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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.43 DISCHARGE PLANNING was out of compliance.

A0802- §482.43 (a)(6) DISCHARGE PLANNING- PATIENT RE-EVALUATION: The hospital's discharge planning process must require regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. Based on document reviews and interviews, the facility failed to reevaluate a patient's condition to identify changes that required modification of the discharge plan in one of one medical records reviewed of patients who attempted to self harm within 24 hours of discharge. (Patient #2)

Based on document reviews and interviews, the facility failed to reevaluate a patient's condition to identify changes that required modification of the discharge plan in one of one medical records reviewed of patients who attempted to self harm within 24 hours of discharge. (Patient #2)

Findings include:

Facility policies:

The Levels of Observation policy read, one to one (1:1) observation is defined as having one staff member assigned specifically to the patient at all times. Continuous visual monitoring is maintained, and staff remain close enough to the patient to intervene. Patients on a 1:1 status must have a physician's order. A licensed provider must order a level of observation change and include the clinical rationale for the level of observation change.

The Case Management/Discharge Planning Protocol policy read, criteria for discharge may include no further need for continuous skilled observation and treatment.

1. The facility failed to reevaluate a patient's condition to identify changes that required modification of the discharge plan.

A. Document Review

i. Medical record review revealed Patient #2 was a 13 year old admitted to the facility on 8/19/24 at 2:30 p.m. for self harming behavior. Emergency medications (administered to a patient without their consent when they engaged in behavior judged by a physician to be a psychiatric or behavioral emergency that placed themselves or others at risk of damage to life or limb) were administered to Patient #2 on 8/24/24, 8/26/24, and 8/27/24.

On 8/26/24 at 12:05 p.m., a provider's order was placed for 1:1 level of observation.

On 8/28/24 at 1:15 p.m., case management documentation revealed a referral was sent to a residential treatment center (RTC) for placement after discharge.

On 8/28/24 at 5:32 a.m., nursing documentation revealed Patient #2 exhibited bizarre behavior, impoverished speech (spoke less), and had a suicide attempt with a telephone cord following a phone call with their grandmother. At 5:03 p.m., nursing documentation read, Patient #2 was behavioral all day and required constant monitoring. Behaviors had increased with each request that had been denied for medication. Patient #2 had self-induced vomiting 10 minutes after they took their medication. At 7:02 p.m., nursing documentation revealed Patient #2 had been accepted to the RTC and their grandmother approved of the placement. Patient #2 had accepted placement when it was explained it was their only option aside from being with their grandmother. Therapy services and case management were arranging transportation.

On 8/29/24 at 12:35 p.m., the psychiatric provider's progress note read, Patient #2's grandmother would like to try for RTC placement.

On 8/29/24 at 6:57 p.m., nursing documentation revealed Patient #2's behaviors had escalated throughout the day. They had endorsed suicidal ideations and self-harmed by scratching. They were not engaged or easily directable.

On 8/30/24 at 10:00 a.m., a provider's order was placed to decrease Patient #2's level of observation from 1:1 to every 15 minutes. There was no rationale for the level of observation change in the medical record.

This was in contrast to the Levels of Observation policy which read, the licensed provider must order a level of observation change and were to include the clinical rationale for the level of observation change.

At 1:09 p.m., nursing documentation revealed Patient #2 admitted that going home caused them anxiety. When the nurse questioned Patient #2 about the anxiety, they backed up with a blank expression and walked into their room. The documentation indicated Patient #2's behaviors did not match their possible medication seeking behavior. Nursing documentation also revealed, with nursing discretion, due to Patient #2's discharge to their grandmother scheduled at 3:00 p.m., 1:1 observations remained in place to see Patient #2 through the behavior pattern they had exhibited for the last 3-5 days.

There was no evidence in the medical record that nursing staff had notified Patient #2's provider of the new behavior or to obtain a new order for the continued need for 1:1 observations.

Medical record review also revealed, at 2:05 p.m., Patient #2's behavior assessment score was zero. They scored negative on the suicide screening assessment at 2:35 p.m. and were discharged from the facility into their grandmother's care at 3:12 p.m.

This was in contrast to the psychiatric provider's progress note on 8/29/24 which revealed Patient #2's grandmother wanted RTC placement.

This was also in contrast to Patient #2's discharge criteria on their master treatment plan which indicated Patient #2 should have had improved stabilization in mood, thinking and/or behavior and no longer needed constant or close observation in order to be discharged.

On 8/30/24, the provider's discharge summary revealed Patient #2 was initially prepared to go to a RTC, but the 13 year old patient withdrew consent and was discharged to their grandmother. There was no consent, or refusal to consent, located in the medical record.

On 8/31/24 at 8:35 p.m., nursing documentation revealed Patient #2's grandmother called to inform the facility that Patient #2 had attempted to jump out of the car on the highway after discharge.

ii. Review of Patient #2's managed care authorization detail revealed the facility had sent Patient #2's insurance a request for RTC authorization on 8/29/24 and the outcome was pending.

B. Interviews

i. On 11/18/24 at 10:35 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated patients were placed on 1:1 observations when they were an imminent threat to themselves or someone else, had violent behaviors, acted out sexually, or if they were at risk for self harm. RN #1 stated 1:1 meant the patient had a staff member within six feet of them at all times. RN #1 stated it would be important to notify the patient's provider if 1:1 observations were needed because the provider needed to know if there had been a change in the patient's condition.

RN #1 also stated they would not want to send a patient home if they required 1:1 observations to remain safe. RN #1 stated patients could not go home if they were unsafe and were going to harm themselves. RN #1 stated if they felt a patient was not ready for discharge, they could stop the discharge and let the patient's therapist, case manager, and provider know so the discharge plan could be revised.

Additionally, RN #1 stated RTC was a long term psychiatric care facility. RN #1 stated 15 years old was the age of consent and if a 13 year old did not want to go to RTC, it would be the guardian's decision. RN #1 stated the need for RTC placement did not go away because a patient withdrew consent. RN #1 also stated it was important to ensure patients were ready for discharge to ensure their safety.

ii. On 11/14/24 at 10:00 a.m., an interview was conducted with RN #2, who cared for Patient #2 on the day they were discharged from the facility. RN #2 stated the plan was for Patient #2 to be discharged to RTC. RN #2 stated they did not know why Patient #2 did not go to RTC and did not know why Patient #2 was kept on 1:1 observations on the day of discharge. Additionally, RN #2 stated case management and therapy were responsible for discharge planning.

iii. On 11/18/24 at 11:11 a.m., an interview and live medical record review was conducted with Therapist #3, who oversaw Patient #2's family meeting and completed their safety plan on the day they were discharged from the facility. Therapist #3 stated they were not able to locate any documentation from therapy or case management that indicated if Patient #2 had been accepted to RTC or not. Therapist #3 stated case management was the primary person to obtain resources for patients outside of the facility. Therapist #3 stated Patient #2's RTC placement status would have been discussed in the treatment team meetings that occurred daily, but those meetings were not documented. Additionally, Therapist #3 stated they did not know if Patient #2's grandmother had withdrawn consent for RTC placement.

iv. On 11/14/24 at 10:19 a.m., an interview and live medical record review was conducted with case manager and utilization director (Director) #4. Director #4 stated they were the case manager for Patient #2. Director #4 stated they had sent a referral for RTC placement on 8/28/24, but were unable to locate any documentation regarding the outcome of the referral. Director #4 stated they believed Patient #2's RTC placement was pending insurance authorization. Director #4 also stated case managers were responsible for setting up aftercare for patients, but the clinical provider determined if patients were safe to discharge.

v. On 11/14/24 at 12:18 p.m., an interview and live medical record review was conducted with the director of clinical services (Director) #5. Director #5 stated other than the nursing documentation from 8/28/24, there was no documentation as to whether Patient #2 had been accepted into RTC in Patient #2's medical record. Director #5 stated they had discussed RTC placement with Patient #2 and they did not want to go. Director #5 stated they were not told about Patient #2's attempt to jump out of the car after discharge.

vi. On 11/14/24 at 1:34 p.m., upon request, the provider who discharged Patient #2 was unable to be interviewed as they were no longer employed at the facility.

vii. On 11/14/24 at 1:49 p.m., an interview and live medical record review was conducted with director of nursing (DON) #6. DON #6 stated Patient #2 had withdrawn consent for RTC placement and their preference was to go home with their grandmother. DON #6 stated they were not aware and should have been notified by staff of Patient #2's attempt to jump out of the car on the highway after they were discharged.

viii. On 11/18/24 at 2:32 p.m., an interview was conducted with psychiatric provider (Provider) #7. Provider #7 stated a patient's provider should have been notified if they were set to be discharged from the facility and 1:1 observations were still required. Provider #7 stated they would want to know if staff saw something the provider did not see in regard to patient safety. Provider #7 stated the patient's provider would have needed to determine if the patient had a barrier to discharge.

This was in contrast to Patient #2's nursing documentation from 8/30/24 which revealed Patient #2 was kept on 1:1 observations until they were discharged from the facility due to their behavior pattern that had occurred over the last 3-5 days. This was also in contrast to Patient #2's medical record review which revealed Patient #2's provider had not been notified of the need for continued 1:1 observations or the new behavior Patient #2 exhibited on the day of discharge. Additionally, this was in contrast to Patient #2's discharge criteria on their master treatment plan which indicated Patient #2 should not have been discharged with the need for continued constant or close observation.

Additionally, Provider #7 stated the age of consent was 15 years old and the need for RTC did not go away because a patient withdrew consent.

This was in contrast to Patient #2's discharge summary in which Patient #2's provider reported they were prepared to go to RTC, but had withdrawn consent although the patient was only 13 years old and was then discharged into their grandmother's care.

Furthermore, Provider #7 stated it was important to ensure a safe discharge plan to ensure patients with self injurious behaviors did not harm themselves after they left the facility.

This was in contrast to Patient #2's nursing documentation from 8/31/24 which revealed Patient #2 attempted to jump out of a car on the highway after they were discharged from the facility.