HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to ensure patients assessed as a suicide risk in the Emergency Department (ED) were monitored to ensure safety for 1 of 2 (Patient #6) sampled patients deemed a suicide risk.

The findings included:

1. Review of the facility's "Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting" policy revealed, "All adolescent and adult patients ...who present for care and services will be screened for suicide ideation and behavior using the Columbia Protocol ...Based on the severity and immediacy of suicide risk assessed using the Columbia Protocol, patient safety measures and interventions will be implemented as a means to keep patients from inflicting harm to self ...Definitions ...Frequent Observation (every 15 min [minute] checks: Intervention for moderate risk for suicide. Observation of patient in clear view every 15 minutes and respond immediately to intervene and assure safety ..."

2. Medical record review revealed Patient #6 presented to the ED on 8/21/2021 at 9:06 AM with chief complaint of suicidal ideation without a plan. A Columbia Suicide assessment was performed at 9:18 AM with the patient assessed as low risk. A physician's order for Suicide Precautions was documented at 9:20 AM. Patient #6 was transferred to an inpatient psychiatric facility on 8/22/2021 at 2:20 AM. There was no documentation Patient #6 was observed every 15 minutes for suicide precautions while housed in the ED.

During an interview on 8/24/2021, the Quality Director verified the flowsheet that documented every 15 minute observations could not be found for Patient #6.