The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MID VALLEY HOSPITAL 810 JASMINE STREET OMAK, WA 98841 Aug. 17, 2017
VIOLATION: PROVISION OF SERVICES Tag No: C0270
Based on observations, review of hospital policies, record review, and interviews, the hospital failed to provide and implement current and updated policies and procedures to direct staff how to assess and care for suicidal patients ( C 271); failed to review and assess policies and procedures annually (C 272); failed to train and supervise staff to provide emergency nursing services for suicidal patients (C 294); and failed to implement safety procedures and corrective actions to meet the on-going assessment and care planning needs of suicidal patients in the emergency room (C 298).

These deficiencies may have contributed to actual harm and the death of 1 of 11 emergency room patients reviewed who were treated for suicidal ideation (Patient #1), and potential harm existed for any suicidal patient seeking emergency services at this hospital.

Due to these deficiencies, Department of Health surveyors notified the Hospital Administrator and Director of Patient Care Services of an IMMEDIATE JEOPARDY at 08/16/17 at 9:45 AM. The hospital had not ensured that suicidal patients in the emergency room were provided safe, effective nursing care due to the failure to have policies and procedures in place to direct staff in how, when, and how often to assess and evaluate the patients' condition, and to ensure a safe care environment that was free of potential hazards including ligatures.

The hospital initiated corrective action on 08/16/17 at 10:52 A.M. The state of IMMEDIATE JEOPARDY was removed on 08/16/17 at 4:00 PM. The hospital presented a plan and evidence that new policies were implemented; and emergency room staff were trained on pertinent subjects including: communication with Law Enforcement, the Suicide Risk Assessment Tool, and procedure for 1:1 Observation prior to working again in the emergency room . Staff training was validated on 08/17/17 at 8 A.M. through observation and staff interviews.

Condition-level deficiencies remained uncorrected at the time of the survey investigation exit conference on 08/17/17 at 9:30 AM. (Cross Reference Complaint Investigation report at Tags C 271, C 272, C 274 and C 298.) Due to the scope and severity of these deficiencies, the Condition of Participation at 42 CFR 485.635 Provision of Services was NOT MET.
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, review of hospital policies, record review, and interviews, the hospital failed to provide and implement current and updated policies and procedures to direct staff how to assess and care for suicidal patients for 1 of 11 patient records reviewed (Patient #1); and failed to ensure that patients were triaged within 15 minutes of arrival as directed by policy for 3 of 11 patients reviewed (Patient #'s 4, 8, and 9).

Findings included:

ITEM #1 Failure to provide policies and procedures to direct staff

1. Review of applicable hospital policies in place at the time of this occurrence (05/16/17) showed: "Mental Health Protocols" dated as last revised 04/2015 (28 months earlier) which required sharp containers or chords to be removed from treatment rooms used for suicidal patients; and "Triage in the Emergency Department" dated as last revised 03/2015 (29 months earlier). There were no other applicable policies in place at the time of this occurrence, or at the time of this investigation.

Patient #1 was brought to the emergency room on [DATE] at 1:56 P.M. by the local Deputy Sheriff. Patient #1 was intoxicated, had been found lying in the road, and told the Deputy he was trying to kill himself. Per review of the Deputy's report dated 05/16/17, and interview on 08/14/17, the Deputy noted that staff recognized Patient #1 from past visits. The Deputy reported that he gave report to the emergency room staff including the admitting clerk and one other. [Note: review of the video tape showed staff members were the Admitting Clerk, Staff F, and a Nursing Assistant, Staff E.] He stated report was given per usual Deputy protocol for any time an Officer brought an individual to the emergency room for treatment. He had spoken with Patient #1's family located in Republic who were coming to get him that same day. Review of Patient #1's medical record showed he was brought in by police with, "...suicidal ideations and a plan."

Interview with Staff E, the nursing assistant on 08/16/17 revealed family had called with information about the patient, but Staff E claimed HIPAA (health privacy law) would not allow her to take information, and did not pass the opportunity to gather additional information to the Charge RN. Per family interview on 08/11/17 and 08/14/17, the family had valuable information about the patient's history and high level of risk to carry out his plan. Staff failed to gather the information, and there was no procedure in place directing them to pass the information source to the Charge RN for inclusion in the patient assessment.

Documentation showed a family member called at 6:18 PM (18 minutes after the last documented observation) when staff took the phone to the patient's treatment room and found him, "... hanging by the neck from the door knob. Called a Code immediately." The Code was unsuccessful and the patient died .

There was no policy formulated, nor evaluation or review of staff failure to gather pertinent information regarding the suicidal patient's history from outside sources (the Deputy and family). Review of the video tape at the time the Deputy brought the patient in showed 4 minutes of interaction with staff. Review of phone logs showed 5 phone calls to the emergency room from Patient #1's family: 2 at 2:36 PM and 3 phone calls at 3:56 PM. There was no evidence that staff gathered information from the Deputy or the family regarding pertinent needs affecting the assessment and care needs to reduce the risk of suicide for Patient #1.

There was no policy or procedure or staff training to ensure that pertinent patient information was passed on to the Charge RN. Staff interviews on 08/15-16/17 revealed that the information was not shared with nursing staff to consider in assessment and care planning needs for this patient.

ITEM #2 Failure to Implement an emergency room Standard of Care policies and procedures to prepare Treatment Rooms that promoted a safe environment for Suicidal Patients

Review of Patient #1's record dated 05/16/17 showed the patient was placed in Treatment Room #8. Staff interview during a tour of the ER on 8/15/17 at 2:30 P.M. with staff who were present during the care of Patient #1 revealed that the room was not prepared for a suicidal patient other than removing the computer from the bedside. The patient was allowed to stay in his own clothes, which included a belt. Suction tubing remained in the room. Both the belt and tubing were potential ligatures and posed a danger to the safety of Patient #1.

Following this occurrence, 2 pertinent and applicable policies in the care of Suicidal patients were formulated: "Removal of Personal Belongings for Patients that Exhibit Behaviors of Self Harm," and "Care of Patients at Risk of Suicide." The procedures remained in Draft form at the time of this investigation (3 months after the patient death).

ITEM #3 Failure to Train Staff in emergency room Standard of Care Related to Patient Rights and Health Privacy Law

Staff interviews conducted on 08/16/17 revealed a lack of staff training related to patient rights. One staff member refused to take pertinent information regarding Patient #1's recent history and care needs from family and get the information to the Charge RN due to a misunderstanding of HIPAA (health care privacy act).

For example, interview with Staff E, the nursing assistant on 08/16/17 revealed family had called with information about the patient, but Staff E claimed HIPAA (health privacy law) would not allow her to take information, and did not pass the opportunity to gather additional information to the Charge RN. Per family interview on 08/11/17 and 08/14/17, the family had valuable information about the patient's history and high level of risk to carry out his plan. Staff failed to gather the information, and there was no procedure in place directing them to pass the information source to the Charge RN for inclusion in the patient assessment.

Another staff member stated there was confusion over what staff could legally remove from a patient including clothing and other belongings, even a belt that could be used by a patient for self harm.

There was no emergency room Standard of Care Policy and Procedure that directed staff to consistently prepare Treatment Rooms furnishings and supplies, including patient clothing and belongings to protect patients from self harm.

The hospital failed to provide care processes to standardize patient care for suicidal patients in the ER.

ITEM #4 Failure to ensure staff triaged patients within 15 minutes of arrival as per policy

Review of the hospital policy, "Triage in the Emergency Department" dated as last reviewed on 03/2015, showed that, "All persons presenting for emergency services will be triaged by an RN within 15 minutes of their arrival."

Review of Patient #4, a suicidal patient who came to the emergency room on [DATE] at 3:58 P.M., triage was not provided until 4:19 P.M., 21 minutes after arrival.

Similar findings were identified for 2 other patient records reviewed (Patient #8 and Patient #9).

The hospital failed to identify and correct delayed triage times for patients arriving in the emergency room .
VIOLATION: PATIENT CARE POLICIES Tag No: C0272
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies and procedures, the hospital failed to ensure that the policies were reviewed annually for 2 of 2 policies reviewed.

Failure to review policies and procedures annually risked patient health and safety.

Findings included:

1. Patient #1 was brought to the emergency room on [DATE] at 1:56 P.M. by the local Deputy Sheriff. Patient #1 was intoxicated, had been found lying in the road, and told the Deputy he was trying to kill himself. Per review of the Deputy's report dated 05/16/17, and interview on 08/14/17, the Deputy noted that staff recognized Patient #1 from past visits. The Deputy reported that he gave report to the emergency room staff but did not know their names or positions. [Note: review of the video tape showed staff members were the Admitting Clerk, Staff F, and a Nursing Assistant, Staff E.] He stated report was given per usual Deputy protocol for any time an Officer brought an individual to the emergency room for treatment. He had spoken with Patient #1's family located in Republic who were coming to get him that same day. Review of Patient #1's medical record showed he was brought in by police with, "...suicidal ideations and a plan."

Review of applicable hospital policies in place at the time of this occurrence (05/16/17) showed: "Mental Health Protocols" dated as last revised 04/2015 (28 months earlier) which required sharp containers or chords to be removed from treatment rooms used for suicidal patients; and "Triage in the Emergency Department" dated as last revised 03/2015 (29 months earlier).

Review of the emergency room log and administrative staff interview (Staff G) on 08/15/17 at 2 P.M. showed an average of 5-8 mental health/suicidal patients per month in the fall/winter/spring months and "more in the summer" in the emergency room . Interview with an emergency room RN (Staff E) on 08/16/17 at 9:30 A.M. revealed that "a ton" of mental health/suicidal/alcoholic patients come through the Mid Valley Hospital emergency room .

The hospital failed to identify a need for updated and current policies and procedures to address the needs of suicidal patients in the emergency room .
VIOLATION: NURSING SERVICES Tag No: C0294
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation and staff interview, the hospital failed to provide on-going nursing assessments and documentation of care for suicidal patients in the emergency room for 1 of 11 patient records reviewed (Patient #1).

Failure to provide appropriate care and train staff for suicidal patients risked patient health and safety.

Findings included:

ITEM #1 Failure to Provide Nursing Care to meet Patient Needs

1. Patient #1 was brought to the emergency room on [DATE] at 1:56 P.M. by the local Deputy Sheriff. Patient #1 was intoxicated, had been found lying in the road, and told the Deputy he was trying to kill himself. Per review of the Deputy's report dated 05/16/17, and interview on 08/14/17, the Deputy noted that staff recognized Patient #1 from past visits. The Deputy reported that he gave report to the emergency room staff but did not know their names or positions. [Note: review of the video tape showed staff members were the Admitting Clerk, Staff F, and a Nursing Assistant, Staff E.] He stated report was given per usual Deputy protocol for any time an Officer brought an individual to the emergency room for treatment. He had spoken with Patient #1's family located in Republic who were coming to get him that same day. Review of Patient #1's medical record showed he was brought in by police with, "...suicidal ideations and a plan."

2. Interview with 2 RNs on 08/15/17 at 4 PM (Staff A and Staff B) and 2 RNs (Staff C and Staff D) and a Nursing Assistant Certified (Staff E) on 08/15/17 at 8 AM who worked in the emergency room that day (05/16/17) revealed that Patient #1 was placed in Treatment Room #8. The patient remained in his clothing which included a "small black belt" which he was allowed to keep. The computer was removed from the room, but all other equipment, including suction tubing (which can be used as a ligature), remained in the room. No other modifications were made. The patient's own belt was the ligature he used to commit suicide in Treatment Room #8.

ITEM #2 Failure to Train Staff to Reduce Risk of Recurrence of Patient Suicide in the emergency room

1. Staff interviews on 08/15-16/17 revealed that no staff training had occurred and no new procedures had been provided to direct staff how to reduce the risk of recurrence. The hospital did not provide updated or revised direction regarding assessment and on-going reassessments of suicidal patients. There was no change in policy related to how often staff were required to document observations of the suicidal patient. There was no direction how and when to modify the treatment room environment to ensure that objects that could be used to harm self or others were removed.

Staff failed to meet the care and safety needs of Patient #1.
VIOLATION: NURSING SERVICES - CARE PLANS Tag No: C0298
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, the hospital failed to ensure that nursing staff formulated a care plan for every patient based on individualized assessment of the patient's care needs for 1 of 11 suicidal emergency room patient records reviewed (Patient #1).

Failure to plan care based on a current and on-going patient assessment risked patient health and safety.

Findings included:

Patient #1 was brought to the emergency room on [DATE] at 1:56 P.M. by the local Deputy Sheriff. Patient #1 was intoxicated, had been found lying in the road, and told the Deputy he was trying to kill himself. Per review of the Deputy's report dated 05/16/17, and interview on 08/14/17, the Deputy noted that staff recognized Patient #1 from past visits. The Deputy reported that he gave report to the emergency room staff but did not know their names or positions. [Note: review of the video tape showed staff members were the Admitting Clerk, Staff F, and a Nursing Assistant, Staff E.] He stated report was given per usual Deputy protocol for any time an Officer brought an individual to the emergency room for treatment. He had spoken with Patient #1's family located in Republic who were coming to get him that same day. Review of Patient #1's medical record showed he was brought in by police with, "...suicidal ideations and a plan."

Record review for Patient #1 showed documentation of staff observations. There was no documentation of on-going assessment of the patient's activities or mental condition from 3:03 PM to 5:15 PM when staff provided a dinner tray and the patient had no complaints (2 hours and 12 minutes). The next check was noted at 6 PM when staff provided warm blankets and the patient "was still eating" (45 minutes). Documentation showed a family member called at 6:18 PM (18 minutes after the last documented observation) when staff took the phone to the patient's treatment room and found him, "... hanging by the neck from the door knob. Called a Code immediately." The Code was unsuccessful and the patient died .

There was no evidence that staff gathered information about the patient from the Deputy Sheriff who brought the patient in for care, or the family who tried to contact the patient and share information with staff (cross reference C 294). There was no evidence that staff reviewed 3 closed records of Patient #1's earlier visits within the last 6 months to the emergency room (11/26/16--Suicidal with a Plan; 12/12/16--Intoxicated and fell ; and 12/7/16--Intoxicated and need for Medical Clearance), or utilized earlier data to formulate appropriate interventions to provide a safe environment.

The hospital failed to ensure that staff assessed and documented available information, on-going observations and care planning to meet patient care needs.
VIOLATION: PERIODIC EVALUATION & QA REVIEW Tag No: C0330
Based on review of hospital records and staff interview, the hospital failed to implement an effective Quality Assurance Program to review and update policies and procedures at least annually (C 334); failed to take corrective actions as identified by outside peer review (C 341); and failed to take corrective actions identified by internal review (C 342).

Due to the scope and severity of these deficiencies, the Condition of Participation at 42 CFR 485.641 Quality Assurance Review was NOT MET.
VIOLATION: PERIODIC EVALUATION OF POLICIES Tag No: C0334
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies and procedures, the hospital failed to ensure that health care policies were reviewed annually for 2 of 2 policies reviewed, failed to ensure that the policies were adequate to meet patient needs; and failed to direct staff how to assess and care for suicidal patients for 11 of 11 patient records reviewed.

Failure to review policies and procedures annually to evaluate adequacy and effectiveness for a high risk population of suicidal patients in the emergency room risked patient health and safety.

Findings included:

Patient #1 was brought to the emergency room on [DATE] at 1:56 P.M. by the local Deputy Sheriff. Patient #1 was intoxicated, had been found lying in the road, and told the Deputy he was trying to kill himself. Per review of the Deputy's report dated 05/16/17, and interview on 08/14/17, the Deputy noted that staff recognized Patient #1 from past visits. The Deputy reported that he gave report to the emergency room staff but did not know their names or positions. [Note: review of the video tape showed staff members were the Admitting Clerk, Staff F, and a Nursing Assistant, Staff E.] He stated report was given per usual Deputy protocol for any time an Officer brought an individual to the emergency room for treatment. He had spoken with Patient #1's family located in Republic who were coming to get him that same day. Review of Patient #1's medical record showed he was brought in by police with, "...suicidal ideations and a plan."

ITEM #1 Failed to review policies annually

Review of applicable hospital policies in place at the time of this occurrence (05/16/17) showed: "Mental Health Protocols" dated as last revised 04/2015 (28 months earlier) which required sharp containers or chords to be removed from treatment rooms used for suicidal patients; and "Triage in the Emergency Department" dated as last revised 03/2015 (29 months earlier).

There were no other applicable policies in place at the time of this occurrence, or at the time of this investigation.

ITEM #2 Failed to revise policies and procedures

Interview with Staff E, the nursing assistant on 08/16/17 revealed family had called with information about the patient, but Staff E claimed HIPAA (health privacy law) would not allow her to take information, and did not pass the opportunity to gather additional information to the Charge RN. Per family interview on 08/11/17 and 08/14/17, the family had valuable information about the patient's history and high level of risk to carry out his plan. Staff failed to gather the information, and there was no procedure in place directing them to pass the information source to the Charge RN for inclusion in the patient assessment.

There was no policy formulated, evaluation or review of staff failure to gather pertinent information regarding the suicidal patient's history from outside sources (the Deputy and family).

ITEM #3 Failed to implement new procedures and train staff in a timely manner

Following this occurrence, 2 pertinent and applicable policies in the care of Suicidal patients had been formulated: "Removal of Personal Belongings for Patients that Exhibit Behaviors of Self Harm," and "Care of Patients at Risk of Suicide." The procedures remained in Draft form at the time of this investigation (3 months after the patient death).

The hospital failed to identify a need for updated and current policies and procedures and train staff to address the needs of suicidal patients in the emergency room .
VIOLATION: QA - PERFORMANCE IMPROVEMENT Tag No: C0341
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the hospital failed to ensure that findings and recommendations issued by an outside peer review process were reviewed and implemented in a timely manner as a result of a patient's suicide in the emergency room on [DATE].

Failure to review and implement appropriate actions recommended through an outside peer review process provided as a result of the suicide of Patient #1 on 05/16/17 risked patient health and safety for suicidal patients who sought and received care in the emergency room .

Findings included:

Patient #1 was brought to the emergency room on [DATE] at 1:56 P.M. by the local Deputy Sheriff. Patient #1 was intoxicated, had been found lying in the road, and told the Deputy he was trying to kill himself. Per review of the Deputy's report dated 05/16/17, and interview on 08/14/17, the Deputy noted that staff recognized Patient #1 from past visits. The Deputy reported that he gave report to the emergency room staff but did not know their names or positions. [Note: review of the video tape showed staff members were the Admitting Clerk, Staff F, and a Nursing Assistant, Staff E.] He stated report was given per usual Deputy protocol for any time an Officer brought an individual to the emergency room for treatment. He had spoken with Patient #1's family located in Republic who were coming to get him that same day. Review of Patient #1's medical record showed he was brought in by police with, "...suicidal ideations and a plan."

The case was reviewed by the outside Rural Health Network within 10 days of the incident. The findings were noted to have been shared with a member of the hospital administration. There was no evidence that findings and recommendations had been shared with the entire Quality Assurance staff, or that recommended actions had been incorporated into the hospital's action plan.

Recommended actions by the outside peer review were not shared with the Quality Assurance Committee, and were not implemented in a timely manner to prevent on-going risk for suicidal patients or provide staff with directives and tools to deliver appropriate care and services.
VIOLATION: QA - PERFORMANCE IMPROVEMENT Tag No: C0342
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the hospital failed to ensure that a comprehensive, accurate analysis was conducted and timely, effective action plans formulated as a result of a patient's suicide in the emergency room on [DATE] were implemented.

Failure to gather and document comprehensive and accurate data, failure to conduct an accurate and thorough analysis of all factors that contributed to this occurrence involving Patient #1, and failure to implement approved action plans in a timely manner risked health and safety for suicidal patients who sought and received care in the emergency room .

Findings included:

Patient #1 was brought to the emergency room on [DATE] at 1:56 P.M. by the local Deputy Sheriff. Patient #1 was intoxicated, had been found lying in the road, and told the Deputy he was trying to kill himself. Per review of the Deputy's report dated 05/16/17, and interview on 08/14/17, the Deputy noted that staff recognized Patient #1 from past visits. The Deputy reported that he gave report to the emergency room staff but did not know their names or positions. [Note: review of the video tape showed staff members were the Admitting Clerk, Staff F, and a Nursing Assistant, Staff E.] He stated report was given per usual Deputy protocol for any time an Officer brought an individual to the emergency room for treatment. He had spoken with Patient #1's family located in Republic who were coming to get him that same day. Review of Patient #1's medical record showed he was brought in by police with, "...suicidal ideations and a plan."

The case was reviewed internally by the hospital and the outside Rural Health Network. Actions included to develop and implement 2 new care policies by 07/31/17. Neither had been approved or implemented at the time of this investigation on 08/15/17. Other additional actions including a Nursing Suicide Risk Assessment Tool and a mandatory Suicide Prevention Class were planned for implementation in 6-9 months from the date of Patient #1's suicide.

Planned actions were not implemented in a timely manner to prevent on-going risk for suicidal patients or provide staff with directives and tools to deliver appropriate care and services.