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 findings from document review, medical record (MR) review and interview, the hospital did not ensure emergency services were performed in a safe and consistent manner. Specifically, 1) in 1 of 3 MRs (Patient #2), staff did not complete a suicide risk screening assessment or re-evaluate a patient as required by the facility's policy and procedure (P&P), and 2) the facility lacked a P&P describing the process for referrals to social services during non business hours (off hours).

Findings related to 1) above:

-- Per review of the facility's P&P titled, "Care of the Suicidal Patient: Suicide Risk Screening, Assessment and Precautions," dated 5/8/15, it indicated a Registered Nurse (RN) or Licensed Social Worker (LSW) will complete a Columbia - Suicide Severity Rating Scale (C-SSRS) upon entry to care/triage ... If unable to complete upon admission, the RN or LSW must re-evaluate the patient every 8 hours until able to complete the C-SSRS.

-- Per review of Patient #2's MR, she (MDS) dated [DATE] at 10:46 pm with suicidal ideation. From 7/12/16 at 10:46 pm until 7/13/16 at 10:50 am, there was no documentation that a C-SSRS was completed or the patient's psychological/psychiatric status was re-evaluated.

-- During interview of Staff D on 7/13/16 at 10:50 am, he/she acknowledged the above finding.

Findings related to 2) above:

-- Interview of staff/providers revealed the facility did not have a process to order social service consults for discharge planning needs during off hours. Additionally, providers were unaware that a mental health evaluation specifically for discharge planning needs, should be ordered in the electronic social service section of the MR and not as a mental health evaluation.

For example, Patient #1, (MDS) dated [DATE] at 12:08 am for a medication refill for antidepressants. On 4/23/16 at 12:56 am, Staff A ordered a stat Consult LMSW (Licensed Master Social Worker)/LCSW (Licensed Clinical Social Worker) Mental Health Evaluation. Referral instructions included: Bipolar disorder, came for med refill, needs psych appointment in one week.

-- During interview of Staff A on 7/13/16 at 10:25 am, he/she revealed all provider orders in the ED are ordered stat. Staff A was not aware he/she could select a different priority level (e.g., routine). In this case the stat mental health evaluation was for outpatient discharge planning needs and did not need to be done "stat." Staff A indicated nursing staff fill out a "Blue sheet" for social services to followup on outpatient appointments and medications. The "Blue sheet" is left in social services mailbox for them to follow up on.

-- During interview of Staff B on 7/12/16 at 3:10 pm and 7/14/16 at 11:30 am, he/she revealed an electronic provider order for a mental health evaluation requested on the off hours, for discharge planning needs, is made to the social services department's on a "Blue sheet" via the department's mailbox. The "Blue sheet" is a written referral completed by the provider, indicating the reason for referral. If a provider only wants discharge planning for a patient, an order can be entered electronically in the social services section instead of ordering a mental health evaluation. Discharge needs/planning by social services should occur on the next business day.

-- Review of the hospital's P&Ps titled "Psychiatric Evaluation in the Emergency Department," dated 4/6/15 and Guidelines for Mental Health Evaluation by the LCSW/LMSW in the emergency room Department," dated 5/8/15, revealed they do not clearly define the process for staff to order mental health consult for discharge planning needs.
Based on findings from document review, medical record (MR) review and interview, in 1 of 2 MR's (Patient #3), lacked a written provider order for restraint application. Also, in 1 of 2 MR's (Patient #4), nursing staff did not document assessment of a patient in restraints per the facility's policy and procedure (P&P). This lack of documentation and assessment could lead to improper use of restraints.

Findings include:

-- Per review of the facility's P&P titled "Restraint Policy/Procedure," dated 4/25/16, it indicated restraints may be applied in a medical emergency with a provider order obtained within 1 hour of restraint initiation. Patient checks and Registered Nurse (RN) monitoring (physical and behavioral assessment) should be documented on the "Medical Management Restraint Observation Record" or on the electronic restraint flow sheet every two hours.

-- Per review of Patient #3's MR, she was intubated on 1/13/16 at 1:34 pm. Nursing documented on 1/13/16 at 3:41 pm "pt (patient) tried pulling the ET (endotracheal) tube out and soft restraints applied with Dr (physician) order." However, there was no written provider order for the restraints documented until 1/14/16 at 8:00 am (18.5 hours) after restraint application.

-- Per review of Patient #4's MR, he was intubated on 7/12/16 at 2:40 am. Nursing documented on 7/12/16 at 2:30 am, order received for soft wrist restraints. A provider order for bilateral wrist restraints was written on 7/12/16 at 3:00 am. There was no nursing documentation of behavioral or physical assessment of the patient related to the restraint use until 7/12/16 at 8:16 am (5.5 hours later) after restraint application.

-- During interview of Staff E on 7/13/16 at 11:15 am, he/she acknowledged the above findings.