HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure suicide risk assessment was completed for at risk patients for one of one medical record reviewed (MR1).

Findings:

Review on September 19, 2023, of the facility policy, "Suicide Assessment And Prevention - Patient Care Services," last reviewed February 2022 revealed "... I. Key Points: ... 2. It is the policy to create an environment of care that will foster the accurate identification and
successful management of patients who are at risk for suicide or self-destructive behaviors.
Patients at risk for suicide require intensive support, close observation, frequent re-assessment, and application of protective measures for their emotional and physical well-being. The scope of this plan begins prior to admission and continues through the patient's discharge. 3. All patients who are being evaluated or treated for behavioral health conditions as a reason for care will be screened for their risk of self-harm using the Columbia Suicide Severity Rating Screen (C-SSRS) ... 4. The C-SSRS assigns a level of risk to the patient. Patients identified as a Suicide Risk will have patient safety measures implemented as defined in the risk stratification/suicide precaution interventions. Patients will have an order for suicide precautions with observation level entered in the EHR. ... 14. ED and inpatient acute care units: If a patient expresses suicidal ideations during or after the admission assessment has been completed, a suicide risk assessment (C-SSRS) will be completed. The appropriate follow up will be initiated based on the risk assessment and suggested interventions. ... II. Purpose: To outline the process for the timely assessment and reassessment of patients' suicide risk and to provide guidelines for safety interventions. ... III. Definitions: CSSRS (Columbia-Suicide Severity Rating Scale) - The Columbia-Suicide Severity Rating Scale (C-SSRS) is an assessment tool that evaluates suicidal ideation and behavior. The C-SSRS risk assessment guides the suicide precaution interventions for the ED and Inpatient Acute Care Units as outlined in Attachment C and D ... Suicidal Ideation: Common term for thoughts about suicide and may be as detailed as a formal plan, without the suicidal act itself. Suicide Risk Assessment: A comprehensive assessment of risk factors and protective factors of each patient to determine suicide risk completed by staff interview during face-to face preadmission screening or in addition to nursing admission assessment. ... VI. Intervention / Guideline: ... 4. Patient Assessment - Inpatient Acute Care Unit a. Suicide Risk Assessment (CSSRS) - (1) Nursing Assessment of Suicide Risk by the RN on admission, not to exceed 2 hours except in the conditions that are consistent with cognitive impairment. ... 5. Patient Reassessment - ... 6. Changes in the assessment are reported to the provider or psychiatric consultant. ..."

Review on September 19, 2023, of MR1 revealed the patient was admitted to the facility on September 5, 2023, for malignant hypertension and opioid withdrawal after experiencing a syncopal episode at a rehabilitation facility. There was documentation the patient was placed in restraints on September 6, 2023, after abusive outbursts towards staff. There was physician documentation restraints were to be removed prior to breakfast but the patient threatened the one restraint that was left in place was making them suicidal. There was no documentation a suicide risk assessment was completed.

Continued review of MR1 revealed nursing documentation dated and timed September 6, 2023, 0932. There was nursing documentation the patient stated one restraint on was giving them suicidal ideation. There was documentation the physician was made aware. There was no documentation a suicide risk assessment was completed.

Interview on September 5, 2023, with EMP1, at approximately 1100, confirmed the above findings.

Continued review of MR1 revealed nursing documentation all patient restraints were removed, and the patient wanted to leave against medical advice (AMA). There was documentation the physician was made aware, and the patient may leave. There was documentation IV lines were removed and security was called to assist the patient off the floor. There was documentation the patient left the floor escorted by security at 1026 on September 6, 2023.

Continued review of MR1 revealed physician documentation dated September 6, 2023. There was documentation the restraint was removed from the patient and they became cooperative. There was documentation the physician had a conversation with the patient to determine if they were at risk. There was documentation the physician stated the patient was not at risk to self or others. There was documentation the patient requested to be discharged a few hours later and discharge was declined because the patient was not medically stable. There was documentation the patient then decided to sign out AMA.

Continued review of MR1 revealed the patient was returned to the facility Emergency Department via EMS on September 6, 2023, at approximately 1405. There was documentation the patient arrived after a witnessed fall from a local bridge into a body of water. There was documentation the patient stated they performed the action with the intent to end their life. There was documentation an involuntary commitment was obtained and the patient was re-admitted to the facility. There was documentation the patient was examined, and a 2-centimeter scalp laceration was repaired using three staples. There was documentation the patient had no other acute injuries related to the fall.

Interview on September 5, 2023, with EMP1, at approximately 1130, confirmed the above findings.