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WESTCHESTER MEDICAL CENTER 100 WOODS RD VALHALLA, NY 10595 May 24, 2019
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, in six (6) of seven (7) medical records reviewed, it was determined the facility failed to complete suicide screens before patients were transferred to a juvenile detention center. This was evident in medical records #s 1, 2, 3, 4, 5 and 6.

This failure may have placed patients at risk for harm.

Findings include:

The policy titled "Assessment For Suicide Risk In General Populations," last revised 11/2017 states: at triage "a risk assessment trigger question regarding patient status will be completed for each patient. The question will be marked 'yes' in the presence of any of the following; the patient is violent, agitated, suicidal, or a risk to him/herself and/or others, has been brought in by police, or a risk to him/herself and/or others, or is an elopement risk and the patient will be immediately brought into the emergency department. If the findings suggest that additional screenings is required, a suicide screen using a standardized risk tool such as the Columbia Suicide Severity Rating Scale
(C-SSRS) with ER triage points (six question form) will be performed."


Review of the Medical Record for Patient #1 identified the following: On 7/25/19 at 3:08 PM, this is a [AGE] year old female resident of a Juvenile Detention Center, was brought to the emergency department (ED) via Emergency Medical Support, accompanied with a staff member from the center and law enforcement, for a blunt head trauma injury and suicide ideation.

The emergency department (ED) physician noted at 3:12 PM, that the patient was brought for self- inflicting head banging against a wall. The ED nurse assigned the patient an Emergency Severity Index code 2 (1 being critical care and 2 being emergent). The nurse noted at 3:14 PM, "The patient appears in mild distress. The distress is related to mental status. Mood: The patient appears angry."

The physician assistant (PA) assessed the patient and the history and physical assessment completed at 3:19 PM, noted that the patient reported feeling depressed on most days and that she tried to kill herself a couple of times before, this year.

The physician requested a psychiatric consultation at 3:29 PM, and at 3:30 PM, ordered the patient to be maintained on close observations.

The psychiatrist conducted an evaluation at 5:56 PM and noted that the patient had a history of Unspecified Depressive Disorder, and a history of two (2) prior suicide attempts. The psychiatrist noted that the patient reports no auditory hallucination or visual hallucination, delusion and illusions. The psychiatrist noted the patient was cooperative and had fair insight and fair judgment. The psychiatric noted that the patient requires inpatient hospitalization for safety, stabilization and medication management. The psychiatrist also noted that the patient needed a Cat Scan of her head for medical clearance and that she was being evaluated for transfer to another acute care forensic unit.

The psychiatrist noted that "if there were no beds available the patient may return to the juvenile detention center for a close observation one to one for safety."

The ED physician noted at 5:27 PM that the patient's head scan was unremarkable, that it reveals no intracranial hemorrhage and that the patient is alert and oriented. He noted that "based on the patient reassessment and response to treatment, arrangements made for discharge back to the facility under 1:1 observation." The ED physician noted that the patient remained under the direct care of an emergency physician for a total observation time of three (3) hours.

The physician noted that "In my judgement, in view of the above findings, this child does not have a condition that requires further testing in the emergency department at this time." The physician noted on the discharge instructions, "Patient will be discharged back to the juvenile detention center under 1:1 observation, suicide ideation." The physician assistant (PA) noted that the patient left the ED at 6:57 PM.

The social worker (SW) noted on 7/26/18 at 9:47 AM ...." Last night the SW called another psychiatric hospital and the staff responsible for forensic admissions had left for the day. So, the patient was sent to the juvenile detention center.

There was no documented evidence of a suicide risk assessment at triage and that additional screenings using the Columbia Suicide Severity Rating Scale screen was conducted prior to the patient's transfer back to the center, under 1:1 observation for suicide ideation.


Review of the Medical Record for Patient #2 identified the following: This [AGE] year old patient (MDS) dated [DATE] at 11:45 PM for a mental health evaluation for banging her head against a wall and attempting to hang herself with sheets. The triage note indicated the patient complained of a change in her sleep pattern and that she had suicidal thoughts and ideations. The medical record revealed the frequency of suicide ideations were chronic at baseline, she had poor impulse control and she was exhibiting inappropriate behavior. The patient also had a flat affect, she was calm and her mood was inappropriate. The psychiatric emergency protocol was initiated. The ED physician ordered a 1:1 constant observation when the patient arrived in the ED.

A nurse documented at 12:02 AM on 5/10/18 that constant observation was present with the patient and the patient's condition was documented. There was no other documentation of nursing staff 1:1 constant observation.

A psychiatrist documented at 1:18 AM on 5/10/18 that court papers indicate the patient broke 15 windows at a residential facility and took the glass and threatened to harm others and herself. The patient endorsed a history of multiple suicide attempts and suicide ideation without a plan. The patient stated to the psychiatrist, "I hate life-I don't wanna live," and that she felt this way "for years" which did not change during a recent inpatient hospitalization where she was discharged on [DATE].

An ED physician signed her notes at 2:41 AM on 5/10/18, which indicated the patient's affect was constricted, her judgement was moderately impaired and her insight was limited. The notes also indicated the patient was re-evaluated multiple times during this visit and during the first reassessment the patient was calm and cooperative. The second reassessment, the patient was cleared for discharge.
The patient remained under the direct care of an emergency physician for a total observation time of four (4) hours. The clinical impression was acute adjustment disorder. The general suicide ideation instructions state "child should not be left alone." The patient was discharged to the juvenile detention center on 5/10/18 at 3:11 AM.

There was no documented evidence of a suicide risk assessment at triage and that the Columbia Suicide Severity Rating Scale screen was completed prior to the patient's transfer back to the center, at 6:57 PM that day.

The patient's vital signs were normal except for pulse of 104 at 11:56 PM and 106 (normal range is 60-100) at 1:46 AM and an EKG was ordered at 1:57 AM.
There was no documentation that the results of the EKG were reviewed or that the patient's pulse was normal before her discharge.

The psychiatrist also recommended a head imaging since the patient banged her head multiple times but there was no evidence that this was done.


Review of the Medical Record for Patient #3 identified the following: The ED doctor documented that this [AGE] year old patient came from a juvenile detention center on 10/23/18 for evaluation of a suicide attempt by hanging and suicidal ideations. The patient reported that when he was not allowed to speak to his mom at the detention center he decided to try to kill himself. The patient tried to hang himself with a bed sheet. Officers saw the patient and rescued him after which he was brought to the ED. The "patient now complains of mild neck pain and occipital headache." The patient stated his prior suicide attempt was to "get what he wants."
The resident documented that the patient had been sentenced to a juvenile detention center two (2) days ago and when he was not able to speak to his mother, he responded by threatening to kill himself. He was then put on observation status and staff was outside his room when he tried to take a pillow case and tried to choke himself with it. This attempt was interrupted by staff. He then tried to hang himself from the door using his shirt.

The resident discussed this case with an attending physician and the decision was made to return the patient to the detention center on continuous one to one observation and that he should see the staff child psychiatrist in the morning.
The patient was discharged to the detention center at 10:34 PM that night, with instructions for 1:1 observation and a psychiatric evaluation in the morning.

The Columbia-Suicide Severity Rating Scale form for this patient was incomplete; the section on "Suicidal and Self-Injurious Behavior" was incomplete, the sections on "Suicidal Ideation" and "Clinical Status (Recent)" were left blank.


Review of the Medical Record for Patient #4 revealed the following: This [AGE] year old patient (MDS) dated [DATE] at 7:13 PM, for a psychiatric evaluation prior to admission to a juvenile detention. The patient had a previous history of Depression for which she was taking four (4) prescribed medications and she had three (3) previous hospitalization s. The patient told the triage nurse she was raped and assaulted the previous night, but she did not provide details of the events.

The psychiatrist documented at 11:08 PM that the patient refused to answer most questions, that she had three (3) prior hospitalization s and that she had a history of suicide attempts, violence/assault and self-mutilation, for which she was getting outpatient treatment. She also had a history of cannabis, alcohol and Xanax use. The resident noted that the patient refused to answer questions about suicidal ideations/homicidal ideations, intent or plan. The patient endorsed poor sleep, poor appetite and a depressed mood. According to the family the patient was in rehab upstate but eloped and came back to the county. When she went to buy drugs, she was reportedly gang-raped by four (4) men. The patient's sister reported unspecified suicidal ideation.

A rape kit was done by the FACT nurse and a medical screening examination was completed.

The patient was discharged at approximately 1:00 AM on 7/19/18 to the juvenile detention center, on 1:1 observation, because she was at risk of self-injury.

The Columbia Suicide Severity Rating Scale screen was not completed. The facility's staff failed to explore the sister's report of the patient's history of suicidal ideation and attempts.


Review of the Medical Record for Patient #5 identified the following: On 7/28/18 at 8:25 PM, this [AGE] year old patient presented from a juvenile detention center to the ED for a psychiatric evaluation. A nurse documented at 8:35 PM, that the patient stated she wanted to get out of her cell, so she banged her head, and that she had pain to the back of her head but she did not let the nurse check it. At 9:47 PM, the patient was given medication for a pain score of 7/10 (reference range of 0 - no pain to 10 - worst pain). The patient had a previous history of psychiatric disorder, Attention Deficit Hyperactivity Disorder (ADHD) and Mood disorder.

The patient was discharged from the ED on 7/29/18 at 2:19 AM.

The additional Columbia Suicide Severity Rating Scale (C-SSRS) screen was not completed, even though the response to the question #1 on the form indicated the patient was a "danger to herself."


Review of the Medical Record for Patient #6 identified the following: This is a sixteen -year old resident at a juvenile detention center, who was brought to the ED on 8/22/18 at 2:43 PM, accompanied by the center's staff and the Westchester County Police. The emergency department (ED) nurse assessed the patient at 2:49 PM as an Emergency Severity Index Level 2 (Level 2 being emergent).

The ED physician noted at 2:49 PM, that the family court sent a form requesting an evaluation of the patient for being a danger to himself and a flight risk. The ED physician noted that "As per patient "I want to kill myself, I just don't want to live anymore especially after what happened in court today."

The ED physician noted at 2:43 PM that the "Patient states he currently wants to hurt himself and plans on using whatever he can get his hands on. He admits to scratching his left forearm with hopes that something would open, and he can dig in his arm." The nurse noted at 3:03 PM that the patient was in the psychiatric area and that the patient's mood was anxious.

The psychiatrist evaluated the patient at 3:40 PM and noted that the patient stated that he was depressed over his mother's death in June 2018, and that he was smoking marijuana since his mother died to help with the anxiety and mourning. The psychiatrist noted that the patient was seen by the chaplain at 2:30 PM, and the chaplain reported that the patient had no remorse over his antisocial behaviors and spoke about the "kid, that he knew and assaulted and the fact that he stole things from him and had a razor blade on him like it was nothing."

The psychiatrist noted at 4:06 PM that the patient may return to a secure detention with psychiatric follow up and grief counseling. The patient was discharged back to the juvenile detention with a discharge diagnosis of Suicidal Ideation.

The staff did complete the additional Columbia Suicide Severity Rating Scale screen, even though the response to question #1 on the form indicated the patient was a "danger to himself," and he had expressed suicidal ideation.

These findings were shared with Staff A, the Vice President of Quality and Safety, on 5/24/19 at approximately 3:00 PM.