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.

Based on medical record review, document review and interview, it was determined that the Emergency Department (ED) failed to follow the facility's policy to: (a) provide a Suicide Risk Assessment to a patient seeking emergency psychiatric service, and (b) provide a safe discharge from the ED. This was found in one (1) of 10 medical records reviewed (Patient # 1).

This deficiency may have placed patients at risk for potential harm.


See Tag A1104.
Based on medical record review, document review and staff interview, it was determined that the Emergency Department failed to adhere to the facility's policy to provide: (a) a Suicide Risk Assessment for a patient presenting with suicidal ideation, and (b) provide discharge services to meet the safety needs of the patient.
This was found in one (1) of 10 medical records reviewed (Patient # 1).

Findings include:

Review of the medical record for Patient #1, found that on 3/18/16 at 2111 (9:21 PM), the patient presented to the emergency department's Comprehensive Psychiatric Emergency Program ( CPEP) unit by EMS ambulance, with the chief complaint of "suicidal. " The Pre-Hospital Care Report (PCR) was noted by EMS staff, that the patient was found crying on the curb stating that she wants to die and that she wants help. She also reported that she has been non-compliant with her psychoactive medications and seizure medications (Tegretol and Neurontin) for 6 days. There was also an admission of doing "crack - cocaine and smoking "MJ" today.

After an initial triage at 2111 (9:21 PM), the patient was found suicidal and assigned the ESI (Emergency Severity Index) #3 (Urgent - treatment and reassessment should occur within 2 hours). The patient and EMS personnel were directed to CPEP (Comprehensive Psychiatric Emergency Program) at 2142 (9:42 PM).

The CPEP nursing documentation in the medical record indicated that for approximately two (2) hours of the time spent in CPEP, the patient was noted as "patient sleeping in geri chair in hall " .
The medical assessment by the Psychiatric Resident on 3/19/16 at 0022 (12:22 AM) noted the patient's chief complaint was "I want to kill myself." She reported that she was having "suicidal thoughts " . The patient reported a history of bipolar disorder, seizures, and asthma. She admitted to using crack-cocaine prior to admission. A brief review of systems (ROS) was noted in the record by the Resident as being positive for suicidal ideation. The resident also noted that the patient would be held and re-evaluated.
At 3/19/16 0049 (12:49 AM), the attending physician noted that he reviewed and signed off on the Resident's note. There is no other entry by the attending physician until the "chart note " on 3/19/16 at 0326 (12:36 AM) that "Patient with crack-cocaine dependence, demanding in CPEP to be admitted as she does not have a place to live. Patient became belligerent, demanding to leave, reported very vague ideas to hurt herself that are conditional to be admitted to the hospital - patient is malingering."
The attending physician discharged the patient at approximately 3:30 AM on 3/19/16 without any documented focused assessment of the patient's risk of suicide that triggered the patient's visit to the CPEP.

There is no documented evidence that the patient received a Suicide Risk Assessment as required by the facility's policy. Review of the Policy and Procedure titled "Suicide Risk Assessment " , dated 6/2/14, states that the Suicide Risk Assessment must be completed by a physician, must describe specific levels of risk, including current symptoms and lack of supports. There was no documented evidence that such a risk assessment was completed by any of the physicians involved in the care of this patient.

There was no assessment of the risks of the patient's stated non-compliance with her medications for 6 days.

There was no order for a toxicology screen or EKG related to the patient ' s presentation to the ED with a reported history of recent substance abuse of undetermined quantity or frequency, and no assessment of drug amounts that she recently reported as having ingested to rule out potential for overdose. The patient ' s primary diagnosis, however, was noted as "Cocaine Abuse- Non complicated."

The discharge instructions, which was noted, "patient refused to sign " , focused on the need for drug rehabilitation and had no reference to suicidality that triggered the patient's visit to the ED.
There was no discharge plan to address the immediate issue of homelessness or noncompliance with psychoactive medications for six (6) days.

The facility's Comprehensive Psychiatric Emergency Program (CPEP) procedure titled "Discharge Services," revised 11/2014, states "Discharge planning services will be provided to all patients and their families/significant others who are receiving CPEP services. The patient's current situation and aftercare needs will be assessed to include referrals to appropriate aftercare programs and ass concrete services." This procedure was not followed with the patient.

The psychiatric assessment process and treatment plan did not record the specific reasons why the patient was not a candidate for inpatient psychiatric admission and did not fully document the details of the suicidal "ideas " .

During interview with the attending psychiatrist on 4/25/16 at 1:00 PM, he stated the following: he had no intention to admit the patient to an inpatient unit from the time the patient arrived in the CPEP. The patient came in posturing with a "crack dance" and was malingering, using suicidal ideation to be admitted to an inpatient psychiatric unit because she was homeless. He offered the patient to stay in the CPEP until 7:00 AM when the patient could be assessed for possible admission to the hospital detox unit. There is no documented record of this treatment plan.

The medical record noted that the patient became belligerent prior to leaving the CPEP at approximately 0336 (3:36 AM). Review of hospital Quality Assurance Report on 4/25/16 indicated that the patient was struck and killed by an automobile, in front on the Hospital's main entrance, minutes after leaving the CPEP on 3/19/16 at approximately 3:40 AM.