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 document review and interview, in one (1) of 31 medical records reviewed, the facility failed to conduct a comprehensive behavioral health screening, as per policy, to determine the appropriate care and treatment for a patient. (Patient # 1).


Review of the medical record for patient # 1 identified: On 07/19/19, at 5:14 pm, this patient was brought to the facility's Emergency Department by EMS for an evaluation due to auditory delusions and non-compliance with his medication regimen. At 5:15 pm, the patient was triaged. At 5:25 pm, the patient was evaluated by Staff I, Physician Assistant, who documented that the patient "presents to the ED for psychiatric evaluation for hearing voices and states that he wants to be free from his body and his soul ...." The Physician Assistant assessment documented that patient had no suicidal ideation and no homicidal ideation.

On 07/19/2019, at 7:09 pm, Staff F, Psychiatric Crisis Assessment & Referral Specialist, documented, the "Patient arrived to the ED calm and cooperative. He was polite and engaging during assessment. He said he is frustrated with his mother because she is very controlling, and he wants to be more independent since he is an adult. He said that he tried to leave the house today because he wants to go to New York City to catch a flight. He said that his plan is to move out of the country so that he can live an independent lifestyle away from his mother. He does not view it as being impulsive because it is something that he wanted to do for a long time, and he has the money to pay for the flight. Patient is not endorsing any dangerous ideation. He denied SI/HI/AVH and contracted for safety. He requested to be discharged ."
Staff F reviewed this information with Staff E, on-call Psychiatrist and documented the "Patient is not displaying any acute psychiatric symptoms at this time that would require an inpatient admission."

On 07/19/2019, at 8:47 pm, Staff I, Physician Assistant, discharged the patient from the Emergency Department.

On 09/20/2019, during the tour of the Emergency Department, when asked of any unusual occurrence, Staff A, OD, ED Director, informed the surveyor that within days after the discharge from the Emergency Department, one of the patients (patient #1) committed suicide by jumping off a Bridge.

Review of policy titled, "Emergency Department - Psychiatric Assessment and Referral", Reviewed 01/19, revealed:
The behavioral health screening shall include:

- Evaluation of the presenting problem including description of major symptoms, problematic behaviors, including onset, duration , and severity of the current behavioral health symptoms;
- Precipitating crisis describing the events which led the client to seek treatment at this time;
- Immediate risk factors including danger to self, danger to others, grave disability or serious medical conditions;
- Review of past psychiatric and addictive disease treatment;
- Screening of current symptoms or complaints which are primarily psychiatric in nature including changes in sleep, changes in appetite, weight loss or gain, disturbance in mood, thought disturbance, psychotic symptoms, current stressors or recent losses, or behavioral changes;
- Review of current psychotropic medications;
- Screening of alcohol and drug use;
- Suicide screening;
- Screening for aggression or violence;
- Review of current legal issues;
- Recommendations for level of care placement, or referral;
- Descriptive rationale for level of care recommendations.

The documented behavioral health screening for the patient did not include these elements.

On 09/20/2019, at 2:15 pm, during an interview with Staff F, Psychiatric Assessment Specialist, she stated that someone told her that if a patient returns within a short period of time after discharge, then a Behavioral Health Initial Screening and Assessment does not have to be performed. Staff F defined the short period time frame as "within a week."

On 09/20/2019, at 10:08 am, during an interview with Staff G, Interim Director of Behavioral Health, he stated that it is a surprise for him that a comprehensive behavioral health initial screening and assessment was not performed on the patient. He confirmed that it should have been done; and, this is the expectation.