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Based on medical record review, staff interview, and policy review, the facility failed to care plan for depression and anxiety for two (Patient #1 and #4) of nine patients reviewed who had anxiety and/or depression as an active problem. This had the potential to affect all of the facility's 65 active patients.

Findings include:

Review of the facility policy titled "Nursing Treatment Plans," approved 06/09/20, revealed the purpose was to develop a nursing plan of care for patients who are admitted with acute problems. Steps under the heading Procedure included:
1. Nursing Treatment Plans will be documented in the electronic medical record (EMR).
2. The admitting nurse will initiate nursing treatment plans on those patients who have current medical and psychiatric problems that will require nursing interventions and education while the patient is at the facility. The nurse will review the treatment plans with the patient and begin to provide any education needed.
3. The problem is to be resolved when it is considered addressed and completed.
4. If the problem will be continuing for the patient, it is not to be resolved.
5. If any new problems are determined while the patient is currently at the facility, the nurse will add the problem to the Treatment Plan section in EMR. Education is given to the patient by the nurse.


1. Review of the medical record revealed Patient #1 was admitted to the facility on 05/05/21 at 7:34 PM. The Admission Nursing Assessment from 05/05/21 listed Patient #1's current psychiatric issues as anxiety/depression.

Review of the medical record for Patient #1 revealed an entry dated 5/06/21 at 1:40 PM, in which Staff R documented Patient #1 currently had complaints of depression and restlessness/anxiety. The patient's affect was appropriate-good. On 05/07/21 at 9:45 AM, Staff R documented Patient #1 currently had complaints of depression and restlessness/anxiety. The patient's affect was depressed. On 05/08/21 at 9:32 AM, Staff R documented Patient #1 currently had complaints of depression and restlessness/anxiety. There was no care plan to address Patient #1's depression and anxiety.

On 05/08/21 at 4:27 PM, Patient #1 was found hanging by a room divider curtain and was discharged to another facility.

Interview on 10/26/21 at 12:47 PM, Staff C confirmed the lack of care plan.

2. Review of the medical record revealed Patient #4 was admitted to the facility on 10/19/21. Active diagnoses included major depressive disorder and anxiety disorder. The care plan for Patient #4 did not contain depression and/or anxiety.

The Admission Nursing Assessment from 10/19/21 listed Patient #4's current psychiatric issues as depression and anxiety.

Review of the record revealed on 10/27/21, Patient #4's mood was documented as Depressed.

Interview on 10/26/21 at 12:47 PM, Staff C confirmed the lack of care plan.

Based on medical record review, policy review and staff interview, the facility failed to ensure all questions on an Against Medical Advice form were completed for one (Patient #1) of two patients reviewed with Against Medical Advice forms reviewed. The facility's active census was 65.

Findings include:

Review of the facility procedure titled "Patients Requesting to Leave Against Medical Advice (AMA) or Against Staff Advice (ASA) - AMA/ ASA Block Procedure,) approved 03/15/21, revealed the purpose was to identify the responsibility to intervene when a patient desires to terminate treatment while in the detoxification unit (AMA) or the rehabilitation unit (ASA) and describe the standard procedure for intervening in such situations. The procedure to follow the policy included:

1. When a patient wants to leave treatment AMA or ASA, the staff will attempt to intervene (block the patient from leaving) by utilizing the AMA/ ASA Block Form in the patient's electronic medical record (EMR). This is to include the completion of the CSSRS Columbia-Suicide Severity Rating Scale (CSSRS) and then follow through of any self-harm indications.
2. If all attempts at intervention were unsuccessful and the patient chooses to leave, whether the discharge is AMA or ASA, the patient will need to complete the standard discharge material and standard discharge process. Remind the patient that they are responsible for securing their own transportation as the facility does not provide transport to those who leave the facility AMA or ASA.
3. Assist the patient in filling out the Continuing Care Plan (Discharge Plan) offering the patient a referral for further treatment. If the patient refuses the referral, record this in the patient's record.
4. The patient needs to meet with a nurse on duty to receive going home instructions. Back to work slips are not given. A statement stating number of days in the hospital may be given. The hospital will not provide prescriptions to patients or pharmacies for patients leaving AMA. Only when a patient is leaving AMA are they asked to sign the Release from Responsibility for AMA Discharge form, and the nurse witnesses the signature.
5. If the medical or nursing staff determines that the patient is impaired, poses a threat to self or others and no responsible party accompanies them as they leave the hospital, the facility's staff may contact the County Sheriff's department regarding the patient's leaving the hospital.
6. All interventions, phone calls, counseling sessions and other pertinent information is to be documented on the AMA/ ASA Block form in the patient's EMR.
7. Any patient who requests to be readmitted within 30 days of an AMA or ASA discharge will be assessed on an individual basis.

Review of the medical record revealed Patient #1 was admitted to the facility on 05/05/21 at 7:34 PM. Patient #1 attempted to leave the facility on 05/07/21. The Columbia-Suicide Severity Rating Scale Suicide Screening Form revealed question #1 was Wish to be Dead: Have you wished you were dead or wished you could go to sleep and not wake up? If No answer question 6. Patient #1 answered NO to question #1. Question #6 was Suicide Behavior: Have you done anything, started to do anything, or prepared to do anything to end your life? If Yes, monitor one on one and notify physician. Patient #1 did not answer question #6.

Interview on 10/28/21 at 9:55 PM, Staff S reviewed the above information and confirmed the missing answer.

Based on medical record review, policy review, and staff interview, the facility failed to complete a discharge summary for two (Patient #1 and #2) of four patients reviewed for discharge. This had the potential to affect all 65 active patients at the facility.

Findings include:

Review of the facility policy titled "Discharge Summary," approved 03/19/19, revealed the purpose was a discharge summary will be completed on every individual treated at the facility to document a summary of patient's treatment progress, assessment and Continuing Care Plans. The procedure included:

1. The discharge summary must be completed within fifteen (15) days after patient is discharged.
2. A discharge summary will be completed on all patients regardless of length of stay.
3. The discharge summary shall include at a minimum the following:
a. Clinical identification
b. Date of admission
c. Date of discharge
d. Date of birth
e. Signature and credentials of a person qualified to provide counseling services.
f. Counseling Treatment Summary:
i The degree of severity at admission and discharge for:
1. intoxication and withdrawal
2. Biomedical conditions and complications
3. Emotional behavioral cognitive conditions and complications
4. Treatment acceptance/ resistance
5. Relapse potential
6. Recovery environment
ii. Level of care and services provided during course of treatment.
iii. Patient's response to treatment
iv. Recommendations and/or referrals for additional alcohol and drug addiction treatment or other services.
g. Continuing Care Plan:
i. Outline of patient's plan for discharge
1. To include follow up with EAP (employee assistance programs)
2. Medical
3. Psychiatric, etc.
h. Physician's discharge note:
i. Final Diagnosis

The medical records for Patient #1 and Patient #2 were reviewed and did not contain discharge summaries. Patient #1 discharged on 05/08/21 and Patient #2 expired on 09/05/21.

Interview with Staff S on 10/28/21 at 9:55 AM verified the above findings.