on observations, review of facility policy, medical records (MR) and interviews, it was determined the facility failed to ensure the staff followed their policy for creating a psych-safe environment in the emergency department (ED) and for implementing interventions appropriate to protect patients were at risk for suicide. These deficient practices affected 7 of 10 records reviewed, including Patient Identifier (PI) # 2, PI # 4, PI # 8, PI # 3, PI # 7, PI # 9, and PI # 10 and had the potential to negatively affect all patients who receive care at this facility.

Findings include:

Facility Policy: Suicide Risk Assessment and Interventions in a Non-Behavioral Health Setting
Policy/Procedure #: DK-PE-111.50
Effective: Jan. 2007

Policy:
All patients who are admitted for care and services will be screened for suicide ideation and/or suicide risk factors during the initial intake/admission assessment process. In addition, patients who present for evaluation and treatment with a primary diagnosis or complaint of an emotional or behavioral disorder or substance abuse; or display the symptoms of an emotional or behavioral disorder, will be assessed for suicide risk. Based on the level of suicide risk, interventions will be implemented as a means to keep patients from inflicting harm to self or others.

Purpose:
To identify patients at risk for suicide and provide safety interventions as indicated by risk level...

Definitions
"Emotional or behavioral disorders" refers to any primary behavioral or emotional disorder (Diagnostic and Statistical Manual of Mental Disorders), including those related to substance abuse. If a patient is identified to be at risk for suicide, then suicide precaution interventions will be implemented including referral to a behavioral health professional.

Suicidal Ideation - thoughts of harming or killing oneself. Intensity determined by assessing the frequency, duration and intensity of these thoughts; in addition to the presence of a plan.

Suicide Attempt - a non-fatal, self-inflicted destructive act with explicit or inferred intent to die...

Observation - observation as referenced in this policy refers to observing a patient and does not refer to level of care such as "placing patient in observation"

Levels of Supervision

A. Continuous visual surveillance - one patient to one observer (1:1)- Observer must maintain 1:1 direct observation and be able to respond to the patient immediately. De-escalation techniques will be used as appropriate.

B. Continuous visual surveillance - patient is under direct observation at all times and observer must be able to respond to the patient rapidly. Ratio may be more than 1:1 as long as observer is able to attend to the immediate needs of one patient without sacrificing surveillance and attendance to the immediate needs of another patient(s). Observe (Observer) must have direct line of sight to patient. If de-escalation techniques are ineffective, patient will be escalated to Level 1.

C. Close observation - patient (acute care) may not be left alone without support person (may be reliable family/friend). Observation is required by hospital staff at a maximum of 15-minute intervals. Supportive family/friend must receive education from staff on expected responsibilities and be willing to sign contract to stay with patient at all times, or know and agree to communicate with/seek staff assistance if chooses to leave. In absence of reliable support person, patient will be escalated to Level 2...

... E. General observation - routine check by clinical staff at a maximum of one-hour intervals.

Procedure

1. A Registered Nurse will screen all patients for suicide risk during any intake/ admission process...

If patient answers "No' to all screening questions, sign, date and time bottom of form. If patient answer "Yes" to any questions, complete the Suicide Risk / Behavioral Disorder Assessment...

2. A registered nurse (RN) will assess the patient presenting with primary complaint of emotional or behavioral disorder or substance abuse, displaying symptoms of an emotional or behavioral disorder or displaying/verbalizing signs and symptoms consistent with suicide ideation, by completing the Suicide Risk/Behavioral Disorder Assessment.

A. Ask screening questions on the Suicide Rick/Behavioral Disorder Assessment...

C. Select the indicators in the columns titled "Observed" and/or "Reported" which most closely apply to the patient's situation or behavior.

D. Then identify the appropriate acuity in the first column that correlates with the HIGHEST level of observed or reported factors.
a. From highest acuity (Level 1) to the lowest acuity (Level 5).

E. Selection of the applicable level box identifies the interventions that are being implemented...

I. The Frequent Observation Flow Sheet is to be utilized for documentation for all patients on whom a Suicide Risk/Behavioral Disorder Assessment is completed.
1. Use form even if observation is less than every 15 minutes,
2. Check box at top of form to indicate level of observation implemented...

3. Physician orders for the level of suicide precautions will be initiated immediately...

6. General safety Interventions to keep patient safe from harm to self or others...

B. Clinical status and patient safety documented every 15 minutes for Acuity 1, 2, and 3 patients.

C. Ensure a safe environment:
Complete Psych-Safe Room Checklist
Remove all needles, sharps and sharps containers from patient's room
Inventory and secure patient personal items and remove potentially harmful items from the room...
... Remove hanging hazards such as rope blinds, call cords, curtains... in room and clothing items such as belts, ties... shoelaces... May replace patient clothing with paper gown, hospital gowns and/or pajamas...
... Every shift, room searches will be conducted for potentially harmful items, utilizing Psych-Safe Room Checklist...

7. Interventions Relative to Level of Suicide Risk:
a. Immediate Risk Patients (Level 1):
Severe behavioral disorder with immediate threat of dangerous violence...
Level of Supervision: Continuous visual surveillance (line of sight) with 1:1 observation
Continuous 1:1 Direct Observation including when transported from unit... Observation will be documented including name and title of person observing, time of observation and name and title of periodic relief person...
"General Safety Interventions"

b. High-Risk Patients (Level 2):
Probable risk of danger to self or others...
Level of Supervision: Continuous visual surveillance
Continuous visual supervision when transported from unit... Observation will be documented including name and title of person observing, time of observation, and name and title of periodic relief person...
"General Safety Interventions"

c. Moderate Risk Patients (Level 3):
Possible danger to self or others...
Level of Supervision: Close observation (15 minutes)
... "General Safety Interventions"

On 9/26/18 at 11:45 AM, the surveyors toured the Emergency Department. During this tour, the surveyors observed exam rooms # 6 and # 7 and questioned Employee Identifier (EI) # 1, Registered Nurse (RN) ED Director about providing a psych-safe room for patients at risk for suicide. EI # 1 pointed out monitor cords, suction tubing that would be removed, plastic trash bag and stated these items would be removed. The surveyors observed hanging from the ceiling were non-removable exam light fixtures, Intravenous (IV) hangers and non-breakaway curtains. EI # 1 verified these items could not be removed, but the IV hangers would not support the weight of a patient and were meant to come down with any amount of weight. She was unable to tell the surveyor the amount of weight these hangers would hold. The surveyors observed there were no windows in any of the exam rooms located in the ED.

1. PI # 2 presented to the facility's ED on 7/17/18 at 2:50 PM with chief complaint of, "... I am having some paranoia and hallucinations, seeing and hearing things. I am seeing good things and bad things. I am not suicidal, I am scared and just want to make sure that everyone is ok. Accompanied by Mother..."

Review of the Nurse's Notes dated 7/17/18 revealed the nurse documented in the Suicide Risk Screening, "Yes" to the patient questions, "Is the patient presenting with primary complaint of emotional or behavioral disorder or substance abuse?" and "Have you had thoughts if suicide in the past?"

There was no documentation a Suicide Risk/Behavioral Disorder Assessment for Non-Behavioral Health Setting, Conversion to Psych-Safe Room Checklist or Patient Observer Monitoring Checklist was completed until 7:00 PM.

Review of the Suicide Risk/Behavioral Disorder Assessment for Non-Behavioral Health Setting dated 7/17/18 at 7:00 PM revealed the patient scored at Level 2, High-Risk situation and "Continuous visual surveillance: May be greater the 1:1 ratio" was implemented. These interventions included, "... Observations at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly... Educate support person (if family or significant other with patient), utilizing "Support Person Education" form. If de-escalation techniques not effective, escalate to Acuity 1..."

Review of the Conversion to Psych-Safe Room Checklist dated 7/17/18 at 7:00 PM revealed the following items on the checklist were blank: Patient is dressed in hospital gown and/or pajama pants if applicable, Personal items are inventoried and secured per hospital policy and Room is free of any potentially hazardous items such as (but not limited to): bandana, headband, belts... non-breakaway curtains, plastic bags, plastic tubing, sharp objects, shoe laces... (multiple others were listed in this section).

Review of the Suicide Risk/Behavioral Disorder Assessment for Non-Behavioral Health Setting dated 7/18/18 at 7:00 AM revealed the patient scored at Level 2, High-Risk situation and "Continuous visual surveillance: May be greater the 1:1 ratio" was implemented. This document was not signed by the physician.

Review of the Conversion to Psych-Safe Room Checklist dated 7/18/18 revealed a line was drawn in the boxes for the following items on the checklist: Personal items are inventoried and secured per hospital policy, Excess linen and linen hamper removed from room, Closets are locked or empty and Windows secure.

Review of the Patient Observer Monitoring Checklist which began at 7:00 AM with 15 minute check completed at 15 minute intervals revealed no documentation of the date and the type of observation level that was being completed for this patient.

An interview was conducted on 9/26/18 at 8:14 AM with EI # 1, who verified the above findings.

2. PI # 4 presented to the facility's ED on 5/13/18 at 11:25 PM with chief complaint of, "... EMS (Emergency Medical Services) states: Patient told them (he/she) took 50 800 mg (milligrams) Neurontin in attempt to overdose because... was suicidal but had now changed... mind and states... is suicidal without a plan and admits to not taking medication..."

Review of the Nurse's Notes dated 5/13/18 revealed the nurse documented in the Suicide Risk Screening, "Yes" to the patient questions, "Is the patient presenting with primary complaint of emotional or behavioral disorder or substance abuse... Do you feel hopeless or helpless... Have you had thoughts of suicide in the past... Are you having thoughts of suicide now... Have you previously attempted suicide... Do you have a plan to hurt yourself or someone else..."

Review of the Suicide Risk/Behavioral Disorder Assessment for Non-Behavioral Health Setting dated 5/13/18 at 11:54 PM revealed the patient scored at Level 2, High-Risk situation and "Continuous visual surveillance: May be greater the 1:1 ratio" was implemented. These interventions included, "... Observations at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly... Educate support person (if family or significant other with patient), utilizing "Support Person Education" form. If de-escalation techniques not effective, escalate to Acuity 1..."

Review of the Conversion to Psych-Safe Room Checklist dated 5/13/18 at 11:54 PM revealed the following items on the checklist were blank: "Windows secure" (no windows in exam rooms in ED) and "Updates communicated to Patient Observer regarding pertinent patient information and plan of care."

Review of the Patient Observer Monitoring Checklist dated 5/13/18 which began at 12:00 AM revealed no documentation every 15 minute observations were conducted from 3:00 AM until the end of documentation at "06". The surveyor was unable to determine when this observation documentation was completed and at which time it ended.

Review of the Suicide Risk/Behavioral Disorder Assessment for Non-Behavioral Health Setting dated 5/14/18 at 6:00 AM revealed the patient scored at Level 2, High-Risk situation and "Continuous visual surveillance: May be greater the 1:1 ratio" was implemented. There was no documentation of a Conversion to Psych-Safe Room Checklist was completed for 5/14/18. Review of the Patient Observer Monitoring Checklist, which began at 7:00 AM and ended at 3:00 PM revealed no documentation this document was dated.

An interview was conducted on 9/26/18 at 8:11 AM with EI # 1, who verified the above findings.

3. PI # 8 presented to the facility's ED on 2/18/18 at 8:55 PM with chief complaint of, "... EMS states (patient) took Actos, Mobic, and Glipizide unknown quantity. pt (patient) states (he/she) took all these because (he/she) wanted to die..."

Review of the Nurse's Notes dated 2/18/18 revealed the nurse documented in the Suicide Risk Screening, "Yes" to the patient questions, "Is the patient presenting with primary complaint of emotional or behavioral disorder or substance abuse... Have you had thoughts of suicide in the past... Are you having thoughts of suicide now... Have you previously attempted suicide... Has a family member or someone else close to you committed suicide or have you been a witness to suicide..."

Review of the Suicide Risk/Behavioral Disorder Assessment for Non-Behavioral Health Setting dated 2/18/18 at 9:00 PM revealed the patient scored at Level 1, Requires immediate life-saving intervention. Immediate danger to self or others. and "Continuous visual surveillance 1:1 ratio: Direct observation by staff at all times. Must be able to respond to patient immediately. Use de-escalation techniques... "

Review of the Conversion to Psych-Safe Room Checklist dated 2/18/18 revealed a line was drawn through the boxes for the following items on the checklist: "Room is free of any potentially hazardous items such as (but not limited to)... and List individualized safety concerns to be checked..."

Review of the Patient Observer Monitoring Checklist dated 2/18/18 revealed no documentation Continuous visual observation 1:1 was conducted from 8:00 PM to 1:30 AM.

An interview was conduced on 9/26/18 at 8:02 AM with EI # 1, who verified the above.



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4. PI # 3 presented to the ED on 7/18/18 at 3:24 AM with a Chief Complaint: "...states that her husband has a girlfriend. States that she was sitting on the bed and the gun was close enough to her that if she needed it she could've got it. EMS states that the police had to take the gun away from pt (patient)."

Review of the Nurse's Notes dated 7/18/18 at 3:48 AM revealed the RN documented PI # 3 answered "Yes" to the following question in the Suicide Risk Screening: Is the patient presenting with primary complaint of emotional or behavioral disorder or substance abuse.

A Suicide Risk/ Behavioral Disorder Assessment was documented on 7/18/18 at 7:00 AM. Level 1 was documented by the RN due to "Verbal commands to do harm to self or others..." Interventions included "Continuous visual surveillance 1:1 ratio: Direct observation by staff at all times..."

Review of the Patient Observer Monitoring Checklist revealed the level of observation documented was both "Continuous visual surveillance 1:1" and "Continuous visual surveillance." The first documented observer was at 5:30 PM.

Review of the Conversion to Psych-Safe Room Checklist dated 7/18/18 at 7:00 AM, revealed in the category of "Room is free of any potentially hazardous items such as:" there are no items checked. The surveyor is unable to determine if these items were present in the room or not. In the categories of "Excess linen and linen hamper removed from the room" and "Closets are locked or empty," the nurse drew a line, but did not initial. The surveyor was unable to determine if excess linens and linen hamper were removed from the room, and if closets were locked and empty. For the shift labeled 7:00 PM to 7:00 AM, the form was blank.

On 7/19/18 at 7:09 AM a second Suicide Risk/ Behavioral Disorder Assessment was performed, (per policy every 24 hours). PI # 3 was assessed at a Level 1 Risk due to "Verbal commands to do harm to self or others..." Interventions included "Continuous visual surveillance 1:1 ratio: Direct observation by staff at all times..." This form was signed by the physician, but no date or time of signature was documented.

A Conversion to Psych-Safe Room Checklist was documented on 7/19/18 at 7:08 AM by the RN. In the area of the form labeled "Room is free of any potentially hazardous items such as..." no boxes were checked. The surveyor was unable to determine if these items were present or not.

An interview was conducted on 9/26/18 at 8:05 AM with EI # 3, RN, Assistant ED Director, who confirmed the above findings.

5. PI # 7 presented to the ED on 2/19/19 at 6:51 PM with Chief Complaint including: "Patient states I'm hearing voices telling me to hurt me and other people..."

Review of the Nurse's Notes dated 2/19/18 at 7:00 PM revealed the patient answered "Yes" to the following Suicide Risk Screening questions: Is the patient presenting with primary complaint of emotional or behavioral disorder or substance abuse? Do you feel hopeless or helpless? Have you had thoughts of suicide in the past? Are you having thoughts of suicide now? Do you have a plan to hurt yourself or someone else?

A Suicide Risk/ Behavioral Disorder Assessment was documented by the RN on 2/19/18 at 7:00 PM. A Level 2 was documented, with no reasons documented on the form. At 10:10 PM, Level 1 was checked on the form, with "Verbal commands to do harm to self or others..." documented.

A Conversion to Psych-Safe Room Checklist was completed on 2/19/18 at 7:00 PM. The following areas on the form were left blank: "Patient is dressed in hospital gown and/or pajama pants if applicable," and "Personal items are inventoried and secured per hospital policy..." The area of the form stating "Room is free of any potentially hazardous items such as..." was initialed by the RN, but no items were checked. The surveyor was unable to determine if these items were present or not.

An interview was conducted on 9/26/18 at 8:05 AM with EI # 3, who confirmed the above findings.

6. PI # 9 presented to the ED on 9/24/18 at 12:45 PM with the following Chief Complaint: "Patient states: Today is first day I haven't had any alcohol in over a yr (year) having suicidal thoughts, got arrested Friday, blew a 0.43 (blood alcohol test), I need help..."

A Suicide Risk Screening was documented on 9/25/18 at 1:01 PM. The RN documented "Yes" to the following questions: Is the patient presenting with primary complaint of emotional or behavioral disorder or substance abuse? Do you feel hopeless or helpless? Have you had thoughts of suicide in the past? Are you having thoughts of suicide now? Do you have a plan to hurt yourself or someone else?

A Conversion to Psych-Safe Room Checklist was documented on 9/24/18 at 1:31 PM and 7:00 PM. At 1:31 PM the RN failed to document 6 of the 8 safety checks on the form. At 7:00 PM the RN failed to document 5 of the 8 safety checks on the form. The surveyor was unable to determine if personal items were inventoried, room was free of any potentially hazardous items, excess linens and linen hamper removed from room, closets were locked or empty, windows secure (no windows are located in ED patient rooms), and updates provided to Patient Observer.

An interview was conducted on 9/26/18 at 8:00 AM with EI # 3, who confirmed the above findings.

7. PI # 10, a minor, presented to the ED on 9/24/18 at 9:24 AM with the following complaint: "Grandparent states he went into the counselors office and told them that he was hearing voices telling him to commit suicide."

A Suicide Risk Screening was documented on 9/24/18 at 9:42 AM by the RN. The RN documented "Yes" to the following patient questions: Is the patient presenting with primary complaint of emotional or behavioral disorder or substance abuse? Have you had thoughts of suicide in the past? Are you having thoughts of suicide now? Have you previously attempted suicide? Do you have a plan to hurt yourself or someone else?

On 9/24/18 at 9:45 AM a Suicide Risk/ Behavioral Disorder Assessment documented the patient was a "Level 2 High Risk situation..., with reported threat to harm self or others, suicidal ideations... with or without a plan, and psychotic symptoms... Interventions implemented included continuous visual surveillance, may be greater than 1:1 ratio... Educate support person... utilizing 'Support Person Education' form. If de-escalation techniques not effective, escalate to Acuity 1."

A Support Person Responsibilities form was not completed until 9/24/18 at 1:55 PM. The form was completed by EI # 3, who identified the signature of the Support Person as the grandparent of PI # 10.

On 9/24/18 at 9:45 AM a Conversion to Psych-Safe Room Checklist was completed. The following safety checks were left blank by the RN: Introductions of oncoming staff to patient, questions answered, Room is free of any potentially hazardous items...(lines were drawn through all items, not initialed by RN), Excess linens and linen hamper removed from room, Windows secure, Updates communicated to Patient Observer... At 10:00 PM the safety checklist was documented by the RN. There was no documentation the RN introduced oncoming staff and answered questions. Lines were drawn through the items listed as potentially hazardous items. The surveyor was unable to determine if the items were present in the room or not.

On 9/25/18 at 7:10 AM the RN documented a Conversion to Psych-Safe Room Checklist. The following safety checks had a line drawn through them: Room is free of any potentially hazardous items..., Excess linen and linen hamper removed from room, Closets are locked or empty, Windows secured. The surveyor was unable to determine if these safety checks were completed.

An interview was conducted on 9/26/18 at 7:55 AM with EI # 3, who confirmed the above findings.