HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure the patients were able to exercise their rights, as evidenced by failing to appropriately and effectively address voluntary requests for discharge at the facility. The facility failed to ensure that if a hospital is informed that a voluntary patient desires to leave the hospital or a voluntary patient's or the patient's LAR requests that the patient be discharged, the hospital shall, in accordance with Texas Health and Safety Code, §572.004: if necessary and as soon as possible, assist the patient in creating a written request for discharge and present it to the patient for the patient's signature

Findings included:


Facility based policy entitled "DISCHARGE, AMA [Against Medical Advice]" stated in part,
"All patients voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency or the person who requested admission on the individual's behalf have the right to request discharge. Any such person expressing a request for release shall be given an explanation of the process for requesting release and afforded the opportunity to request release in writing.

o When a written request for release is presented to any direct care staff of the hospital, it should be signed, dated, and timed by the individual or a person legally responsible for the individual.

o If an individual informs a person associated with or employed by the hospital of the individual's desire to leave, the employee or person shall, as soon as possible, assist the individual in creating the written request and present it to the individual to sign, date, and time. Without regard to whether the individual agrees to sign paperwork requesting discharge from services, the request will be documented and processed by staff. The refusal or inability of the individual to sign the request for discharge will be documented on the unsigned written request.

o All written or prepared requests for discharge will be timed, dated, and signed by the staff member, who shall provide information to the individual that pursuant to law, during the ensuing period of up to 24 hours, the individual will be observed and evaluated to determine the clinical appropriateness of seeking an involuntary commitment to services. The form and format for requesting release and the information to be provided may be prescribed by the department.

All patients voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency have the right to be discharged within four hours of a request for release unless the individual's treating physician (or another physician if the treating physician is not available) determines that there is cause to believe that the individual might meet the criteria for court-ordered mental health services or emergency detention.

o Each patient detained beyond four hours has the right to be examined in person by a physician and assessed for discharge readiness within 24 hours of the filing of a request for release, with results of the assessment and recommendation resulting documented in the medical record and disclosed to the individual. Patients have the right not to be detained beyond the completion of the in-person examination unless:

o the person who filed the request for release files a written withdrawal of the request or asks a staff member to withdraw the request (the staff member must put the request in writing);

o the patient, in the physician's clinical judgment, meets the criteria for involuntary commitment outlined in the Texas Health and Safety Code, §573.022, and an application for court-ordered mental health services, chemical-dependency services or emergency detention will be filed and an order obtained not later than 4 p.m. on the next succeeding business day after the date on which the examination occurs and the individual is detained under the provisions of the relevant statute; ...

PROCEDURE

o If the patient requests discharge, the patient will be advised of the AMA procedure to include completion of an AMA Request Form
o The RN will notify the patient's attending physician
o The attending physician must determine if patient will be discharged or if meets criteria for court order to continue care. Determination must occur within four hours of patient's AMA request. Physician will document rationale for decision to hold or discharge patient.

o If the attending physician decides to discharge AMA:
o The RN will take the order to discharge the patient AMA
o Request that the patient read and sign the Against Medical Advice Discharge form. If the patient refuses staff shall document refusal on the form
o Complete discharge procedure (See Policy "Discharge Planning")
o Clearly document the entire procedure in the patient's chart
o Complete Suicide Risk Assessment
o If the attending/covering physician assesses the patient to be harmful to self or others or is unable to meet basic needs due to psychiatric condition the physician may initiate a Certificate of Medical Examination (CME) within 24 hours of patient's AMA request."

Review of medical records revealed 2 of 3 patients (#1 and 2) voicing a desire to leave the facility and/or be discharged did not have their request appropriately addressed.
Patient #1's medical record had the following documentation:
* This patient was admitted on an Emergency Detention order on 03/09/22 related to not taking medications and running into traffic. Patient #1 signed in voluntarily to the facility on 03/10/22. This patient signed "Agrees to be admitted on a voluntary basis, evidenced by his/her signature below" portion of the NOTICE OF RESULTS OF RE-EXAMINATION dated 03/10/22.
* A physician note in this patient's medical record indicated verbalizing a desire to leave.
"CHIEF COMPLAINT: I want to leave today because my daughter's birthday is tomorrow.
HISTORY OF PRESENT ILLNESS: The patient arrived to consultation crying, stating she wanted to leave because her daughter's birthday is tomorrow. She reports that her daughter is turning 21. The patient has been noncompliant with her medication...The patient presents with tangential thought process."

There was no documented follow up regarding this request to leave the facility. No physician order or application for mental health services was present in her file. Therefore, it appears this voluntary patient's request to leave was not properly addressed per facility policy and regulatory requirements. This patient was not discharged until after 03/22/22, well after making the initial request to discharge on 03/17/22.

Patient #2's medical record had the following documentation:.
* This patient was initially admitted to the facility on an Emergency Detention order on 03/11/22. This patient signed in voluntarily to the facility on 03/14/22. This patient signed "Agrees to be admitted on a voluntary basis, evidenced by his/her signature below" portion of the NOTICE OF RESULTS OF RE-EXAMINATION dated 03/14/22.
* A physician note on 03/22/22 stated in part, "The patient states wants to go home at this time. The patient is very upset and is banging on the walls with fist. States that she has a dog that is at home alone and she needs to get home. Treatment team notified and aware per nursing staff the patient's concerns of going home. The patient otherwise denies any pain. Denies any distress at this time. States she is just very upset and wants to go home and wants to know what her discharge plan is."
* Nursing notes included the following:
On 03/16/22 at 1430 stated in part, "Patient became agitated demanding to be discharged ..."
On 03/17/22 at 1735 stated in part, "Pt initially irritated because she wanted to leave facility. Nurse attempted to talk to patient and process with her 1:1 but was unsuccessful ..."
On 03/23/22 sat 1100 stated in part, "Patient throwing shoes at staff, irritable, yelling breaking hospital property. Patient yelling demanding to leave to take care of apartment. 1:1 verbal de-escalation given by BHA [Behavioral Health Associate] ...Patient mood irritable, patient remains agitated discharge focus."

There was no documented follow up regarding this request to leave the facility. No physician order or application for mental health services was present in her file. Therefore, it appears this voluntary patient's request to leave was not properly addressed per facility policy and regulatory requirements. This patient was not discharged until after 03/23/22, well after making the initial request to discharge on 03/16/22.

Based on the above findings, the facility also failed to assist the individuals who voiced a desire to leave the facility, with creating a written request and presenting it to the individual to sign, date, and time. The facility failed to ensure that if the voluntary patient is not released within 4 hours of a request to discharge or if hospital intends to detain a patient, an application will be filed to obtain a court order for further detention of the patient, each patient has the right to be examined in person by the physician with documentation of the reasons for the decision to detain the patient in the patient's medical record.

The above findings were verified with staff members #1 and 3 in interview on 05/25/22.