Observations
Based on a review of client records, interviews with facility staff, and a review of the facility ' s root cause analysis completed on April 18, 2023, the facility failed to assist a client in obtaining psychiatric supportive services resulting in a sentinel event, as evidence by:
(1)A campus-wide alert system was not activated when client went missing resulting in other clients searching for the client and finding him/her two and a half hours later. At no point should clients be searching for another client with documented suicidal risk.
(2)An email from family about change in mental state and concern for suicide was not addressed. The facility ' s psychiatrist review of family emails was documented after the client ' s sentinel event.
(3)During a group counseling session on March 13, 2023, client spoke about suicidality encroaching. No emergency safety plan was executed.
(4)Staff had conversation with client on March 21, 2023 at 10:00pm in which the client stated he was struggling " physically and emotionally " with anxiety and " triggers " . No emergency safety plan was executed.
(5)Staff had conversation with client on March 22, 2023 in the morning when client stated feeling " like he did when he first got here " which was suicidal. No emergency safety plan was executed.
The findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Caron Treatment Centers has policies and procedures in place that guide staff in how to assist patients in obtaining psychiatric supportive services, when necessary. All direct care staff are being re-educated on the policies and procedures in how to assist patients in obtaining psychiatric supportive services, as part of Risk Assessment/CSSRS training. The Risk Assessment/CSSRS training includes how to determine when a Risk Assessment/CSSRS is warranted based on the patient's risk factors and warning signs. This training also includes an overview of interventions that could be implemented depending on the assessed level of risk. Examples of possible interventions include the development of a Personal Safety Plan, 1:1 observation/monitoring, calling an on-call psychologist or medical provider for further assessment, calling 911, etc... All direct care staff are expected to complete this training by 2/29/24. Supervisors and Directors will discuss the Risk Assessments/CSSRS process with their teams on an ongoing basis during team meetings and supervision meetings. The Training Department will send a progress report to the Compliance Department on 3/1/24, to ensure compliance with completion of the training. All direct care staff will also take a refresher training on Risk Assessment/CSSRS on an annual basis. |