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DIVINE SAVIOR HEALTHCARE 2817 NEW PINERY ROAD PORTAGE, WI 53901 April 13, 2021
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility nursing staff failed to ensure that patients at risk for intentional harm to themselves or others were protected in the Emergency Department prior to discharge or transfer in 8 of 16 (Patients #1, #5, #9, #11, #12, #13, #15, #21) patient medical records reviewed involving presentation to the Emergency Department with chief complaints of suicidal ideations in a total universe of 22 records.

Findings include:

A review of the facility's policy # 02 titled, "Suicide Prevention," last approved 10/2019, revealed, "POLICY: It is the policy ...for patients to receive care in a safe setting that minimizes self-harm and suicide. This will be achieved by maintaining a safe environment for patients who present with attempted suicide or verbalization of suicidal ideation. Providers will conduct universal suicide risk screenings on all patients ages 12 years and older seeking care ...Definitions: A. Levels of Observation: a. General - The minimally acceptable level of observation in which qualified staff know the patient's location at all times. b. Intermittent - Qualified staff engage with the patient at regular intervals. The frequency of these intervals is no less than every 15 minutes ...Staff will document patient's condition with each observation. c. Constant - Constant periods of one-on-one observation of the patient by qualified staff within arms-length at all times. Staff will document patient's condition every 15 minutes ....E. PSS-3 Screening tool ...Patient Safety Screener used in the hospital and outpatient clinic setting to primarily screen patients for suicide and self-harm ...G. ESS-6 Screening tool: A secondary patient safety screening tool to determine the patient's level of risk for suicide and self-harm if the primary screen is positive ...SCREENING PROCEDURE ...a. At a minimum, a member of the nursing staff will screen all patients presenting to the emergency department ...using the Patient Safety Screener tool (PSS-3) ...b. If a patient is positive on the primary screening tool, staff will administer the secondary screening to determine next steps in the patients care and level of observation needed ...iv. The patient's score and critical item review will determine risk category which in turn will dictate the level of observation and further interventions required ...1. Mild Risk ...Level of observation: General. 2. Moderate Risk ...Level of observation: Intermittent. 3. High Risk ...Level of observation: Constant ..."

A review of the facility's policy # 02 titled, "Suicide Prevention," last approved 10/2019, revealed, "Screening Procedure: Hospital: a. At a minimum, a member of the nursing staff will screen all patients presenting to the emergency department...or for admission to Divine Savior using the Patient Safety Screener tool (PSS-3)"

Patient #1's electronic medical record was reviewed on 04/13/2021 at 8:00 AM with Director of Emergency Department B who confirmed the following per interview:

Patient #1 (MDS) dated [DATE] at 7:58 PM with a chief complaint for medical clearance to mental health.

A review of Physician Documentation on 02/17/2021 at 8:04 PM, "Patient presents with PD (Police Department) escort after eloping from the hospital about 1 hour ago. Patient is here again for medical clearance for suicidal ideation."

A review of Nurse's Notes on 02/18/2021 at 12:15 AM, "discharged to home on safety plan per Northwest Connections."

The initial PSS-3 suicide screen was not completed by nursing. There was no documented secondary suicide screening completed by nursing to determine Patient #5's level of suicide risk and observation needs during the emergency room stay. There was no nursing documentation of suicide precautions initiated or increased level of observations while Patient #1 was in the emergency room .

During an interview on 04/13/2021 at 8:15 AM, Director of Emergency Department B stated the initial patient safety screener-3 suicide screen was not completed by nursing staff, the nursing staff completed it for his first encounter earlier that day but it should have been completed again.

Patient #5's electronic medical record was reviewed on 04/12/2021 at 3:05 PM with Director of Emergency Department B who confirmed the following per interview:

Patient #5 (MDS) dated [DATE] at 4:43 AM with a chief complaint of intentionally trying to harm self by overdose.

A review of the "Triage Note" on 11/06/2021 at 4:43 AM revealed, "Patient stated s/he was trying to self harm and took 15 Motrin, 2 ciders and vodka 2 hours ago. Pt. (Patient) also has several lacs (lacerations) to L (left) wrist of differing thickness."

A review of Physician Documentation on 11/06/2020 at 12:52 PM, "Evaluation completed by NW (Northwest) Connections in person. Patient to go home with care plan. NW will arrange follow up. I think this is appropriate based on my interview of the patient."

The initial PSS-3 suicide screen was not completed by nursing. There was no documented secondary suicide screening completed by nursing to determine Patient #5's level of suicide risk and observation needs during the emergency room stay. There was no documentation by nursing staff of suicide precautions initiated or increased level of observations.

Patient #9's electronic medical record was reviewed on 04/12/2021 at 3:36 PM with Quality Analyst C who confirmed the following per interview:

Patient #9 (MDS) dated [DATE] at 10:39 AM with a chief complaint of intentional overdose.

A review of the "Nurse's Notes" on 03/08/2021 at 10:48 AM revealed, "Presenting Complaint ...[s/he] intentionally took 8 tablets of doxylamine (an over-the-counter sleep aid) 25mg (milligrams) last evening around 830pm (sic) ..."

The initial PSS-3 suicide screening completed on 03/08/2021 at 10:51 AM revealed, "Positive Screen Yes."

A review of the "Physician's Notes" on 03/08/2021 at 12:24 PM revealed, " ...[AGE]-year-old ...brought in by family for suicide attempt by overdose ...Patient states [s/he] is still feeling suicidal and doesn't understand why it is such a big deal ..."

Patient #9 was admitted to the medical-surgical inpatient unit of the facility on 03/08/2021 at 3:36 PM due to electrolyte imbalance.

There was no documented secondary suicide screening completed by nursing to determine Patient #9's level of suicide risk and observation needs during the emergency room stay. There was no documentation by the nursing staff of suicide precautions initiated or increased level of observations.

Patient #11's electronic medical record was reviewed on 04/12/2021 at 2:00 PM with Quality Analyst C who confirmed the following per interview:

Patient #11 (MDS) dated [DATE] at 12:47 PM with a chief complaint of medical clearance.

A review of the "Nurse's Notes" on 01/04/2021 at 12:50 PM revealed, "Presenting complaint ...reports the pt (patient) is feeling suicidal today and took a bottle of melatonin (over-the-counter sleep aid) and a pair of scissors to the school counselor telling [him/her] that [s/he] wants to die ...an ED (Emergency Detention) is being placed."

The initial PSS-3 suicide screening completed on 01/04/2021 at 12:52 PM revealed, "Positive Screen Yes."

A review of the "Physician's Notes" on 01/04/2021 at 1:24 PM revealed, " ...14 yrs (years) old ...reports [s/he] has had feelings of depression with suicidal ideations over the past couple years but they have gotten worse over the past 2 weeks ...does exhibit self-harm behavior and has multiple superficial lacerations to bilateral forearms ..."

Patient #11 was transferred to an inpatient psychiatric hospital on [DATE] at 5:32 PM.

There was no documented secondary suicide screening completed by nursing to determine Patient #11's level of suicide risk and observation needs during the emergency room stay. There was no documentation by the nurses of suicide precautions initiated or increased level of observations.

Patient #12's electronic medical record was reviewed on 04/12/2021 at 2:45 PM with Quality Analyst C who confirmed the following per interview:

Patient #12 (MDS) dated [DATE] at 1:44 PM with a chief complaint of psych (psychiatric) problem.

A review of the "Nurse's Notes" on 02/01/2021 at 1:48 PM revealed, "Presenting complaint: Patient states: patient needs medical clearance for [Inpatient psychiatric facility name]."

The initial PSS-3 suicide screening completed on 02/01/2021 at 5:33 PM revealed, "Positive Screen Yes."

A review of the "Physician's Notes" on 02/01/2021 at 4:04 PM revealed, " ...26 yrs (years) old ...complaining of depression and suicidal thoughts for a few weeks ...arranged for voluntary admission to [Inpatient psychiatric facility name]. [S/He] presents to the emergency department for medical clearance ..."

Patient #12 was transferred to an inpatient psychiatric hospital on [DATE] at 5:37 PM.

There was no documented secondary suicide screening completed by nursing to determine Patient #12's level of suicide risk and observation needs during the emergency room stay. There was no documentation of suicide precautions by nursing staff initiated or increased level of observations.

Patient #13's electronic medical record was reviewed on 04/12/2021 at 2:56 PM with Quality Analyst C who confirmed the following per interview:

Patient #13 (MDS) dated [DATE] at 11:25 AM with a chief complaint of psych (psychiatric) problem.

The initial PSS-3 suicide screening completed on 02/03/2021 at 11:47 AM revealed, "Positive Screen Yes."

A review of the "Nurse's Notes" on 02/03/2021 at 11:59 AM revealed, " ...pt (patient) visible (sic) upset and unkept (sic), sobbing profusely, pt states [s/he] is suicidal at this time but does not have a plan in place ..."

A review of the "Physician's Notes" on 02/03/2021 at 11:43 AM revealed, "Patient is a [AGE]-year-old ...here for evaluation of depression and suicidal thoughts. Does not have a specific plan ...has been suicidal over the past 2 days ...cut the dorsal aspect of [his/her] left forearm 2 days ago. No active bleeding ..."

Patient #13 was transferred to an inpatient psychiatric hospital on [DATE] at 2:56 PM.

There was no documented secondary suicide screening completed by nursing to determine Patient #13's level of suicide risk and observation needs during the emergency room stay. There was no documentation of suicide precautions initiated by nursing staff or increased level of observations.

Patient #15's electronic medical record was reviewed on 04/13/2021 at 8:10 AM with Quality Analyst C who confirmed the following per interview:

Patient #15 (MDS) dated [DATE] at 7:34 AM with a chief complaint of overdose and unresponsive.

A review of the "Nurse's Notes" on 03/10/2021 at 7:39 AM revealed, "EMS (Emergency Medical Services) call for patient found unresponsive ...started CPR (cardiopulmonary resuscitation) ...Was given narcan (a medication used to reverse a narcotic overdose) 2 mg twice ...Patient currently alert, not following commands, breathing on own ..."

A review of the "Physician's Notes" on 03/10/2021 at 1:03 PM revealed, " ...Drug screen positive for cocaine, THC (chemical found in marijuana), opiates. Patient also with track marks consistent with IV (intravenous) drug abuse ...suspect this was a heroin overdose ...Patient was offered extended observation in the ED to monitor blood pressure, [s/he] states 'I hate hospitals' and elected to leave ..."

Patient #15 left AMA (Against Medical Advice) on 03/10/2021 at 1:29 PM.

There was no documented initial suicide screening completed by nursing per facility policy. There was no documentation of suicide precautions initiated by nursing staff or increased level of observations.

Patient #21's electronic medical record was reviewed on 04/12/2021 at 3:20 PM with Quality Analyst C who confirmed the following per interview:

Patient #21 (MDS) dated [DATE] at 12:30 PM with a chief complaint of depression with suicidal thoughts and pregnancy.

A review of the "Nurse's Notes" on 02/04/2021 at 12:43 PM revealed, " ...patient stated she has been having suicidal depression for 11 years ...feels like she just cant (sic) do all this on her own. Patient stated she has OD'd (overdosed) before but she doesn't want to hurt the baby ..."

The initial PSS-3 suicide screening completed on 02/04/2021 at 12:45 PM revealed, "Positive Screen Yes."

The secondary ESS-6 suicide screening completed on 02/04/2021 at 1:00 PM revealed, "Moderate Risk."

A review of the "Physician's Notes" on 02/04/2021 at 12:50 PM revealed, "Patient is a [AGE]-year-old ...with history of depression, ADHD, bipolar disorder who presents for evaluation of suicidal thoughts. She plans to overdose ...She is approximately 26 weeks pregnant ...has been an (sic) inpatient psych facilities multiple times for history of depression and suicidal thoughts. She is (sic) not actively hurt herself recently ...Denies suicidal plan ..."

Patient #21 was transferred to an inpatient psychiatric hospital on [DATE] at 6:23 PM.

There was no evidence of documented observations of Patient #21 at least every 15 minutes, per facility policy regarding frequency of observations required by nursing staff for a patient identified as "Moderate Risk" for suicide.

During an interview on 4/12/21 at 2:13 PM Director of Emergency Services B stated, "Nurses should be completing the Patient Safety Screener 3 on every patient that is admitted over the age of 12, If there is a positive screen, then a secondary screen tool is to be completed by nursing to determine the level of observation that is required. Moderate risk requires intermittent observation which is intervals no less than every 15 minutes. High risk requires constant periods of one-on-one observation. Staff will document patient's condition every 15 minutes. The nurses know they should be completing these assessment."