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Based upon record review and interview, the hospital failed to ensure all entries entered into the medical record were timed and dated by the person responsible for providing or evaluating the service provided. Findings:

Review of patient #1's medical record revealed physician progress notes dated 06/14/17, 06/15/17, 06/19/17, 06/22/17 and 06/26/17 that were not timed. S6 Psychiatrist was the author of the untimed progress notes.

Furthur review of patient #1's medical record revealed S7APRN wrote a letter "To Whom It May Concern"; however, the letter was not dated.

Based upon record review and interview, the hospital failed to evaluate and provide 1 of 6 sampled patients (Patient #1) with an appropriate discharge plan as evidenced by discharging Patient #1 from inpatient psychiatric services to home despite documenting that the patient was having suicidal and homicidal ideations and was in need of long term inpatient psychiatric hospitlization services. Findings:

Review of patient #1's medical record revealed the patient was admitted on 06/12/17 on a Physician Emergency Certificate (PEC) from the Emergency Department of Hospital A. According to the PEC, the patient was exhibiting suicidal ideations with a plan, and paranoia. On 06/13/17, a Coroner's Emergency Certificate was implemented for continued Suicidal Ideations.

Review of the Psycho-Social Assessment completed by S5RSW dated 06/13/17 at 1:00 p.m., revealed patient #1 was capable of learning skills through psychotherapy interventions to resolve suicidal and homicidal ideations, control anger and frustration, and to decrease paranoia. S5RSW further documented the patient had current homicidal and suicidal ideations with a plan to get a firearm and shoot hospital staff that abused him in Longview Texas. On 06/23/17 at 10:00 a.m., S5RSW documented patient #1 had continued thoughts of suicidal and homicidal ideations and he (S5RSW) was going to contact family members to discuss judicial proceedings for long term psychiatric placement.

Further review of patient #1's medical record revealed S6Psychiatrist wrote a letter dated 06/23/17 and addressed "To Whom It May Concern" related to patient #1 with the following "...multiple medications were tried without much success. He continues to exhibit symptoms of mood liability, intrusive thoughts, anger and agitation, impulsive behavior, and command auditory hallucinations asking to hurt himself and others. He has made homicidal threats towards (police lieutenant) and a nurse at (Hospital B) in Longview Texas. He plans to obtain a firearm with plans to shoot these individuals in the face..."

Review of a letter written by S7APRN (Advanced Practice Registered Nurse) (letter was not dated) related to patient #1 and addressed "To Whom It May Concern" revealed in part "The patient has suicidal ideations, increased paranoia, auditory hallucinations, depressed mood, social isolation, mood swings, irritability, is easily agitated and is hostile at times. He also has anxiety. He admitted to homicidal ideations, and has a plan to hurt others whom he felt had mistreated him in the past. He plans to use a gun...The patient has a history of multiple arrests and jail terms. These include cocaine possession and distribution, assault on an EMS worker, and armed robbery. The patient remains impulsive, a high risk for violence, and also has intrusive thoughts, poor insight, and poor judgement. The patient is still positive for auditory command hallucinations. Multiple medications have been tried for stabilization for this patient. He is not at baseline...Because of the above documentation, we feel that this patient would benefit from long term treatment at an inpatient facility, as he is a danger to himself, others, and is gravely disabled."

Further review of patient #1's medical record revealed on the day of discharge, 06/26/17, 8:00 a.m., S7RN documented "Behavior: Labile mood and affect, isolative and withdrawn, easily agitated. Aggravated this AM at everyone. He states to his therapist that he is homicidal and suicidal this morning..." Documentation by S5RSW dated 06/26/17 from 10:00 a.m. to 11:00 a.m. revealed "(patient #1) was present for group sessions and provided limited feedback towards activity. He was in a depressed mood due to suicidal or homicidal ideation towards self and individuals in Longview Texas."

Interview on 08/29/17 at 10:05 a.m. with S2RN/DON revealed after reviewing patient #1's medical record, she was asked about the patient requiring long term placement. Her response was that the letters written by S6Psychiatrist and S7APRN were for the judicial commitment patient's mother was implementing in order to obtain inpatient long term psychiatric placement.

On 08/29/17 at 1:10 p.m. a telephone interview was conducted with S6Psychiatrist. When asked about the letter written by her dated 06/23/17, S6Psychiatrist replied patient #1's mother was in the process of implementing a judicial commitment in order to obtain in-patient long term placement for the patient. S6Psychiatrist further added the mother wanted to take care of the commitment because she new the judge that would be handling the case. When asked about patient #1's behavior on the day of discharge, S6Psychiatrist replied when she assessed him he voiced no suicidal or homicidal ideations. When asked if she was aware of the assessments of patient #1 by the Registered Nurse and the Social Worker the day the patient was discharged on 06/26/17, she replied "no".

On 08/30/17 at 10:00 a.m. an interview was conducted with S5RSW. When asked about patient #1's behavior on the day of discharge, 06/26/17, S5RSW replied during the morning the patient was agitated and had suicidal and homicidal ideations; however, after speaking with the psychiatrist the patient's behaviors were better.

Two days after patient #1 was discharged, 06/26/17, the patient presented to the Emergency Department of Hospital A with the same complaints of Suicidal and Homicidal Ideations.

Based upon record review and interview, the hospital failed to ensure the discharge plan for 1 of 6 sampled patients (Patient #1) was reassesed prior to discharge when the patient voiced suicidal and homicidal ideations to S8RN (Registered Nurse) and S5RSW (Registered Social Worker) on 06/26/17 (day of discharge) prior to being discharged to home. Findings:

Review of patient #1's medical record revealed the patient was transferred on 06/12/17 from Hospital A on a Physician Emergency Certificate for suicidal ideation with plan and paranoia. On 06/13/17, a Coroner's Emergency Certificate was implemented for continued Suicidal Ideations. Review of the initial discharge planning revealed the patient was to be discharged to home.

Review of the Psycho-Social Assessment completed by S5RSW dated 06/13/17 at 1:00 p.m., revealed patient #1 was capable of learning skills through psychotherapy interventions to resolve suicidal and homicidal ideations, control anger and frustration, and to decrease paranoia. S5RSW further documented the patient had a current homicidal and suicidal ideations with a plan to get a firearm and shoot hospital staff that abused him in Longview Texas. On 06/23/17 at 10:00 a.m. S5RSW documented patient #1 continued thoughts of suicidal and homicidal ideations and he (S5RSW) was going to contact family members to discuss judicial proceedings for long term psychiatric placement.

Further review of patient #1's medical record revealed S6Psychiatrist wrote a letter dated 06/23/17 and addressed "To Whom It May Concern" related to patient #1 with the following "...multiple medications were tried without much success. He continues to exhibit symptoms of mood liability, intrusive thoughts, anger and agitation, impulsive behavior, and command auditory hallucinations asking to hurt himself and others. He has made homicidal threats towards (police lieutenant) and a nurse at (Hospital B) in Longview Texas. He plans to obtain a firearm with plans to shoot these individuals in the face..."

Review of a letter written by S7APRN related to patient #1 and addressed "To Whom It May Concern" (letter not dated) revealed in part "The patient has suicidal ideations, increased paranoia, auditory hallucinations, depressed mood, social isolation, mood swings, irritability, is easily agitated and is hostile at times. He also has anxiety. He admitted to homicidal ideations, and has a plan to hurt others whom be felt had mistreated him in the past. He plans to use a gun...The patient has a history of multiple arrests and jail terms. These include cocaine possession and distribution, assault on an EMS worker, and armed robbery. The patient remains impulsive, a high risk for violence, and also has intrusive thoughts, poor insight, and poor judgement. The patient is still positive for auditory command hallucinations. Multiple medications have been tried for stabilization for this patient. He is not at baseline...Because of the above documentation, we feel that this patient would benefit from long term treatment at an inpatient facility, as he is a danger to himself, others, and is gravely disabled."

Further review of patient #1's medical record revealed on the day of discharge, 06/26/17, 8:00 a.m., S7RN documented "Behavior: Labile mood and affect, isolative and withdrawn, easily agitated. Aggravated this AM at everyone. He states to his therapist that he is homicidal and suicidal this morning..." Documentation by S5RSW dated 06/26/17 from 10:00 a.m. to 11:00 a.m. revealed "(patient #1) was present for group sessions and provided limited feedback towards activity. He was in a depressed mood due to suicidal or homicidal ideation towards self and individuals in Longview Texas."

Review of the physician progress notes by S6Psychiatrist dated 06/26/17 (no time) revealed in part "...discussed at length about long term plan for long term hospitalization and the mother is working with a judge. He is willing to go home and stay with the parents. The parents will supervise him closely. He agreed not to go anywhere by himself until he gets his long term placement. He understands that if he has urges to hurt himself or others, he could still go to the emergency room and seek treatment..."

Interview on 08/29/17 at 10:05 a.m. with S2RN/DON revealed after reviewing patient #1's medical record, she was asked about the patient requiring long term placement. Her response was that the letters written by S6Psychiatrist and S7APRN were for the judicial commitment the patient's mother was trying to implement.

On 08/29/17 at 1:10 p.m. a telephone interview was conducted with S6Psychiatrist. When asked about the letter written by her dated 06/23/17, S6Psychiatrist replied patient #1's mother was in the process of implementing a judicial commitment in order to obtain in-patient long term placement for the patient. S6Psychiatrist further added the mother wanted to take care of the committment because she knew the judge that would be handling the case. When asked about patient #1's behavior on the day of discharge, S6Psychiatrist replied when she assessed him he voiced no suicidal or homicidal ideations. When asked if she was aware of the assessments of patient #1 by the Registered Nurse and the Social Worker the day the patient was discharged on 06/26/17, she replied "no".

On 08/30/17 at 10:00 a.m. an interview was conducted with S5RSW. When asked about patient #1's behavior on the day of discharge, 06/26/17, S5RSW replied during the morning the patient was agitated and had suicidal and homicidal ideations; however, after speaking with the psychiatrist the patient's behaviors were better.

On 08/30/17 at 11:00 a.m., a telephone interview was conducted with S8RN. When asked about patient #1, S8RN responded she did not really remember the patient. After describing the patient to her, S8RN related that if the Psychiatrist had seen the patient that morning and wrote a discharge order, then the patient was stable for discharge.

Even though P6Psychiatrist, S7APRN, S5RSW all identified patient #1 required inpatient long term placement, there failed to be documented evidence the discharge planning identified this need and placement was attempted. According to the discharge planning, the patient was instructed to follow-up with an outpatient psychiatric facility.

Interview on 08/30/17 at 1:05 p.m. with S9RN/Emergency Room Nursing Director from Hospital A revealed on 06/28/17, patient #1 presented to the Emergency Room accompanied by his mother with the same complaint of Suicidal and Homicidal Ideations. The ER Physician implemented a Physician Emergency Certificate. The patient stayed in the Emergency Room for 10 days until a Hospital could be found that would accept the patient and provide inpatient psychiatric care.

Review of the Dishcarge Planning policy #2056, effective 07/2010, revealed in part "Procedure: Potential for out-of-home placement will be assessed and appropriate level of care options for long term care will be explored with the patient and family. Review of the medical record for patient #1 revealed there failed to be documented evidence the hospital attempted to secure long term psychiatric placement even though it was documented the patient required this placement.