HospitalInspections.org

The facility failed to notify one minor patient (P)2's legal guardian (mother) in a timely manner to reconcile home medications, discuss the treatment plan and honor those decisions. Specifically on the Emergency Department (ED) encounter 11/28/21 to 12/03/21 the mother refused a medication (venlafaxine) to be given to P2 on 12/02/2021. The medication was administered one time on 12/03/21 prior to discharge without the mother's consent. On a subsequent ED encounter (12/22/21 to 12/26/21) the ED again did not contact the mother in a timely manner to verify/reconcile P2's medications. As a result of this deficiency, there was the potential P2 could experience side effects due to omission of home medications or administration of new medications.

Findings include:

1) P2 was a 13 year old male with a psychiatric history. He has had multiple trips to the ED and inpatient hospitalizations for psychiatric care. P2 has been diagnosed with major depressive disorder and behavior included threats of harm to others..//, In addition, P2 has a history of asthma, and gastroesophageal reflux disease (GERD). His medications include Pristiq (antidepressant), Vistaril (Hydroxyzine) for anxiety, Advair (for Asthma) and Prilosec for GERD.

2) P2's 11/28/2021 ED encounter RR revealed the following:
11/28/2021 02:18 PM note by ED Physician (Doctor of Osteopathic Medicine/DO)1: "The patient (P2) presents with threatening behavior on the background of psychiatric illness. He meets criteria for involuntary psychiatric hold at this time and appears to be gravely disabled by psychiatric illness. The patient was placed on involuntary hold for safety and inpatient treatment. My evaluation at this time, patient is at significant risk of harming others if discharged. After history, physical exam, and required diagnostic evaluation, the patient was found to be medically stable for psychiatric transfer. Unfortunately there are no beds available. ...Regular diet has been ordered and the patient will receive appropriate custodial care awaiting transfer."
12/02/2021 09:54 PM DO1 ordered venlafaxine (effexor) "100 mg (milligrams) oral, daily tab (tablet)" for major depressive disorder.
12/02/2021 09:54 PM MD2 note: "Patient (P2) did have one episode of emesis and nausea resolved with dose of Zofran. Patients mother arrived to the ED and is questioning whether he has been taking his home medications. On further history patient has not been taking home medications which were found in his belongings. His home medications were ordered. Likely had an episode of vomiting due to overeating versus not being on his Prilosec.
12/03/21 01:00 AM Registered Nurse (RN)1 documented on the medication administration record (MAR): "mother refused medication (venlafaxine). Patient has not been given this medication for 4 days and she would like to speak to a psychiatrist before she proceeds first."
12/03/21 11:09 AM RN2 clinical note: "Pt's family asked to speak to the MD about the possibility of pt. returning home and following up with outpatient psychiatrist."
12/03/2021 09:36 AM MAR documented 100 mg venlafaxine given orally by RN2.
12/03/2021 01:45 PM P2 was discharged home. The discharge Instructions documented P2 received venlafaxine 50 mg. 2 tabs orally at 09:36 AM. P1's mother was not aware her son had been given the venlafaxine until she read the discharge papers.
12/04/2021 at 04:03 AM, DO1 discontinued the order for venlafaxine.

After P2's mother directed the MD and staff not to give her son venlafaxine, it was given without her consent because the order was not discontinued in the computer.

3) P2's ED encounter 12/22/2021 to 12/26/2021. RR revealed the following:
12/25/2021 02:00 PM note by MD3: "Mother states that patient to be on desvenlafaxine (prileq) at 50 mg currently. We do not have this in pharmacy and just have venlafaxine (which he was receiving) but the dose was decreased from 75 to 50 mg. per mothers information. Mother later stated she will bring in home medications for patient. This is with RN's and will be given as home medication as well as folic acid which mom brought as well."

MAR (not inclusive):
12/23/2021 at 09:38 AM: venlafaxine 75 mg. given
12/24/2021 at 08:11 AM: venlafaxine 75 mg. given
12/25/2021 at 08:23 AM: venlafaxine 75 mg. given
12/26/2021 at 08:23 AM: desvenlafaxine 50 mg given (P2's own meds).
P2's medications were changed after reconciling them with mother and she brought the medications in.

4) Review of the facility policies and documents:
Policy titled "Consent and informed consent" review date 10/26/2021 included the definition "Legal representative is used to indicate a person acting on behalf of a patient which includes consent for treatment." Legal representative was further defined to include "A parent whose parental rights have not been terminated."

Policy titled "Care Planning, Multidisciplinary" last reviewed 04/22/2021 included "E. ...Patient/Family/Caregiver will be included in collaborative care planning as appropriate."

"Patient Handbook Emergency & Outpatient Services" provided to all patients/patient representative included the "Patient Bill of Rights ...Participation in Care Planning: The right to make informed decisions regarding his or her care, to be informed of his or her health status and to be involved in care planning and treatment. The right to refuse treatment..."

The facility failed to ensure each pediatric behavioral health (BH) patient (P) in the Emergency Department (ED)received care in a safe "ligature free" environment. A pediatric/adolescent BH patient in the ED who is identified as high risk for self harm or harm to others is placed in a room with a television (TV) control cord that is not removed from the room. In addition, it was reported by staff on 03/10/22, a patient safety attendant (PSA) was assigned to two patients, P1 who was to be 1:1 constant observation for high risk of self harm and another patient screened "no risk." The PSA left P1 unattended to escort the other patient to the bathroom. As a result of these deficiencies, the risk for self harm was increased. o

Findings include:

1) The facility does not admit patients less than 18 years of age, and does not have access to a pediatric Psychiatrist or pediatric BH services. Patients younger than 18 years of age who require inpatient care for psychiatric crisis remain in the ED (boarded) until an appropriate transfer or discharge plan is determined.

2) Review of the facility policy/procedures revealed the following definitions/content:
Model Policy (systemwide) number (No.) 13497 titled Suicide Prevention review date 03/18/2022:
"Patient Safety Attendant (PSA)-Associates or personnel trained in patient safety including environment risk mitigation, warning signs, and appropriate hand-off. ..."
"Constant Observation or 1:1-Constant visual observation of a patient by a PSA who is in close proximity to the patient. PSA may not engage in any activities that diverts attention away from the patient including when the patient is sleeping and using bathroom/shower. Peripheral vision can be used to provide a sense of privacy when appropriate. ..."
"Line of Sight: Patient is kept in line of sight which allows for a PSA to view multiple patients if they can be viewed in the same field of vision at all times, including when the patient is sleeping. If multiple patients are viewed, an additional PSA would be necessary when patients need to use the bathroom, as the PSA would accompany the patient for trips to the bathroom to maintain line of sight at all times."

The policy directed staff to use an "environmental checklist" to document risk items removed and included attachment G as an example of the minimum information that should be documented. The policy said: "Items that remain will be justified, for example, oxygen tubing due to pulmonary issues. ... Remove ligature risks that can be removed and are not required for the use of patient care." Review of attachment G titled "Room-Environment Assessment for Suicide Prevention" revealed it listed several items to be removed from the room, which included but not limited to "monitor cords and all sheets/blankets except for fitted sheet."

Policy No. CMEDPPO30062 titled "Behavioral Health Patients-Care in the Emergency Department" last reviewed 02/05/2021:
"Sitter-Hospital staff assigned on a one to one basis with a patient that has been determined to be high risk to be danger to self or others."
The policy directs staff to complete the form titled "Moderate or high-risk for suicide and ligature risk care plan." The instructions on the form directed the Registered Nurse (RN) to customize the plan by completing an assessment and selecting applicable interventions by checking a boxes next to the applicable item assessed and intervention initiated. The assessment included "4. Sitter to assess environment for anything which could be used to attach a cord, rope, or other material for hanging or strangulation. Ligature points include, but not limited to shower heads, grab bars, coat hooks, pipes, bedrails, window or door frames, ceiling fittings, handles, hinges and closures." The policy said to ensure any risk unable to be removed be "part of the risk status report during handoff."

3) P1 was a 15 year old female who presented to the ED with suicide ideation. She had a history of major depression. P1 was assessed to be a high risk on the C-SSRS and was boarded in the ED waiting for a bed at a pediatric BH facility. The note dated 03/08/2022 by MD4 documented: "Patient has been here for 223 hours."

Review of P1's medical records revealed the staff do not use attachment G referenced in policy no. 13497, but use a form titled "Risk for suicide and ligature Care plan." RR of the form revealed it was incomplete. The assessment for ligature risks, devices to inflict self-harm or harm to others, and other suffocation risks had staff initials in the designated area, but the assessments were not checked completed. There was no documentation regarding the TV control cord.

4) On 03/18/2022 at 09:15 AM, during an interview with RN4, she referred to a "1:1 sitter" for high risk and a 1:1 sitter for peds (pediatric)." When asked what the difference was between a "1:1 sitter" and a "1:1 for Peds," RN4 explained all pediatric BH patients have a 1:1, even if they are not assessed as a high risk, "just because they are peds." RN4 said the "1:1 sitter" is for the patients assessed as high risk for self harm or harm to others. RN4 went on to say they use four rooms in one section to keep them (peds BH patients) in the same area. When asked why they didn't utilize the behavioral health area that is a safe environment, RN4 said they move them to the ED side so they can watch TV and it's not as isolated. RN4 said they remove everything out of the room except the TV cord.

5) On 03/18/2022 at approximately 10:40 AM, toured the ED area and rooms where the pediatric BH patients are routinely placed. RN4 pointed out the equipment they remove from the room. The cord with the TV control was noted to be a heavy cord approximately eight feet long. RN4 showed surveyor where the "sitter" is located (outside entrance of patient room) so they had constant visualization. If they were assigned two P's, which could be done if they were both no risk they would sit in the middle of the hall to visualize both. RN4 was unsure how may patients a sitter could watch at a time if they were no risk. She also said she was thinking about safety risks, and wondered if the sheets and blankets were safe.

RN4 said on 03/10/2022 her assigned area had one sitter assigned to two patients. P1 was a high risk and to have "1:1 sitter with constant observation" and the other patient had been rescreened as "no risk," but needed a sitter because he was a BH adolescent. She said the sitter was located in the middle of the hall between bed 20 and 21. RN4 went on to say she observed the sitter escorting the no risk patient back from the bathroom to his room, which left P1 unmonitored. RN4 agreed this was not standard of care and did not follow the facility policies.

Based on interviews and record review (RR), the facility did not meet the standards of care or follow their own policy for medication reconciliation. Three patients (P)1, P2 and P3 of a sample size of five did not have medication reconciliation completed in a timely manner by the nursing staff in the Emergency Department (ED). As a result of this deficiency, there was the potential of adverse outcomes due to the omission of home medications. This could effect any patient who presents to the ED.

Findings include:

1) P1 is a 15 year old female who presented with suicide ideation and had a history of depression. Her home medications included atomoxetine (for attention deficit disorder/ADHD), clonidene (for high blood pressure) and aripiprzole for bipolar disorder.

P1 was admitted to ED on 02/26/2022. She was boarded in the ED because there were no inpatient pediatric behavioral health beds available on island. After an extended stay in the ED, P1 was assessed to be safe and discharged on 03/08/2022 at 03:34 PM in the custody of her father. P1's father was going to take her to her grandparents to stay.

P1 returned to the ED 03/09/2022 at 09:13 PM after attempted suicide with an overdose with Tylenol. RR revealed her "Documented-medications" list in the electronic medical record (EMR) from the previous visit included: "Clonidine .01 mg 1 oral tablet. Order details: "Take 1 tablet (0.1 mg) by mouth at 2 PM, and 2 tablet (.02 mg) at 8 PM for school use only." The medication reconciliation wasn't completed until the next day. There was a missed dose of blood pressure medication on 03/10/2022 and it is unknown if she took her medications for blood pressure and ADHD prior to coming to the hospital the evening of 03/09/2022.

2) P2 was a 13 year old male with a psychiatric history. He has had multiple trips to the ED and inpatient hospitalizations at psychiatric facilities. P2 was diagnosed with major depressive disorder and had behavior that included threats of harm to others. P2 also had a history of asthma, and gastroesophageal reflux disease (GERD). His medications include pristiq (antidepressant), vistaril (Hydroxyzine) for anxiety, advair (for Asthma) and prilosec for GERD.

11/28/2021-12/03/21 P2's ED encounter RR revealed the following:
11/28/2021 02:18 PM note by MD1: "The patient (P2) presents with threatening behavior on the background of psychiatric illness. He meets criteria for involuntary psychiatric hold at this time and appears to be gravely disabled by psychiatric illness. The patient was placed on involuntary hold for safety and inpatient treatment. My evaluation is at this patient is at significant risk of harming others if discharged. After history, physical exam, and required diagnostic evaluation, the patient was found to be medically stable for psychiatric transfer. Unfortunately there are no beds available ....Regular diet has been ordered and the patient will receive appropriate custodial care awaiting transfer."
12/02/2021 09:54 PM note by MD2: "Patient (P)2 did have one episode of emesis and nausea resolved with dose of Zofran. Patients mother arrived to the ED and is questioning whether he has been taking his home medications. On further history patient has not been taking home medications which were found in his belongings. His home medications were ordered. Likely had an episode of vomiting due to overeating versus not being on his prilosec."

P2 did not receive his home medications for four days.

P2's ED encounter 12/22/2021 to 12/26/2021.
12/25/2021 02:00 PM by MD3: "Mother states that patient to be on desvenlafaxine (prileq) at 50 milligrams (mg) currently. We do not have this in pharmacy and just have venlafaxine but the dose was decreased from 75 to 50 mg. per mothers information. Mother later stated she will bring in home medications for patient. This is with RN's and will be given as home medication as well as folic acid which mom brought as well."
P1 did not receive his home medication of prileq and was given venlafasxine instead until the med rec was completed.

3) P3 is a 17 year old male who was brought to the ED on 01/10/2022 at 09:09 AM by ambulance presenting with methamphetamine abuse and suicidal ideation. He is a ward of the state and is homeless. While in the ED he displayed behaviors that included but not limited to pacing, attempting to leave, and urinating on the floor.

RR included:
01/10/2022 MD7 note: "Patient is acutely suicidal. He also appears to have psychosis. He is unable to tell us what medications he is on at this point. He has not been taking them. His mother also cannot tell me what medications he has been taking. He is medically cleared. Patient will be sent for admission to pediatric psychiatric facility."
01/13/2022 MD5 note: "...Reportedly, he (P3) was recently admitted to the Hospital (H)1. ...On review of his records at H1, he appears to be on benztropine (for side effects of certain psychiatric drugs) twice daily, risperidone (antipsycotic) 1 mg. in the morning and 2 mg. at bedtime. I am restarting those medications."
01/18/2022 MD5 note included: "...His (P3) behavior has seemed to mellow since I started him on the risperidone he had been on at H1 previously."

4) On 03/18/2022 at 09:15 AM during an interview with RN4, she said was assigned P1 on 03/10/2022 and noticed the med rec had not been completed so she contacted P1's mother and reviewed the medications with her. P1's mother said the dose of the Clonidine was incorrect and P1 was currently taking only .01 mg. at night. RN4 corrected the medication list in the EMR, signed off on the reconciliation, informed the MD who then ordered the home medications on 03/10/2022 at 11:11 AM.

On RR it was noted RN4 signed she completed the med rec when on P2's 11/28/2021 encounter. After review of the EMR, she said she took over the care of P2 from another RN and the belongings had already been removed. RN4 said she did not receive any information in report of medications brought with P2. RN4 said they (RN's) often are not able to do the medication reconciliation right away due to time constraints and other priorities in the ED, so it depends on the volume and acuity when it gets done. RN4 said she did not contact P2's mother to do the reconciliation and probably just marked it off as correct because he (P)2 is there so often. RN4 acknowledged this was not the correct way to do med rec.

5) On 03/18/2022 at approximately 11:00 AM during an interview with the pharmacist (PHM), she said their priority was inpatients and they do med rec on all inpatients. She went on to say they do assist in the ED if requested, but that they had never done behavioral health patients. The PHM said it would be expected the med rec be completed "within about an hour" of arrival," and if the patient is a minor and parent is not present, the RN should contact a parent or listed emergency contact. The PHM said when they do a med rec they review the medical records and go to the room to interview the patient. If the patient is not a good historian, they contact the primary care MD's office, and contact the pharmacies to validate correct dose. The PHM agreed med rec on a BH peds patient in a psychiatric crisis should be a priority.

6) Review of the systemwide model policy number 12273 titled "Medication Reconciliation Procedure Guidelines-CPOE" review date 03/03/2022 revealed the following content:
"Reconciliation: The process of comparing the medication information the patient brought to the hospital with the medications ordered by the hospital in order to identify and resolve discrepancies."
"Discrepancies: Omissions, duplications, contraindications, unclear information, and changes."
Policy A.2. "Information on medications the patient is currently taking will be obtained and documented in the patient record in the beginning of any episode."
Procedure 1c iv "If patient is unaccompanied on admission and/or unreliable historian, check "unable to obtain information."Follow-up using other resource(s) to obtain medication list as soon as possible. Other resources may include: family/Caregiver, Home Care Agency, Transfer form from other entity, Patients primary pharmacist, and patients primary care provider."

Based on interviews and record review (RR), the Emergency Department (ED) failed to establish appropriate policies for the care of the pediatric/adolescent behavioral health (BH) patient boarded in the ED waiting for transfer to a pediatric psychiatric facility or discharge. Three policies were reviewed which contained conflicting information and did not provide clear direction for the ED staff to meet the needs of this population. The policies did not address basic needs such as hygiene, interaction, activities appropriate for age group, process to take the patient outside, or guidance what to do should they elope. The ED currently do not develop a written discharge plan as outlined in their policy and which is standard of care. In addition, although the increasing trend was recognized as a significant issue by the ED staff, ED leadership and hospital Administration, the facility did not have data to know the severity of the problem and had not incorporated any measures into the department QAPI activities.

Findings include:

1) On 03/17/2022 during an interview with two ED security staff (SS) in the behavioral health unit (secured, environment safe) of the ED, they said the psychiatric pediatric patients is a "big problem." SS1 said when the BH pediatric comes in, they go straight to the ED rather than through the BH entrance and are cared for on the medical side. He went on to say the security staff will go over to the medical side and assist with processing the patient which includes changing clothing and securing belongings.

On 03/17/2022 during an interview with RN3, he explained the intake process for the BH pediatric patient and said they are kept on the medical side of the ED. RN3 said they had a high volume of BH peds and that it was difficult because they stay in the ED for days or weeks until an open bed is available on island. When asked how they manage the situation, he explained they get staff to help do the 1:1's. RN3 explained the high risk are assigned 1:1 constant monitoring, but when they are assessed to no longer be a risk for suicide, they still have a "peds 1:1." Inquired what the patients do during all that time and he said they (staff) usually are able to come up with something like cards or a magazine.

On 03/18/2022 at 09:15 AM during an interview with RN4, she said they have had four pediatric patients boarded at the same time and use four beds located in one section of the ED to keep them in one area. RN4 said they initially come through the ED BH side and if they need to be boarded, they are transferred over to medical side. She said they do not keep them in the ED BH unit (safe environment) because its more isolated and the rooms don't have TV's. RN4 said the patient is assessed for risk on admission and immediately assigned a "1:1." She went on to say they are reassessed every shift and if no longer a risk, the level of monitoring is changed, but still had a "1:1 because they were peds." RN4 said she asked for clarification if the "peds 1:1" needed documentation every 15 minutes and had been told no. RN4 was also unsure of how many patients a "sitter (peds 1:1)" could monitor. RN4 said the department did not have any specific guidelines for what to do for these patients as they were medically cleared and just waiting. She said hygiene is an issue and they do not have a routine for showering or basic hygiene. She also said "all they really do is watch TV." RN4 said the past two to three weeks they started some new things and are involving the Social Worker and Chaplain.

On 03/18/22 at approximately 02:00 PM during an interview with the ED Nurse Manager (NM), she said there had been a significant increase of pediatric BH patients since COVID. Inquired what the ED process was for monitoring the patients while they were boarded in the ED. The NM said they use 1:1 monitoring. Inquired what the difference was between "1:1" for self harm and "1:1 for peds." The NM said when a patient is assessed to no longer be a risk for harm or violence, they assign a sitter just because they are a pediatric patient. The NM said these patients do not require the 15 minute documentation and the other ones do. When asked if the "1:1 peds" is addressed in a policy, she said she did not think so. Inquired what the ED had for the patients to do, and if COVID presented a problem with infection control and resources. The NM said "we do not have anything (activities/resources)." Inquired how severe the problem was, and if they had data. The NM said she wanted to collect data, but had none at this time. When asked about the ED quality plan, and measures, she said they monitor patient turn around times, but not specifically for the pediatric BH patient. The NM went on to say one of the ED physicians had just started a work group to address some of the issues and they recently had their first meeting, but did not take minutes. She said they had started some new initiatives that included Social Worker visits and Clergy visits including walks outside. When asked if there was anything in writing to help staff structure the custodial care (i.e. hygiene, activities), SW or Clergy visits, she said no.

2) Review of the facility policy/procedures:
Model Policy (systemwide) number 13497 titled Suicide Prevention review date 03/18/2022 included the following definitions and content:
"Patient Safety Attendant (PSA)-Associates or personnel trained in patient safety including environments risk mitigation, warning signs, and appropriate hand-off. ..."
"Constant Observation or 1:1-Constant visual observation of a patient by a PSA who is in close proximity to the patient. PSA may not engage in any activities that diverts attention away from the patient including when the patient is sleeping and using bathroom/shower. Peripheral vision can be used to provide a sense of privacy when appropriate. ..."
"Line of Sight: Patient is kept in line of sight which allows for a PSA to view multiple patients if they can be viewed in the same field of vision at all times, including when the patient is sleeping. If multiple patients are, an additional PSA would be necessary when patients need to use the bathroom, as the PSA would accompany the patient for trips to the bathroom to maintain line of sight al all times."
"Patient Safety Plan- A written patient safety plan created and agreed upon with the patient that contain steps the patient will follow when experiencing suicidal thoughts. Items that may be included in a patient safety plan are: warning signs that a crisis may be developing internal coping strategies, people and social settings that provide distraction, people who can be asked for help, professionals or agencies to contact in a crisis, ways to make the environment safe, and the identification of the patients; most important thing that is worth living for."
Discharge: 3b "Prior to discharge, a Patient Safety Plan is developed with the patient. ...Upon discharge review the Patient Safety Plan with the patient and remind the patient to use it to stay safe after discharge. ..."

ED policy titled: "Behavioral Health Patients-Care in the Emergency Department" last reviewed 02/05/2021 included the following:
"Safety Hold- A patient identified as incapacitated and at medical risk or dangerous to self or others and unable to make a rational decision."
"Sitter- Hospital staff assigned on a one to one basis with a patient that has been determined to be high risk to be be danger to self or others."
"Policy C. The level of patient safety monitoring is determined by the Suicide and Violence Screening (TM33) score.
"Procedure A3. The orange ID band indicates the patient is a safety hold should the patient attempt to leave."
"Procedure B. Patient Care 2. RN will completed appropriate assessment...This includes...screening for suicide and violence (TM33) ...4. All other patients will be reassessed for suicide and violence using C-SSRS every 12 hours. ...7. The patient care plan is developed collaboratively between ED RN, psychiatrist, ED MD, social worker, and CITAP and documented in the medical record. ...9. A care conference may be arranged as needed which should include the case manager, Social Services. ED manager/ED director, CITAP, or psychiatrist as needed."
"G. Pediatric Behavioral Health Patients: 1. CMC does not admit patients less than 18 years of age... 2. ACCESS line is available for request of an evaluation as determined by the ED physician, social work and psychiatrist. 3. ED physician, ED staff, case manager and social services will encourage parent(s) to stay...when appropriate. 4. Care conferences may be held as needed..."

This policy content does not match current practice. An orange band is no longer used and per interviews, the initial screen is the C-SSRC. "1:1" for high risk of danger to self is defined as a "sitter" and the other policy uses PCA (1:1, or constant observation or line of sight). CITAP was a behavioral health nurse who responded to the ED to assess behavioral health patients and the position does not currently exist. In addition, care conferences are not held or documented.

Nursing Administration Policy No 10901: "Sitter & 1:1 Direct Observation" review date 06/15/21:
"Sitter: Hospital or contracted staff assigned to stay with one or two patients for safety reasons because the patient is confused, agitated, is disruptive or attempts to disrupt therapy, or is a high fall or flight risk."
"1:1 Constant Observation Sitter: Hospital or contracted staff assigned on a one to one basis with a patient that has been determine to be a danger to self or others."
"Policy B. A physician order is required for a 1:1 Direct Observation..."
"Policy J. 1:1 direct observation: 1. Staff on BHS (Behavioral Health Services and on Medical units will follow the same procedures for patients requiring 1:1 Direct Observation... b. Refer to Suicide and Violence Risk Assessment Guidelines. i. A physicians order is required. ..." This refers to Policy "Suicide and Violence Risk Assessment Guidelines."
Request was made for the Suicide and Violence Risk Assessment Guidelines, but the Quality Director said it was not available as it was being revised.

The policy stated an order is required for a 1:1 direct observation, which is not the current practice. The intent was not to seclude the patient, but to provide the least restrictive measures to ensure safety and allow visitors as appropriate. The policy does not reflect current practice or standardize terminology for staff clarity.

3) P1 is a 15 year old female who presented to the ED on 02/26/2022 with suicide ideation and had a history of depression. She was boarded in the ED because there were no inpatient pediatric behavioral health beds available on island. After an extended stay in the ED, P1 was assessed to be safe and discharged on 03/08/2022 at 03:34 PM in the custody of her father. P1's father was going to take her to her grandparents to stay. P1 returned to the ED 03/09/2022 at 09:13 PM after attempted suicide with an overdose with Tylenol.

Review of her discharge instructions completed on 03/08/2022 at 01:34 PM, revealed P1 did not have a written discharge safety plan. The discharge instructions included brief information on depression. but there was no personalized safety plan collaboratively developed with P1.