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Based on a review of facility documents and staff interviews, the facility failed to complete patient Discharge Suicide Risk Assessments for 9 of 10 patients (Patients #1-4 & 6-10) and Discharge Safety Plans for 7 of 10 patients (Patients #1-2, 4, 6-8, & 10) according to facility documentation policy and form requirements. Incomplete and inconsistently documented Discharge Suicide Risk Assessments and Safety Plans placed all potentially suicidal patients at risk for suicide upon discharge. In addition, the facility failed to ensure Daily Suicide Risk Assessment forms were completed on 7 of 10 patients on suicide precautions (Patients #1-4, 7-8 & 10). This form updated the status of each patient's suicidality and thus ensured current information was available to determine the effectiveness of interventions and to guide future treatment planning. This issue had the potential to impact all suicidal patients at the facility.

Findings were:

Facility policy #PC-D-1 entitled "Discharge Planning and Aftercare," last reviewed 12/15/17, included the following:
"INTERDISCIPLINARY DISCHARGE INSTRUCTIONS/PLAN
8. The Discharge Safety Crisis Plan will be completed, signed by patient/guardian and staff, copied and given to patient upon discharge. Discharge educational materials on "Suicide Prevention" are also given to the patient ..."

Facility policy #PC-S-4 entitled "Special Precautions," last revised 8/19/15, included the following:
"16. When a patient no longer presents risk in identified area of precaution, precautions must be discontinued with an order from the licensed independent practitioner ...
SUICIDE PRECAUTIONS
Any patient displaying self-injurious behavior geared to suicide, verbalizing suicidal ideation, is unable to contract for safety or who is assessed to be at a heightened risk for suicide may be placed on precautions ..."

Facility policy #PC-A-1 entitled "Nursing Assessments," last revised 8/19/15, included the following:
"The nursing re-assessment (12-Hr Nursing Assessment) shall include the following elements: ...
b. Risk assessments ...
9) Suicide
c. Review of special precautions and observation level ..."

Patient #1 was admitted to Austin Oaks Hospital on 11/10/17. Admitting orders on 11/10/17 at 9:00 a.m. included that Patient #1 be admitted with diagnosis of "Major Depressive Disorder." He was ordered to be on suicide and elopement precautions. Patient #1 continued on Suicide Precautions until his discharge from the facility on 11/14/17.

A Discharge Suicide Risk Assessment form for Patient #1 was only partially completed upon his discharge. It had no staff signature, and no signature on the line labeled "MD who reviewed and approved assessment and discharge decision." There was no date or time on the form. The assessment form included the following item: "Was the patient on suicide precautions or heightened observations for suicidal ideation or self-injurious behaviors in the past 24 hours?" The unknown individual completing the form had written an "X" under "No" as the answer. Patient #1 was had continued on suicide precautions the entire time he was at the hospital and up to the moment of discharge.

A Discharge Safety Plan for Patient #1 was signed by a Licensed Profession Counselor (LPC) on 11/12/17 at 4:00 p.m. It was also signed by the mother of Patient #1. There was no signature of the patient on the form. There was no signature in the area that read, "MD review and approval."

Daily Suicide Risk Assessment forms were included in the patient record of Patient #1. The Assessment on 11/10/17 at 8:21 p.m. was blank except for two checked boxes at the top indicating no new suicidal thoughts or behavior. It was not a complete form or assessment. The record included no Suicide Risk Assessment for 11/13/17. The patient was discharged on 11/14/17.

Patient #3 was admitted to the facility on 12/20/17. She was placed on precautions for suicide, self harm and aggression. The Daily Suicide Risk Assessments on 12/27/17 and 12/28/17 were left completely blank. On 12/26/17, only the very top of the form was completed and did not address whether there were or were not any changes in the patient's clinical presentation and did not indicate whether there were changes in her risk status for suicide.

Patient #4 was admitted to the hospital on 12/21/17. She was on precautions for suicide, self harm and elopement until the moment of her discharge on 12/31/17. Her Discharge Safety Plan included no patient signature, no staff signature and no signature of the physician who reviewed and approved the form. The Discharge Suicide Risk Assessment for Patient #4 was included in the clinical record, but was completely blank.

Patient #8 was admitted to the facility on 12/19/17 with major depressive disorder. She was placed on precautions for suicide and self harm. The Daily Suicide Risk Assessment on 12/22/17 was left completely blank - a date she was documented to have been engaging in self harm behaviors. The Daily Suicide Risk Assessment on 12/14/17 was only partially completed, again without addressing changes in the patient's clinical presentation or whether there were changes in her risk status for suicide.

These are representative examples of the issues noted repeatedly in the patient records as described above.

In an interview with Staff #5, RN, on 1/9/18 at 12:25 p.m. in the facility conference room, she stated, "The Discharge Suicide Risk Assessment is supposed to be completed on the date of discharge and it's usually done by the therapist of each patient. The Continuing Care Plan is also usually completed by the therapist. Then they give a copy to the patient, their parents, and one copy stays in the chart." When asked exactly what the Daily Suicide Risk Assessment form was and how it was used, she stated, "That's an assessment that's done daily to assess for suicidality. It's not a brand new form, we've used it for a number of months now. It should be done each day."

In an interview with Staff #1, Director of Risk Management, on the morning of 1/9/18 at approximately 9:40 a.m. in the facility conference room, she stated, "That ...form got handed down from corporate ..." Staff #1 agreed that the form was inconsistently and incorrectly completed.

The above findings were all confirmed in an interview with the facility CEO and other administrative staff on the afternoon of 1/9/18 in the facility conference room.

Based on a review of facility documentation and staff interviews, the facility failed to ensure discharge documents, specifically the Continuing Care Plan, was made available for each patient and his/her parent or legally authorized representative for 1 of 10 patients (Patient #1). In addition, for the same patient, the facility failed to ensure patient and family involvement in the discharge planning process.

Findings were:

Facility policy #PC-D-1 entitled "Discharge Planning and Aftercare," last reviewed 12/15/17, included the following:
"INTERDISCIPLINARY DISCHARGE INSTRUCTIONS/PLAN
8. The Discharge Safety Crisis Plan will be completed, signed by patient/guardian and staff, copied and given to patient upon discharge. Discharge educational materials on "Suicide Prevention" are also given to the patient.
9. Nursing, therapist and care management staff will complete Discharge Instructions/Plan. The Discharge Instructions/Plan form will be given to the discharging patient and contain the following information:
a. Record of discharge prescriptions given to the patient
b. List of current medications upon discharge
c. Explanation of medication instructions and continued treatment
d. Post discharge goals
e. Aftercare level of treatment recommended ...

DISCHARGE EDUCATIONAL MATERIALS
12. Educational materials provided to the patient at discharge will be designated on the "Patient Discharge Instructions/Plan. Suicide Prevention materials will be provided to every patient at the time of discharge.

DISCHARGE PLAN SENT TO NEXT PROVIDER
13. Using contact information on the Discharge Instructions/Plan, along with the Psychiatric Evaluation, History and Physical, Discharge Orders and relevant laboratory reports are faxed to the next care provider within five days of discharge ..."

A review of the clinical record of Patient #1, a 15-year-old male, revealed a Continuing Care Discharge Plan/Patient Instructions for Home Medications form was completed on 11/14/17, the date of discharge for Patient #1. It was signed by a facility therapist, nurse, and by an individual identified in staff interview as the patient's probation officer. The line the probation officer signed was labeled, "Family/Support Person Signature." The signature line for the patient to sign included only the handwritten note "pt refused to sign." There was no indication the patient's parents were aware of the information included in the Discharge Plan.

In a telephone interview with the mother of Patient #1 on 1/8/18 at 6:21 p.m., she stated, " ...I didn't get a copy of ... the care plan when [Patient #1] was discharged. Suddenly I found out he was being discharged even after I'd spoken with the facility the day before. They didn't tell me it was going to happen then. I knew they were thinking about it, and I disagreed with the idea. But then suddenly it was done."

In an interview with Staff #6, a facility LMSW, on 1/9/18 at 12:40 p.m. in the facility conference room, she stated, "When I complete the Continuing Care Plan, I don't give it to the parent necessarily. I think it needs to go to the person who's going to be in charge of the patient upon discharge. In this case, it would have been the probation officer because [Patient #1] was going back to juvenile. That person would have needed to know all that information."

In an interview with Staff #5, RN, on 1/9/18 at 12:25 p.m. in the facility conference room, she stated, "The Discharge Suicide Risk Assessment is supposed to be completed on the date of discharge and it's usually done by the therapist of each patient. The Continuing Care Plan is also usually completed by the therapist. Then they give a copy to the patient, their parents, and one copy stays in the chart."

These findings were confirmed in an interview with the facility CEO and other administrative staff on the afternoon of 1/9/18 in the facility conference room.