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ASCENSION ST FRANCIS HOSPITAL 3237 S 16TH ST MILWAUKEE, WI 53215 July 14, 2020
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review and interview the facility failed to ensure that suicidal patients had a medical screening exam per facility policy for one patient (Patient #9) and failed to ensure suicidal patients had a reassessment of suicide risk prior to discharge per facility policy in 2 of 24 medical records reviewed (Patient #'s 9 & 13)) in a total of 24 medical records reviewed.

Findings include:

The facility staff failed to ensure that patients who entered the Emergency Department for suicidal ideations received an reassessment of suicidality or a medical screening prior to being discharged from Emergency Department. See tag #'s A2406 & A2407.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on record review the facility failed to ensure that a medical screening exam was completed as per facility policy prior to discharge in 1 of 24 medical records reviewed (Patient # 9) in a total of 24 medical records reviewed.

Findings include:

The facility policy titled "Emergency Medical and Treatment (EMTALA)" # 30 last revised on 2/2020 was reviewed on 7/7/2020. This document revealed "PROCEDURE: Medical Screening and Stabilizing Treatment 2. c. When an individual presents with psychiatric symptoms, the Medical Screening Exam should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the Hospital determines that an individual poses a danger to self or others, this is considered an Emergency Medical Condition."

Patient #9 was seen in the ED on 3/29/2020 for suicidal ideations. Patient was brought in by fire departmentat 3:03 AM "Patient called crisis line stating he wants to hurt himself by taking all his medication." At 3:10 AM "First Provider Evaluation of Patient" was documented as complete by Physician's Assistant. Admission CSSR was documented as completed at 3:25 AM and documented Patient #9 as "3-High Risk". At 3:26 AM orders placed "High Risk Suicide Precaution; 1:1 Supervision: No-Contact Physician" by Physician's Assistant. At 3:30 AM Patient #9 was started on 15 minute "Suicide/Safety Checks".

At 3:35 AM "ED Notes" completed by Registered Nurse documented "Patient now states he is not suicidal and is just drunk and wants to go home and sleep." At 3:55 AM patient was documented as discharged from ED. There was no documented medical screening exam completed by provider and no history and physical completed prior to Patient #9 being discharged from the ED.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on record review and interview the facility failed to ensure that suicidal patients had an re-evaluation of suicide risk prior to discharge to ensure safety per facility policy in 2 of 24 medical records reviewed (Patient #'s 9 & 13) in a total of 24 medical records reviewed.

Findings include:

The facility policy titled "Emergency Medical and Treatment (EMTALA)" # 30 last revised on 2/2020 was reviewed on 7/7/2020. This document revealed "PROCEDURE: Medical Screening and Stabilizing Treatment 2. c. When an individual presents with psychiatric symptoms, the Medical Screening Exam should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the Hospital determines that an individual poses a danger to self or others, this is considered an Emergency Medical Condition."

The facility policy titled "Care of the Patient with Suicidal Ideation Policy" # 99 last revised 6/23/2020 was reviewed on 7/7/2020. This document revealed "III. Discontinuation of Suicide Precautions: 1. ED, Inpatient and Behavioral Health i. All suicide precautions must be discontinued by a physician order. ii. When the suicide precautions are discontinued, the RN will continue to complete a suicide screening daily until discharge. IV. Discharge. 1. ED, Inpatient and Behavioral Health. i. Patients that screen as low, moderate or high risk for suicide at any time during their hospitalization will be reassessed on the day of discharge. A. If the patient screens positive for any risk level place the patient in the appropriate precautions and notify the provider. The provider will evaluate the patient and determine when the patient is safe for discharge."

Patient #9 was seen in the ED on 3/29/2020 for suicidal ideations. Patient was brought in by fire departmentat 3:03 AM "Patient called crisis line stating he wants to hurt himself by taking all his medication." At 3:10 AM "First Provider Evaluation of Patient" was documented as complete by Physician's Assistant. Admission CSSR was documented as completed at 3:25 AM and documented Patient #9 as "3-High Risk". At 3:26 AM orders placed "High Risk Suicide Precaution; 1:1 Supervision: No-Contact Physician" by Physician's Assistant. At 3:30 AM Patient #9 was started on 15 minute "Suicide/Safety Checks". At 3:35 AM "ED Notes" completed by Registered Nurse documented "Patient now states he is not suicidal and is just drunk and wants to go home and sleep." At 3:55 AM patient was documented as discharged from ED. There was no documented reassessment to evaluate suicidality and no history and physical completed prior to Patient #9 being discharged from the ED.

Patient #13 was seen in the ED on 5/27/2020 for suicidal ideations. "Patient presents with a 2 day history of suicidal thoughts. States he plans on overdosing on his medications, but denies any suicidal attempts." At 5:00 PM Patient #13 was started on 15 minute "Suicide/Safety Checks". Admission CSSR was documented as completed at 11:50 PM and documented Patient #13 as "2-Moderate Risk". At 12:08 AM was given oral doses of Remeron (antidepressant) and Risperdal (antipsychotic) and remained on every 15 minute checks until COVID-19 test resulted as negative at 8:58 AM on 5/28/2020. At 12:23 PM patient was discharged and taken to an admitting facility via public transportation. There was no documented CSSR reassessment completed to evaluate suicidality prior to discharge from the ED and no safety assessment related to Patient #13's discharge to an admitting facility via public transportation.

An interview was conducted on 7/8/2020 in regards to evaluation of suicide risk on discharge using the Columbia Suicide Severity Rating Scale (C-SSRS) for Patients #9 and #13. Manager of Quality and Patient Safety A stated "There were no C-SSRS completed at discharge for any of the patients."

Review of the patient records does not find re-evaluation of patient suicide or safety risk prior to discharge per facility policy.