HospitalInspections.org

Based on medical record review and interviews, the hospital failed to provide care in a safe setting in the Emergency Department (ED) in accordance to the hospital's ED departmental policies and procedures.

Findings include:

The policy titled "The Management of the Suicidal Patient," last reviewed 06/16/2022, states under the procedure section, #8: A reassessment of each patient's risk of suicidal ideation will occur as the condition warrants or at a minimum of every 12 hours and prior to discharge using the Repeat Columbia-Suicide Severity Rating Scale (R-CSSRS).

Medical record review was conducted on 11/08/2022 at 11:15 A.M. Record review of Patient #4 (a behavioral health patient) did not indicate an R-CSSRS was completed since 11/06/2022 at 3:42 P.M. At this point it was approximately 43 hours since Patient #4's last documented R-CSSRS.

The observation flowsheet for Patient #3, dated 11/07/2022, indicated that the Registered Nurse (RN) - Observer report section (this section indicates whether the observer has received a patient report from the RN and also indicates whether safe environment guidelines (SEG) are needed and if so, are the SEG appropriately reviewed between the RN and the observer) in the top left section of the observation flowsheet was completely blank. The level of observation section that denotes whether a patient is determined to be either on constant observation or intermittent observation was also left blank.

The surveyor interviewed the Chief Nursing Officer (CNO) on 11/08/2022 at 9:50 A.M. The CNO acknowledged that the RN - Observer report section and the level of observation section should have been completed.