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Based on interview and record review, it was determined, that the hospital failed to have a discharge planning process that applied to all patients. Specifically, 3 out of 11 (seven, plus 4 supplemental patients chosen for removal of immediate jeopardy review) sampled discharge patients did not receive adequate discharge planning to ensure safe and appropriate discharge. Additionally, 4 out of the 11 sampled discharge patients, had or had been expected to, arrange there own discharge placement. (Patient identifiers: 1, 3, 4 and 12)

This resulted in a finding of Immediate Jeopardy (IJ). The hospital was notified of this finding verbally and in writing on 7/13/23 at 1:40 PM.

The Hospital submitted an IJ removal/abatement plan on 7/14/23 via email at 4:42 PM, alleging removal as of 7/18/23 at 5:00 PM. The plan was accepted, and the hospital was notified on 7/14/23 at 4:43 PM.

An onsite visit was conducted on 7/19/23 and determined the IJ was removed as of 7/18/23 at 5:00 PM. The hospital was notified of IJ removal on 7/20/23 at 7:54 AM.

Findings include:

1. Patient 3 was admitted on 6/15/23 with a diagnosis of psychosis. Patient 3 was discharged on 7/5/23.

Patient 3's record review was completed on 7/20/23 and revealed the following:

The following conversation with patient 3's father was documented in a therapy note on 6/20/23 at 6:00 PM. "He (patient 3's father) reported that he may be able to live in Texas with an Uncle and that he is worried about his housing situation. I explained that the Acute care model is focused on crisis resolution and stabilization and that the difficulty of providing him with housing and placement resources through local providers would be unlikely to happen before his discharge is due to local demand for housing, waitlists, and potential qualification concerns. He stated he was in the middle of military move and would be in contact with me shortly when he was able to talk further."

The following was documented in therapy note dated 6/29/23 at 2:15 PM. "(Name of patient 3) cannot live with his father due to some abuse his 14 year old sister and him being unwilling to allow (Name of patient 3) to let him live with him... His grandparents have a house that is full and he could not live with them due to them caring for 2 other family members with mental health concerns. His uncle in Texas has (sic) a recently had (sic) open heart surgery and could be an option. We talked about RTC (residential treatment center) care and if he would be interested in attempting to our (sic) reach (name of RTC). I gave him resources."

There was no documented evidence of a follow-up from the therapist or anyone else regarding patient 3's post discharge needs in patient 3's medical record after 6/29/23. Additionally, there was no documentation of a follow-up into RTC placement, or any evidence of documentation from the discharge planner in the medical record.

On a document titled Discharge Care Plan and Home Medications it was documented that patient 3 was being discharged to "family's home." It was further documented that patient 3's mode of transportation was going to be "family picking up."

a. On 7/12/23 at 11:00 AM, patient 3's grandfather was interviewed. He stated he was very disappointed in how patient 3 was discharged. The grandfather stated he spoke with a therapist three days before patient 3 was discharged. He stated it was discussed that patient 3 would be discharged around the 17th. (Note: He was discharged on 7/5/23.) He stated patient 3 called him from the Utah transit authority (UTA) trax station and asked him to come pick him up. Surveyors asked if he was okay with patient 3 being discharged to him. He stated, "Absolutely not, we were not okay with him being discharged to us, we are old. We were wondering if he escaped. We had no idea he was being released." He stated the hospital turned him lose without any plan. The grandpa stated they were supposed to be finding him another placement. He further stated he tried calling the hospital to get more information; they told the grandfather they provided patient 3 with a folder with information. He stated he eventually found patient 3's prescriptions, but he was unable to get them filled by a pharmacy - according to the grandfather, the pharmacy stated that 3 out the 4 had been discontinued, and the other reguared the phaysican to register woth the pharamcy before the medciation could be filled, which had not occurred. He stated he tried calling the hospital again, he even left a message for the CEO (chief executive officer). He stated this was still going on today (7/12/23), patient 3 still did not have all his medication. The grandfather stated he had not heard back from anyone. He stated patient 3's father lived in Arizona and had 7 other children and was unable to take patient 3. He further stated he felt there was no coordination or communication between staff. Surveyors asked the grandfather if he was aware of any follow-up information. He stated he was not. He stated the hospital expected patient 3 to be stable enough to know what the discharge plan was. He further stated we have always spoken to facility's about discharge plans. The grandfather stated there was a lack of qualified personnel, and felt the staff did not have any training.

b. The discharge planning policy was reviewed and stated the following: "...Documented efforts to educate and involve the family and/or parent/legal guardian in discharge planning and treatment interventions..." There was no documented evidence in patient 3's medical record of patient 3's final discharge plan being discussed with family and/or parent/legal guardian.

c. Therapist 2 was interviewed on 7/13/23 at 10:40 AM. Therapist 2 was asked about patient 3's discharge plan.
He stated he worked with patient 3's father. He stated patient 3's father was on a military move and was not too involved. He further stated his father wanted to look into RTC placement or Texas. Therapist 2 stated the father was not willing to let patient 3 live with him. Therapist 2 stated he gave the father avphone number for a local RTC. He stated the father was going to look into the local RTC. Therapist 2 stated the plan was to transport patient 3 to Texas to live with his uncle. He further stated the last time he spoke to the father (note: on 6/29/2023, 6 days prior discharge), patient 3 was going to discharge to the father (note: it was documented in the therapy note on 6/29/23, patient 3 could not live with his father due to some abuse). Therapist 2 stated the father was going to arrange transportation to Texas. Therapist 2 was asked if he knew whether the father lived in Utah or not. He stated he did not know. Therapist 2 was asked if there was any other follow-up information documented to which he replied he was not aware of how patient 3 ended up being discharged. He stated he was off when patient 3 was discharged. He further stated he passed the information he had to the treatment team and the discharge planner. He further stated he did not set up placement into RTC's - that was the discharge planners (DP) responsibility.

d. Registered nurse (RN) 2 was interviewed on 7/13/23 at 11:11 AM. He stated patient 3 was discharged to his father. RN 2 stated they set him up with a UTA trax pass to go meet his dad. RN 2 stated the therapist and discharge planner sets up post discharge arrangements.

e. On 7/13/23 11:43 AM, the DP was interviewed. The DP stated patient 3 was discharged to home with family. He stated he did not remember what family member. He stated there were issues with patient 3's dad so they were going to transfer him to Texas. The DP further stated he did not speak to any family member; that was the therapist's responsibility. The DP stated he was responsible for arranging for patients to go to an RTC. He further stated he was not aware of discussions about patient 3 going to an RTC. The DP stated he always writes a discharge note summarizing where the patients are going and their follow-up information. The DP was asked for patient's 3's discharge note. He was unable to provide a discharge note for patient 3. He stated there should be one, but there was not. During this interview the DP stated, "I'm kind of a slacker."

f. Education and training of the hospital's discharge planners was requested. No formal education or training in discharge planning was provided to survey staff.

On 7/10/23 around 10:00 AM, the CEO was asked if discharge planners had specific discharge planning training. He stated he was not aware of any.

2. Patient 12 was admitted on 7/4/23 with a diagnosis of bipolar disorder.

a. Patient 12 was interviewed on 7/11/23 at 10:39 AM. Patient 12 was asked if anyone had spoken to her about discharge. She stated they had not spoken to her about discharge planning. She stated they just mentioned she would be discharged today (7/11/23). Patient 12 stated she did not feel safe to be dischargead and that "nothing was figured out yet." She further stated the hospital wanted her to go back to her prior living situation (a local residential addiction center) and she did not feel safe going back there. Patient 12 stated she tried to speak to the discharge planner about the situation; she stated the discharge planner replied that he was busy. Patient 12 was asked if she had any family or support in Utah to help her. She replied she did not - all her family lived in Arizona. Patient 12 stated she had a bed at another residential addiction center that she arranged on her own while at the hospital, she just needed to go to her mental health court for them to sign off on her going there. She stated her mental health court was at 2:00 PM that day, but the hospital was trying to send her home before her court time.

b. The DP was interviewed on 7/11/23 at 10:53 AM. The DP was asked if he was aware that patient 12 did not feel safe to discharge. He stated he "did not know a ton about her, they just started talking." He stated she had been very proactive in setting up her aftercare. He stated she arranged her aftercare at a residential addiction center on her own. He further stated if there was not a problem getting her into chosen program, he would work on that. He stated he would verify she had a bed there. The DP was asked if patient 12 would still be discharged if she could not get into her chosen program and did not feel safe to go back to her prior placement. He replied she would still be discharged. He stated if her insurance covered it, she could stay at the hospital until Thursday. He stated he would talk with patient 12 and get back to surveyors with the outcome.

On 7/12/23 at 8:17 AM, the DP called surveyors back and stated he followed up with the facility that patient 12 had arranged to transfer to. The DP stated, "she (patient 12) got what she wanted." The DP stated patient 12 attended her mental health court then went to the facility of her choice.

c. Patient 12's record review was completed on 7/20/23 and revealed the following:

Patient 12 was discharged on 7/11/23. Her discharge care plan was reviewed. Nothing was documented as to what setting patient 12 was discharged to and what mode of transportation was used.

On 7/11/23 at 1:00 PM, the DP documented the following statement in a note. "Spoke with patient about where she would be going after discharge. She gave me the number for (name of her chosen) program so I could verify that they had a bed. I called three times and left a message, but never heard back. Patient told me that she would have her attorney call them. I gave her a bus pass and she discharge (sic). She had a court appointment at 2:30 PM."

d. On 7/18/23 at 12:13 PM, the DP was interviewed again. He was asked if patient 12 was discharged to her chosen program. He stated he reached out to her chosen program and never heard back. He also stated he tried calling patient 12 to see if she made it there. He stated he was unsure what ended up happening with patient 12. He stated she was discharged with an all-day bus pass. The DP was asked if patients were discharged without any place to go. The DP replied he "discharged patients to the streets all the time, it sucks, but being homeless is not a criteria for inpatient."

e. On 7/19/23 at 8:19 AM, a communication specialist from patient 12's chosen program, was interviewed. She stated there was a bed available for patient 12, but patient 12 had not checked in.

(Note: Surveyors tried to contact patient 12, but the hospital did not have an active phone number on file for her.)

f. On 7/18/23 at 12:30 PM, the CEO was interviewed. The CEO was asked what his expectations were with their discharge planning process. He replied "I think there are some things we could have done differently." The CEO was asked if patients were discharged if they do not feel safe. He stated if the patient did not feel safe and there was a reason why they did not feel safe, they would not discharge them.

3. Patient 4's medical record was reviewed during survey and revealed the following:

Patient 4 was admitted on 5/20/23 with a diagnosis of suicidal ideation.

In a document titled Intake Assessment dated 5/20/23, it was documented that patient 4 had recently been sexually assaulted and it triggered her suicidal ideation.

In a document titled Discharge Care Plan dated 5/25/23 and timed 10:37 AM, there was no evidence that patient 4 had been referred for outpatient therapy or counseling for follow up regarding her sexual assault. It was further documented that patient 4 was leaving the hospital by cab/taxi/ride share. In the case management section, it was documented that coordination with the facility she previously lived in was conducted in person at 1:00 PM on 5/25/23.

In a document titled Care Coordination Communication Log, it was documented on 5/22/23, that patient 4 lived at a specific facility and the facility would accept her back as a resident after her hospitalization. No further discharge coordination with the facility was evident in the medical record until 1:00 PM on 5/25/23, where it was documented "in person" on the Discharge Care Plan.

In a document titled Disclosure Tracking Log, it was documented that on 5/25/23, pertinent information regarding patient 4's hospital course was provided, in person, to a representative of the facility she previously lived at.

In a document titled Psychiatric Evaluation and dated 5/21/23, it was documented that the person who sexually assaulted patient 4 lived in the same facility as patient 4.

Note: There was no documented evidence that the hospital had verified returning to the same facility was safe for patient 4 due to the potential of the perpetrator still residing at the facility.

There was no further discharge planning or coordination with the receiving facility evident in patient 4's medical record.

Interviews were conducted with hospital staff regarding patient 4, however, no staff members had specific recollections of this patient due to the amount of time since her discharge.

On 7/27/23 at 10:52 AM, an interview was conducted with a staff member of the facility where patient 4 resided. The staff member stated patient 4 showed up in a cab on 5/25/23, without any notice or coordination from the hospital. The staff member stated she had called the hospital several times and did not get any response to her request for information on patient 4 or coordination of care. She stated after some time they decided to drive to the hospital to request the needed information. She stated when they arrived at the hospital and requested the information, they waited over 90 minutes. When they did speak with hospital staff it was the medical records person who was resistant to providing the needed information. The staff member stated the medical records person eventually provided the requested documentation, so they were able to admit patient 4 to their facility.

(Note: Surveyor attempted to interview patient 4 but was unable to reach her.)

4. Patient 1's medical record review was initially reviewed on 7/12/23 and was awaiting additional information from the risk manager prior to the IJ being called. Additional information about patient 1's discharge was received on 7/18/23, when medical record review was then completed and revealed the following:

Patient 1 was admitted on 6/23/23 with diagnoses of schizophrenia paranoid type with psychosis, possible methamphetamine induced, and post-traumatic stress disorder.

The psychiatric evaluation completed on admission by the psychiatric nurse practitioner documented the following information:

Patient 1 was involuntarily committed due to psychosis and had been admitted to Highland Ridge Hospital "many times" primarily for psychosis and suicidality, with the last visit being approximately 1 month prior. It was documented patient was admitted for suicide ideation, substance use, inability to safely care for self, and psychosis. It was also documented that patient 1 was a danger to self and others and needed a controlled environment with 24-hour care and medication management. The initial discharge plan was documented as: the patient would be discharged per patient and discharge team arrangements for safest location and to continue with outpatient treatment providers. Prognosis was documented as: poor due to a strong history of inpatient status, psychosis, and substance abuse. Patient limitations were documented as: recent medication noncompliance, lack of social support, pathological unsupported environment, substance abuse, financial stress, chronicity of mental illness, lack of insight, and poor coping skills.

Note: during entrance request, a patient discharge list was requested for the previous 3 months. For the 3 months of discharges reviewed, it was noted that patient 1 had an admission on 4/20/23 - 4/30/23, was readmitted from 5/12/23 - 5/22/23, and then again from 6/23/23 - 7/14/23.

On 6/29/23 and 7/7/23, the interdisciplinary treatment plan documented under the "Social Services" section for discharge planning issues: pending for: placement needed to "Treatment program."

On 6/28/23, a progress note entry was completed by the discharge planner. It read, "Gave patient (1) a list of sober living places to call."

On 7/13/23, a progress note entry was completed by utilization review. It documented, patient 1 would discharge on 7/14/23 to a homeless shelter (approximately 46 miles away) via Trax (a public light rail system) with outpatient services.

On 7/18/23 at 12:32 PM, the risk manager was asked via email if the surveyor had received all the documentation they had for patient 1. The risk manager did not provide any other relevant documentation that documented the hospital's efforts to arrange a suitable treatment program for patient 1.

5. Further interviews regarding discharge planning were conducted during the survey, as follows:

On 7/10/23 at approximately 9:30 AM, the CEO was interviewed. The CEO stated they wanted patients to be in charge of their own discharge planning. He stated they wanted patients to take ownership of their discharge.

On 7/11/23 at 9:38 AM, an interview was conducted with the CEO and risk manager. They stated it was up to the patient to call facilities to find placement for post hospital care. They further stated clinical staff was to follow up with the facilities to confirm placement.

6. The hospital failed to have and implement an effective discharge planning process that focused on the patients' goals and treatment preferences and included the patient and their caregiver support person(s) in the discharge planning for post-discharge care. The hospital's discharge planning process and the discharge plan were not consistent with the patients' goals for care and their treatment preferences, and failed to ensure an effective transition of the patients' from hospital to post-discharge care that would reduce the likelihood of another hospital readmission. Additionally, the hospital's discharge planning process was to have patients' facilitate and arrange their own post-hospital placement.