HospitalInspections.org

Based on document review and staff interviews, the Governing Body failed to:

1. Ensure the hospital's medical staff as a group is accountable to the governing body for the quality of care that patients receive. Please refer to A-0049.

2. Ensure the hospital staff provide a safe discharge plan prior to a patient discharge. Please refer to A-0802.

3. Ensure the hospital staff must have in place a routine reassessment of all plans prior to patients discharge. Please refer to A-0802.

4. Ensure the hospital staff have a process for triggering a reassessment of a patient's discharge and post-discharge needs. A-0802.

The cumulative effect of the systemic failure and deficient practice resulted in the hospital's inability to effectively care out the responsibilities of the hospital to ensure patients received appropriate care and treatment in a safe setting and ensure quality health care provided to patients. The Hospital's administrative staff identified a census of 133 patients at the beginning of the survey.

During the investigation of incident 110472-C, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Governing Body (42 CFR 482.12). The hospital staff failed to ensure the medical staff as a group is accountable to the governing body for the quality of care provided to patients.

1. The governing body failed to ensure the medical staff delivered the quality of care to all patients.

2. While on-site, the survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 2/10/23 at 3:48 PM. The hospital staff acted and removed the immediacy of the situation prior to the survey team exiting the complaint investigation when the hospital administrative staff took the following steps:

The behavioral health leadership will promptly inform the Chief Medical Officer of any incidents where escalation processes from the Discharge Huddle process were utilized or required consults were not performed.

The Chief Medical Officer will determine where informal or formal peer review procedures under the Medical Staff Peer Review Oversight Policy will be initiated, in accordance with the Medical Staff Bylaws.

The Chief Medical Officer will work with the Chief Nursing Executive and the Quality Department to ensure audit data and actions taken will be reported to the Quality Management Council and the Board Quality Committee on at least a quarterly basis.

The Chief Medical Officer will ensure peer review opportunities arising from this Plan of Correction are taken to the Peer Review Committee of the Medical Staff, and subsequently to the Medical Staff's Medical Executive Committee and to the Board of Directors, to ensure accountability and responsibility of the Governing Body.

The following Condition level deficiency remained for the Conditions of Participation for Governing Body (42 CFR 482.12).

Based on staff interviews and document review, the acute care hospital's administrative staff failed to ensure that the medical staff as a group, is accountable for the quality of care provided to 1 of 20 (Patient #1) medical records reviewed. Failure to hold the medical staff accountable for the quality of care provided to its patients could result in misdiagnosis, inaccurate treatment, inappropriate discharge that would lead to complications or death. The hospitals administrative staff identified an average monthly census of behavioral health inpatients is 266.

Findings include:

1. Review of the Medical Staff Bylaws, dated 2/2018, revealed in part, "The purpose for which the Medical Staff is organized are to:

Promote high standards of diagnosis and care in the Medical Center, commensurate with the ability, training, and resources of this Medical Staff and of the Medical Center and its professional staff."

2. Review of the Medical Staff Rules and Regulations, dated 2/2018, revealed in part, " ...discharge planning shall be considered for each patient at admission. Planning decisions shall include preparation for self-care or placement in suitable alternative care facilities after considering the patient's social, economic and physical condition."

3. Review of the medical record revealed the follow:

Patient #1 attempted suicide by hanging suspended from a jail cell bar on 11/26/22. They were transferred for medical clearance at a critical access hospital.

On 11/27/22 at 6:36 AM, Patient #1 arrived for psychiatric evaluation at the acute care hospital's inpatient behavioral health unit with a 48-hour hold.

Patient #1 has a history of polysubstance use, verbal abuse, prior suicide attempts, but no mental health diagnoses. Patient #1's current stressors were finances, loss of driver's license, living arrangement, and no support.

At 5:16 PM, ARNP B performed an initial psychiatric assessment, noting the patient attempted suicide by hanging and strangulation while in jail. Patient #1 was newly diagnosed with Major Depressive Disorder and scored "high" on the Columbia Suicide Severity Rating Scale. At 3:23 PM, Patient #1 was started on Lexapro (antidepressant) 10mg tablet.

At 12:03 PM RN D documented Patient #1 has disturbed/interrupted sleep.

On 11/28/22 at 9:00 AM and 11:00 AM, Therapist C documented Patient #1 attended a group session but did not participate. Patient #1 was administered a 2nd dose of Lexapro.

At 3:08 PM, ARNP E performed a discharge summary documenting that patient had a superficial suicide attempt in jail. Denies that it was truly a suicide attempt. The last time Patient #1 felt like this was when he lost custody of his kids. It does feel like he cannot get anything to work for him. Patient #1's girlfriend is currently in jail. Patient #1 wants to hitch hike home. Will increase Lexapro to 20mg. Diagnoses: Major depressive disorder with suicide attempt in jail, Cannabis and methamphetamine use disorder.

Patient #1 was discharged on 11/28/22 at 1:31 PM. The same day, Patient #1 stepped in front of semi-truck on the interstate and was killed.

4. During an interview on 2/7/23 at 3:40 PM with Psychiatrist H revealed the Patient #1 should not have been discharged and allowed to hitchhike home (Patient #1's home is approximately 160 miles from the inpatient behavioral health unit). Since Patient #1 did not have transportation or support he should have been held until it was established. Psychiatrist H further disagreed that the Patient #1's suicide attempt was superficial. He further elaborates that the 48-hour hold was meant to keep the patient safe especially with a new diagnosis of depression. Psychiatrist H also reveals he would not have discharged the patient after an increasing the antidepressant medication without further evaluation.

Based on policy review, documentation review, and interviews, the Acute Care Hospital 's (ACH) administration staff failed to:

1. Ensure the hospital staff identified and reported allegations of abuse and losses of controlled substances in accordance with the applicable Federal and State laws. Pharmacy staff failed to identify potential drug diversions in the emergency department (ED).

The cumulative effect of these failures and deficient practices resulted in the hospitals inability to identify impaired behavior, and prevent unauthorized access to medications for personal use or distribution potentially resulting in criminal behavior and risking the safety of patients. These failures also led to at least one nurse stealing more than 100 vials, of a combination of hospital grade medications being found in the home of RN A. Please see A-509.

Based on policy review, documentation review, and interviews, the Acute Care Hospital 's (ACH) administration staff failed to identify impaired behavior, and prevent unauthorized access to medications for personal use or distribution potentially resulting in criminal behavior and risking the safety of patients. These failures also led to at least one nurse stealing more than 100 vials, of a combination of hospital grade medications being found in the home of RN A. The Acute Care Hospital identified an average daily census of 135 patients.

Findings include:

1. Review of a hospital policy titled "Controlled Drug Policies and Procedures," revised on 07/2022, revealed in part, "Controlled Substance Manager (CSM) is an automated dispensing system intended for the secure storage and accurate documentation of the storage and movement of controlled substances and selected other medications (med). In addition, CSM will maintain a perpetual inventory of controlled medications. Omnicell Medication stations (automated medication dispensing system that nurses use for obtaining medication for patient administration in the hospital setting) account for discrepancies created by Omnicell end users. Discrepancies will be managed by the Pharmacists. The Director of Pharmacist designee will periodically review reports of active discrepancies on the floor and in Omnicell machines, and resolve outstanding issues."

2. Review of a hospital policy titled "Med Storage, Diversion Prevention, Security Plan," revised on 02/2022, revealed in part, "all drug storage in the acute care hospital shall be secure and accessible only to authorized personnel ... throughout the cycle of handling, preparation, delivery, storage, checking of outdates, administration to patients, and disposition of unused partial or whole doses." Section IV of the policy notes "Diversion Surveillance and Procedure when Diversion is identified or suspected ... Monthly the Pharmacy Director or Designee (PDOD) will run Pandora reports to proactively look at possible diversion. This report surveys all controlled meds in any Omnicell, including CSM (Pharmacy), and mathematically compares controlled med pulls for all employees in that area to their peers. This report is sent monthly to all managers when controlled medications are used. If an individual pulls more meds than their peers, (we usually look for greater than 5 standard deviations) then further investigation may be warranted. Also, if employee personal work habits have changed, or if a fellow employee expresses concerns about a co-worker a full investigation may be triggered."

3. Review of the Pandora report noted in Registered Nurse (RN) A's personnel file revealed RN A had a significantly higher usage then her peers over an 8 month period in the same department for several medications such as Intravenous (IV) diphenhydramine (Benadryl)(an antihistamine and sedative mainly used to treat allergies, insomnia, and symptoms of the common cold) 50 milligram per 1 ml (mg/ml), Hydromorphone (Dilaudid) (an opioid used to treat moderate to severe pain) 1 mg/1 ml syringe, Hydromorphone 0.5 mg/0.5 ml, Fentanyl (synthetic opioid that is 50-100 times stronger than morphine and is used to treat patients with severe pain and for anesthesia in the hospital setting) 100 microgram per 2 milliliters (mcg/ml), Morphine (strong opioid used to treat severe pain) 4 mg/1 ml, Morphine 2 mg/1 ml. According to the usage report RN A used 109 doses of Benadryl compared to 38 doses used by the next highest user, 68 doses of Morphine 4 mg/1 ml compared to one other nurse using 66 doses and all other nurses using 32 doses and/or less, 85 doses of Hydromorphone 0.5 mg/0.5 ml compared to 51 doses used by the next highest user, 59 doses of Morphine 4 mg/1 ml compared to 36 doses used by the next highest user, 34 doses of Fentanyl 100 mcg/2 ml compared to 11 doses used by the next highest user, 66 doses of Hydromorphone 1 mg/1 ml compared to 32 doses used by the next highest user.

8/3/2020 - Written notice was placed in RN A ' s file noting that on 7/26/2020, it was reported to pharmacy that 4 vials of Morphine 10 Milligrams per 1 milliliter (mg/ml) had the caps missing, the vials were pulled by pharmacy, and upon further investigation it was noted the vials had been entered with a needle, and the remaining amount in the vial was less than 1 ml that should have been in the vial. The "week of" 8/17/2020, it was noted that RN A pulled morphine sulfate (MS) for a patient in EPIC (Electronic charting system) without an order. On 8/27/2020, writing notes RN A had no recollection of pulling the medication for the patient without an order, and notes that disciplinary action would be taken with RN A if this happens again.

12/16/21 - a Just Culture investigation (investigation/corrective action plan to minimize errors and focus on safety) was completed for a medication error for pediatric patient and Narcan dosing. The investigation was completed on 12/20/21 by ED leader.

8/5/22 - a Just Culture investigation was started for narcotic usage, Benadryl usage, and bar code scanning report by the ED department manager. On 8/11/22, employee health reported a negative drug screen. The ED leader reviewed the negative drug screen, their findings, and the just culture investigation with the ED department manager and Human Resource (HR), and the decision was made to terminate RN A. On 8/11/22, 8/12/22, and 8/15/22, ED leader attempted to contact RN A by phone with no answer, a voice message was left each time with request for call back or for an in-person meeting. RN A did not return the calls. No further documentation was noted in RN A personnel file.

4. Review of the local Police Department (PD) report identified that on 10/17/2022, an initial concern was brought to the local PD by RN A's sister. RN A's sister learned that RN A had recently lost her job at the hospital, and when she went to the home of RN A, she discovered the residence was vacant with tons of trash all over and a bunch of used needles. The initial officer took down the report and sent it for further investigation. RN A's sister followed up with sending several photos of RN A's residence, and that she had found "tons of used needles, and empty bottles of Dilaudid and Fentanyl."

5. During an interview on 1/26/23 at 11:35 AM with the alleged perpetrator 's sister, it was identified the sister had information pertaining to RN A 's investigation including the drugs with LOT numbers (an identification number assigned to a particular quantity or lot of material from a single manufacturer) and 2 patient records found in the home of RN A (pictures were provided of this, and only 1 patient name, date of birth, and date of service from the acute care hospital was identified). RN A's sister identified "a provider that worked with" RN A "confronted" RN A "prior to her being fired" from the acute care hospital. According to RN A's sister the provider "called her out on her diversion." She could not recall the name of the provider.

6. During an interview on 1/30/23 at 2:00 PM with the Director of Pharmacy and Staff Pharmacist N, stated if a tablet or two are missing, we don't typically do anything, but if it is a significant amount then it is reported to DEA and possible Board of Pharmacy. Anything missing or concerns such as med errors, we use an RL system (reporting system) to report to administration.
In early March 2021 intravenous (IV) grade Benadryl was added to the narcotic count (requiring nursing staff to count the medication each time they remove the medication for administration) and cameras were put up in the medication rooms after suspicion of IV grade Benadryl was disappearing. The Director of Pharmacy reported that the Pharmacy Technicians "kept" reporting the Benadryl "count was off", and the medication was "disappearing." After putting the intervention in place of requiring a Benadryl count, they were able to identified RN A's usage was significantly higher than other nurses, and then she began removing the medication under the "respiratory patient" (a "dummy" patient). She was also pulling two vials out at one time for a patient, then "wasting" the medication right away.

The Director of Pharmacy reported RN A "hit our radar once about a year ago" and was talked to, which "kind of resolved it for a while," but then she came up again in August 2022, on the proactive reports the Pharmacy Director looks at. It was identified that RN A's usage was significantly higher than her peers in the emergency department (ED) for 5 different medications and/or doses such as Hydromorphone 0.5 mg, Hydromorphone 1 mg, Fentanyl 100 mcg, Morphine 2 mg and 4 mg, and Benadryl.

The acute care hospital failed to report the loss of medications by RN A that would support a possible drug diversion according to Federal and State Laws.

Based on staff interviews and document review, the administrative staff failed to:

1. Ensure a staff adheres to accepted standards of practice to prevent the transmission of infection. Please refer to A-0750.

2. Ensure the Administrative staff provides surveillance, prevention, and control procedures that adheres to national recognized guidelines. Please refer to A-750.

3. Ensure the Administrative staff provides a competency-based training and education of hospital personnel and staff in the practice to prevent the transmission of infection. Please refer to A-750.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively identify and maintain a clean and sanitary environment to avoid sources in the transmission of infection. The hospital's administrative staff identified a census of 133 patients at the time of the survey.

Based on observation, document review, and staff interviews, the hospital's administrative staff failed to maintain food preparation and storage equipment in a clean and sanitary condition to reduce the risk of contamination and food-borne illness. Failure to ensure staff properly maintained food preparation and storage equipment in a clean and sanitary condition could potentially result in a food contamination and patients with foodborne illness. The hospital's administrative staff identified a census of 133 patients at the time of the survey.

Findings include:

1. During the initial kitchen environment tour, on 1/23/23, beginning at 2:50 PM, revealed the following concerns:

Multiple picture of Kitchen: 3 walk in refrigerators, 2 Freezers, 1 storage room, 1 chest freezer, several upright refrigerators.

Back hall entrance to kitchen near elevator the floors was littered with debris (old hairnet, gloves, paper, food particles, and small food cups) and dirty, floor did not appear to be cleaned.

Metal cart next line tray had paper items and food that had fallen behind and underneath the cart (teal colored).

Double door refrigerator had the right handle taped and did not appear to work.

White chest freezer had an open bag of chicken strips with food particles at the bottom of the freezer as well as on the lip of the freezer.

Back of kitchen is a room that was utilized for catering but now is collecting misc. items. The area appeared dusty and the floor was unkempt.

Large container of mac and cheese was on the counter left uncovered during extent of tour ½ hour.

Employee was creating yogurt cups with hair out of hair net.

Several garbage container did not have a lid on them.

There was a pan under a warmer that was full of old grease and food particles.

Employee's purse was in the walk-in refrigerator #2.

l. Walk in refrigerator #3 had uncovered food in trays.



Upright refrigerator that had plates to keep cold had old food particles with plastic stuck to bottom of door. Bins within the refrigerator was full of old food particles, and dried liquid under the bins and on the shelves.

In the upright refrigerator's freezer had plates and hair with a dust ball.

In another chest freezer which had sliding glass doors on the top had dried food on the glass and on the lip of the freezer had food particles.

Hanging on the wall next to the fryer were metal food baskets with long handles that had dried, fried food particles, which had appeared to not been utilized that day.

In a metal cart that had a clean coffee craft placed upside down on a shelf with dried liquid and dust.

A fly strip with flies on it over an area that had beverage containers.

A multiple bunt pan tray that was in the clean dish area turned upside down with grease and food particles on it.

Metal shelving for clean pans, which the shelves were greasy and dusty.

Sink in which staff wash their hands did not appear to be cleaned. Handles appear to have dirt and hard water build up.

Metal shelving in the back room by walk in freezer had an open bag of yellow onions with food and remnants of red onions scattered underneath the shelving.

Metal shelving in the back storage had a Dixie cup with lid and some food spilled on the floor for some time.

2. During a tour of the Emergency Department (ED), Surgical Suites, 2nd floor (mom & baby/labor & delivery), 5A- Medical/Surgical floor, 4A - Medical/Surgical/Oncology floor on 1/23/23, approximately at 2:50 PM, revealed the following concerns:

The ER's nutrition room's refrigerator had dried red liquid and stickiness on the bottom of the refrigerator. Garbage was overflowing.

On the 2nd floor in room 230 there was a sticky residue on the floor. In room 227, the shower had mold in it. In the staff breakroom there was an "Otis Spunkmeyer" oven that was utilized to bake cookies in for the patients, that was not on a cleaning schedule or maintenance schedule.

On 5A floor the nutrition room's refrigerator was overflowing with dietary items and the refrigerator did not appear to have been cleaned. It had dried liquid on the shelves and the front of the refrigerators door and handle were sticky with food particles.

On 4A floor the nutrition room's refrigerator did not appear to have been cleaned. It had dried liquid on the shelves and sticky with food particles.

3. Review of the policy "Environmental Cleaning Schedule," revised 2/08, revealed in part, " ...To properly train the employee in the new position so that the efficiency of the operation is not hindered." "Kitchen Nurses Station, Housekeeping cleans daily, 8AM-11:00PM ..."

4. Interview on 2/1/23 at 10:00 AM with Cook/Housekeeper I revealed there was currently only one janitor, there used to be two to cover areas in the hospital. Cook/Housekeeper I acknowledged the only way to identify if something is dirty or needs attention outside of the weekly schedule is by someone notifying him. Cook/Housekeeper I also revealed that the ice machines are not on a schedule to be cleaned. He believed these machines were cleaned by nursing staff and at times Cook/Housekeeper I would be sent to the inpatient floors to clean he ice machines.

5. Interview on 2/1/23 at 11:21 PM with Food Service Associate/Cook J revealed they did not recall to have had any competency training on cleaning in the kitchen or food services. Food Service Associate/Cook J further revealed new hires are trained by follow a peer and the peer will check off competencies on a check list.

6. Interview on 2/16/23 at 12:00 PM with Food Service Director revealed that there was only one janitor that will do the cleaning of the floors, equipment and areas in the kitchen. If a refrigerator on an inpatient floor needs cleaned on the inside we would be notified by the environmental staff that stocked that refrigerator on the floor. The Food Service Director acknowledge there were no logs to document these notifications and no logs on how often the managers verify these areas had been cleaned routinely and efficiently. The Food Services Director further acknowledged there were no policies or procedures on cleaning the kitchen, its equipment or non-clinical areas, such as nourishment rooms with the hospital.

I. Based on document review and staff interviews, the Administrative staff failed to:

1. Ensure there was an effect discharge planning process. Please refer to A-0802.

2. Ensure the focus was on the patient's realistic goals and treatment preferences. Please refer to A-0802.

3. Ensure the hospital's discharge planning process must require a regular re-evaluation of the patient's conditions to identify changes that require modification of the discharge plan. Please refer to A-802.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively carry out their discharge planning to meet the unique needs of behavioral health patients. The hospital's administrative staff identified a census of 133 patients at the time of the survey.

II. During the investigation of incident 110472-C and 110643-C, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Discharge Planning (42 CFR 482.43). The hospital staff failed to ensure the discharge planning had a process that would trigger a reevaluation to ensure patient safety prior to discharge.

1. The administrative staff failed to identify, develop and implement a process for mental health reevaluation to ensure all disciplines are involved in a safe, effective discharge plan.

2. While on-site, the survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 2/10/22 at 3:48 PM. The administrative staff promptly acted to remove the immediacy of the situation. The hospital staff removed the immediacy prior to the survey team exiting the complaint investigation when the hospital administrative staff took the following steps:

A behavioral health (BH) Discharge Huddle will convene prior to a BH patient being discharge.

Admission to the BH unit, patients are assessed and discharge planning is initiated per BH policy.

Advanced Practice Practitioner's will perform a reassessment prior to determining if a patient is appropriate for discharge.

Education of changes provided to BH staff and providers.

Auditing of charts of all discharged patients from BH unit.

The following Condition level deficiency remained for the Conditions of Participation for Discharge Planning (42 CFR 482.43) (A-0802).

Based on document review and staff interview, the acute care hospital's staff failed to provide an adequate discharge plan to 1 of 20 (Patient #1) patient's medical records reviewed. Failure to provide an adequate discharge plan with evaluation resulted in Patient #1 being discharged and ultimately possible lead to his death. The hospitals administrative staff identified an average monthly census of behavioral health inpatients is 266.

Findings include:

1. Review of the medical record revealed the follow:

Patient #1 was in jail on 11/26/22 due to drive while his license was barred. Patient #1 attempted to suicide by hanging while in jail. Patient #1 tied his pants around his neck and the jail cell bar and suspended himself off of the ground. At which, Patient #1 lost consciousness several times before he lost bladder control and awoke gasping for air.

The jail staff discovered Patient #1's attempt due to the redness and swelling in his neck. The jail staff also discovered a suicide note and urine on the floor of Patient #1 cell.

At 5:45 PM, telehealth psych evaluation was conducted at the jail by Psychiatric ARNP A. Psychiatric ARNP A documented Patient #1's functional status was severely impaired, Patient #1 posed a great risk of harm to himself, and in need of inpatient hospitalization related to suicide attempt with continued suicidal ideation and plan to use whatever means available, severe depression, and multiple psychosocial stressors.

On 11/26/22 at 7:05 PM Patient #1 arrived at local hospital for a medical clearance. The hospital's documentation revealed Patient #1 had pain, swelling and abrasions around his neck. Medical work up and a CAT scan (CT- a procedure used to see detailed x-ray images of organs, bone and tissue) were performed. Tests and CT showed no acute findings. Local hospital medical cleared Patient #1.

On 11/27/22 at approximately 2:23 AM Patient #1 was accepted as a direct admission to an inpatient behavioral health facility. Local Sheriff's department transported Patient #1 with a copy of the medical record, jail documents, psych evaluation performed in the jail and a verbal order for a 48-hour hold.

On 11/27/22 at approximately 6:36 AM Patient #1 arrived at the behavioral health unit. The medical record revealed Patient #1 was given the following medication:

at 11:17 AM, 1:44 PM, and 5:25 PM Nicotine gum 2 mg
at 11:17 AM Ibuprofen 400 mg tablet
at 3:23 PM Lexapro 10 mg (antidepressant) tablet
at 11:29 PM Seroquel 25 mg (antipsychotic medication used for depression) tablet

On 11/27/22 at 12:09 PM RN D documented Patient #1 scored high on the Columbia Suicide Scale and notified Psychiatric ARNP B. Documentation for the Columbia Suicide Severity Rating Scale Flowsheet revealed Patient #1 verbalized 'yes' to the following questions:

1. In the last month have you wished you were dead or wished you could go to sleep and not wake up?
2. In the last month have you actually had any thoughts of killing yourself?
3. Have you been thinking about how you might do this?
4. Have you had these thoughts and had some intention of acting on them?
5. In the last month have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
6. Have you ever done anything, started to do anything, or prepared to do anything to end your life?
7. Was this within the past 3 months?

Columbia Calculated Risk Level- High, indicating a high risk of suicide.

RN D further documented that Patient #1 had a history of psychological trauma, circumstantial thoughts, self-blaming, impaired judgement, depressed, caused by an accumulation of things, financial issues and fines as well as not having a driver's license.

On 11/27/22 at 5:16 PM the Psychiatric ARNP B performed a psychiatric evaluation admit. ARNP B documented Patient #1 had a major depressive disorder with an unsuccessful suicide attempt. Patient #1 had no past psychiatric history and was quite unwilling to take medications.

On 11/28/22 at 7:06 AM with ARNP E, RN F, SW G had a behavioral health staffing conference which SW G documented Patient #1 was voluntary.

On 11/28/22 at 9:00 AM and 11:00 AM Therapist C documented Patient #1 attended a group session but did not participate.

On 11/28/22 Patient #1 was administered the follow medication:

at 9:07 AM and at 12:10 PM Lexapro (antidepressant) 10 mg tablet

On 11/28/22 at 8:43 AM Therapist C documented a psychosocial assessment was performed on Patient #1 by chart review and not face to face.

On 11/28/22 at 12:32 PM ARNP E signed a discharge order for Patient #1.

On 11/28/22 at 3:08 PM ARNP E's documentation revealed Patient #1 made a superficial suicide attempt in jail. ARNP E increased Patient #1's antidepressant prior to discharge and that Patient #1 refused transportation and wants to hitch hike home.

At approximately 1:28 PM RN F walked Patient #1 out of the facility.

On 11/29/22 at 11:06 AM SW G documentation revealed, Patient #1 reported he was going back home which is approximately 169 miles from the facility and did not have transportation, but wanted to hitch hike home. SW G informed ARNP E Patient #1 wanted to hitch hike and ARNP E advised SW G that Patient #1 had a right to choose his mode of transportation. Further documentation revealed following Patient #1 discharge on 11/28/22 SW G received court orders for a court committal for Patient #1.

2. During an interview on 2/1/23 at 4:13 PM with SW G revealed, the 48 hours hold time does not start on weekends and holidays. The 48-hour clock will start on the first business day. Patient #1 arrived on Sunday and was discharged on Monday. The 48-hour clock would have started on Monday, 11/28/22 at 12:01 AM and expired on Wednesday, 11/30/22 at 12:01 AM. SW G also revealed she received a court committal via email at 1:52 PM on 11/28/22 but did not see the email until 2:19 PM.

3. During an interview on 2/7/23 at 3:40 PM with Psychiatrist H revealed the Patient #1 should not have been discharged and allowed to hitchhike home. Since Patient #1 did not have transportation or support he should have been held until it was established. Psychiatrist H further disagreed that the Patient #1's suicide attempt was superficial. He further elaborates that the 48-hour hold was meant to keep the patient safe especially with a new diagnosis of depression. Psychiatrist H also reveals he would not have discharged the patient after an increasing the antidepressant medication without further evaluation.

4. Review of the policy "Patient and Family Education Policy" approved 08/2021, revealed in part, " ...the patient care professional has responsibility for assessing and incorporating in the plan of care patient and family educational needs." " ...consideration will be given to special learning such as language barriers, physical and/or cognitive limitations ...emotional barriers, health literacy, financial aspects of care choices, desire and motivation to learn."

The hospital staff failed to identify the need of a reassessment of Patient #1's discharge and post-discharge needs prior to the discharge. The hospital's discharge policy also lacked further direction for staff to ensure that patients are safe when discharging. The accumulation of both these items resulted in Patient #1 committing suicide shortly after being discharge from hospital on 11/28/22.