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Based on medical record review and interview, in six (6) of seven (7) medical records reviewed, it was determined the staff failed to: (a) perform reassessments of patients' behavior who presented with history of suicidal attempts, suicidal ideations or self-injurious thoughts, and ensure that these patients were stable before they were transferred to a juvenile detention center. (b) The nursing staff failed to perform monitoring for patients who were placed on 1:1 constant observation for behavioral issues.
This was evident in Medical Records #s 1, 2, 3, 4, 6 and 7.

These failures may have placed patients at risk for harm.

Findings include:

See detailed findings at A 1104.

Based on medical record review and interview, in six (6) of seven (7) medical records reviewed, it was determined the facility: (a) failed to perform reassessments of patients' behavior who presented with history of suicidal attempts, suicidal ideations or self-injurious thoughts, (b) the nursing staff failed to perform monitoring for patients who were placed on 1:1 constant observation for behavioral issues and (c) staff did not ensure that these patients were stable before they were transferred to a juvenile detention center.
This was evident in Medical Records #s 1, 2, 3, 4, 6 and 7.

Findings include:

Review of Medical Record #1 identified: A 13 year old patient presented to the emergency department (ED) at 3:08 PM on 7/25/18, because of self-injurious behavior of banging her head against a wall and suicidal ideation. The triage nurse noted the patient appeared to be in mild distress which was related to her mood and that she appeared angry.

A physician assistant (PA) documented at 3:19 PM that the patient reported feeling depressed on most days and that she tried to kill herself a couple of times before this year. The PA also documented that the patient had stopped taking her four (4) psychiatric medications.

The ED physician placed the patient on close observations at 3:30 PM and requested a psychiatric consultation and diagnostic workup.

The psychiatrist conducted a consultation at 5:56 PM and noted the patient had a history of Unspecified Depressive Disorder and a history of two (2) prior suicide attempts. He noted the patient requires an inpatient hospitalization for safety, stabilization and medication management and that if there were no beds in an acute inpatient hospital, the patient could be sent back to the juvenile detention center "for a close observation one to one for safety." The patient was discharged at 6:57 PM to the juvenile detention center.

There was no documentation that the patient's behavior was monitored and reassessed at frequent intervals during her stay in the ED, and that her condition had stabilized.


Review of Medical Record #3 identified the following: The triage nurse documented that this 14 year old patient presented to the emergency department (ED) on 10/23/18 at 8:00 PM from a jail, for evaluation of suicidal ideations and for attempting to hang himself.

The ED doctor documented that the patient came from a juvenile detention center for evaluation of a suicide attempt by hanging. The patient reported that when he was not allowed to speak to his mom at the detention center, he decided to try to kill himself. The patient tried to hang himself with a bed sheet in the center. Officers saw the patient and rescued him, after which he was brought to the ED. The "patient now complains of mild neck pain and occipital headache." The patient stated his prior suicide attempt was to "get what he wants." The patient's past medical history was significant for depression, Attention Deficit Hyperactivity Disorder (ADHD) and exercise induced asthma and he had a history of marijuana use.

The resident documented a detailed history of the patient's aggressive behaviors and his sentencing to a juvenile center. The resident discussed this case with an attending psychiatrist and the decision was made to return the patient to the detention center on continuous one to one observation, and that he should see the staff child psychiatrist in the morning.

The patient was discharged to the detention center at 10:34 PM that night, with instructions for 1:1 observation and a psychiatric evaluation in the morning.

There was no documentation in the medical record that the patient was placed on constant observation during his stay in the ED, or that his condition was monitored and reassessed at frequent intervals prior to his discharge, and to determine his stabilization.

During an interview on 5/20/19 at 10:45 AM, the Medical Director of the ED stated a psychiatrist and a security officer monitors patients that are on constant 1:1 or close observations in a designated area of the ED.


Similar findings were noted in Medical Record #s 4, 6 and 7, for patients with mental and behavioral issues,who were discharged to the juvenile detention center for 1:1 constant or close observation.

These findings were shared with Staff A, the Vice President of Quality and Safety on 5/23/19 at approximately 3:00 PM who acknowledged, the facility does not have a policy for 1:1 constant or close observations in the ED.


Review of Medical Record #2 identified the following: This 15 year old patient presented to the ED on 5/9/18 at 11:45 PM, for a mental health evaluation for banging her head against a wall and attempting to hang herself with sheets. The triage note indicated the patient complained of a change in sleep pattern and that she had suicidal thoughts and ideations. The medical record revealed the frequency of suicide ideations was chronic at baseline, she had poor impulse control and she was exhibiting inappropriate behavior. The patient also had a flat affect, she was calm and her mood was inappropriate. A psychiatric emergency protocol was initiated and the physician ordered a 1:1 constant observation when the patient arrived in the ED.

At 12:02 AM on 5/10/18, a nurse documented constant observation present with patient and the patient's condition was documented. There was no other documentation in the medical record of nursing 1:1 constant observation.

A psychiatrist documented at 1:18 AM on 5/10/18 that court papers indicate the patient broke 15 windows at a residential facility and took the glass and threatened to harm others and herself. The patient endorsed a history of multiple suicide attempts and suicide ideation without a plan. The patient stated to the psychiatrist "I hate life-I don't wanna live," and that she felt this way "for years" which did not change during a recent inpatient hospitalization where she was discharged on 5/9/18.

The psychiatrist also recommended a head imaging since the patient banged her head multiple times but there was no evidence that this was done.

The patient's vital signs documented at the time of arrival 11:56 PM, 5/9/18, noted a pulse rate of 104, and at 1:46 AM, a pulse rate of 106 (normal range is 60-100). An EKG was completed at 1:57 AM. There was no documentation that the results of the EKG were reviewed or that the patient's pulse was normal before her discharge.

An ED physician signed her notes at 2:41 AM on 5/10/18. The notes also indicated the patient was re-evaluated multiple times during this visit and during the first reassessment the patient was calm and cooperative. The second reassessment, the patient was cleared for discharge. The patient remained under the direct care of an emergency physician for a total observation time of four (4) hours. The clinical impression was acute adjustment disorder. The general suicide ideation discharge instructions stated "child should not be left alone."

The patient was discharged to the juvenile detention center on 5/10/18 at 3:11 AM.

There was no documentation in the medical record that the nursing staff reassessed the patient's behavior throughout her stay in the ED.

These findings were shared with Staff A, the Vice President of Quality and Safety on 5/23/19 at approximately 3:00 PM.