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Based on medical record review, review of facility policy, and staff interview, the facility failed to ensure Emergency Department (ED) staff followed the current facility policy for the requirement of obtaining psychiatric consultation within 24 hours if a patient has been assessed to be suicidal. This affected one of 9 patients who presented as suicidal to the ED out of 11 medical records reviewed. (Patient #9)

Findings include:

The medical record of Patient #9 was reviewed on 03/26/14. The patient presented to the on 02/08/14 at 8:45 PM with complaints of having taken 8-10 Wellbutrin tablets in an attempt to commit suicide.

Review of Patient #9's admission nursing note on 02/08/14 at 8:45 PM revealed a SAD PERSONS scale, a widely used risk assessment tool for suicidal behavior, was completed by a staff nurse. The results of the assessment included 1 point for 'Depression" with a note the patient appeared depressed or excessively sad. Patient #9 also received 1 point for 'Psychiatric Care' with a note of having a previous psychiatric admission. Two additional points were received for an 'organized suicide attempt' and a 'stated plan for future attempt' for a total SAD PERSONS score of 4.

Review of nursing notes dated 02/08/14 at 8:53 PM revealed an order for suicide precautions was entered by Staff J.

Staff D, educator, was interviewed on 03/26/14 at 4:00 PM. According to Staff D, a score between 3-5 means there is a medium risk the patient will commit suicide. Staff D was asked to provide a copy of a policy/protocol on the Suicide Risk Assessment. Staff D stated: "I don't know if we have anything in writing." No policy or protocol for suicide assessment was provided prior to exit.

Review of the triage nursing note dated 02/08/14 revealed a safety companion was noted to be in the room with the patient, as required by facility policy at 8:50 PM. The patient's initial vital signs were within normal limits. The blood pressure was 127/88, pulse was 71, respirations 20, and temperature was 97.6. A second set of vital signs were taken at 12:12 AM and were noted to be within normal limits.

Review of the laboratory results indicated Ethanol, Salicylate, and Acetaminophen levels were normal. Patient 9's Hepatic Function panel, Basic Metabolic panel, and CBC with differential were all within normal limits. A nursing note written by Staff J dated 02/08/14 at 9:30 PM indicated the Emergency Department Physician, Staff H, noted "no safety companion needed at this time. Family remains in room with patient."

Review of a nursing note dated 02/08/14 at 11:25 PM revealed Patient #9 was sitting up in bed talking with 2 visitors, voicing no complaints of pain. Patient #9 was given discharge instructions and noted to be discharged home at 12:13 AM, three hours and 28 minutes after initially presenting with complaints of a suicide attempt. No psychiatric consult was ordered while in the Emergency Department, however, the discharge instructions stated to call the county mental health clinic to schedule follow up appointment.

Review of the History and Physical by Staff H, the ED physician, dated 02/08/14 at 11:35 PM noted Patient #9 had been hospitalized previously for suicide ideation. It further noted the patient's mood disorder was not depressed, there was no thought disorder, judgement and insight appeared intact, and there was no suicidal or homicidal ideation. The last dictated sentences read: "The patient denies suicide ideation. The patient is willing to contract for safety. The patient is going home with friend and friend's mother who are supportive of discharge and feel the patient is safe."


On 02/09/14 at 11:15 AM Patient #9 re-presented to the Emergency Department and was seen by ED physician , Staff I. Review of the ED medical record admission note dated 02/09/14 revealed Patient #9 passed out at work and fell face first, hitting his/her head on the floor. It was reported by a co-worker the patient looked as if he/she had a seizure before falling. A laceration below the right eye required 14 sutures. Review of a nursing note dated 02/09/14 at 11:52 AM indicated Patient #9 experienced a grand mal seizure. The seizure lasted for 30 seconds without respiratory compromise. Patient #9 was admitted and suicidal precautions were ordered and initiated. A safety companion was placed in the room with Patient #9 despite family and friends being at the patient's bedside. Review of a nursing note dated 02/09/14 at 7:25 PM indicated Patient #9 again had another grand mal seizure lasting for approximately 3 minutes.

Patient #9 remained on a telemetry unit where he/she experienced visual and auditory hallucinations, tachycardia( increased heart rate) and was consulted by a psychiatrist for his/her suicide attempt the night before.

Review of the history and physical written by an Staff I, Emergency Department physician at 12:10 PM on 02/09/14 : "I have contacted Poison Control. The poison control specialist recommends admission and states they would have recommended admission yesterday also, as there is delayed seizure activity with Wellbutrin overdose up to 24 hours. As this is a now a delayed presentation, the patient is no longer a candidate for any decontamination and they do not recommend any charcoal or whole bowel irrigation."

The facility policy entitled Suicidal Patients and Those at Risk for Behavioral Emergencies was reviewed on 03/27/14 at 1:45 PM. The purpose of the policy was listed as the following: To provide a safe environment for the nursing management of patients who are suicidal or who have attempted suicide. Under the heading: Request of Physicians located at item Number 3 reads as follows: A psychiatric consultation should be obtained within 24 hours if the patient has been assessed as suicidal by a non-psychiatrist.


During an interview on 03/27/14 at 5:30 PM Staff A, Director of Quality, confirmed the facility policy was not followed by Emergency Department staff when Patient #9 was discharged home after presenting with a suicide attempt.