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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 §482.13 Patient Rights was out of compliance.

A-0131 STANDARD: (b)(2) INFORMED CONSENT The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. Based on interviews and document review, the psychiatric emergency department (PED) failed to ensure a patient's discharge disposition complied with their court-ordered involuntary commitment order. In addition, the facility did not obtain approval from the legal custodian, the Colorado Behavioral Health Administration (BHA), in accordance with the Colorado Revised Statutes (CRS) before discharging the patient to an unsupervised setting. This occurred in one of one records reviewed of a patient who presented to the PED on an IC hold. (Patient #4)

Based on interviews and document review, the psychiatric emergency department (PED) failed to ensure a patient's discharge disposition complied with their court-ordered involuntary commitment order. In addition, the facility did not obtain approval from the legal custodian, the Colorado Behavioral Health Administration (BHA), in accordance with the Colorado Revised Statutes (CRS) before discharging the patient to an unsupervised setting. This occurred in one of one records reviewed of a patient who presented to the PED on an IC hold. (Patient #4)

Findings include:

Facility policies:

The Alcohol and Drug Involuntary Commitments section of the Mental Health Hold for Involuntary Treatment policy read, the Department (Colorado Behavioral Health Administration) shall be the legal custodian of individuals involuntarily committed to treatment. Requests for early discharge and/or transfer to other treatment programs shall be submitted to the Colorado Behavioral Health Administration for approval.

The Informed Consent policy defined capacity as a person's ability to Understand the nature and consequences of a proposed treatment, including benefits, risks, side effects, and alternatives to the proposed treatment, and make a decision whether to undergo the proposed treatment. Informed Consent is consent given by a person or the person's legally authorized representative. The policy defined a patient's personal representative as the person with the right to make informed decisions regarding the patient's care. The Facility will obtain consent for admission and treatment to all programs except when the patient has been involuntarily admitted for treatment under state law.

References:

The Screening Assessment and Level of Care (LOC) forms, identified by staff as a psychiatric assessment/evaluation, determine the level of care needed for the patient, read, the psychiatric assessment/evaluation assists in acquiring information about a patient's immediate psychiatric needs and any psychiatric care and treatment the patient has received. The screening and LOC assessments contain patient background information, medical history, medication history, associated psychiatric conditions, and any collateral patient information from external facilities, friends, and family.

According to the Department of Human Services 2 CCR 502-1, Behavioral Health, Section 21.270 -Alcohol and Drug Involuntary Commitments, (C), the Department shall be the legal custodian of individuals involuntarily committed to treatment and (G) Requests for early discharge and/or transfer to other treatment programs shall be submitted to the Department for approval.

According to the Department of Human Services 2 CCR 502-1, Behavioral Health, Chapter 5 -Behavioral Health Residential and Level 3, Including ASAM 3.5 - Withdrawal Management Services, Part 5.9.1 Section Service Delivery and Setting (A) American Society of Addiction Medicine (ASAM) 3.5 - Residential Services are for individuals who have multifaceted treatment needs requiring a twenty-four (24) hour treatment environment, and who are unable to be properly treated at a lower level of residential care and (B)(2) the individual engages in behaviors and/or thought processes that contribute to impaired social, interpersonal, and/or vocational functioning, necessitating this highly structured twenty-four (24) hour treatment environment.

According to the Colorado Behavioral Health Administration (BHA) website https://bha.colorado.gov/for-people-in-colorado/involuntary-treatment/substance-use-commitment#substance-use-emergency-commitment, an Involuntary Commitment (IC) is a process in which a person is placed in substance use treatment for up to 270 days without their consent. During this period, they are enrolled in a treatment program that aligns with their needs and placed under the custody of the BHA. The BHA monitors their treatment progress and reports to the court as necessary. An IC follows an emergency commitment and is considered a last resort for individuals who refuse all voluntary substance use treatment, pose a danger to themselves or others due to their substance use, and can benefit from treatment once sober. A person must have refused voluntary treatment and meet one of two criteria: either they pose a danger to themselves or others, demonstrated through threats or acts of physical harm, or they are incapacitated to the extent that they present a danger to themselves or others.

1. The facility failed to receive and review a patient's IC hold order. Specifically, it did not ensure the patient's discharge disposition complied with the court-ordered IC hold and failed to obtain approval from the patient's legal custodian before they discharged the patient to an unsupervised setting, placing the patient's safety at risk and increasing their risk of relapse.

A. Document review revealed despite being on a court-ordered IC hold and having a documented inability to make safe decisions, Patient #4 was discharged to an unsupervised setting.

i. A review of the referral documents provided to the PED from a residential recovery center (an inpatient substance use disorder and mental health treatment center) for Patient #4 revealed the following:

a. On 12/4/24 at 11:00 a.m., the residential recovery center admitted Patient #4 for substance use treatment.

A review of Patient #4's Admission Assessment at the recovery center revealed Patient #4 required continuous 24-hour care and was placed in a Level 3.5 ASAM treatment program (structured residential setting with 24-hour care and monitoring, which falls under inpatient treatment), which provided structured, intensive residential care based on patient needs.

According to the Medical Evaluation performed on 12/4/24 at 11:30 a.m., Patient #4 was on a court-ordered IC hold due to substance use and had recently relapsed while on the IC hold.

b. On 12/5/24 at 7:30 p.m., emergency medical services (EMS) transported Patient #4 to an acute care emergency department (ED) for a medical evaluation. According to the Provider Note, recovery center staff told EMS not to leave Patient #4 unattended or discharge them since the court-mandated IC hold required them to receive substance use treatment at the residential recovery center.

ii. A review of the facility's PED screening and LOC assessment for Patient #4 on 12/6/24 revealed the following:

a. At 5:38 p.m., the PED received a referral from the residential recovery center, where Patient #4 was an inpatient. The referral requested the PED perform a psychiatric screening and LOC assessment for Patient #4.

b. At 6:17 p.m., Patient #4 arrived at the PED with staff from the residential recovery center. Upon arrival, intake specialist (Specialist) #1 asked the residential recovery center staff accompanying Patient #4 to remain during the screening and LOC assessment. However, the recovery center staff left before Specialist #1 completed the assessments.

At 7:20 p.m., Specialist #1 documented Patient #4 was on a court-ordered IC hold and obtained collateral information for Patient #4's screening assessment from the referral and medical records the residential recovery center provided.

At 7:42 p.m., Specialist #1 completed the screening and LOC assessment for Patient #4 and reviewed the results with Provider #2, who recommended against admission and referred Patient #4 to intensive outpatient treatment.

Additionally, Specialist #1 documented they presented and reviewed the screening and LOC assessments with the PED intake supervisor, the administrator on call (AOC), and the chief executive officer (CEO) before they discharged Patient #4.

At 8:33 p.m., Specialist #1 reviewed the recommendation for intensive outpatient treatment with Patient #4, and Patient #4 signed the Screening Assessment and Personalized Treatment Recommendation form.

At 8:45 p.m., Patient #4 was discharged to an unconfirmed location without supervision.

Upon request, the facility could not provide evidence that it had received and reviewed Patient #4's court-ordered IC hold, attempted to coordinate the patient's return to the residential recovery center, complied with the IC hold requirements, or obtained approval from the patient's legal custodian before discharge. Additionally, the facility could not confirm Patient #4 was discharged to a safe and supervised location.

Furthermore, these events and the facility's failure to provide evidence contrasted with CSR 2 CCR 502-1, Behavioral Health, Section 21.270 - Alcohol and Drug Involuntary Commitments, which stated individuals on an IC hold were under the custody of the BHA and required BHA approval before discharging or transferring a patient to ensure compliance with the court-ordered IC hold and continuity of court-ordered treatment.

B. Interviews revealed staff failed to review the court-ordered IC hold and medical records from the recovery center, leaving them unaware Patient #4 was an inpatient with 24-hour oversight for substance use relapse risk. As a result, they discharged the patient to an unsupervised setting.

i. On 1/29/25, at 8:00 a.m., Specialist #1 was interviewed. Specialist #1 stated they did not understand how to apply an IC hold at the facility or assess a patient with one. Specialist #1 also stated they did not know what actions to take when a patient on an IC hold did not meet admission criteria. Specialist #1 stated while they believed an IC hold mandated treatment, they did not know whether or how an IC hold would be enforced at the facility.

Specialist #1 stated they did not receive or review the court-ordered IC hold for Patient #4. They also stated they did not know Patient #4 was receiving inpatient substance use disorder treatment at the residential recovery center, which led them to discharge the patient unsupervised.

ii. On 1/29/25 at 9:11 a.m., assessment supervisor (Supervisor) #3 was interviewed. Supervisor #3 stated an IC hold was a court-ordered hold that required a patient to receive substance use treatment and specified the treatment the patient had to receive. Additionally, Supervisor #3 stated staff should have been provided the IC hold order and reviewed the court-ordered treatment outlined in the IC hold order.

Supervisor #3 stated patients who were admitted for inpatient substance use treatment exhibited impaired judgment, engaged in risky behaviors, and had an increased risk of overdose when unsupervised.

These interviews conflicted with Patient #4's medical records from the residential recovery center, which stated Patient #4 had been admitted as an inpatient to an ASAM Level 3.5 treatment program for continuous 24-hour, structured, intensive care based on Patient #4's substance disorder treatment needs.

Additionally, these interviews conflicted with 2 CCR 502-1, Behavioral Health, Chapter 5, which stated individuals with substance use disorders admitted to ASAM Level 3.5 residential care had impaired social behaviors and thought patterns and needed 24-hour highly structured and monitored care.