HospitalInspections.org

Based on document review and interview, the facility failed to provide care in a safe setting for 1 of 10 patient Medical Records (MRs) reviewed (P7).


Findings include:
1. Facility policy titled, Psychiatric Emergencies, PolicyStat ID 12366744, last revised 1/2023 indicated on page 3, under PROCEDURE: E. If patient scores moderate to high on Columbia Suicide Severity Rating Scale (C-SSRS) perform Ligature Assessment and Environmental Awareness Checklist prior to placing in room.

2. Review of P7's medical record (MR) indicated:
a. On 4/6/2025 at 1032 hours, ligature risk items were removed from P7's room which included, but not limted to: linen.

b. On 4/6/2025 at 1510 hours, technician note indicated P7 removed the pillowcase from the pillow.

3. In interview with A5 on 05/30/25 at approximately 3:27 p.m., he/she indicated P7 put their blanket over their head and was picking scabs from the superficial wounds. When P7 was told to stop, they took the pillowcase off the pillow and attempted to tie it around their neck.

Based on document review and interview, nursing services failed to update the provider on the patient's condition after patient communication in one instance (P7).

Findings include:

1. Review of medical record (MR) for P7 indicated the following:

a. P7 admitted to F1 on 04/06/25 at 1011 hours. Patient arrived at the emergency department (ED) via emergency medical services (EMS) for diagnosis of suicidal ideation (SI) and intentional self-harm of bilateral arm cutting.

b. At 1422 hours, P7 handed the technician a note that indicated they felt suicidal badly, they want to self-harm badly. MR lacked documentation that nurse and/or provider were notified of note.

c. At 1522 hours, P7 was discharged with their guardian in stable condition.

d. At 1535 hours, addendum to Crisis evaluation (eval) progress note: Upon discharge, P7 ran into traffic and indicated they were trying to get hit by a vehicle and indicated SI. P7 's providers discussed this situation and recommended that P7 be admitted to inpatient at this time. P7 indicated they were attempting to end their life and continued to have thoughts of harming themselves.

2. In interview on 5/30/2025 at approximately 3:27 p.m. with A5, he/she indicated they were able to recall P7 from a list provided, they provided 1:1 care for P7. A5 indicated P7 was being discharged home and ran into traffic trying to get hit by a car.