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.

SOUTH SHORE HOSPITAL 55 FOGG ROAD SOUTH WEYMOUTH, MA 02190 Aug. 30, 2017
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on observations, records reviewed and interviews the Hospital failed for one (Patient #1) of ten records reviewed to implement immediate corrective action(s) after discovering an Emergency Department (ED) Registered Nurse (RN) permitted Patient #1 to leave the ED instead of having Patient #1's evaluation of suicidal thoughts expedited, in breach of ED standard of care and practice.

Findings included:

Patient #1's ED Medical Record, dated 8/23/17 at 9:04 P.M. and documented by RN #1, indicated Patient #1 presented to the ED, stated he/she had suicidal thoughts, did not have a suicide plan, needed an evaluation and requested to go out for a cigarette prior to starting an evaluation. The ED Medical Record indicated approximately 5 minutes later a visitor said someone was trying to hang himself/herself in the parking lot.

The Surveyor observed the ED registration to evaluation process, at 11:30 A.M. on 8/25/17, noting that an ED Staff member registered a patient and the patient preceded to the Clinical Initiation Area (CIA) for an evaluation by a provider (doctor or physician assistant).

The Surveyor interviewed the ED Nurse Manager at 1:45 P.M. on 8/25/17. The ED Nurse Manager said RN #1 did not follow ED process for behavioral health patients who presented to the ED. The ED Nurse Manager said she sent an electronic mail (e-mail) to Hospital Administrators about the event and did not receive guidance for additional corrective actions.

The Surveyor interviewed RN #1 at 8:00 A.M. on 8/30/17. RN #1 said she did not follow ED process for behavioral health patients who presented to the ED.

The document titled, ED CIA Workflow, undated, indicated when a patient presented to the ED for care, hospital staff registered the patient and then a hospital staff member escorted the patient to the CIA for provider evaluation.

The protocol titled, Behavioral Health ED RN Protocol, dated 4/19/16, indicated an expedited evaluation process for behavioral health patients that presented with a request for mental health services.

The E-mail, dated 8/24/17 at 6:50 A.M., indicated the ED Nurse Manager notified Hospital Administrators that RN #1 did not follow the ED process for behavioral health patients who presented to the ED.

The hospital policy titled, Sentinel Event Alert Response, dated 7/15/16, indicated areas of identified risk were addressed with action plans to resolve the risk.

The E-mail titled, News of the Week, dated 8/25/17, and the Attendance Sheet, dated 8/30/17, indicated staff education of the Hospital's Risk Acuity Tool for behavioral health patients in the Emergency Department. The E-mail and Attendance Sheet indicated implementation of corrective actions occurred during the Survey more than 24 hours after the ED Nurse Manager notified Hospital Administrators that RN #1 did not follow the ED process for behavioral health patients who presented to the ED. The E-mail and Attendance Sheet did not indicate the Hospital implemented immediate corrective actions after the ED Nurse Manager notified Hospital Administrators.