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Based on record review and interview, the facility failed to ensure staff completed medical screenings and evaluations, developed treatment plans and provided a safe disposition plan prior to discharge of psychiatric patients presenting in the ED with actual suicide attempts or suicidal ideations to self-harm, resulting in the death of a patient.

This finding puts all patients at risk for poor outcomes including risk of death.
Evident in eight (8) of eight (8) patients (patient A, B, C, D, E, F, G, and H)

Findings:

Medical record review for Patient # A on 08/25/15 revealed a 25 -year-old male admitted on 06/22/15 at 11:58 AM with chief complaint of suicide attempt by intentionally stepping off a twenty storied building.
The patient stated to the Triage nurse "My life is over".

The patient was brought to the Emergency Department (ED) by New York Police Department (NYPD) who had prevented him from falling. The Fire Department New York (FDNY) " Prehospital Care Report " dated 6/22/15 11:47 AM documented, " found a 25 year old male on top of 20 story building threatening to jump. After one and half hours of negotiations patient was finally subdued by NYPD. Patient says he wanted to kill himself. Taken to LMC ED as a psychiatric Emergency. "

The RN noted the patient ' s sister was present in the ED and reported " patient had been acting different for the past two or three days, after getting into a fight with his girlfriend who has his daughter and the girl friend took his daughter away from him. "

The patient was an acuity Triage level two because of the mode of his suicide attempt.

On 06/22/15 at 11:58 AM, the Triage RN performed the " Columbia Suicide Severity Rating Scale (C-SS/RS)" which resulted in a positive screen.

When a patient has a "Columbia Suicide Severity Rating Scale (C-SS/RS)" with a positive result then according to facility policy that would trigger the physician needing to perform the Columbia Suicide Severity Risk Assessment (C-SS/RA) within 60 minutes. However, this was not performed by the physician on the initial assessment.

The patient was brought to Medical Emergency Room Area B with chief complaint of Depression with suicide attempt.

The patient was seen by a medical doctor who documented at 1:45 PM, " Labs within normal limits pending a urine toxicology. Patient refused to give urine. The patient was seen and examined by me in the Medical ER Area B. The patient was brought in with suicidal ideation and found on the roof of a building threatening to jump. He was talked down by police who brought him here. I confirm/reviewed all findings assessment and plan done by the Medical Resident and medically cleared the patient for transfer to psychiatry for further care and evaluation. No past medical history. Ambulating without difficulty. He denies any alcohol or drug use. Neurological status intact, no reported physical complaints including fever, chills or recent illness. He is hemodynamically stable and medically optimized for psychiatric evaluation and management. Will remain on close observation pending psychiatric disposition. Case discussed with Psychiatric ED Attending. Disposition from Medical ED: Admitted as an Inpatient to Psychiatric Services. "

The patient signed consent for PSYCKES data base access. However the PSYCKES recorded history was not obtained during the 6/22/15 to 6/23/15 hospital encounter by the Psychiatrist or the social worker.

The Psychiatric Attending documented an assessment note at 2:00 PM, " Chief complaint, Depressed and suicidal.
The patient denies any past psychiatric history but the patient ' s brother reports that last year the patient was hospitalized for two weeks at Bellevue after the patient jumped in front of a train. The patient ' s brother was called and he doesn ' t feel that the patient is safe to go home " and " sometimes my brother sounds ok but he is not. " The patient ' s brother reported he spoke with the patient for four hours last night and said that two days ago the patient tried to choke his girlfriend and spray painted on his door " the government is trying to kill me. "

He lives by himself and up until recently was working in a warehouse but he lost his job two weeks ago and is now unemployed. He didn ' t say how he lost his job. He says he has a daughter and wants to be a part of her life but his girlfriend moved out and now he cannot see either of them. Patient says he has hit rock bottom. He has lost all faith in himself. He admits to drinking alcohol and used to smoke marijuana until he recently replaced marijuana use with drinking alcohol. He doesn ' t want people to be stressing out about him. At times the patient was speaking tangentially and made paranoid statements like " someone is out to get me. "
Axis I Diagnosis Psychosis rule out substance induced. Axis II Deferred. Axis III family discord, lack of social support, job issues. Axis V GAF 30 Plan: Observe the patient and reevaluate in the morning for disposition Seroquel 100 mg orally at bed time.

The psychiatrist failed to access the "Quadra - Med" HHC database system and didn ' t obtain collateral information of the patients recent past psychiatric history from Bellevue Hospital. The psychiatrist failed to access the PSYKES Access system despite patients signed consent to do this.

The patient was medically optimized for psychiatric admission and transferred for continuation of care to the PES at 5:00 PM.

The Social Worker (SW) documented at 05:07 AM, "the patient was electronically referred for social work intervention and met high risk criterion due to history of psych, he is a military veteran, receiving Medicaid, he lives in a private residence, the sibling ' s phone numbers are listed but the patient didn't give verbal consent to contact them at this time. The patient met with SW in the PES area wearing hospital scrubs, poorly groomed, he was alert and oriented and receptive to this writer. He verbalizes adequate understanding of verbal information. The patient endorsed feelings of hopelessness and helplessness when admitted to standing on the edge of a roof top of the twenty story building where he lives. The patient stated he took stock of his life, what made him, what broke and how he is viewed by others seems important to him. He reported that he resides on a world which is divided into groups of people and he wants to conform to society. The patient feels he is an outcast and he is viewed by others as such and this troubles him. He is consumed with worry that people are looking at him and not liking what they see. The patient stated he wants to fix it so others would not look at him as though he does not belong. The patient stated he was happy there were people to help him in his time of need. The physician notes state patient is pending a psychiatrists re-evaluation thus the case is endorsed for social worker follow-up."

The Social Worker follow up note documented at 11:18 AM, " Patient remains in PES pending psychiatrists evaluation. This worker was contacted by the patients NYCHA worker who stated that the property staff contacted EMS yesterday after the patient was found on the roof of his building. The worker also reported that the patient ' s girlfriend moved out three days ago (on Father ' s Day) and took his child with her. This writer contacted NYPCC and they stated that the patient can visit their office anytime between 10:00 AM and 2:00 PM and they will begin the intake process and assign an appointment. The patient was advised to visit NYPCC upon being discharged from the ED."

However the referral request form for outpatient services follow up was not evident in the medical record on review 08/11/15 at 11:30 AM.

The RN documented a note at 6: 20 AM, " This patient brought in with complaints of feeling depressed and suicidal with no known medical history and an unclear psychiatric history. Urine for toxicology is still pending as patient refused to give urine. Patent stayed in his room most of the time, calm and cooperative, and slept well. For pyschiatrist revaluation and endorsed to incoming shift."

There was no Psychiatric Attending revaluation documented since the 2:00 PM note on 6/22/15. The medical record lacked evidence that a psychiatrist reevaluated the patient overnight. The first Attending did the initial psychiatric consult with a comprehensive evaluation at 2:00 PM, and had endorsed a re-evaluation for the psychiatrist working in PES but no follow up re-evaluation was performed until the disposition evaluation on 6/23/15 at 10:25 AM.
The psychiatric evaluation and disposition note documented on 6/23/15 at 10:25 AM, "presented with suicidal ideation and plans to jump off a roof (he was found on a roof). Tox screen not done. Patient states he feels better and denies any signs of acute depression. His affect is constricted and normal. His speech is normal and his thought process is goal directed and logical. He denies any suicidal or homicidal thoughts or intent. He contracts for safety. He has fair judgement, insight and impulse control. He is alert and oriented. The patient is not actively psychotic, suicidal, or homicidal now, therefore there is no need for psychiatric hospitalization at this time.

Diagnosis at Discharge is Depressive Disorder. Discharge today. Patient referred to NYPCC and patient is to go there today to their walk in clinic which is open until 2:00 PM. No medicines prescribed. Patient agrees with plan."

The Psychiatric Attending did not perform the Columbia Suicide Severity Risk Assessment (C-SS/RA) at disposition and there was no safety plan signed by the patient.
Discharge instructions were not signed by the patient.

RN documented a note at 11: 20 AM, " Patient received from tour 1 with a past psychiatric history of psychosis and suicidal ideation. Patient came to the ED due to depression and suicide ideation. The patient denies suicidal ideation and is for discharge."

RN documented a second note at 11: 41 AM, "The Patient was seen and cleared by the psychiatrist. Patient verbalized and understood to stay away from drugs and alcohol and to call 911 in case of emergencies. The patient left the ED alert and oriented and not in any distress. He had a pair of boxer shorts, a pair of socks and shoes and no money and no cell phone and no other valuables to return."

Discharge disposition: Treated and released.

The Social Worker documented a second note on 06/23/15 at 11:29 AM," The patient has been medically cleared for discharge. The patient had remained in the PES pending a psychiatric evaluation. The patient has been evaluated and is now for discharge. The patient has been provided with clothing from the volunteer office and a referral to follow up at NYPCC for outpatient services."

The RN documented on 06/24/15 at 6:48 PM, " At 11:54 AM today this 25 year old male was brought into the ED by EMS status post jumped from a twenty one story building to his death. On arrival the patient was unresponsive, asystole, apneic. (no heart beat, no breathing) Patient was pronounced dead by MD at 11: 12 AM. Patient transferred to morgue."

The MD documented a post mortem note at 2:47 PM. "Brought in by EMS a traumatic cardiac arrest after apparent intentional jump from 21 story building. The patient had no vital signs by EMS first contact. Intubation failed en route to the ED. Presented with full spinal immobilization and no spontaneous respiration's and no cardiac activity. Bilateral pupils fixed and dilated, large hematoma to back and spinal elements feel unstable. Pelvis unstable. Right lower extremity internally rotated and left lower extremity externally rotated. Time of death 11:12 AM. Next of kin notified in person. ME accepted the case."

Discharge Disposition: Dead on Arrival.

During interview on 8/12/15 at 12:30 pm, staff #2 was present during this interview. Staff #13 stated it was likely that Patient # A " probably needed inpatient admission based on her initial assessment but he still needed further evaluation in the PES by the Psychiatrist there. My intention was to move the patient to the PES and have a revaluation done later in the day by the next Physician coming on duty. " When asked why she didn't just admit him herself directly to the inpatient unit under an involuntary emergency legal status. Staff #13 stated " involuntary admissions are done upstairs once they are admitted. We don ' t do that in the ED."

Review of PES Policy titled, " Psychiatric Admissions: legal status." 09/14, " Emergency Admissions (9.39) the examining psychiatrist has determined that patient requires immediate hospitalization and completes the application for admission. "

Staff #13 stated " you don ' t know what its like here, we can't admit everyone. We see so many patients every day. We don't even behave like doctors here. We function more like social workers then doctors. "

Staff #13 was asked why in her treatment plan she wrote the patient should receive Seroquel 100 mg by mouth at bedtime and didn't write the order for nursing staff to administer the medicine.

Staff #13 said that "the treatment plan for medicines would be done later by the next physician on duty. "

When asked why is obtaining the patients prior psychiatric history from " Quadra- Med " important.

" it ' s helpful to know the patients past diagnosis, any medicines and treatment they had. "

Does that help to diagnose and treat the patient? " Yes, the QMed system is accessable for all our City hospitals and it helps in formulating a diagnosis in consideration to the patients past psychiatric history. "

Did you access the Q- Med for this patients past history from Bellevue. " No "

Did you access the PYSKES data base, the patient had given consent for PYSKES to be obtained. " No that ' s the social workers job to do that. "

During interview on 8/12/15 at 12:30 pm, Staff #2 the CMO was present at time of this interview.
Staff #2 was asked to explain how the patient ' s condition improved without any treatment interventions like medications being provided and what was it that caused his emergency medical condition to change from time of arrival and actively suicidal to stabilized for discharge back to his home.
Staff #2 stated " Really it was just time passing. We believe he had a substance induced psychosis and by keeping him here the drugs had sufficient time to pass from his system. "
Staff # 2 was asked with the Toxicology screen not being collected and no result obtained to confirm the diagnosis of a substance induced psychosis how did you determine that.
" Yes. He refused to give a urine specimen but he told us on interview he smoked marijuana."
Why wasn ' t the patient referred for Mentally ill Chemically Addicted (MICA) intensive outpatient or a partial hospital program to address his substance abuses.
"The counselling center would arrange all that if they felt it was necessary. "
Could the patient possibly have an untreated psychosis disorder from when he was discharged from Bellevue and have mentally decompensated prior to this psychiatric crisis on the roof top? " We don ' t know that. "
Staff #14 was interviewed on 8/13/15 at 11:00 AM a and confirmed he was the patients Attending Physician on 6/22/15 from 8:00 pm to 8:00 am on 6/23/15 and he confirmed that he didn ' t perform an evaluation overnight or document a treatment plan or treatment note and stated " it isn ' t our policy to reevaluate overnight unless the nurses bring a change in the patient condition to our attention. "
Staff #8 explained our standard procedures are "the patient gets a comprehensive evaluation done on an initial assessment performed by the consultant psychiatrist and then a reevaluation is performed in the morning for readiness for discharge."

Staff #14 was asked if Staff #13 (who was the physician handing off the patients care to him) had spoken with him at the 8:00 PM on 6/22/15 shift handoff and had staff #13 request that he do a reevaluation for this patient and he said "no."

Were you informed by Staff # 13 that the patient needed additional evaluation and a treatment plan developed including prescribing Seroquel at bed time?
Staff # 14 stated, " No. "

During interview on 8/12/15 at 11:15 AM Staff #12 was asked what criteria he used to determine patient A's readiness for discharge and he stated,

" I interviewed the patient and he wasn't expressing any suicidal or homicidal ideation he said he didn't have any intents or a plan to take to hurt himself. He wasn't describing any feelings of hopelessness or helplessness".

The follow up plans for Patient # A was to walk from the ED on 6/23/15 to the outpatient behavioral health center.

Staff #12 stated, "He was instructed to go to the outpatient center for counseling and the social worker made an appointment for him that day. "

Did anyone call the patients brother and inform him that the patient was being discharged? " No, the patient didnt want us to. "

When asked whether he had spoken with either Physicians who had preceded him in the continuum of the patients care prior to patients discharge he said " No " .

Staff #13 was also working the morning of 6/23/15 and although she had performed the initial assessment at 2:00 pm the previous day she was not assigned Patient A on 6/23/15. She also confirmed that she had no conversation about Patient # A with Staff # 12 on the morning of 6/23/15.

During interview on 8/17/15 at 11:00 Am Staff #16 was shown the patients medical record and stated " Yes, the medical record does say the patient gave signed consent for PYSKES. "

When asked why the PYSKES database was not accessed for collateral information?

Staff # 16 stated " The patient verbally withdrew his consent and I made a mistake and didn ' t enter that into the patient ' s record. "

When asked why is PYSKES important to access and utilize the databank she said " it ' s tells us their past diagnosis, how many hospital visits they have had and any medicines they are taking. It helps us to provide better services to the patient and helps to decide their after care services. "

Why was there no " aftercare support service plan " in the medical record?
Social Worker Staff #16, "we hand the patient the referrals to outpatient programs but we don't call and schedule the patients appointment. They are told to go make their way there before the center closes. When they get to the center they will schedule with the patient an appointment for when the patient can be seen by a social worker there. We don ' t fax them or send NYCCP any of the patients ' medical information. That ' s not what we do. "

Did anyone call the patients brother and inform him that the patient was being discharged? " I wouldn ' t know. But the patient didn ' t want me to call anyone in his family when I met with him during the night. "

Review of Patient # B medical record revealed on 6/26/15 at 5:35 AM was brought to the ED with suicidal ideation. The patient was treated and released from the ED at 5:57 PM. The psychiatrist failed to perform the " Columbia Suicide Severity Risk Assessment (C-SS/RA) " on admission and the medical record lacked a " Suicide Risk Assessment at disposition. "

There was no safety plan signed by the patient in the medical record.

Review of Patient # C medical record documented on 7/30/15 was brought to the ED with suicidal ideation and Triage note at 1:15 AM noted tried to "jump off of a building." As per patients brother this is the fourth time this month. He was talked down by police who brought him here. The patient was placed on one to one observation in the MER and was seen by the psychiatrist was on 7/30/15 at 4:58 AM. Disposition was on 7/30/15 at 11:21 AM into the community. The patient was instructed to go to NYPCC for outpatient services.

The psychiatrist failed to perform the Columbia Suicide Severity Risk Assessment (C-SS/RA) within the sixty minute time frame and the medical record lacked a Suicide Risk Assessment at disposition.
There was no safety plan signed by the patient.


Review of medical record revealed Patient # H was brought to the ED on 7/10/15 at 8:58 AM with suicidal ideation and the Columbia Suicide Severity Rating Scale was not done by the Triage RN and no Columbia Suicide Severity Risk Assessment was done by the doctor on admission or discharge. Disposition was treated and released on 6/11/15 at 11:05 AM.

There was no safety plan signed by the patient.

Patient #H did not sign consent for PSYCKES data base access. PSYCKES recorded history was not obtained during the 7/10/15 hospital encounter by the Psychiatrist, RN or the social worker.

The Psychiatrist failed to identify whether this was a clinical emergency allowing PSYCKES to be accessed for 72 hours without the need for patient consent as per policy.

Similiar findings were found in Patient #D, E, F, G.

Hospital Policies reviewed on 8/25/15 revealed:

1) PES Policy titled, " Suicide Risk Assessment and Management in Psychiatric Emergency services and inpatient Psychiatric Unit: with ' Columbia Suicide Severity Rating Scale Tool ' and 'Columbia Suicide Severity Risk Assessment' attachments provided. Dated 05/2015

" If the patient has a positive screen, as part of the overall comprehensive assessment and formulation processes, the C-SSRS Risk Assessment shall be completed with an interdisciplinary treatment plan that addresses modifiable suicide risk factors.
A " Patient Safety Plan " will be developed and implemented in close collaboration with patients who are discharged from PES or the psychiatric inpatient units who are deemed at moderate or high risk for suicide.
Definitions: Suicidal patient is any person who has recently made an attempt in the last 12 months or has a plan (with or without intent)
High Risk: a patient has made an attempt within the past three months or has a plan with intent to kill him/her self.
Moderate Risk: patient has no immediate plan, or a low risk plan and their intent to die from their actions is low
Low or No Risk a patient who exhibits strong protective factors, may have thoughts of death but no plan for suicide.

Patient Safety Plan: is a prioritized written list of coping strategies and sources of support that patients can use who have been deemed at risk for suicide. Risk Factors are variables that increase the risk for suicide being attempted is likely.
A Safety Plan covers warning signs, coping strategies, personal and professional support options and environmental safety. A patient can use these strategies before or during a suicidal crisis.
Positive Screen is a positive response to the questions to the questions of having a plan or intent or having made an attempt within the past 3 months on the Columbia Suicide Severity Rating Scale Tool
Upon admission to PES all patients are screen using the ' Columbia Suicide Severity Rating Scale Tool '

When a patient has a positive the patient must be classified as emergent and seen by a Psychiatrists within sixty minutes for evaluation using the "Columbia Suicide Severity Risk Assessment' (Using the tool attached in policy).
The patient must be assigned a risk level by a Psychiatrists and an individualized interdisciplinary care plan developed to address suicide risk factors.
Upon discharge the patient must have another "Columbia Suicide Severity Risk Assessment' (Using the tool attached in policy).
Completed by a Psychiatrists to determine safety to leave the hospital and that all modifiable risk factors have been addressed.

Patients deemed at moderate risk for suicide, a Patient safety Plan shall be completed with the patient prior to discharge with resources for community support clearly identified.
Every attempt should be made to provide and communicate the patient ' s history of suicide risk to the family and after care provider.
All relevant clinical documentation will be sent to the next level of care provider for all patients who are given follow up appointments.
Patients discharged from PES will have an appropriate plan for follow up care including a Safety Plan developed with the patient.

2) PES Policy titled, "Hand Offs" dated 09/14 states, " To provide guidelines for effective handoff communication at change of shift and change of providers in the PES. To ensure appropriate medical information is shared among all providers to allow for continuity of care across shifts.

3) PES Policy titled, " Clinical assessments and documentation " dated 09/14 states,
" All patients triaged or consulted to the PES at LMC will receive accurate assessments and appropriate documentation.
The RN is responsible for ensuring coordination of care among other disciplines and support staff based on the initial patient assessment and ongoing on interval assessments. "
The Physicians, Nurses and social workers are responsible for collection of data through mechanisms such as observation, interview and diagnostic tests. This data is analyzed to create information necessary to determine the approach to meeting care needs and to identify any additional information required. Decisions are made and executed regarding delivery of care on the basis of the assessment.

The Physician ' s Reassessment is the Reevaluation of the patient at regularly specified times according to the patients course of treatment, response to treatment or when a significant change occurs in the patient ' s condition and/or diagnosis.
Reassessments will be initiated according to acuity of the patient ' s condition. Reassessments are required at minimum on a daily basis and are reflected in a progress note or consult follow up note. "

PES Policy titled, " Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES) " dated 09/14 states " To facilitate access by hospital Behavioral Health providers to the Psychiatric Services and Clinical Knowledge Enhancement System is a web base of Medicaid enrollees who had a behavioral health services, diagnosis or psychotropic medication in the past five years. Access to this database is designed to support clinical evaluation, treatment planning, and coordination of care and quality improvement. All patients requesting or requiring acute psychiatric care at LMMHC who are or were enrolled in Medicaid will be asked to sign consent to allow access to Psychiatric Services and Clinical Knowledge Enhancement System.
In the PES when a patient is brought in and refuses to consent or is unable to consent, the psychiatrist can identify this as a clinical emergency allowing PSYCKES to be accessed for 72 hours.
A copy of the patients profile can be printed and kept in the PES until transfer or discharge at which point all paper chart material is sent to Medical Records and will be scanned into Quadramed. The responsibility for obtaining consents and accessing PSYCKES is all members of the interdisciplinary staff.