HospitalInspections.org

Based on record review and interviews the facility failed to meet the Condition of Participation to protect and promote patient's rights as evidenced by not obtaining proper informed consent and not providing the correct information for patients to reach the patient advocate.

The findings are:

A. The facility failed to provide the patients with the correct number to contact the patient advocate for grievances. Refer to tag A-0118.

B. The facility failed to obtain proper written informed consent. Refer to tag A-0131.

Based on record review, observation and interview, the facility failed to inform the patients and/or the patient's representatives of the internal grievance process, including whom to contact to file a grievance. This deficient practice will likely prevent all patients from filing an internal complaint or grievance; and prevent all patients from exercising their patient rights.
The findings are:

A. Record Review of Patient Grievance Policy, Policy Number: 1800.23, finds: "All patients are made aware of the complaint procedure upon admission and throughout monthly patient training/staff training conducted by the Patient Advocate as incorporated in the patient rights. In addition, the name and contact number of the Patient Advocate is incorporated in the patient rights. In addition, the name and contact number of the Patient Advocate is posted in clear view on every unit."

B. Record review of the "Admission Packet, Attachment C Complaint and Grievance Process" on 04/03/2023 at 02:00 pm finds:
1. "Patient Advocate Extension 4979": when called on internal telephone system rings to another staff member who is not the Patient Advocate. The name of the Patient Advocate is not included on the form.
2. Contact information for the State Agency is not provided.

C. On 04/04/2023 at 01:30 pm during Observation of 3 patient units-Unit 1 South (adolescent unit), Unit 2 North (adolescent unit), and Unit 4 North (adult unit) found:
1. Patient Rights signs posted in hall on each unit informing the patients of the complaint and grievance process have the incorrect telephone number and extension for the Patient Advocate.
a. The internal extension "4979" when called rings to another staff member who is not the Patient Advocate. The Patient Advocate's name is not included on the sign.
b. The telephone number listed "575-520-2979" when called rings to a private individual not associated with the hospital.

D. On 04/04/23 at 01:30 pm, during an interview with Risk Management Coordinator Staff (S)2 confirms the telephone number and the extension listed on signs for the Patient Advocate are not the correct telephone number and extension.

E. On 04/04/2023 at 01:30 pm during Observation of 3 patient units-Unit 1 South (adolescent unit), Unit 2 North (adolescent unit), and Unit 4 North (adult unit). The State Agency contact information is not provided on the Patient Rights signs posted in the 3 patient units.

Based on record review and interviews the facility failed to obtain written consent from parents and/or legal guardians for the administration of psychotropic medications to 4 [P(patient)1, P3, P7, P8] out of 10 patients reviewed for involving parents and/or guardians in the care of minors. This failed practice can lead to a violation of patient rights due to the lack of informed consent.

The findings are:

A) Record review of the facility policy titled, "Informed Consent for Psychotropic Medication" revised on 07/2019 states on page 1, "All patients who have a psychotropic medication ordered, and the parent(s)/guardian of minors who have a psychotropic medication ordered, will be informed of the benefits risks involved in taking prescribed medication by the treating Practitioner. The nurse may also provide education and obtain consent in the event the Practitioner cannot make contact with guardian. The properly executed informed consent contains documentation of a patient's mutual understanding of and agreement for treatment with psychotropic medication through written signature; electronic signature or, when patient is unable to provide a signature, documentation of the verbal agreement by the patient or surrogate decision-maker. The treating Practitioner may alternatively document the Patient's or Legal Representative's informed consent and the substance of the informed consent process in the medical record. Except in emergency situations, informed consent will be obtained prior to administering psychotropic medication." Under "Procedure" it states, "2.2 The Practitioner RN or LPN [Registered Nurse or Licensed Practical Nurse] on the unit will obtain and witness the patient's (parent and/or) written consent to take prescribed medications on the Consent for Psychotropic Medication Sheet before medication is administered." On page 2, it states "4. When parent(s) or guardian are not physically available, telephone consent will be obtained.
4.1 Notation will be made on the medication education Sheet: telephone consent for the following medications obtained from parent/guardian name, time, and date".
4.2 The Practitioner who supplied the information regarding prescribed medications will sign the consent.
4.3 The parent/guardian will countersign the document when they come in.
4.4 A RN/LPN and clinical staff member can obtain or witness the phone approval of the parent/ guardian."

P1 Findings:
B) Record review of medical records for P(Patient)1 revealed the following:
1) Document titled, "Standardized Intake Assessment" dated 2/3/23 on Page 1, it states "Does Patient have a legal guardian?" the box for "Yes" has an "X".
2) Document titled, "Medication Consent For: Mood Stabilizers" has a sticker in the top right corner with P1's information on it, this sticker is dated 02/16/2023. In the box that states, "Medication Name" it is written "lithium". The second page of this document reveals:
a) The following statements have a line for patient initials next to them. The initials line is blank for the following statements: "The nature of my condition and the reasons for prescribing the specific medication has been explained to me."
"Alternative treatments and their benefits and disadvantages have been explained to me."
"The type of medication, the dosage, how often It must be taken and how it must be taken as well as how long it must be taken has been explained to me."
"I have informed the doctor of all of my allergies."
"I have informed the doctor of all medications I am currently taking including prescriptions, over- the-counter [sic] remedies, herbal therapies and supplements, aspirin and any other recreational drug or alcohol use."
"I have been advised whether I should avoid drinking alcoholic beverages."
"I am aware and accept that no guarantee about the results of the treatment has been made."
"I have been advised of the probable consequences of declining recommended or alternative therapies."
b) There is illegible writing on a line for patient initials for the statement, "The doctor has answered all of my questions regarding this treatment."
c) There is a statement "I authorize and direct [illegible writing], MD/DO [doctor of medicine/Doctor of osteopathic medicine], to provide treatment with the following medication [illegible writing]."
d) The line indicating "Patient or Legal Representative" there is an illegible signature, next to it the line indicating "Relationship to Patient/Legal Representative" there is illegible writing.
e) There are two witness signatures one indicates "2nd witness required for telephone consent", both lines are blank.
f) There is a statement, ". . . I have answered all questions fully, and I believe that the patient/legal representative (circle one) fully understands what I have explained." Neither patient or legal representative is circled. Below this statement is a line for the practitioner signature and the date and time. The date and time written are illegible.
g) There are lines for initials next to the statements "Copy given to patient" and "original placed in chart". Both lines are blank.
3) Document titled, "Medication Consent For: Mood [Stabilizers]" has a sticker in the top right corner with P1's information on it, this sticker is dated 02/16/2023. In the box that states, "Medication Name" it is written "Olanzapine". The second page of this document reveals:
a) The following statements have a line for patient initials next to them. The initials line is blank for the following statements: "The nature of my condition and the reasons for prescribing the specific medication has been explained to me."
"Alternative treatments and their benefits and disadvantages have been explained to me."
"The type of medication, the dosage, how often It must be taken and how it must be taken as well as how long it must be taken has been explained to me."
"I have informed the doctor of all of my allergies."
"I have Informed the doctor of all medications I am currently taking including prescriptions, over- the-counter [sic] remedies, herbal therapies and supplements, aspirin and any other recreational drug or alcohol use."
"I have been advised whether I should avoid drinking alcoholic beverages."
"I am aware and accept that no guarantee about the results of the treatment has been made."
"I have been advised of the probable consequences of declining recommended or alternative therapies."
b) There is illegible writing on a line for patient initials for the statement, "The doctor has answered all of my questions regarding this treatment."
c) There is a statement "I authorize and direct [illegible writing], MD/DO [doctor of medicine/Doctor of osteopathic medicine], to provide treatment with the following medication [illegible writing]."
d) The line indicating "Patient or Legal Representative" there is an illegible signature, next to it on the line indicating "Relationship to Patient/Legal Representative" there is illegible writing.
e) There are two witness signatures one indicates "2nd witness required for telephone consent", both lines are blank.
f) There is a statement, ". . . I have answered all questions fully, and I believe that the patient/legal representative (circle one) fully understands what I have explained." Neither patient or legal representative is circled. Below this statement is a line for the practitioner signature and the date and time. The date and time written are illegible.
g) There are lines for initials next to the statements "Copy given to patient" and "original placed in chart". Both these lines are blank.
4) Document titled, "Medication Consent For: Mood Stabilizers" has a sticker in the top right corner with P1's information on it, this sticker is dated 02/16/2023. In the box that states, "Medication Name" it is written "Clonidine". The second page of this document reveals:
a) The following statements have a line for patient initials next to them. The initials line is blank for the following statements: "The nature of my condition and the reasons for prescribing the specific medication has been explained to me."
"Alternative treatments and their benefits and disadvantages have been explained to me."
"The type of medication, the dosage, how often it must be taken and how it must be taken as well as how long it must be taken has been explained to me."
"I have informed the doctor of all of my allergies."
"I have informed the doctor of all medications I am currently taking including prescriptions, over- the-counter [sic] remedies, herbal therapies and supplements, aspirin and any other recreational drug or alcohol use."
"I have been advised whether I should avoid drinking alcoholic beverages."
"I am aware and accept that no guarantee about the results of the treatment has been made."
"I have been advised of the probable consequences of declining recommended or alternative therapies."
b) There is illegible writing on a line for patient initials for the statement, "The doctor has answered all of my questions regarding this treatment."
c) There is a statement "I authorize and direct [illegible writing], MD/DO [doctor of medicine/Doctor of osteopathic medicine], to provide treatment with the following medication [illegible writing]."
d) The line indicating "Patient or Legal Representative" there is an illegible signature, next to the "Relationship to Patient/Legal Representative" it is written [name of state child agency].
e) There are two witness signatures one indicates "2nd witness required for telephone consent", both lines are blank.
5) Document titled, "Medication Consent For: Mood [Stabilizers]" has a sticker in the top right corner with P1's information on it, this sticker is dated 02/16/2023. In the box that states "Medication Name" there is illegible handwriting. The second page of this document reveals:
a) The following statements have a line for patient initials next to them. The initials line is blank for the following statements: "The nature of my condition and the reasons for prescribing the specific medication has been explained to me."
"Alternative treatments and their benefits and disadvantages have been explained to me."
"The type of medication, the dosage, how often It must be taken and how it must be taken as well as how long it must be taken has been explained to me."
"I have informed the doctor of all of my allergies."
"I have informed the doctor of all medications I am currently taking including prescriptions, over- the-counter [sic] remedies, herbal therapies and supplements, aspirin and any other recreational drug or alcohol use."
"I have been advised whether I should avoid drinking alcoholic beverages."
"I am aware and accept that no guarantee about the results of the treatment has been made."
"I have been advised of the probable consequences of declining recommended or alternative therapies."
b) There is illegible writing on a line for patient initials for the statement, "The doctor has answered all of my questions regarding this treatment."
c) There is a statement "I authorize and direct [illegible writing], MD/DO [doctor of medicine/Doctor of osteopathic medicine], to provide treatment with the following medication [illegible writing]."
d) The line indicating "Patient or Legal Representative" there is an illegible signature, next to it the line indicating, "Relationship to Patient/Legal Representative" there is illegible writing.
e) There are two witness signatures one indicates "2nd witness required for telephone consent", both lines are blank.
f) There is a statement, ". . . I have answered all questions fully, and I believe that the patient/legal representative (circle one) fully understands what I have explained." Neither patient or legal representative is circled. Below this statement is a line for the practitioner signature and the date and time. The date and time written are illegible.
g) There are lines for initials next to the statements "Copy given to patient" and "original placed in chart". Both lines are blank.

C) During an interview with S(Staff)19, MD (Doctor of Medicine) on 04/05/2023 at 10:43 AM they were asked how the guardians/parents are involved in the care of patients it was stated, "They're our primary contact. We aren't allowed to do anything in their treatment without their permission, pharmacologically and/or non-pharmacologically [meaning medication related or not]." An example of the consents (2-5 above) was referenced in this interview. When asked about documenting this consent it was explained that it is documented in the provider notes and on the consent, the nurses are witness to these conversations as the nurses and provider are working at the same desk space. When asked if the consent indicates that it is a telephone consent, S19, MD pointed to the initials on the second page next to the statement, "The doctor has answered all of my questions regarding this treatment."

D) During an interview with S2, Risk Management Director on 04/05/2023 at 10:43 AM they explained that the provider did document in P1's notes that the legal guardian was contacted and consented to medications. The dates of this note and the consent in the chart could not be verified as the handwriting was illegible.

P3 Findings:
E) Record review of medical records for P3 revealed the following:
1) Document titled, "Standardized Intake Assessment" dated 1/17/23 on Page 1, it states "Does Patient have a legal guardian?" the box for "Yes" has an "X".
2) Document titled, "Medication Consent For: Mood Stabilizers" has a sticker in the top right corner with P3's information on it, this sticker is dated 01/17/2023. In the box that states, "Medication Name" it is written "lithium". The second page of this document reveals:
a) The following statements have a line for patient initials next to them. The initials line is blank for the following statements: "The nature of my condition and the reasons for prescribing the specific medication has been explained to me."
"Alternative treatments and their benefits and disadvantages have been explained to me."
"The type of medication, the dosage, how often It must be taken and how it must be taken as well as how long it must be taken has been explained to me."
"I have informed the doctor of all of my allergies."
"I have informed the doctor of all medications I am currently taking including prescriptions, over- the-counter [sic] remedies, herbal therapies and supplements, aspirin and any other recreational drug or alcohol use."
"I have been advised whether I should avoid drinking alcoholic beverages."
"I am aware and accept that no guarantee about the results of the treatment has been made."
"I have been advised of the probable consequences of declining recommended or alternative therapies."
b) There is illegible writing on a line for patient initials for the statement, "The doctor has answered all of my questions regarding this treatment."
c) There is a statement "I authorize and direct [illegible writing], MD/DO [doctor of medicine/Doctor of osteopathic medicine], to provide treatment with the following medication [written lithium]."
d) The line indicating "Patient or Legal Representative" there is an illegible signature, next to it the line indicating, "Relationship to Patient/Legal Representative" there is illegible writing.
e) There are two witness signatures one indicates "2nd witness required for telephone consent", both lines are blank.
f) There is a statement, ". . . I have answered all questions fully, and I believe that the patient/legal representative (circle one) fully understands what I have explained." Neither patient or legal representative is circled. Below this statement is a line for the practitioner signature and the date and time. The date and time written are illegible.
g) There are lines for initials next to the statements "Copy given to patient" and "original placed in chart". Both these lines are blank.

P7 Findings:
F) Record review of medical records for P7 revealed the following:
1) Document titled, "Standardized Intake Assessment" dated 1/24/23 on Page 1, it states, "Does Patient have a legal guardian?" the box for "Yes" has an "X".
2) Document titled, "Medication Consent For: Mood Stabilizers" has a sticker in the top right corner with P7's information on it, this sticker is dated, 01/24/2023. In the box that states "Medication Name" there is illegible handwriting. The second page of this document reveals:
a) The following statements have a line for patient initials next to them. The initials line is blank for the following statements: "The nature of my condition and the reasons for prescribing the specific medication has been explained to me."
"Alternative treatments and their benefits and disadvantages have been explained to me."
"The type of medication, the dosage, how often It must be taken and how it must be taken as well as how long it must be taken has been explained to me."
"I have informed the doctor of all of my allergies."
"I have informed the doctor of all medications I am currently taking including prescriptions, over- the-counter [sic] remedies, herbal therapies and supplements, aspirin and any other recreational drug or alcohol use."
"I have been advised whether I should avoid drinking alcoholic beverages."
"I am aware and accept that no guarantee about the results of the treatment has been made."
"I have been advised of the probable consequences of declining recommended or alternative therapies."
b) There is illegible writing on a line for patient initials for the statement, "The doctor has answered all of my questions regarding this treatment."
c) There is a statement "I authorize and direct [illegible writing], MD/DO [doctor of medicine/Doctor of osteopathic medicine], to provide treatment with the following medication [illegible writing]."
d) The line indicating "Patient or Legal Representative" there is an illegible signature, next to it the line indicating, "Relationship to Patient/Legal Representative" there is illegible writing.
e) There are two witness signatures one indicates "2nd witness required for telephone consent", both lines are blank.
f) There is a statement, ". . . I have answered all questions fully, and I believe that the patient/legal representative (circle one) fully understands what I have explained." Neither patient or legal representative is circled. Below this statement is a line for the practitioner signature and the date and time. The date and time written are illegible.
g) There are lines for initials next to the statements "Copy given to patient" and "original placed in chart". Both these lines are blank.

P8 Findings:
G) Record review of medical records for P8 revealed the following:
1) Document titled, "Psychosocial Assessment" dated 04/03/23 on Page 3, under "Family/Support System", the contact is listed as "Legal Guardian" and contact information is provided.
2) Document titled, "Medication Consent For: Mood Stabilizers", this document does not have a legible date on it. P8's name is written in the top right corner, first name only. In the box that states "Medication Name" there is illegible handwriting. The second page of this document reveals:
a) The following statements have a line for patient initials next to them. The initials line is blank for the following statements: "The nature of my condition and the reasons for prescribing the specific medication has been explained to me."
"Alternative treatments and their benefits and disadvantages have been explained to me."
"The type of medication, the dosage, how often It must be taken and how it must be taken as well as how long it must be taken has been explained to me."
"I have informed the doctor of all of my allergies."
"I have informed the doctor of all medications I am currently taking including prescriptions, over- the-counter [sic] remedies, herbal therapies and supplements, aspirin and any other recreational drug or alcohol use."
"I have been advised whether I should avoid drinking alcoholic beverages."
"I am aware and accept that no guarantee about the results of the treatment has been made."
"I have been advised of the probable consequences of declining recommended or alternative therapies."
b) There is illegible writing on a line for patient initials for the statement, "The doctor has answered all of my questions regarding this treatment."
c) There is a statement "I authorize and direct [illegible writing], MD/DO [doctor of medicine/Doctor of osteopathic medicine], to provide treatment with the following medication [illegible writing]."
d) The line indicating "Patient or Legal Representative" there is an illegible signature, next to it, the line indicating, "Relationship to Patient/Legal Representative" there is illegible writing.
e) There are two witness signatures one indicates "2nd witness required for telephone consent", both lines are blank.
f) There is a statement, ". . . I have answered all questions fully, and I believe that the patient/legal representative (circle one) fully understands what I have explained." Neither patient or legal representative is circled. Below this statement is a line for the practitioner signature and the date and time. The date and time written are illegible.
g) There are lines for initials next to the statements "Copy given to patient" and "original placed in chart". Both these lines are blank.
3) Document titled, "Medication Consent For: Mood Stabilizers", this document does not have a legible date on it. P8's first name only is written in the top right corner. In the box that states "Medication Name" there is illegible handwriting. The second page of this document reveals:
a) The following statements have a line for patient initials next to them. The initials line is blank for the following statements: "The nature of my condition and the reasons for prescribing the specific medication has been explained to me."
"Alternative treatments and their benefits and disadvantages have been explained to me."
"The type of medication, the dosage, how often It must be taken and how it must be taken as well as how long it must be taken has been explained to me."
"I have informed the doctor of all of my allergies."
"I have Informed the doctor of all medications I am currently taking including prescriptions, over- the-counter [sic] remedies, herbal therapies and supplements, aspirin and any other recreational drug or alcohol use."
"I have been advised whether I should avoid drinking alcoholic beverages."
"I am aware and accept that no guarantee about the results of the treatment has been made."
"I have been advised of the probable consequences of declining recommended or alternative therapies."
b) There is illegible writing on a line for patient initials for the statement, "The doctor has answered all of my questions regarding this treatment."
c) There is a statement "I authorize and direct [illegible writing], MD/DO [doctor of medicine/Doctor of osteopathic medicine], to provide treatment with the following medication [illegible writing]."
d) The line indicating "Patient or Legal Representative" there is an illegible signature, next to it the line indicating, "Relationship to Patient/Legal Representative" there is illegible writing.
e) There are two witness signatures one indicates "2nd witness required for telephone consent", both lines are blank.
f) There is a statement, ". . . I have answered all questions fully, and I believe that the patient/legal representative (circle one) fully understands what I have explained." Neither patient or legal representative is circled. Below this statement is a line for the practitioner signature and the date and time. The date and time written are illegible.
g) There are lines for initials next to the statements "Copy given to patient" and "original placed in chart". Both these lines are blank.
4) Document titled, "Medication Consent For: Mood Stabilizers", this document does not have a legible date on it. P8's first name only is written in the top right corner. In the box that states "Medication Name" there is illegible handwriting. The second page of this document reveals:
a) The following statements have a line for patient initials next to them. The initials line is blank for the following statements: "The nature of my condition and the reasons for prescribing the specific medication has been explained to me."
"Alternative treatments and their benefits and disadvantages have been explained to me."
"The type of medication, the dosage, how often It must be taken and how it must be taken as well as how long it must be taken has been explained to me."
"I have informed the doctor of all of my allergies."
"I have informed the doctor of all medications I am currently taking including prescriptions, over- the-counter [sic] remedies, herbal therapies and supplements, aspirin and any other recreational drug or alcohol use."
"I have been advised whether I should avoid drinking alcoholic beverages."
"I am aware and accept that no guarantee about the results of the treatment has been made."
"I have been advised of the probable consequences of declining recommended or alternative therapies."
b) There is illegible writing on a line for patient initials for the statement, "The doctor has answered all of my questions regarding this treatment."
c) There is a statement "I authorize and direct [illegible writing], MD/DO [doctor of medicine/Doctor of osteopathic medicine], to provide treatment with the following medication [illegible writing]."
d) The line indicating "Patient or Legal Representative" there is an illegible signature, next to it the line indicating, "Relationship to Patient/Legal Representative" there is illegible writing.
e) There are two witness signatures one indicates "2nd witness required for telephone consent", both lines are blank.
f) There is a statement, ". . . I have answered all questions fully, and I believe that the patient/legal representative (circle one) fully understands what I have explained." Neither patient or legal representative is circled. Below this statement is a line for the practitioner signature and the date and time. The date and time written are illegible.
g) There are lines for initials next to the statements "Copy given to patient" and "original placed in chart". Both these lines are blank.

H) Record review of the consents referenced in items B, E, F, and G reveal identical handwriting.

I) During an interview with S1, CEO (Chief Executive Officer), on 04/06/2023 at 9:30 AM the consents referenced in items B, E, F, and G were reviewed and it was confirmed that the legibility of these consents is an area of concern.

Based on record review and interviews the facility failed to update the discharge plan based on patient's living situation and needs outside of the hospital for 1 (P[patient]1) out of 10 patients reviewed for discharge planning. This deficiency can lead to unsafe discharges and increased re-admissions.

The findings are:

A) Record review of a facility document titled, "Communication & [and] Discharge Planning by Discipline Protocol" revised 2/2023 it states:
1) Under "Nursing", ". . . Discharge - Document any information related to discharge on the Multidisciplinary note, including updates to discharge changes. AT Discharge: Nurse is to review patient record to ensure all discharge planning activities are completed, documented, and signed which includes: -Discharge orders in HCS [electronic charting and order system] - Transition of Care Packet - Transition of Care Pg. [page] 1 'Discharge Plan Part 1' - Transition Record Part 2 'AfterCare/Discharge Plan' - Transition of Record Part 3- 'Discharge Medication Summary for Patient' - Transition of Record Part 4 'Safety Plan' - Transition of Record Part 5 'Advanced Directive/HealthCare Proxy Acknowledgement'. . . "
2) Under "Provider", ". . . Contact parent/guardian to review course of treatment, discharge plan, medications patient is discharging with, and answer any questions. Document in the Provider's Discharge Note. Enter discharge orders into HCS. Any change in discharge date upon entering into HCS, provider must cancel Discharge Orders or give orders to cancel to Unit Nurse."
3) Under "Therapist", ". . . *ANY CHANGE IN DISCHARGE PLANNING DATES WILL BE DISCUSSED AT TREATMENT TEAM. IF ANY CHANGES OCCUR AFTER TREATMENT TEAM, THE THERAPIST OR DESIGNEE IS RESPONSIBLE FOR DOCUMENTING CHANGE IN DISCHARGE PLANS IN LIVE TIME ON A MULTIDISCIPLINARY NOTE, INCLUDING [sic] WHO WAS NOTIFIED AND TIME/DATE."

B) Record review of facilities policy titled, "Aftercare/Discharge Plan" revised 01/2019 on page 1 under "Procedure" it states, ". . . 2. The nurse or therapist, in consultation with other clinical disciplines, completes the discharge plan and assures that all-important elements of the discharge plan/care are included. 3. The treatment team or designee addresses discharge planning with the family and patient during family therapy sessions and conferences on an ongoing basis. This is documented throughout the course of treatment in the medical record. 4. Program Staff Member reviews the plan upon discharge with the patient and/or family and obtains their signatures. 5. The therapist and nurse will sign the discharge instructions at the time of discharge. 6. The therapist or nursing staff will ensure understanding of the discharge plan by the patient and/or the patient's caretaker. . . 8. The therapist and/or discharge planner if appropriate, coordinates discharge planning with the community agency to which the patient is referred."

C) Record Review of medical records for P1 revealed the following:
1) Document titled, "Patient Demographic Profile" reveals "Admit Date/Time 2/03/23 11:53 [AM]" and Disch [discharge] Date/Time 2/11/23 6:31 [AM]"
2) Document titled; "Discharge Summary" signed by providers on 02/19/2023 reveals on page 1 that P1 was admitted for suicidal ideations. On page 2 it states, "Discharge Decision: The decision to discharge this patient was made as she has met her treatment goals.". On page 3 it states, "Consultation Team Discussion: The discharge decision was discussed with the entire team on the morning of 02/10/2023 and all were in agreement."
3) Document titled, "Transition of Record Part 2 Form [name of hospital]-1005" revised 7/14/22 states "Discharge Disposition" the box for "Home With" is checked and [name of child state agency] is written. Under "Mode of Transportation" the box for "Family Member" is checked and [name of child state agency] is written. At the bottom of this document, it states "I have received a copy of my transition record. . ." with signature lines for the patient and/or their parent/guardian. Both signature lines are blank.
4) Document titled "MD/PMHNP [Doctor of Medicine/Psychiatric-Mental Health Nurse Practitioner] Discharge Note" is signed and dated 02/10/23 9:00 AM.
5) Document titled "Multidisciplinary [sic] Progress Notes" has several notes regarding patients discharge:
a) "2/10/23 1617 [4:17 PM] Received phone call from [S(staff)15] [name of child state agency] worker regarding [P1]. He states [P1] was scheduled for discharge today, 2/10/23, however requested extension for 2/11/23 after speaking with [S6, Discharge Planner] on 2/9/23. He stated patient's Children's Youth Attorney, [name] and [name of child state agency] are requesting patient continue inpatient stay due to concerns with patient. [He/She] explains they are concerned patient has been, and possibly being trafficked and it is not in her best interest to discharge without a safe discharge plan. [He/She] reports that [he/she] was notified on 2/9/23 of patient's discharge and he has been working since her admission to find placement. [He/She] did state [he/she] has documentation from a prior stay that [name of facility] recommended RTC [residential treatment center] for patient, in which [P1] refused. [S15, Supervisor at state agency] requested an extension through Tuesday, 2/14/23, in order to have a discharge planning meeting and find placement, possibly TFC [treatment foster care] for P1. Notified I would contact the provider and call back."
b) "2/10/23 1626 [4:26 PM] Spoke to [S17] PMHNP [nurse practitioner] and discussed concerns for discharge. [They] agreed to having patient stay inpatient until discharge meeting on 2/13/23.
c) "2/10/23 1628 [4:28 PM] Called [S15, supervisor at state agency] at [name of state child agency] and notified [them] patient the provider agreed to continue inpatient care."
d) "2/10/23 1630 [4:30 PM] Contacted [S6, Discharge Planner] to notify discharge is canceled."
e) "2/10/23 1634 [4:34PM] Spoke to [staff at state child agency] to notify [them] I spoke with provider and patient would not discharge until discharge planning meeting."
f) "2/10/23 1639 [4:39 PM] Sent tiger text [internal secure messaging system] to notify concerns for discharge."
g) Below these comments there is a signature by S11, Director of Clinical Services dated 2/13/23.
6) Document titled "[name of agency] Nursing Progress Note" dated 02/11/2023 states "Patient left unit D/C [discharge] 2/11/23 @ [at] 6:31 [AM]. Patient was picked-up by [name of transportation company]. [Name of transportation company] also transporting other adult males. This RN [registered nurse] spoke to Nurse supervisor about males being transported with patient. Supervisor notified this RN to tell [name of transportation company] driver to put this patient in front of car (passenger side). This RN notified [name of transportation company] to put patient in front passenger side of car for all of transport."
7) Document titled "Final Ancillary Orders (non-med)" on page 10 there is an order for discharge. Discharge date is listed as 02/10/2023. The start time of this order is 2/9/23 19:00 [7:00 PM], stop time is blank.

D) During an interview on 04/06/2023 at 8:46 AM with S6, Discharge Planner, it was confirmed that the "Transition Record" (refer to 3 above) should be signed by patient and/or guardian during discharge.

E) During an interview on 04/05/2023 at 3:31 PM with S18, RN House Supervisor, it was explained that there are instances a discharge order may not be discontinued, such as, transportation fell through, but the discharge is still ordered. It was asked if it was reasonable to assume the order would be carried out if it was still active and it was stated, "usually the communication [between staff members] is real time."

F) During an interview on 04/04/2023 at 1:19 PM with S2, Risk Management Director, it was asked why this patient was discharged despite the communication notes 2/10/23 it was stated, "What happened is that the discharge was supposed to be canceled but [state child agency] did not cancel their transportation and patient got discharged." When asked if there were other staff members that could shed more light on the situation it was stated, "No, it was an error on both sides and there's nothing more to say about it."