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Based on record review and interview the facility failed to meet the Condition of Participation to protect the patient's rights to be free from all forms of abuse, neglect, and harassment. This deficient practice led to patient death.

The findings are:

A. The facility failed to ensure that patients remained free from neglect by denying a patient psychiatric care when the patient reported they were actively suicidal. Refer to tag A-0145.

Based on record review and interview the facility failed to protect patients from neglect by denying psychiatric care for a patient that was reporting active suicidal thoughts for 1 (P [patient] 2) of 10 (P1-P10) patients reviewed for patient rights. This deficient practice led to a patient death.

The findings are:

A. Record review of the facility's "Patient Handbook" undated, on page 8 under "Patient Rights" it stated, "You have the right to . . . - To be informed of proposed services, treatments, therapies, and alternatives. - To give consent or to refuse any services, treatments, therapies, and alternatives. - To participate in the development of an individualized treatment plan. . .- To refuse medications or treatment procedures."

B. Record review of P2 electronic medical record for admission from 11/20/2022 - 12/12/2022 revealed the following:

1. Review of "[Initials of facility] Psychiatric Progress Note" dated 12/01/2022, stated, "[patient] admitted for severe depression and suicidal ideation seen today in a private area of the [name of unit]. [Patient] was found to be fairly groomed and [patient] was seen sitting with other residents interacting with them in a calm manner. Upon [patient] interview [patient] stated that [patient] continues to be severely depressed. [Patient] stated that this time of year is really difficult for [patient] because [patient's] mother passed away during the holidays and that [patient] is always severely depressed and suicidal during Christmas. [Patient] stated that [patient] is doing okay on [patients] current medications but that [patient] continues with refractory depression and has stated has thoughts of harming [self] but has no plan."

2. Review of "[Initials of facility] Psychiatric Progress Note" dated 12/11/2022 it is documented, "The patient reported [patient] has been doing well, however [patient] is extremely anxious about discharge tomorrow, patient was barely able to sleep, appetite has been normal, energy and concentration has been poor. The patient stated today's date is "December 11, 2022", patient is still endorsing suicidal ideations without a plan. Patient requested changes in [patient] medications . . . agree in continuing as inpatient, and with the current regimen of medications and adjustments. The patient denied having other doubts, questions or concerns at this time." Further, on page 6 it stated, ". . . Patient is discharged more likely [sic] will be postponed due to patient's endorsing suicidal ideations. Seems patient is having difficulties to cope with anxiety, as well as lack of skills to take care of herself and be able to enroll in her previous outpatient life."

3. Review of "Physician Discharge Summary" dated 12/12/2022 8:22 AM, it is documented, ". . . Even though the patient showed enough improvement to the point that [the patient] was in a euthymic mood every single day [patient] was here [patient] said [patient] was depressed and suicidal. [Patient] stated that [patient] wanted to stay here for the entire month of December. The patient has been hospitalized more than 10 times during the last 2 to 3 years. The patient had not been interested in getting better prior to January. The patient told me that [patient] wanted to be discharged Monday, 12/12/2022. We can offer [the patient] many resources to help [the patient] after [patient] is discharged from this facility, including safe house, domestic violence placement, outpatient resources for battered women, case management with [name of insurance company], etc. [patient] refused every help that was provided to [the patient]. [Patient] stated that all [patient] wanted to do was lives [sic] with a friend. This is a patient that is chronically depressed and suicidal. It seems to me that [the patient] may also be very manipulative and uses suicide to stay in hospitals. That is why [the patient] has been hospitalized more than 10 times in the last 2 or 3 years. It seems that [the patient] loves to be in hospitals. At this point the patient is ready for discharge. [Patient] seems to be in a euthymic mood even though [the patient] said [patient] is depressed and suicidal. [The patient] had been here more than 22 days. And even though [patient] had been doing better [patient] continues to verbalize that [patient] is depressed and suicidal. The patient is in a euthymic mood and [patient] is ready for discharge. Even though we offer [the patient] a lot of different help for outpatient, [patient] refused all that help that was recommended to [the patient]. It seems to me that [patient] will continue the pattern of going to emergency room's saying that [patient] is depressed and suicidal to be hospitalized psychiatrically. But at this point I think [patient] is ready to be discharged and I do not think [patient] is a danger to herself or others. . . Discharge Recommendations: Recommend patient take medications as prescribed without stopping or changing before talking to a provider. The patient will discharge to home with a friend because the patient refused all the resources that were offered to [the patient] . . . [The patient] prognosis is poor as long as [patient] continues with the same behavior. It seems that [patient] will continue to go to emergency rooms and say [patient] is depressed and suicidal so [patient] will be hospitalized psychiatrically."

4. Review of "[Initials of facility] Nursing Shift Note" dated 12/12/2022 at 8:23 AM, it was documented, ". . . Assessment complete. Patient is oriented to person, place, date, time and situation. Patient is appropriate calm and cooperative. [Patient] is preoccupied with the thought of discharge. [Patient] is still reporting that [patient] will kill [self] if discharged. MD [provider] aware. [Patient] is participating in group therapy. Patient does socialize with other clients and staff. . . Patient was brought up in care team meeting. Per Social worker: "Patient has been offered opportunities to continue care in an environment that [patient] will have access to other [sic] 24 hours a day and [patient] has declined these opportunities." [Patient] will be moving forward with discharge. 1424 [2:24 PM] [Patient] gave me a hug with tears rolling down her face and said "Goodbye." Patient belongings inventoried and accounted for. Patient signed release. Patient is discharged to go home with a friend. Escorted to insurance vehicle by nurse and MHT [mental health technician]."

5. Review of "Discharge Summary" dated 12/12/2022 at 9:27 AM by Social Services it was documented, "Writer attempted to meet with the patient today to complete discharge documents, safety plan and a Columbia Assessment. Patient is ANO [alert and oriented, no confusion or alteration noted] X (Times) 4. Patient endorsed SI [suicidal ideations], pt stated that if [patient] is discharged today, [patient] will kill [self]. [Patient] stated that [patient] is not ready to discharge. Patient presents as anxious and irritated today. Patient will be provided with follow up appointments in [patients] packet. Patient will be picked up by insurance transportation. Pt will be discharge [sic] to her friends house. Patient medications were sent to the pharmacy of choice. Patient was provided with a COVID negative test, COVID education and mask for transportation. At this time patient refused a MOCA [patient] stated it is an insult to [patients] intelligence and if the writer will not help [patient] stay here [patient] did not want to talk to [staff member]. Patient was offered numerous shelters and Domestic Violence Shelters. [Patient] was accepted into [name of community program], a referral was made to [name of community program] for their services and it will be valid for three months if [patient] decided to partake in the program. UPDATE: Patient is currently very upset and suicidal. [Patient] stated that [patient] does not want to go to [patient's] friend's house and that [patient] just wants to return to [patient's] partner house where the problem originated."

6. Review of "[Initials of facility] Discharge - Columbia-Suicide Severity Rating Scale dated 12/12/2022 at 10:10 AM on page 2, the risk rating given to the patient was "High." Below that under, "Level of Risk Explanation" it was documented, "Pt is currently a High Risk due to statements made today, admission criteria, lifetime of attempts and current life stressors."

7. Review of "[Initials of facility] Safety Plan" dated 12/12/2022 at 10:12 AM [this note is completed by social services], it was documented after each statement, "Pt [patient] refused to complete a Safety Plan, [patient] stated [patient] is going to kill [self] anyways."

C. During an interview on 10/16/2023 at 9:05 AM, the Complainant confirmed P2 committed suicide two weeks after discharge from the facility.

D. During an interview on 10/16/2023 at 4:05 PM. S9, Case Manager, was asked what would happen if a patient reported suicidal ideations at discharge. S9, Case Manager explained the provider would be called to assess the patient, the discharge would likely be cancelled.

E. During an interview on 10/17/2023 at 11:59 AM, S7, Nurse Practitioner confirmed it would not be appropriate to discharge a patient who is actively suicidal.

F. During an interview on 10/17/2023 at 12:15 PM, S8, Physician Assistant, confirmed it would not be appropriate to discharge a patient who is actively suicidal.

Based on observation and interview the facility failed to label medication and administer medications safely in accordance with Federal and State laws. This failed practice can lead to medication errors resulting in harm to all patients.

Findings are.

A. During an observation on 10/16/2023 at 10:09 am of the nurses' station on a work station on wheels (WOW) an unknown pill and nicotine patch was left unattended.

B. During an interview on 10/16/2023 at 10:15 am with S4, RN, when asked what the medications were that were left unattended on her workstation, S4 stated it was a nicotine patch and allergy pill. When asked "Do you usually leave medications unattended" S4 stated, "Not usually."

C. During an interview on 10/16/2023 at 2:56 pm with S2, CNO when asked "What is the standard on medications being left unattended?" S2 answered, "No medications should ever be left unattended."

Based on record review and interview the facility failed to adjust discharge plan based on a change in patients condition that warranted further evaluation for 1 (P [patient] 2) of 10 patients (P1-P10) reviewed for discharge planning. This failed practice resulted in an inappropriate discharge from a psychiatric facility and resulted in patient death.

The findings are:

A. Record review of P2 electronic medical record for admission from 11/20/2022 - 12/12/2022 revealed the following timeline:

1. 3. Review of "Physician Discharge Summary" dated 12/12/2022 8:22 AM, it is documented, ". . . Even though the patient showed enough improvement to the point that [the patient] was in a euthymic mood every single day [patient] was here [patient] said [patient] was depressed and suicidal. [Patient] stated that [patient] wanted to stay here for the entire month of December. The patient has been hospitalized more than 10 times during the last 2 to 3 years. The patient had not been interested in getting better prior to January. The patient told me that [patient] wanted to be discharged Monday, 12/12/2022. We can offer [the patient] many resources to help [the patient] after [patient] is discharged from this facility, including safe house, domestic violence placement, outpatient resources for battered women, case management with [name of insurance company], etc. [patient] refused every help that was provided to [the patient]. [Patient] stated that all [patient] wanted to do was lives [sic] with a friend. This is a patient that is chronically depressed and suicidal. It seems to me that [the patient] may also be very manipulative and uses suicide to stay in hospitals. That is why [the patient] has been hospitalized more than 10 times in the last 2 or 3 years. It seems that [the patient] loves to be in hospitals. At this point the patient is ready for discharge. [Patient] seems to be in a euthymic mood even though [the patient] said [patient] is depressed and suicidal. [The patient] had been here more than 22 days. And even though [patient] had been doing better [patient] continues to verbalize that [patient] is depressed and suicidal. The patient is in a euthymic mood and [patient] is ready for discharge. Even though we offer [the patient] a lot of different help for outpatient, [patient] refused all that help that was recommended to [the patient]. It seems to me that [patient] will continue the pattern of going to emergency room's saying that [patient] is depressed and suicidal to be hospitalized psychiatrically. But at this point I think [patient] is ready to be discharged and I do not think [patient] is a danger to herself or others. . .Discharge Recommendations: Recommend patient take medications as prescribed without stopping or changing before talking to a provider. The patient will discharge to home with a friend because the patient refused all the resources that were offered to [the patient] . . . [The patient] prognosis is poor as long as [patient] continues with the same behavior. It seems that [patient] will continue to go to emergency rooms and say [patient] is depressed and suicidal so [patient] will be hospitalized psychiatrically."

2. Review of "[Initials of facility] Nursing Shift Note" dated 12/12/2022 at 8:23 AM, it was documented, ". . . Assessment complete. Patient is oriented to person, place, date, time and situation. Patient is appropriate calm and cooperative. [Patient] is preoccupied with the thought of discharge. [Patient] is still reporting that [patient] will kill [self] if discharged. MD [provider] aware. [Patient] is participating in group therapy. Patient does socialize with other clients and staff. . . Patient was brought up in care team meeting. Per Social worker: "Patient has been offered opportunities to continue care in an environment that [patient] will have access to other [sic] 24 hours a day and [patient] has declined these opportunities." [Patient] will be moving forward with discharge 1424 [2:24 PM] [Patient] gave me a hug with tears rolling down her face and said "Goodbye." Patient belongings inventoried and accounted for. Patient signed release. Patient is discharged to go home with a friend. Escorted to insurance vehicle by nurse and MHT [mental health technician]."

3. Review of "Discharge Summary" dated 12/12/2022 at 9:27 AM by Social Services it was documented, "Writer attempted to meet with the patient today to complete discharge documents, safety plan and a Columbia Assessment. Patient is ANO[alert and oriented, no confusion or alteration noted] X (times) 4. Patient endorsed SI [suicidal ideations], pt stated that if [patient] is discharged today, [patient] will kill [self]. [Patient] stated that [patient] is not ready to discharge. Patient presents as anxious and irritated today. Patient will be provided with follow up appointments in [patients] packet. Patient will be picked up by insurance transportation. Pt will be discharge [sic] to [patient's] friends house. Patient medications were sent to the pharmacy of choice. Patient was provided with a COVID negative test, COVID education and mask for transportation. At this time patient refused a MOCA [patient] stated it is an insult to [patients] intelligence and if the writer will not help [patient] stay here [patient] did not want to talk to [staff member]. Patient was offered numerous shelters and Domestic Violence Shelters. [Patient] was accepted into [name of community program], a referral was made to [name of community program] for their services and it will be valid for three months if [patient] decided to partake in the program. UPDATE: Patient is currently very upset and suicidal. [Patient] stated that [patient] does not want to go to [patient's] friend's house and that [patient] just wants to return to [patient's] partner's house where the problem originated."

4. Review of "[Initials of facility] Discharge - Columbia-Suicide Severity Rating Scale dated 12/12/2022 at 10:10 AM on page 2, the risk rating given to the patient was "High". Below that under, "Level of Risk Explanation" it is stated, "Pt is currently a High Risk due to statements made today, admission criteria, lifetime of attempts and current life stressors."

5. Review of "[Initials of facility] Safety Plan" dated 12/12/2022 at 10:12 AM [this note was completed by social services], it was documented after each statement, "Pt [patient] refused to complete a Safety Plan, [patient] stated [patient] is going to kill [self] anyways."

B. During an interview on 10/16/2023 at 4:05 PM, S9, Case Manager, was asked what would happen if a patient reported suicidal ideations at discharge. S9, Case Manager explained that the provider would be called to assess the patient, the discharge would usually be cancelled.

C. During an interview on 10/17/2023 at 11:59 AM, S7, Nurse Practitioner confirmed that it would not be appropriate to discharge a patient who is actively suicidal.

D. During an interview on 10/17/2023 at 12:15 PM, S8, Physician Assistant, confirmed it would not be appropriate to discharge a patient who is actively suicidal.