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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 §482.43 Discharge Planning was out of compliance.

A-0802: The hospital's discharge planning process must require regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. Based on document review and interviews, the facility failed to ensure patients on M-1 holds (an involuntary 72-hour mental health hold) were evaluated for changes in condition over the full three-day mental health hold intended to keep them safe from imminent self-harm prior to discharge in one of 10 patient medical records reviewed.

Based on document review and interviews, the facility failed to ensure patients on M-1 holds (an involuntary 72-hour mental health hold) were evaluated for changes in condition over the full three-day mental health hold intended to keep them safe from imminent self-harm prior to discharge in one of 10 patient medical records reviewed (Patient #2).

Findings include:

Facility policies:

The Involuntary Certification policy read, the purpose of this policy is to ensure that ethical considerations and proper protocol are followed in accordance with legal mandates for the initiation of involuntary commitments to inpatient psychiatric treatment and evaluation at the facility. The following criteria should be used to determine whether enactment of an Emergency Mental Illness Report and Application (M-1 mental health hold) is indicated. Under Colorado law, a 72-hour hold is mandatory when the following criteria are present: i. A person appears to have a mental illness and as a result of such mental illness, appears to be an imminent danger to self or others. ii. A person appears to be mentally ill, and as a result, gravely disabled (incapable of making informed decisions about or providing for his or her essential needs). Under Colorado law, professionals may temporarily commit a mentally ill person into custody, or cause such person to be taken into custody and placed in a facility of the Department of Human Services for a 72-hour treatment and evaluation. It is the policy of the facility to comply with Colorado statutes and rules concerning the initiation and execution of the M-1 hold. All individuals presenting for an assessment will be assessed to determine the lowest level of care appropriate to meet their individual needs. When it is determined that any patient who has been assessed is mentally ill, and as a result of such mental illness, appears to be in imminent danger to others or to himself or appears gravely disabled and he or she is not willing to sign in voluntarily, the evaluator must initiate assertion of a 72-hour hold. Discontinuation of an Involuntary Hold (mental health hold): If the patient has been admitted and no longer meets the requirements for involuntary treatment before the hold has expired, the discharging physician will obtain a second opinion from the Medical Director prior to the hold being discontinued. The second opinion will be documented. If the Medical Director agrees with the opinion of the discharging professional, an order to discontinue the hold will be completed by the discharging physician. The patient can either discharge voluntarily or seek sign-in voluntarily.

Short-Term Certification: Any person who has first been detained for 72 hours evaluation and still requires treatment and won't sign in voluntarily may be certified for short-term treatment under the following conditions: a. A staff psychiatrist has analyzed the person's condition and has found the patient to be mentally ill and, as a result of mental illness, a danger to others or self, or gravely disabled and, b. The person has been advised of the availability of, but has not accepted voluntary treatment. c. the person has accepted voluntary treatment; however reasonable grounds exist to believe the person will not remain in a voluntary treatment program.

The Discharge Planning - Acute policy read, clinical staff will ensure that discharge planning provides for continuing care to meet the individual's assessed needs at the time of discharge, including formal and informal supports. Procedure: Clinical staff provides information to individuals and to other health professionals in a timely manner of the need for planning discharge. It is the overall goal of the treatment team to facilitate and implement a safe and effective discharge plan prior to the patient's discharge. Acute patients will be seen for a face-to-face evaluation by the attending physician on the day of discharge.

The Suicide Risk Assessment and Management policy read, it is the facility's policy to create an environment of care that will foster the accurate identification and successful management of patients who are at increased risk for suicide or self-destructive behaviors. Patients at higher risk for suicide or self-destructive behaviors require intensive support, active supervision, frequent re-assessment and indicated protective measures for their emotional and physical well-being at all times. Discharge Planning: A well-conceived discharge plan is an important element in the safe management of the suicidal patient and sets the stage for a successful recovery. Discharge planning for the patient identified as being at risk for suicidality shall follow normal discharge planning protocols as outlined in the facility's Discharge Planning policy and procedure.

The Shift to Shift Report policy read, it is the facility's policy to maintain consistency in planning and implementation of treatment. Communication of pertinent information regarding patients or unusual occurrences on the unit will be provided to the on-coming shift. Shift report sheets will be available to staff members to use for reference and written comment. Used as a tool by the nurse to give a report of shift activities and pertinent information from the preceding shift report.

1. The facility failed to ensure a patient placed in the facility on a mental health hold was evaluated and treated for the entire duration of the 72 hours intended to keep her safe from imminent harm to herself. Six days after being discharged home from the facility, the patient was found dead.

A. Document review

i. Patient #2's medical record was reviewed. The Emergency Mental Illness Report and Application (mental health hold form) in the medical record revealed prior to Patient #2's admission to the facility, Patient #2 was found unconscious twice and both times brought to an emergency department (ED) in one week's time. The mental health hold form revealed on 4/9/23, she was admitted medically at a separate hospital for a suspected Ambien (medication used to help with sleep) overdose in the setting of a past history of suicide attempts. Patient #2 was placed on a 72-hour mental health hold starting on 4/9/23 at 6:14 p.m.

a. The Nursing Admission Assessment revealed Patient #2 was admitted to the facility on 4/10/23 at 1:00 a.m. from the ED.

b. Review of Patient #2's medical record revealed she was at the facility from 4/10/23 to 4/12/23. Record review revealed her discharge date and time was to have been on 4/12/23 at 6:14 p.m., the expiration time of the 72-hour mental health hold, but she was discharged early on 4/12/23 at 9:00 a.m. This was nine hours and 14 minutes before the mental health hold, placed to keep her safe from imminent harm to herself, expired.

c. A Notice for Certification and Certification for Short-Term Treatment (short-term cert) was dated 4/11/23 at 2:53 p.m. and signed by Physician #1. This notice revealed Patient #2 was originally detained for a 72-hour evaluation, her condition was analyzed, and she was found to be mentally ill, and as a result of mental illness, a danger to herself. The notice stated Patient #2 accepted voluntary treatment; however, reasonable grounds existed to believe she would not remain in a voluntary program. The bottom section of this notice had a handwritten note by Physician #1 which read, "Safety plan has been completed for patient to discharge to her father; however patient is attempting to discharge in an alternative scenario that has not been deemed to be safe and reliable."

d. The Discharge Plan Part II revealed she was discharged from the facility on 4/12/23 at 9:00 a.m. with her father.

This was in contrast to the Involuntary Certification policy which read, for discontinuation of the mental health hold, if the patient no longer met hold criteria, the discharging physician would obtain a second documented opinion from the Medical Director prior to the hold being discontinued. If the Medical Director agreed with the opinion of the discharging professional, an order to discontinue the hold would be completed.

There was no evidence in the medical record that showed the medical director was contacted for a second opinion prior to discharging the patient earlier than the 72-hour hold expiration date and time.

This was also in contrast to the Suicide Risk Assessment and Management policy which read, patients at higher risk for suicide or self-destructive behaviors required intensive support, active supervision, frequent re-assessment, and protective measures for their emotional and physical well-being at all times. The policy also stated a well-conceived discharge plan was an important element in the safe management of the suicidal patient in order to set the stage for a successful recovery.

ii. A review of the shift reports, which were lists of patients on each unit along with patient information such as date of birth, involuntary or voluntary status at the facility, expiration date and time of mental health holds, allergies, and any changes in health was conducted on two separate occasions.

a. Shift reports dated 5/8/23 revealed of the six units at the facility, there were 16 patients on mental health holds. Of these 16 patients, three patients' mental health hold expiration dates or times were incorrect. For example, one patient was placed on a mental health hold on 5/6/23 at 2:14 p.m. The shift report inaccurately read this patient's mental health hold expired on 5/10/23 at 2:00 p.m., an additional 23 hours and 46 minutes after the patient's mental health hold expired.

b. Shift reports dated 5/9/23 revealed of the six units at the facility, there were 21 patients on mental health holds. Of these 21 patients, the mental health hold expiration time was incorrect for one patient. This patient's mental health hold was placed on 5/6/23 at 8:57 p.m. The shift report inaccurately read this patient's mental health hold expired on 5/9/23 at 7:57 p.m., an hour before the patient's mental health hold expired.

This was in contrast to the Shift to Shift Report policy which read, it was the facility's policy to maintain consistency in planning and implementation of treatment. Communication of pertinent information regarding patients was to have been provided to the on-coming shift.

B. Interviews

i. On 5/8/23 at 3:09 p.m., an interview was conducted with Physician #1. Physician #1 stated the shift report listed Patient #2's mental health hold expiration date and time as 4/11/23 at 5:00 p.m., rather than the correct date and time of 4/12/23 at 6:14 p.m. Physician #1 stated on 4/11/23, with the facility under the impression the mental health hold would expire soon, Patient #2 requested voluntary hospitalization and planned to discharge home with her boyfriend the same day. Physician #1 stated she did not feel discharging Patient #2 home with her boyfriend was safe, and believing the patient's 72-hour mental health hold expired 4/11/23, she filed a short-term certification to keep the patient involuntarily until 4/12/23 when she was discharged home with her father. Physician #1 stated she later realized she had discharged Patient #2 prior to the 72-hour mental health hold expiring and she would not have requested the short-term certification nor discharged Patient #2 at that time if she had known the original mental health hold had not yet expired.

Physician #1 stated the facility had only recently been contacted by the father of Patient #2 who told them Patient #2 had died on 4/18/23, six days after discharge. She stated Patient #2's cause of death was not yet known as an autopsy had not yet been completed.

Physician #1 stated the shift report was a way of communicating important patient information with staff. She stated she had observed the shift report frequently contained inaccurate information regarding the expiration of patients' mental health hold dates and times. Physician #1 also stated without accurate information, and working with incorrect timelines, patients would not receive the best aftercare when discharged from the facility.

Physician #1 stated the 72-hour mental health hold allowed for time to evaluate patients and get a sense of imminent risk of self-harm or harm to others or if the patients were gravely disabled. She stated the hold allowed the facility to start treatment to help the patients stabilize and become safe. Physician #1 stated discharging someone before their 72-hour mental health hold had expired posed a risk to the patient's safety.

ii. On 5/9/23 at 1:35 p.m., an interview was conducted with licensed professional counselor candidate (Therapist) #6. Therapist #6 stated because the shift report contained inaccurate information about Patient #2's mental health hold expiration date and time, staff thought Patient #2 had come into the facility with only 24 hours remaining on her 72-hour mental health hold. She stated this was why the facility was ready to discharge Patient #2 on 4/11/23.

Therapist #6 stated she used the shift report when assessing for discharge dates and times. She stated she frequently saw inaccurate information on the shift report, including incorrect mental health hold expiration dates and times. Therapist #6 stated inaccurate information on the shift report created confusion about when to appropriately discharge a patient.

iii. On 5/9/23 at 2:21 p.m., an interview was conducted with medical director (Director) #2. Director #2 stated a review of the patient's mental health hold date and time was part of his overall patient evaluation. He stated he used the expiration of the hold date and time as contained on the shift report to determine if patients were able to stay voluntarily, be discharged, or be kept at the facility on a short-term certification if not deemed safe to leave. Director #2 stated the shift report's mental health hold expiration dates and times were frequently inaccurate. He also stated there was an expectation the shift report contained accurate information.

Director #2 stated the 72-hour mental health hold was a standard of care for patient evaluation. He stated 72 hours was long enough to evaluate a patient but not so long that it infringed upon their rights. Director #2 stated he had seen patients at the facility accidentally placed on a voluntary status in the past while still on their involuntary 72-hour mental health holds. He also stated if a patient was at the facility on a mental health hold, and the physician wanted to discharge the patient early, the physician needed a second opinion from another provider to prove the patient was safe before discharge.

Director #2 further stated there was an expectation the mental health hold was maintained for the duration of the 72 hours for all patients at the facility.

iv. On 5/10/23 at 12:28 p.m., an interview was conducted with Physician #7. Physician #7 stated the risk of discharging patients prior to expiration of the 72-hour mental health hold was less time spent in the discharge planning process, which helped prepare patients to enter the community safely.

v. On 5/9/23 at 1:05 p.m., an interview was conducted with registered nurse (RN) #5. RN #5 stated the mental health hold was used to protect patients at risk of harming themselves or others, or patients who were gravely disabled. She stated in order to discharge a patient before their mental health hold expired, a second opinion would be required from another provider. RN #5 stated there was always a risk to the patient with any discharge, including those who discharged early.

RN #5 stated the shift report included the patient's name, date of birth, age, picture, legal status, the expiration date and time of the mental health hold, any precautions, allergies, and a daily note. She stated the shift report should have been updated and corrected at least once per shift. RN #5 stated she occasionally saw errors carried over from shift to shift, including in the mental health hold expiration date and time. She also stated the physicians used the shift report to help determine patients' discharge dates and times.

vi. On 5/9/23 at 1:55 p.m., an interview was conducted with RN #8. RN #8 stated a mental health hold was placed to keep patients safe from themselves or to prevent patients from harming others. She stated if a hold was to be released early, two doctors would need to sign off on this early release. RN #8 also stated the facility expected staff to wait 72 hours from when a mental health hold was placed to discharge a patient.

RN #8 stated she occasionally saw inaccuracies in the mental health hold expiration date and time on the shift report, which the doctors used to help determine the discharge date. She also stated the risk to the patient would be their safety going home.

vii. On 5/8/23 at 2:30 p.m. and at 4:09 p.m., an interview was conducted with the director of performance improvement (Director) #4. Director #4 stated the mental health hold was a 72-hour hold, which allowed for 72 hours to evaluate patients in danger of self-harm, harming others, or patients who were gravely disabled. She stated after this 72-hour assessment, patients were able to sign in voluntarily, be discharged, or the doctor could keep patients on a short-term certification to allow for extra treatment time.

Director #4 stated the facility was just recently notified Patient #2 had passed away. She stated the facility contacted the coroner's office but would not have the autopsy report for four or more weeks. Director #4 stated the facility had not finished its investigations into the incident and did not yet have corrective action in place.

viii. On 5/8/23 at 11:04 a.m. and on 5/10/23 at 8:59 a.m., an interview was conducted with the director of clinical services (Director) #3. Director #3 stated she was responsible for overseeing discharge planning at the facility. She stated staff relied on the shift report to determine clinical treatment and the expiration dates and times of mental health holds. Director #3 stated mental health holds were 72-hour safety holds to protect patients at risk of harming themselves. She stated these holds allowed the facility to determine how to keep the patients in their care safe moving forwards.