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Based on record review, document review and staff interview it was determined the facility failed to ensure the medical staff completed an appropriate discharge summary within thirty (30) days after discharge. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #19). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #19 revealed the patient was admitted on 10/8/20 with a diagnosis of Conduct Disorder and was discharged to a local hospital on 12/1/20 after ingesting a cleaning liquid. The physician documented on 12/1/20: "Patient #19 did not qualify for the PRTF {Psychiatric Resident Treatment Facility} or the acute care but the DHHR {Department of Health and Human Resources} said patient #19 was not safe outside the facility. Patient #19 was discharged to the local hospital on 12/1/20. Patient #19 was readmitted to the facility on 12/3/20. Patient #19 was court ordered to return to the facility." On 12/8/20 at 10:21 p.m. nursing stated in part: "Remains 1:1 {one on one} ... While in dayroom she got hold of controller and took a battery, ran out of dayroom, and swallowed battery. She then told staff she swallowed the battery. She is being sent to ER {emergency room} for treatment and observation per physician. Supervisor aware. Will continue to monitor. DHHR was notified the patient ingested a battery. The patient was discharged back to the facility on 12/9/20. While in the intake room she ran behind the desk, grabbed a cleaning solution, and attempted to ingest the solution, but staff was able to intervene. She was sent back to the hospital by ambulance and DHHR was with the patient during intake." No emergency transfer document was noted in the medical record. She did not return to the facility after discharge from the hospital and was in DHHR custody. An incident report was filed on 12/1/20 for ingestion of cleaning fluid, but no follow up from the Risk Manager was completed. An incident report was completed on 12/8/20 for swallowing a battery and a follow up was completed. An incident report was completed on 12/9/20 for the patient going behind the desk and grabbing cleaning liquid and attempting to drink but staff intervened. No discharge summary was noted in the medical record for the 12/8/20 discharge when the patient was admitted to the local hospital.

2. An interview was conducted with the Division Vice President on 4/20/21 at approximately 8:45 a.m. He stated patient #19 was not readmitted to the facility on 12/9/20. He stated during intake after she grabbed the cleaning solution, the legal guardian took her back to the local hospital and she never returned. He stated the legal guardian was with her in intake.

3. A review of the Medical Staff Rules and Regulations, dated 3/16, stated in part: "DISCHARGE SUMMARY, each physician, or his designee, shall dictate a discharge summary within 30 days of discharge."

4. An interview was conducted with the Corporate Director of Compliance and Risk Management on 4/20/21 at 10:15 a.m. He concurred no discharge summary was documented in the medical record for patient #19 on 12/8/20.

Based on record review, document review and staff interview it was determined the facility failed to follow their complaint/grievance policy. This failure was identified in one (1) of five (5) incident reports reviewed (patient #5). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #5 revealed the patient was admitted on 12/7/20 with a diagnosis of Suicidal Ideations. On 12/10/20, an incident report was completed due to the patient reported she stuck a staple in her left forearm. The physician was notified and a verbal order was obtained. The verbal order stated in part: "Consult PA {Physician Assistant} to remove staple (?)." A second order was obtained for a medical consult for a staple in her forearm on 12/14/20. The order stated: "Medical Consult staple in forearm, hand, one time only." An order on 12/20/20 at 11:52 a.m. stated: "Transfer to ER {emergency room} for evaluation, Reason: other- PT {patient} reports she put a piece of metal in her left forearm." No object was found in the forearm. No nursing documentation was noted in the medical record the PA had been notified of the medical consults. The patient was discharged on 12/29/20. An incident report was completed on 12/10/20 but no follow-up from Risk Management was completed.

2. A review of the policy titled "Complaint Process," dated 7-24-19, stated in part: "The Quality Department staff reviews and monitors the Grievance process. All grievances received are assessed for risk level and urgency. The Director of Quality and Risk Management will oversee the investigation to completion."

3. An interview was conducted with the Corporate Director of Compliance and Risk Management on 4/20/21 at 10:15 a.m. He concurred no follow-up was completed on the incident for patient #5 on 12/10/20. He stated a follow-up should have been completed.

Based on document review and staff interview it was determined the facility failed to notify the representative of the patient's health status. This failure was identified in one (1) of five (5) incidents reviewed (patient #5). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of a document filed on 12/10/20 for patient #5 revealed the legal guardian, Department of Health and Human Resources, was not notified of an incident for patient #5.

2. An interview was conducted with the Corporate Director of Compliance and Risk Management on 4/20/21 at 10:15 a.m. He concurred no follow-up was completed on the document that involved the health status for patient #5 on 12/10/20. He stated a follow-up should have been completed.

A. Based on record review, document review, video review and staff interview it was determined the hospital failed to provide care in a safe setting in one (1) of twenty (20) medical records reviewed (patient #1). This failure has the potential to harm all patients.

Findings include:

1. A review of the medical record for patient #1 revealed he is a seventeen (17) year old male with a history of depression, anxiety, post-traumatic stress disorder (PTSD) and conduct disorder. On 3/31/21 he was admitted to the hospital after having suicidal ideation, cutting, and becoming violent at the shelter he was residing in. Upon admission to the facility, he had a fifth metacarpal fracture and was wearing a splint with metal stays. On 4/6/21 he had to transfer to the local emergency room after hitting his already injured hand on the wall. On 4/10/21 while in the gym he injured his left knee. He was ordered by the physician's assistant to be transferred to the local emergency room on 4/11/21 due to swelling and pain in his left knee. When he returned to the facility, he was ordered crutches and a knee brace and was using a wheelchair in the facility. The record revealed the patient was transferred to the hospital following an incident on 4/14/21 in which he snorted a pill. He was eventually placed in the pediatric intensive care unit (PICU) and never returned to the facility.

2. On 4/21/21 at approximately 10:30 a.m., a hospital video was reviewed. During the video patient #1 can be seen sitting in a wheelchair eating cereal at 4:17 p.m. At 4:17:15 the nurse can be seen giving the patient medication in which he holds his head down and then drinks the water the nurse provides. At 4:17:25 the nurse looks briefly into the patient's mouth but does not check under his tongue or in his cheeks to see if he took the pill. At 4:17:33 the patient spits the pill out of his mouth into his hand. Behavioral Health Technician (BHT) #1 can be seen sitting in the room by the door behind the patient. Other patients can be seen gathering around him with one (1) patient handing him a piece of paper. Patient #1 can be seen at 4:18:44 snorting the pill. At 4:19:15 he can be seen wiping his nose off. At 4:19:38 he takes his shirt off and begins fanning himself. At 4:20:21 another patient puts ice on the back of his neck. At 4:22:19 he pulls his wheelchair out and sits down on floor. At 4:23:30 he hops to the bathroom. At 4:23:56 he hops back into the day room. At 4:24:30 he falls back in chair and at 4:25:25 he lays his head down on the table. BHT #2 from outside the dayroom comes in to check on the patient. At no time do you see BHT #1 get up and check on the patient. At 4:26:30 his head is laying down on the table. At 4:27:11 another patient is at the nursing station talking to the nurse and at 4:27:23 BHT #2 is at the nurse's desk speaking with her. At 4:27:38 the nurse walks down the hallway, turns around and goes back to the nursing station. At 4:28:01 the patient falls into the hallway with BHT #2 by his side. At 4:28:10 the nurse bends down to check on patient #1 in the hallway and at 4:28:17 two (2) nurses can be seen with him.

3. A review of the hospital document entitled "Avatar eMar Hard Copy," dated 4/14/21, revealed patient #1 was ordered Vistaril 50 milligrams (mg) as needed for anxiety/agitation. The record revealed he was given the medication at 4:18 p.m. There is no documentation that shows why the medication was given to the patient.

4. An interview was conducted with the Corporate Vice President on 4/21/21 at 10:55 a.m. When questioned if the nurse performed a proper mouth check he stated, "I would say she did a fifty (50) percent mouth check."

5. An interview was conducted with the Adult Services Nurse Manager on 4/22/21 at approximately 2:15 p.m. She stated her expectation of an oral mouth check is to look in the mouth, under the tongue, and up in the patient's cheeks. She concurred a proper mouth check should take longer than three (3) seconds.



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B. Based on record review and staff interview it was determined the facility failed to provide care in a safe setting by not ensuring verbal orders for care were communicated to appropriate staff. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #5). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #5 revealed the patient was admitted on 12/7/20 with a diagnosis of Suicidal Ideations. On 12/10/20 an incident report was completed due to the patient reported she stuck a staple in her left forearm. The physician was notified, and a verbal order was obtained. The verbal order stated in part: "Consult PA {Physician Assistant} to remove staple (?)." A second order was obtained for a medical consult for a staple in her forearm on 12/14/20. The order stated: "Medical Consult staple in forearm, hand, one time only." An order on 12/20/20 at 11:52 a.m. stated: "Transfer to ER {emergency room} for evaluation, Reason: other- PT {patient} reports she put a piece of metal in her left forearm." No object was found in the forearm. No nursing documentation was noted in the medical record the PA had been notified of the medical consults. The patient was discharged on 12/29/20.

2. An interview was conducted with the PA/Infection Preventionist on 4/20/21 at 11:18 a.m. When asked about the medical consult order for patient #5, she stated she was never notified about a medical consult for the patient. She concurred she was never contacted by the nursing staff to see the patient. She stated unless the nursing staff notifies her, she has no way of knowing about the orders. She stated the computer system does not flag these orders to her. She stated nursing knows to call or text her about the orders.

3. A telephone interview was conducted with the Medical Record Liaison on 4/20/21 at 12:28 p.m. When asked about the verbal orders, he stated, "The only physician flagged in the medical record is the ordering physician so they can counter sign the order." He stated the consulting physician would have to be physically notified about the order.

4. A telephone interview was conducted with the Medical Record Liaison on 4/20/21 at 12:45 p.m. He stated he reviewed the medical record for patient #5 and no nursing documentation is noted in the medical record of notification to the PA for the medical consults.

5. An interview was conducted with the Corporate Director of Compliance and Risk Management on 4/21/21 at 2:30 p.m. When asked to speak to the Interim Chief Nursing Officer (CNO), he stated, "She is not available today." When asked about the verbal orders and notification for all the staff, he stated she addressed it with all the nursing staff on 4/20/21. He stated she sent an email to all the nursing staff on 4/20/21 and the nursing staff must sign they have read and understood the email. He concurred the Interim CNO could not find documentation the PA was notified of the medical consults for patient #5.

Based on record review and staff interview it was determined the Director of Quality and Compliance failed to ensure all patient transfers and event reports were completed as required by hospital policy in eight (8) out of twenty (20) medical records reviewed (patients # 1, 2, 3, 7, 8, 17, 18, and 20). This failure has the potential to negatively impact any patient receiving care at this facility.

Findings include:

1. A review of the medical records for patients #1, 2, 3, 7, 8, 17, 18, and 20 revealed no Interagency Transfer Sheet was found.

2. An interview was conducted with the Corporate Director of Quality and Compliance on 4/23/21 at approximately 9:00 a.m. When asked if he had a transfer log of patients transferred to the emergency room or to another facility, he stated he was not aware of it. He had just begun in the position due to the former Director of Compliance leaving with only a two (2)-day notice. He stated, "I am finding out there are a lot of things that has not been tracked and trended as it should have been." He brought the event reports in which all transfers should have had an event report for, but realized there were some patient transfers not captured. He concurred there were multiple instances without proper documentation of the patients' transfer.

Based on record review, document review and staff interview it was determined staff failed to complete an appropriate discharge summary within thirty (30) days after discharge as per the Medical Staff Rules and Regulations. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #19). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #19 revealed the patient was admitted on 10/8/20 with a diagnosis of Conduct Disorder and was discharged to a local hospital on 12/1/20 after ingesting a cleaning liquid. The physician documented on 12/1/20: "Patient #19 did not qualify for the PRTF {Psychiatric Resident Treatment Facility} or the acute care but the DHHR {Department of Health and Human Resources} said patient #19 was not safe outside the facility. Patient #19 was discharged to the local hospital on 12/1/20. Patient #19 was readmitted to the facility on 12/3/20. Patient #19 was court ordered to return to the facility." On 12/8/20 at 10:21 p.m. nursing stated in part: "Remains 1:1 {one on one} ... While in dayroom she got hold of controller and took a battery, ran out of dayroom, and swallowed battery. She then told staff she swallowed the battery. She is being sent to ER {emergency room} for treatment and observation per physician. Supervisor aware. Will continue to monitor. DHHR was notified the patient ingested a battery. The patient was discharged back to the facility on 12/9/20. While in the intake room she ran behind the desk, grabbed a cleaning solution, and attempted to ingest the solution, but staff was able to intervene. She was sent back to the hospital by ambulance and DHHR was with the patient during intake." No emergency transfer document was noted in the medical record. She did not return to the facility after discharge from the hospital and was in DHHR custody. An incident report was filed on 12/1/20 for ingestion of cleaning fluid, but no follow up from the Risk Manager was completed. An incident report was completed on 12/8/20 for swallowing a battery and a follow up was completed. An incident report was completed on 12/9/20 for the patient going behind the desk and grabbing cleaning liquid and attempting to drink but staff intervened. No discharge summary was noted in the medical record for the 12/8/20 discharge when the patient was admitted to the local hospital.

2. An interview was conducted with the Division Vice President on 4/20/21 at approximately 8:45 a.m. He stated patient #19 was not readmitted to the facility on 12/9/20. He stated during intake after she grabbed the cleaning solution, the legal guardian took her back to the hospital and she never returned. He stated the legal guardian was with her in intake.

3. A review of the Medical Staff Rules and Regulations, dated 3/16, stated in part: "DISCHARGE SUMMARY, Each physician, or his designee, shall dictate a discharge summary within 30 days of discharge."

4. An interview was conducted with the Corporate Director of Compliance and Risk Management on 4/20/21 at 10:15 a.m. He concurred no discharge summary was documented in the medical record for patient #19 on 12/8/20.

Based on document review and staff interview it was determined nursing staff failed to ensure all verbal orders received were communicated to appropriate staff. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #5). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #5 revealed the patient was admitted on 12/7/20 with a diagnosis of Suicidal Ideations. On 12/10/20 an incident report was completed due to the patient reported she stuck a staple in her left forearm. The physician was notified, and a verbal order was obtained. The verbal order stated in part: "Consult PA {Physician Assistant} to remove staple (?)." A second order was obtained for a medical consult for a staple in her forearm on 12/14/20. The order stated: "Medical Consult staple in forearm, hand, one time only." An order on 12/20/20 at 11:52 a.m. stated: "Transfer to ER {emergency room} for evaluation, Reason: other- PT {patient} reports she put a piece of metal in her left forearm." No object was found in the forearm. No nursing documentation was noted in the medical record the PA had been notified of the medical consults. No documentation the legal representative was notified of the injury on 12/10/20. The patient was discharged on 12/29/20.

2. An interview was conducted with the PA/Infection Preventionist on 4/20/21 at 11:18 a.m. When asked about the medical consult order for patient #5, she stated she was never notified about a medical consult for the patient. She concurred she was never contacted by the nursing staff to see the patient. She stated unless the nursing staff notifies her, she has no way of knowing about the orders. She stated the computer system does not flag these orders to her. She stated nursing knows to call or text her about the orders.

3. A telephone interview was conducted with the Medical Record Liaison on 4/20/21 at 12:28 p.m. When asked about the verbal orders, he stated, "The only physician flagged in the medical record is the ordering physician so they can counter sign the order." He stated the consulting physician would have to be physically notified about the order.

4. A telephone interview was conducted with the Medical Record Liaison on 4/20/21 at 12:45 p.m. He stated he reviewed the medical record for patient #5 and no nursing documentation was noted in the medical record of notification to the PA for the medical consults.

5. An interview was conducted with the Corporate Director of Compliance and Risk Management on 4/21/21 at 2:30 p.m. When asked to speak to the Interim Chief Nursing Officer (CNO), he stated, "She is not available today." When asked about the verbal orders and notification for all the staff, he stated she addressed it with all the nursing staff on 4/20/21. He stated she sent an email to all the nursing staff on 4/20/21 and the nursing staff must sign they have read and understood the email. He concurred the Interim CNO could not find documentation the PA was notified of the medical consults for patient #5.

Based on record review, document review, video review and staff interview it was determined the hospital failed to ensure staff performed appropriate mouth checks that led to patient #1 snorting a medication provided to him by the hospital. This failure led to the patient receiving life-saving care at local emergency room.

Findings include:

1. A review of the medical record for patient #1 revealed he is a seventeen (17) year old male with a history of depression, anxiety, post-traumatic stress disorder (PTSD) and conduct disorder. On 3/31/21 he was admitted to the hospital after having suicidal ideation, cutting, and becoming violent at the shelter he was residing in. Upon admission to the facility, he had a fifth metacarpal fracture and was wearing a splint with metal stays. On 4/6/21 he had to transfer to the local emergency room after hitting his already injured hand on the wall. On 4/10/21 while in the gym he injured his left knee. He was ordered by the physician's assistant to be transferred to the local emergency room on 4/11/21 due to swelling and pain in his left knee. When he returned to the facility, he was ordered crutches and a knee brace and was using a wheelchair in the facility. The record revealed the patient was transferred to the hospital following an incident on 4/14/21 in which he snorted a pill. He was eventually placed in the pediatric intensive care unit (PICU) and never returned to the facility.

2. A review of hospital video was conducted on 4/21/21 at approximately 10:30 a.m. During the video patient #1 can be seen sitting in a wheelchair eating cereal at 4:17 p.m. At 4:17:15 the nurse can be seen giving the patient medication in which he holds his head down and then drinks the water the nurse provides. At 4:17:25 the nurse looks briefly into the patient's mouth but does not check under his tongue or in his cheeks to see if he took the pill. At 4:17:33 the patient spits the pill out of his mouth into his hand. Behavioral Health Technician (BHT) #1 can be seen sitting in the room by the door behind the patient. Other patients can be seen gathering around him with one (1) patient handing him a piece of paper. Patient #1 can be seen at 4:18:44 snorting the pill. At 4:19:15 he can be seen wiping his nose off. At 4:19:38 he takes his shirt off and begins fanning himself. At 4:20:21 another patient puts ice on back of neck. At 4:22:19 he pulls his wheelchair out and sits down on floor. At 4:23:30 he hops to bathroom. At 4:23:56 he hops back into the day room. At 4:24:30 he falls back in chair and at 4:25:25 he lays his head down on the table. BHT #2 from outside the dayroom comes into check on the patient. At no time do you see BHT #1 get up and check on the patient. At 4:26:30 his head is laying down on the table. At 4:27:11 another patient is at the nursing station talking to the nurse and at 4:27:23 BHT #2 is at the nurse's desk speaking with her. At 4:27:38 the nurse walks down the hallway, turns around and goes back to the nursing station. At 4:28:01 the patient falls into the hallway with BHT #2 by his side. At 4:28:10 the nurse bends down to check on patient #1 in the hallway and at 4:28:17 two (2) nurses can be seen with him.

3. A review of the hospital document entitled "Avatar eMar Hard Copy," dated 4/14/21, revealed patient #1 was ordered Vistaril 50 milligrams (mg) as needed for anxiety/agitation. The record revealed he was given the medication at 4:18 p.m. There was no documentation that shows why the medication was given to the patient.

4. An interview was conducted with the Corporate Vice President on 4/21/21 at 10:55 a.m. When questioned if the nurse performed a proper mouth check, he stated, "I would say she did a fifty (50) percent mouth check."

5. An interview was conducted with the Adult Services Nurse Manager on 4/22/21 at approximately 2:15 p.m. She stated her expectation of an oral mouth check is to look in the mouth, under the tongue, and up in the patient's cheeks. She concurred a proper mouth check should take longer than three (3) seconds.

Based on record review, document review and staff interview it was determined nursing failed to follow policies and procedures for completion of the emergency medical transfers checklist. This failure was identified in two (2) of three (3) patients transferred to the emergency department (ED) for evaluation (patients #2 and 19). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #2 revealed the patient was admitted on 11/21/20 for Major Depressive Disorder. The patient was sent to a local hospital on 12/1/20 for potential ingestion of a liquid cleaner; per hospital documentation all systems were normal, and the patient returned to the facility. On 12/7/20 the patient swallowed a two (2) inch screw. It was documented the patient was sent back to the local hospital and underwent surgery to remove the screw. It was noted the patient had also swallowed a battery. No emergency medical transfer checklists were noted in the medical record as per policy. The patient did not return to the facility. A discharge summary was noted on 12/7/20.

2. A review of the medical record for patient #19 revealed the patient was admitted on 10/8/20 with a diagnosis of Conduct Disorder and was discharged to a local hospital on 12/1/20 after she ingested a cleaning liquid. The patient was readmitted to the facility on 12/3/20 via court order. On 12/8/20 at 10:21 p.m. nursing stated in part: "Remains 1:1{one on one} ... While in dayroom she got hold of controller and took a battery, ran out of dayroom, and swallowed battery. She then told staff she swallowed the battery. She is being sent to ER {emergency room} for treatment and observation per physician. Supervisor aware. Will continue to monitor. Department of Health and Human Resources (DHHR) was notified of the patient ingesting a battery. She was transferred to the ED {emergency department} on 12/8/20 and was discharged back to the facility on 12/9/20. While in the intake room she ran behind the desk, grabbed a cleaning solution, and attempted to ingest the solution, but staff was able to intervene. She was sent back to the hospital by ambulance. DHHR was with the patient during intake." No emergency medical transfer checklists were documented in the medical record as per policy for all transfers to the ED.

3. A review of the policy titled "Emergency Medical Care and Transfer," dated 1/17, stated in part: "Complete the Emergency Medical Transfer Checklist."

4. An interview was conducted with the Clinical Nurse Manager on 4/22/21 at 3:33 p.m. She concurred no emergency medical transfer checklists were noted in the medical record for patients #2 and 19 when they were sent to the ED.

Based on document review, record review and staff interview it was determined the facility failed to reassess the patient's discharge plan for the appropriateness of a discharge (See Tag A 802), failed to notify the patient's guardian in a timely manner (See Tag A 805), and failed to provide appropriate medical information pertaining to the patient's course of illness and treatment (See Tag A 813).

A. Based on record review, document review and staff interview it was determined the facility failed to reassess a patient's discharge plan for the appropriateness of a discharge in one (1) of twenty (20) records reviewed (patient #2). This failure has the potential for harm or death to all patients.

Findings include:

1. A review of the medical record for patient #2 revealed an eleven (11) year old female that was admitted to the facility on 4/15/21 with a diagnosis of Unspecified Mood Disorder. She was placed on the 2 East unit of the facility. On 4/22/21 the patient was ordered to be discharged home to the care of her mother by the physician at 12:04 p.m. The patient had a Columbia-Suicide Rating Scale completed daily and has remained on a suicide level of yellow (moderate risk) since her arrival to the hospital. The last suicide risk assessment was scored at 1:11 p.m. by the registered nurse to which the patient continued to be a yellow risk level. The nurse did not notify the physician of the patient's continued yellow risk level. The patient's mother asked for her to be transferred to another psychiatric hospital because she didn't think the patient was safe to go home. Prior to the transfer the patient threatened to harm herself by either overdosing on her medications or hanging herself. The physician was not notified of the patient's threat. The treatment plan was not updated to include the patient's continued suicide level of yellow or her change in mental status to have an active suicide plan.

2. A review of the hospital document entitled "Risk Assessment," dated 4/22/21 at 1:11 p.m. and signed by Registered Nurse #2, revealed in part: "Patient Assigned Risk: Moderate (yellow) Moderate Risk: Monitor Q 15 minutes and document, search all belongings for contraband, Mouth checks after med administration, may attend off unit activities with staff, may use safety razors with supervision, Complete Suicide Risk Assessment daily, Yellow Suicide Precaution."

3. An interview was conducted with the physician of patient #2 on 4/27/21 at approximately 11:30 p.m. She stated she did not approve the transfer of patient #2 because the patient was stable for discharge when she put the discharge order in. When questioned if she was made aware of the patient's continued suicide risk level of yellow at 1:11 p.m., she stated she was not made aware. She further stated, "I would not discharge a patient home at a yellow level." When asked if she was made aware of the patient's plan to either overdose or hang herself if she was sent to another psychiatric facility, she stated, "No. I was never made aware."

4. An interview was conducted with Social Worker #1 on 4/27/21 at approximately 1:50 p.m. She stated, "My understanding was the mother was not made aware of the discharge until the morning of the 22nd. She called back and said she didn't feel comfortable with taking the patient home because she had said on the family therapy meeting that she would still continue to cut herself. The next thing I know I got a call from the insurance company saying that they were going to transfer the patient to another facility. I continued to make arrangements for a home discharge because that is what the physician had ordered but she was transferred to the other hospital."

5. A review of the hospital document entitled "Treatment Plan," dated 4/16/21, states: "Criteria for Discharge: Stable Mood, No suicidal thoughts, No self-harming behavior."

6. An interview was conducted with the Director of Therapy Services on 4/27/21 at approximately 10:40 a.m. She concurred patient #2's treatment plan was not updated, and the patient did not have a transfer order placed by the physician to send the patient to another hospital.

7. An interview was conducted with the Corporate Director of Quality and Compliance at 4:10 p.m. on 4/28/21. The Director concurred there was no Interagency Transfer Sheet found in the medical record of patient #2 showing the patient's guardian or the receiving hospital was notified of the patient's condition.

B. Based on record review and staff interview it was determined the facility failed to provide an appropriate discharge planning evaluation. This failure was identified in two (2) of two (2) medical records reviewed (patients #15 and 16). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #15 revealed the patient was admitted on 4/19/21 with a diagnosis of Schizoaffective Disorder. Case Management documentation revealed there was no discharge planning evaluation in the medical record until day of discharge on 4/28/21.

2. A review of the medical record for patient #16 revealed the patient was admitted on 4/16/21 with a diagnosis of Bipolar disorder. Case Management documentation revealed there was no discharge planning evaluation in the medical record until 4/28/21.

3. An interview was conducted with the Case Manager of the Acute Adult unit on 4/28/21 at 2:22 p.m. When asked about the discharge documentation in the medical record for patient #15, he stated, "I just discharged him today, I haven't had time to put it in there yet." He stated when they know they are going to be discharged, he works on the discharge information and meets with the patient in his office to do a discharge plan. He stated the physician does not know of discharge until the day of discharge. He stated the physician will keep the patient for ten (10) days, if they are court ordered for ten (10) days, before he will discharge the patients. He stated they will talk in therapy about discharge, but he completes his discharge planning on the day of discharge.

4. An interview was conducted with the Director of Clinical Services on 4/28/21 at 3:19 p.m. She concurred the discharge planning evaluation was not completed in a timely basis to ensure appropriate discharge of patient #15 and patient #16.

Based on record review, document review and staff interview it was determined the facility failed to allow a timely manner of discharge in one (1) out of twenty (20) records reviewed (patient #3). This failure had the potential to negatively impact the guardian of patient #3 the ability to find a suitable foster home placement.

Findings include:

1. A review of the medical record for patient #3 revealed an eleven (11) year old female admitted to the hospital for Depressive Disorder on 4/12/21. The patient's treatment plan showed she was supposed to receive family therapy as part of her care. The record shows no family therapy was provided to the patient until the day of discharge. The patient was discharged to a foster family that she was not made aware that she was going to until the day of discharge. The patient's discharge instructions did not provide the foster parents a discharge diagnosis. The family was not made aware of the patient's diagnosis at discharge.

2. A telephone interview was conducted with the Department of Health and Human Resources (DHHR) Case Manager of patient #3 on 4/21/21 at approximately 9:15 a.m. When discussing the possibility of discharge of the patient, she stated, "I talked to the social worker at the hospital on Monday (April 19th) and no mention was made about discharge. So, on the morning of the 20th, I receive a call telling me they are discharging her. There was an active investigation going on with her current foster home so she could not be placed there. I was scrambling trying to find a foster home that would take her. I finally get a foster family lined up and the hospital says there needs to be a family meeting with the new foster home parents before they discharge her. The foster father called and spoke with the hospital and was introduced to patient #3 at that time. She didn't even know for sure until that day that she would not be returning to her original foster home. I arrived at the facility with the foster parents to pick her up at 4:30 p.m. I had to wait until 6:30 p.m. before someone walked her down to us. I was handed a paper that had her medication list on it, a prescription and had her follow-up appointments on it. The discharge instructions didn't have any diagnosis or things to look out for on the paperwork."

3. A review of the hospital document given to patient #3's foster family, dated 4/20/21, revealed there was no discharge diagnosis or signature showing the foster family received the discharge instructions.

4. An interview was conducted with the Director of Clinical Services on 4/28/21 at approximately 3:20 p.m. She concurred there was no documentation to prove the foster family was made aware of the discharge diagnosis.

Base on record review, document review and staff interview it was determined the facility failed to provide necessary medical information when the patient was discharged/transferred in eight (8) out of twenty (20) medical records reviewed (patients # 1, 2, 3, 7, 8, 17,18 and 20). This failure has the potential to lead to missed medical and/or psychological medical information; therefore, leading to potential harmful treatment of the patients.

Findings include:

1. A review of the medical record for patient #1 revealed he is a seventeen (17) year old male with a history of depression, anxiety, post-traumatic stress disorder (PTSD) and conduct disorder. On 3/31/21 he was admitted to the hospital after having suicidal ideation, cutting, and becoming violent at the shelter he was residing in. Upon admission to the facility, he had a fifth metacarpal fracture and was wearing a splint with metal stays. On 4/6/21 he had to transfer to the local emergency room after hitting his already injured hand on the wall. On 4/10/21 while in the gym he injured his left knee. He was ordered by the physician's assistant to be transferred to the local emergency room on 4/11/21 due to swelling and pain in his left knee. When he returned to the facility, he was ordered crutches and a knee brace and was using a wheelchair in the facility. The record revealed the patient was transferred to the hospital following an incident on 4/14/21 in which he snorted a pill. He was eventually placed in the pediatric intensive care unit (PICU) and never returned to the facility.

2. A review of the hospital document entitled "Emergency Medical Care and Transfer," revised 1/17, states: "All staff will report complaint or statements made by a patient which indicate physical distress to the charge nurse. The charge nurse will assess the patient's physical status and report all findings to the patient's attending physician. A note will be made by the charge nurse in the patient's medical record of the physical findings, the time the patient's physician was notified and the physician's response. In case of an emergency, any physician member of the medical staff shall be permitted to do everything possible to save the life of a patient, employee, or visitor. This includes provision of care to a minor not accompanied by a parent or to an unconscious patient who presents with a life-threatening condition. Any employee, in any service/department, can initiate a Code Blue. Any employee trained in CPR can institute CPR as indicated. A registered nurse will be responsible for assessing the patient, visitor, or employee and will initiate appropriate life saving measures until Emergency Medical Services (EMS) arrives to transport. A registered nurse is responsible for notifying the patient's physician, family, and receiving medical facility immediately after transfer ... Print a copy of the patient's latest lab work results, (Medication Administration Record) MAR showing all medications the patient has received in the past twenty-four (24) hours, EKG when available, copy of the transfer order, check box with Highland Hospital billing number on it, and an Advance Directive Acknowledgement form. Send these items with the patient to the emergency room staff, along with a completed Interagency Transfer Sheet."

3. An interview was conducted with Registered Nurse (RN) #1 on 4/22/21 at approximately 4:10 p.m. She stated she filled the transfer paperwork out for patient #1 but didn't make a copy for the medical record.

4. On 4/28/21 at 4:10 p.m. the Corporate Director of Quality and Compliance concurred there was no Interagency Transfer Sheet found in the medical record of patient #1 showing the patient's guardian or the receiving hospital was notified of the patient's condition.

5. A review of the medical record for patient #2 revealed an eleven (11) year old female that was admitted to the facility on 4/15/21 with a diagnosis of Unspecified Mood Disorder. She was placed on the 2 East unit of the facility. On 4/22/21 the patient was ordered to be discharged home to the care of her mother by the physician at 12:04 p.m. The patient had been a suicide level of yellow (moderate risk) since her arrival to the hospital. The last suicide risk assessment was scored at 1:11 p.m. by the RN to which the patient continued to be a yellow risk level. The nurse did not notify the physician of the patient's continued yellow risk level. The patient's mother asked for her to be transferred to another psychiatric hospital because she didn't think the patient was safe to go home. Prior to the transfer the patient threatened to harm herself by either overdosing on her medications or hanging herself. The physician was not notified of the patient's threat. The treatment plan was not updated to include the patient's continued suicide level of yellow or her change in mental status to have an active suicide plan.

6. On 4/28/21 at 4:10 p.m. the Corporate Director of Quality and Compliance concurred there was no Interagency Transfer Sheet found in the medical record of patient #2 showing the patient's guardian or the receiving hospital was notified of the patient's condition.

7. A review of the medical record of patient #3 revealed an eleven (11) year old female admitted to the hospital for Depressive Disorder on 4/12/21. The patient's treatment plan showed she was supposed to receive family therapy as part of her care. The record revealed no family therapy was provided to the patient until the day of discharge. The patient was discharged to a foster family that she was not made aware that she was going to until the day of discharge. The patient's discharge instructions did not provide the foster parents a discharge diagnosis. The foster family was not made aware of the patient's diagnosis at discharge.

8. A telephone interview was conducted with the Department of Health and Human Resources (DHHR) Case Manager of patient # 3 on 4/21/21 at approximately 9:15 a.m. When discussing the possibility of discharge of the patient, she stated, "I talked to the social worker at the hospital on Monday (April 19th) and no mention was made about discharge. So, on the morning of the 20th, I receive a call telling me they are discharging her. There was an active investigation going on with her current foster home so she could not be placed there. I was scrambling trying to find a foster home that would take her. I finally get a foster family lined up and the hospital says there needs to be a family meeting with the new foster home parents before they discharge her. The foster father called and spoke with the hospital and was introduced to patient #3 at that time. She didn't even know for sure until that day that she would not be returning to her original foster home. I arrived at the facility with the foster parents to pick her up at 4:30 p.m. I had to wait until 6:30 p.m. before someone walked her down to us. I was handed a paper that had her medication list on it, a prescription and had her follow-up appointments on it. The discharge instructions didn't have any diagnosis or things to look out for on the paperwork."

9. A review of the hospital document given to patient # 3's foster family dated 4/20/21 revealed there was no discharge diagnosis or signature showing the foster family received the discharge instructions.

10. An interview was conducted with the Director of Clinical Services on 4/28/21 at approximately 3:20 p.m. She concurred there was no documentation to prove the foster family was made aware of the discharge diagnosis.

11. A review of the medical record for patient #7 revealed a fourteen (14) year old female that was admitted to the hospital with a diagnosis of Major Depressive Disorder. On 4/4/21 the record indicates the patient was involved in an altercation with a Behavioral Health Technician that required her to be transported to the hospital to be evaluated. The record did not include the required Interagency Transfer Sheet paperwork.

12. On 4/28/21 at 4:10 p.m. the Corporate Director of Quality and Compliance concurred there was no Interagency Transfer Sheet found in the medical record of patient #7 showing the patient's guardian or the receiving hospital was notified of the patient's condition.

13. A review of the medical record for patient #8 revealed a fifteen (15) year old male that was admitted to the hospital on 11/6/20 with a diagnosis of Psychosis. On 12/10/20 the patient was transported to a local emergency room with complaints of blood in his emesis confirmed by hemoccult. The medical record did not contain the required Interagency Transfer Sheet paperwork.

14. On 4/28/21 at 4:10 p.m. the Corporate Director of Quality and Compliance concurred there was no Interagency Transfer Sheet found in the medical record of patient #8 showing the patient's guardian or the receiving hospital was notified of the patient's condition.

15. A review of the medical record for patient #17 revealed an eleven (11) year old male that was admitted with a diagnosis of Major Depressive Disorder on 1/30/20. On 4/3/21 the patient was transported to the local emergency room due to him sticking a Trazodone pill in his ear. The medical record did not contain the required Interagency Transfer Sheet paperwork.

16. On 4/28/21 at 4:10 p.m. the Corporate Director of Quality and Compliance concurred there was no Interagency Transfer Sheet found in the medical record of patient #17 showing the patient's guardian or the receiving hospital was notified of the patient's condition.

17. A review of the medical record for patient #18 revealed a sixteen (16) year old female admitted to the hospital on 11/21/20 with a diagnosis of Major Depressive Disorder. On 12/1/20 the patient had to be transported to a local emergency room because she took a bottle of cleaning solution behind the nurse's desk and took it to the bathroom to drink it. The medical record did not contain the required Interagency Transfer Sheet paperwork.

18. On 4/28/21 at 4:10 p.m. the Corporate Director of Quality and Compliance concurred there was no Interagency Transfer Sheet found in the medical record of patient #18 showing the patient's guardian or the receiving hospital was notified of the patient's condition.

19. A review of the medical record for patient #20 revealed a fifteen (15) year old female admitted to the hospital on 12/7/20 with a diagnosis of suicidal ideation. On 12/20/20 the patient was taken to the local emergency room after it was reported she put a piece of metal in her left forearm. The medical record did not contain the required Interagency Transfer Sheet.

20. On 4/28/21 at 4:10 p.m. the Corporate Director of Quality and Compliance concurred there was no Interagency Transfer Sheet found in the medical record of patient #20 showing the patient's guardian or the receiving hospital was notified of the patient's condition.