HospitalInspections.org

Based on interview and record review the hospital failed to ensure four of 30 sampled patients (Patient 16, Patient 17, Patient 1, and Patient 30) were provided safe discharge (D/C) planning when:

1.a. Patient 16's Master Treatment Plan (MTP) was not reviewed after change in Patient 16's behavior (on 3/23/25 night shift).

1.b. Patient 16's family member (FM) 1 was not notified of Patient 16's D/C plan.

1.c. Patient 16's order for cancellation of D/C was not followed.

1.d. Patient 16's intake assessment was not completed and provider was not consulted before Patient 16 was returned to the locked unit.

1.e. Patient 16 was D/C'd to FM 2's home (Patient 16's identified trigger for suicidal ideation [SI - thoughts about ending one's own life]).

2. Patient 17 was D/C'd home without a plan for ensuring safe self care.

3. There was no documentation from physician indicating Patient 1 was no longer a danger to self before D/C from the hospital.

4. Patient 30 was D/C'd to FM 5 without confirmation of legal documentation for guardianship.

These failures had the potential to result in Patient 16, Patient 17, Patient 1, Patient 30 and Patient 3 to have unsafe D/Cs and negative physical and mental health outcomes.

Findings:

1.a. During a review of Patient 16's "Discharge Summary (DS)," dated 3/27/25, the DS indicated, "History of Present Illness: Patient [16] was a 14-year-old. . . currently was brought in here [hospital] on 5150 hold for being danger to self and for having suicidal ideation with plan to run into the traffic. . . Admission Diagnoses: 1. Major depressive disorder, recurrent, severe, with psychotic features. 2. Posttraumatic stress disorder. . . Course of Hospitalization: Patient . . . was admitted to Adolescent Psychiatric Unit, on 03/16/2025, involuntarily [against will]."

During a review of Patient 16's "Physician Orders (PO)," dated 3/24/25 at 9 a.m., the PO indicated, "D/C Home."

During a concurrent interview and record review on 5/7/25 at 8:20 a.m. with Medical Doctor (MD) 1, Patient 16's "Master Treatment Plan Review (MTPR)," dated 3/21/25 was reviewed. The MTPR indicated Patient 16 had an incident on 3/20/25 of severe agitation, claiming to hear music and was given an emergency medication injection. MD 1 stated there was no MTPR for Monday 3/24/25 after Patient 16 had an incident on 3/23/25 at 7:25 p.m. and was given an emergency medication injection. MD 1 stated a MTPR should have been done on 3/24/25 after Patient 16's change in behavior on 3/23/25.

During a concurrent interview and record review on 5/7/25 at 8:33 a.m. with MD 1, Patient 16's "Nursing Night Shift Notes (NNSN)," dated 3/23/25 were reviewed. The NNSN indicated Patient 16 was scratching at her arms, was not redirectable, was anxious, trying to harm herself and emergency medication injection was given on 3/23/25 at 7:25 p.m.

During a review of the hospital's policy and procedure (P&P) titled, "Multidisciplinary Treatment Planning," dated 3/25/25. The P&P indicated, "2. A Master Treatment Plan is required for all patients within 72 hours of admission to guide individualized care, establish measurable treatment goals, and ensure a coordinated, patient centered approach to recovery. Including functional status in the treatment plan ensures that care strategies address cognitive, behavioral, emotional, and social capabilities, optimizing patient outcomes and discharge readiness. The Master Treatment Plan is fluid and should be reviewed and updated based on the patient's progress or changes in behavior or mental status. . . 4. Discharge Planning & Continuity of Care Identification of discharge criteria and readiness indicators. . . The discharge plan and goals shall address the living situation, continuing treatment/aftercare, medication, safety, and support."

1.b. During an interview on 5/5/25 at 4:23 p.m. with Patient 16's Family Member (FM) 1, FM 1 stated the hospital did not contact her regarding Patient 16's discharge plan. FM 1 stated she informed Case Manager (CM) 2, the morning of 3/24/25 that she had not been contacted about Patient 16's D/C plan. CM 2 stated she would call FM 1 back. CM 2 called FM 1 back and stated Patient 16 had been D/C'd and was in route to FM 1's home. FM 1 stated the nurse had called the night prior (3/23/25) to report that Patient 16 had an incident of self harm and was given medications to calm the behavior. FM 1 stated she was concerned that Patient 16 was not ready to be discharged and was still a danger to herself. FM 1 requested that CM 2 have Patient 16 return to the hospital. FM 1 stated CM 2 called and stated the Nurse Practitioner (NP) gave an order to cancel the D/C and he would see Patient 16 the next morning (3/25/25). FM 1 stated she received a call from Licensed Marriage and Family Therapist (LMFT) stating that Patient 16 had returned to the hospital but did not meet criteria for readmission and threatened to call Child Protective Services (CPS) if FM 1 did not accept Patient 16 home. FM 1 stated Patient 16 was D/C'd to FM 2 on 3/24/25. FM 1 stated one week later Patient 16 was admitted to another behavior hospital for self harm behaviors.

During an interview on 5/7/25 at 8:38 a.m. with MD 1, MD 1 stated patients with SI were at highest risk of suicide within the first 15 days after D/C.

During a concurrent interview and record review on 5/7/25 at 9:04 a.m. with Interim Chief Nursing Officer (ICNO), Patient 16's "Social Services Progress Notes (SSPN)," dated 3/17/25 through 3/24/25 were reviewed. ICNO stated there was no note indicating FM 1 was notified of Patient 16's D/C plan details and follow up appointments.

During a concurrent interview and record review on 5/7/25 at 9:12 a.m. with MD 1, Patient 16's "SSPN," dated 3/24/25 at 10 a.m. was reviewed. The SSPN indicated FM 1 found out Patient 16 was D/C'd the morning of 3/24/25 after Patient 16 was already in transport van on her way to FM 1's home. The SSPN indicated FM 1 was upset and could not receive Patient 16 home at that time due to safety concerns. MD 1 stated the team needed to collaborate with FM 1 for Patient 16's safe D/C and document the discussions.

During a review of the hospital's P&P titled, "Discharge of Patients," dated 4/10/25. The P&P indicated, "If the patient is a minor, the case manager and/or nursing staff will communicate and coordinate the discharge time with the legal guardian."

During a review of the hospital's P&P titled, "Discharge Planning," dated 3/25/25. The P&P indicated, "6. The Case Manager, with the patient's consent, engages family or caregivers in planning to ensure they are prepared to support the patient post-discharge."

1.c. During a concurrent interview and record review on 5/7/25 at 4:40 p.m. with CM 2, Patient 16's "SSPN," dated 3/24/25 at 10 a.m. was reviewed. CM 2 stated she called FM 1 regarding D/C of Patient 16 and FM 1 expressed concern about the D/C and stated Patient 16 had threatened to kill herself when she returned home. CM 2 stated she called NP who gave an order to cancel Patient 16's D/C and keep her until 3/26/25. CM 2 stated she went to inform Registered Nurse (RN) 3 of the NP order, but Patient 16 was already in route to FM 1's home via the hospital transport van.

During a concurrent interview and record review on 5/8/25 at 2:54 p.m. with RN 3, Patient 16's "Nursing Progress Notes (NPN)," dated 3/24/25 was reviewed. RN 3 stated she was assigned care of Patient 16 on 3/24/25. RN 3 stated she D/C'd Patient 16 at approximately 10 a.m. RN 3 stated she became aware that Patient 16 was returning to the hospital when CM 2 informed her that NP canceled Patient 16's D/C. RN 3 stated she did not contact the Physician or NP regarding the canceled D/C.

During an interview on 5/8/25 at 8:22 a.m. with NP, NP stated CM 2 notified him that Patient 16 was having SI while in route to FM 1's home. NP stated he gave a verbal order to cancel Patient 16's D/C but did not speak to an RN. NP stated he was waiting for a RN to contact him for the order.

1.d. During a concurrent interview and record review on 5/7/25 at 9:35 a.m. with MD 1, Patient 16's medical record (MR) was reviewed. There was no Intake Assessment (IA) in the MR for Patient 16's return to hospital on 3/24/25. MD 1 stated Patient 16 needed to be reassessed by a physician or NP to determine if criteria for readmission was met.

During a concurrent interview and record review on 5/7/25 at 9:40 a.m. with MD 1, Patient 16's "SSPN," dated 3/24/25 at 1:09 p.m. was reviewed. The SSPN indicated LMFT contacted FM 1 and explained that Patient 16 did not meet criteria for admission. MD 1 stated LMFT was not able to make the determination if Patient 16 did not meet criteria for readmission. MD 1 stated intake RN should have assessed Patient 16 and contacted a physician or NP.

During an interview on 5/7/25 at 2:35 p.m. with RN 2, RN 2 stated she was the RN in the intake area (where patients are assessed for admission to the hospital) on 3/24/25. RN 2 stated she was not informed that Patient 16 was returning to the hospital, did not complete an intake assessment and did not communicate with the physician or NP regarding Patient 16.

During an interview on 5/8/25 at 2:54 p.m. with RN 3, RN 3 stated Patient 16 was taken to the locked unit by CM 2 at approximately 2 p.m. RN 3 stated an intake assessment was not completed. RN 3 stated she did not communicate with NP or physician when Patient 16 returned to the locked unit.

During an interview on 5/7/25 at 9:45 a.m. with ICNO, ICNO stated when Patient 16 returned to the hospital on 3/24/25 a new patient packet should have been completed including contraband screening, belongings list and intake assessment by therapist, RN, and psychological evaluation by physician. ICNO stated a physician or NP should have been notified of Patient 16's return to the hospital and assessed Patient 16 for readmission.

During an interview on 5/7/25 at 2:35 p.m. with RN 2, RN 2 stated a skin assessment, contraband search, and face to face patient handoff was not done on 3/24/25 when Patient 16 returned to the locked unit.

During an interview on 5/8/25 at 8:22 a.m. with NP, NP stated it was expected that a provider would have seen Patient 16 and done a new intake assessment and evaluation. NP stated the process would be the intake RN would call the on-call NP or physician to accept the admission. NP stated it was not acceptable to take Patient 16 back to the locked unit without any assessment. NP stated he would expect the RN on the unit to contact NP or physician to get orders for medications and monitoring. NP stated returning Patient 16 to the locked unit without a physician order could be considered being held against her will.

During an interview on 5/8/25 at 2 p.m. with LMFT, LMFT stated CM 2 informed her that Patient 16 was returning to the hospital. LMFT stated she assessed Patient 16 upon return to the hospital and determined Patient 16 did not meet criteria for readmission. LMFT stated she did not notify the intake RN, physician or NP.

During a review of the hospital's P&P titled, "Admission Protocol," dated 8/24/22. The P&P indicated, "When admission is deemed appropriate, the Intake staff will call the physician, submitting the information gathered in the intake process. The physician makes the final determination regarding admission of the patient. The procedure for voluntary admission is as follows: . . . 4. Intake RN meets with patient and conducts medical triage. . . 6. Intake RN or clinician completes the Intake assessment. . . 8. When patient is medically appropriate a psychiatrist is notified and presented with the patient's symptoms. The patient is admitted per the psychiatrist's assessment of presenting symptoms. . . 10. Intake then obtains consents. 11. Once the consent for admission has been signed, the patient will be escorted to the nursing floor. In the event that consents cannot be obtained at the time of admission, intake will make up to three additional attempts to secure consent. If, after these attempts, consent remains unobtainable or the patient or family refuses to sign, the consent documentation will be marked accordingly to reflect that consent was not obtained. . . If the patient is admitted, they will receive a contraband search, which will include wanding patient's belongings that will go with them to the unit. The patient will then be taken to the exam room for the skin check and body check."

1.e. During a concurrent interview and record review on 5/7/25 at 8:41 a.m. with MD 1, Patient 16's "Application for up to 72 hour Assessment, Evaluation and Crisis Intervention (5150)," dated 3/16/25 was reviewed. The 5150 indicated, ". . . youth [Patient 16] expressed suicidal ideation [SI] with no plan and an increase in urges to self-harm. . . Youth noted that there was not specific trigger to this recent increase but did note over the past week she has been having conflict with her father [FM 2]. Youth reported feeling misunderstood by him and that she does not feel that he is receptive to her when she tries to having [sic] conversations about how she is feeling. Youth stated that her father. . . continued to bring up her diet and exercise which was triggering to the youth. Youth acknowledged overall she does not feel "stable with my mental health" and that any triggering conversation would "put me over the edge." MD 1 stated Patient 16 identified FM 2 as a trigger for her SI.

During a concurrent interview and record review on 5/7/25 at 8:45 a.m. with MD 1, Patient 16's "Master Treatment Plan (MTP)," dated 3/17/25 was reviewed. The MTP indicated, "Post-Discharge Goal(s) (Patient's own words) To not go back to my dads." MD 1 stated Patient 16's therapist and CM should have explored the reasons that Patient 16 did not want to go to FM 2's home. MD 1 stated there was no documentation that the reasons were explored with Patient 16.

During an interview on 5/7/25 at 9:51 a.m. with MD 1, MD 1 stated psychosocially the hospital team "dropped the ball" for Patient 16 by not ensuring a safe D/C to FM 1's house and ultimately D/C'd to FM 2's home, who Patient 16 identified was a trigger for her SI.

During a review of the hospital's P&P titled, "Discharge Planning," dated 4/10/25. The P&P indicated, "Discharge planning begins at the time of admission. Based on input from the patient, family/significant other, physician and members of the multidisciplinary team, a discharge plan is developed. . . Patient will be discharged to the least restrictive environment, taking the patient's choices into consideration and complying with that choice when possible."

2. During a review of Patient 17's "5150," dated 6/10/24, the 5150 indicated, "[Patient 17] was gravely disabled [GD - unable to provide basic personal needs for food, clothing, or shelter] . . . refused to eat a complete meal, she refuses to adhere to her prescribed medication and she is urinating in a bucket as opposed to using the toilet. . . presents as paranoid, guarded and uncooperative. . . unable to formulate a viable plan for food and refused third party assistance. . . was observed drinking contaminated water from a bucket. . . Per [FM 3] [Patient 17] gives away the food they provide her. She stopped taking her psych meds [medications] and she refuses to complete activities of daily living. . . showering, changing into clean clothes and using the bathroom in an appropriate manner. [Patient 17] refuses to have food in the house."

During a review of Patient 17's "Intake Assessment (IA)," dated 6/11/24, the IA indicated, "Patient Designated Family Caregiver to Assist in Aftercare Plan: [FM 3 and FM 4]."

During an interview on 5/7/25 at 3:31 p.m. with ICNO, ICNO stated when Patient 17 was identified as GD.

During a concurrent interview and record review on 5/8/25 at 9:35 a.m. with MD 2, Patient 17's "Riese Petition [determines a person's ability to refuse medication to treat mental disorder] - Medication Capacity Petition (RP)," dated 6/12/24 was reviewed. The RP indicated Patient 17 suffers from Schizoaffective disorder (mental illness including paranoid thoughts, depression, mania and unable to care for self). The RP indicated Patient 17 was not aware of her mental disorder and was not able to understand the behaviors that led to involuntary hospitalization. The RP indicated Patient 17 was not able to understand the risks and benefits of medications, was not able to rationally understand and evaluate information regarding informed consent and had minimal participation in treatment decisions. MD 2 stated Patient 17 was refusing medications to treat her mental disorder. MD 2 stated the court authorized the facility to administer the medications to Patient 17.

During a concurrent interview and record review on 5/8/25 at 9:38 a.m. with MD 2, Patient 17's "PPN," dated 6/16/24 was reviewed. The PPN indicated, Patient 17 had "poor discharge planning, no viable safety plan and poor participation in treatment." MD 2 stated Patient 17 was considered gravely disabled meaning she was unable to secure food, clothing and shelter for self. MD 2 stated Patient 17 needed assistance with activities of daily living. MD 2 stated decisions about patient care and D/C planning were made as a collective team with input from CM, therapist, RN, and physician.

During a concurrent interview and record review on 5/8/25 at 9:42 a.m. with MD 2, Patient 17's "Interdisciplinary Team (IDT - group of health care providers)," dated 6/14/24, was reviewed. The IDT indicated Patient 17 would be monitored for improvement over weekend and tentative D/C based on improvement. MD 2 stated there was no IDT completed before Patient 17's D/C on 6/17/24. MD 2 stated IDT should have been done to decide if Patient 17 had improved over the weekend and had a safe plan for D/C.

During a concurrent interview and record review on 5/8/25 at 9:45 a.m. with ICNO, Patient 17's "SSPN," dated 6/13/24 through 6/17/24 were reviewed. ICNO stated there was no plan to ensure Patient 17 was able to care for herself after D/C. ICNO stated FM 3 and FM 4 were not notified of Patient 17's D/C plan.

During a review of Patient 17's "Nursing Progress Notes (NPN)," dated 6/17/25 at 11:36 a.m., the NPN indicated Patient 17 was D/C'd via hospital transport.

During a review of the hospital's P&P titled, "Multidisciplinary Treatment Planning," dated 3/25/25. The P&P indicated, "2. A Master Treatment Plan is required for all patients within 72 hours of admission to guide individualized care, establish measurable treatment goals, and ensure a coordinated, patient centered approach to recovery. Including functional status in the treatment plan ensures that care strategies address cognitive, behavioral, emotional, and social capabilities, optimizing patient outcomes and discharge readiness. The Master Treatment Plan is fluid and should be reviewed and updated based on the patient's progress or changes in behavior or mental status. . . 4. Discharge Planning & Continuity of Care Identification of discharge criteria and readiness indicators. . . The discharge plan and goals shall address the living situation, continuing treatment/aftercare, medication, safety, and support."


51320

3. During a review of Patient 1's "5150," date 3/19/25, the 5150 indicated Patient 1 was on an involuntary (against their will) hold for SI.

During a review of Patient 1's "IA," dated 3/19/25, the IA indicated Patient 1 stated "I am going to hang myself."

During a review of Patient 1's "Nursing Admission Assessment (NAA)," dated 3/19/25, the NAA indicated Patient 1 was banging her head against the wall and tried to strangle herself with her shirt. Patient 1 was unable to be redirected, was placed on a one-to-one observation and received emergency medication for danger to self.

During a review of Patient 1's "PO", the PO indicated emergency medications administered to Patient 1 on:

3/19/25 at 7:06 p.m. - Ativan (medication for relaxation) 2 mg (milligrams) and Benadryl (medication for relaxation) 50 mg IM (Intramuscular injection - medication that goes into a muscle for absorption) for severe agitation.

3/20/25 at 11:40 a.m. - Seroquel (medication for psychosis) 20 mg po (by mouth) for agitation, Ativan 2 mg and Benadryl 50 mg po for severe agitation.

3/20/25 at 11:45 a.m. - Benadryl 50 and Ativan 2 mg IM now for severe agitation.

During a review of Patient 1's "Nursing Day shift note (NDSN)," dated 3/20/25, the NDSN indicated Patient 1 was on a one to one observation for SI.

During a review of Patient 1's "Psychiatric Evaluation (PE)," dated 3/20/25, the PE indicated Patient 1's estimated length of stay was one to three days, prognosis (outcome) was poor and plan of care to address aggressive/violent behaviors.

During a review of Patient 1's "Discharge Aftercare Plan (DAP)," dated 3/20/25, the DAP indicated Patient 1 was D/C's from the facility at 5 p.m.

During a concurrent interview and record review on 5/7/24 at 9:47 a.m. with MD 1, Patient 1's MR was reviewed. MD 1 stated there was no physician progress note documentation regarding Patient 1's change in behavior and no determination that she was not a danger to self prior to D/C.

During a review of the hospital's P&P tilted, "Discharge Planning," dated 3/25/25, the P&P indicated, "Discharge Planning is intended to maintain continuity of care, maintain progress achieved during treatment, and minimize the risk of relapse or readmission."

4. During a review of Patient 30's "5150," dated 4/28/25, the 5150 indicated Patient 30 was on an involuntary hold for SI.

During a concurrent interview and record review on 5/8/25 at 4:48 p.m. with Licensed Case Social Worker (LCSW) 1, Patient 30's "Psychosocial Assessment (PA)," dated 4/29/25 was reviewed. PA indicated Patient 30's mother had passed away and Patient 30 was living with FM 5. The PA indicated Patient 30 felt FM 5 did not want her anymore and had started drinking again. LCSW stated there was no documentation in the MR indicating FM 5 had legal guardianship of Patient 30.

During a concurrent interview and record review on 5/8/25 at 3:21 p.m. with CM 1, Patient 30's MR was reviewed. CM 1 stated there was no documentation that she addressed Patient 30's request for alternative living arrangements. CM 1 stated she assumed FM 5 was the legal guardian of Patient 30 as he had signed the treatment consents.

During a review of Patient 30's "DAP," dated 4/6/25, the DAP indicated Patient 30 was D/C'd to FM 5.

During an interview on 5/8/25 at 5:02 p.m. with ICNO, the ICNO stated staff needed to verify legal guardianship before signing consents for treatment of adolescent patients and to ensure safe D/C of patient.

During a review of the hospital's P&P tilted, "Discharge of Patients," dated 4/10/25, the P&P indicated, "If the patient is a minor, the case manager and/or nursing staff will communicate and coordinate the discharge time with the legal guardian."