HospitalInspections.org

Based on document review and interview, the registered nurse failed to evaluate a patient per policy in one (1) instance. (Patient # 10)

Findings include:

1. The facility policy titled, Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting, version eight (8), no policy number, indicated on page two (2) - section Procedure - Required Action Steps - Guidance - Determining suicide risk level can include additional information and sources other than the patient, such as Emergency Medical Services, significant others and/or other observers who report suicide ideation, intent and/or behavior. This policy was last revised on 06/08/2022.

2. Patient # 10's MR (medical record) indicated the patient was a 24 y/o (year/old) brought into H # 2's (Acute Care Hospital) Emergency Department (ED) by police on several dates including, but not limited to, the following:
a. The Law Enforcement Statement In Support of Emergency Detention and Transport dated 01/15/2025 at 6:16 pm, indicated the patient was believed to be mentally ill due to - intellectual disability and other psychiatric disorders that substantially disturbed the individual's thinking, feeling, or behavior and impaired the individual's ability to function, and the person named above (patient # 10) was - dangerous to self and was in immediate need of hospitalization and treatment for the following reasons: Patient # 10 stated he/she would go in his/her room and self-harm.
b. The Nurses note dated 01/15/2025 at 6:63 pm by N # 2 (Registered Nurse-RN), indicated the patient refused to answer the questions for the Columbia Suicide Risk Assessment. The patient was calculated (per the computer system) at low risk for suicide with no action interventions required.
c. The Provider note dated 01/15/2025 at 7:34 pm by M # 2 (Doctor of Osteopathy-DO/Family Medicine), indicated Medical Decision Making - Patient had medical screening examination. The patient refused to cooperate with evaluation. There appears to be no acute change in his/her condition. He/she was considered safe to return to his/her group home. Patient was discharged back to H # 3 (Group Home).
d. The Provider note dated 01/16/2025 at 6:45 pm by M # 2, indicated the diagnosis to be - intentional self-harm by strangulation. History of present illness - patient was found at his/her facility (H # 3) with a cord wrapped around his/her neck. The patient appeared to be hypoxic.

3. In interview on 02/27/2025 at approximately 2:50 pm with staff member A # 1 (Chief Nursing Officer-CNO), confirmed when the patient doesn't answer and/or refuses to answer the Columbia Suicide Risk Questions the system will automatically default to low risk.

4. In interview on 02/28/2025 at approximately 3:48 pm with medical staff member M # 4 (Chief Medical Officer-CMO), confirmed he/she believed it was a communication gap with the consult from H # 4. The nurse should use her discretion to change the suicide risk assessment if and/or when necessary.

Based on document review and interview, the facility failed to provide appropriate discharge planning evaluation for a patient who had been previously identified as suicidal in one instance. (Patient # 10)

Findings include:

1. The facility policy titled, Discharge Planning and Follow Up Care, version two (2), no policy number, indicated on page one (1) - section Procedure - number two (2) - to discharge a patient, obtain the completed chart and verify that all orders and reassessments have been completed and signed. This policy was last revised on 11/25/2024.

2. The facility policy titled, Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting, version eight (8), no policy number, indicated on page two (2) - section Procedure - Required Action Steps - Guidance - Determining suicide risk level can include additional information and sources other than the patient, such as Emergency Medical Services, significant others and/or other observers who report suicide ideation, intent and/or behavior. This policy was last revised on 06/08/2022.

3. Patient # 10's MR indicated the following: The patient was a 24 y/o (year/old) brought into H # 2's (Acute Care Hospital) Emergency Department (ED) by police on several dates including, but not limited to, the following:
a. The patient arrived to the ED on 01/14/2025 with the diagnosis of foreign body in hand, pica, and suicidal ideation.
b. The Psychiatric Consult was ordered by M # 3 (Doctor of Osteopathy-DO/Emergency Medicine).
c. The Case Management (CM) note dated 01/15/2025 at 7:53 am, indicated the medical record chart was further reviewed by T # 1 (Transition Care Coordinator-TCC) with the current complaint being that the patient wants to overdose.
d. The CM note dated 01/15/2025 at 12:07 pm, indicated H # 3, H # 2's charge nurse, Case Manager Director and Nurse Administration were all updated/aware, and were in agreement related to patient # 10 being discharged.
e. The Provider note dated 01/15/2025 at 12:12 pm by M # 3, indicated - Calls-Consults - recommended H # 4 come and see the patient. It was felt that patient # 10 was not truly suicidal, but he/she had behavioral issues. The patient was discharged to H # 3 at 1:46 pm.
f. The Law Enforcement Statement In Support of Emergency Detention and Transport dated 01/15/2025 at 6:16 pm, indicated the patient was back in the ED and was believed to be mentally ill due to - intellectual disability and other psychiatric disorders that substantially disturbed the individual's thinking, feeling, or behavior and impaired the individual's ability to function, and the person named above (patient # 10) was - dangerous to self and was in immediate need of hospitalization and treatment for the following reasons: Patient # 10 stated he/she would go in his/her room and self-harm.
g. The Nurses note dated 01/15/2025 at 6:63 pm by N # 2 (Registered Nurse-RN), indicated the patient refused to answer the questions for the Columbia Suicide Risk Assessment. The patient was calculated (per the computer system) at low risk for suicide with no action interventions required.
h. The Provider note dated 01/15/2025 at 7:34 pm by M # 2, Medical Decision Making - Patient had medical screening examination. The patient refused to cooperate with evaluation. He/she had numerous recent formal evaluations from H # 4 and was previously cleared to return to his/her group home. There appears to be no acute change in his/her condition. He/she was considered safe to return to his/her group home. Patient was discharged.
i. The Triage Assessment dated 01/15/2025, signed by M # 1 on 01/16/2025 at 8:35 am on page 7, section Crisis Type - indicated suicidal, section Psychiatric Recommendations/Outcomes - M # 1 recommended that the client (patient # 10) needed to stay in the ED for the time being, and section Admission Criteria Met - indicated recent suicide attempt or gesture within seventy-two (72) hours prior to admit.
j. The patient arrived to the ED on 01/16/2025 with the diagnosis of intentional self-harm by strangulation.
k. The Provider note dated 01/16/2025 at 6:45 pm by M # 2, indicated the diagnosis to be - intentional self-harm by strangulation. History of present illness - patient was found at his/her facility (H # 3) with a cord wrapped around his/her neck. The patient appeared to be hypoxic. Patient was alone for approximately ten (10) to fifteen (15) minutes. Patient # 10 appeared stable on arrival to ED. He/she did not wish to answer questions at this time.

4. In interview on 02/27/2025 at approximately 2:50 pm with staff member A # 1 (Chief Nursing Officer-CNO), confirmed when the patient doesn't answer and/or refuses to answer the Columbia Suicide Risk Questions the system will automatically default to low risk.

5. In interview on 02/28/2025 at approximately 1:45 pm with medical staff member M # 2, confirmed when patient # 10 arrived to the ED in the evening of 01/15/2025, nothing had changed from earlier in the afternoon when he/she was discharged by medical staff member M # 3. When H # 4 comes in for a psychiatric consultation first they go talk to the patient, then go into a room where they phone the psychiatrist to discuss the assessment, then they are supposed to come find us to let us know their findings. Honestly, we all thought it was just attention seeking and maybe that clouded our judgement.

6. In interview on 02/28/2025 at approximately 2:10 pm with medical staff member M # 3, confirmed he/she never spoke to anyone from H # 4 related to the psychiatric evaluation recommendations. He/she confirmed receiving a call from CM (doesn't remember the name of person), indicating a meeting was held by CM, H # 3, patient # 10's guardian, hospital administration who all agreed to discharge patient # 10. Everyone thought it was behavioral issues. M # 3 further confirmed that he/she thought it was the "wrong play" to discharge the patient, but "I did".

7. In interview on 02/28/2025 at approximately 3:48 pm with medical staff member M # 4 (Chief Medical Officer-CMO), confirmed he/she believed it was a communication gap with the consults at H # 4. The nurse should use her discretion to change the suicide risk assessment if and/or when necessary.