HospitalInspections.org

Based on record review and interviews, the facility failed to ensure patients' rights to request or refuse treatment for 1 of 1 patient reviewed (Patient #1) with a patient rights complaint.

Specifically, Patient #1 was admitted voluntarily and informed multiple employees of the psychiatric hospital his desire to leave and the employees failed to assist Patient #1 in creating the written request and process the request for discharge from services; in accordance with the facility's policy and procedures and State Law.

Findings included:

Review of Complaint Intake Information for TX00533586 dated 2/18/2025, alleged the facility failed to timely discharge Patient #1, a voluntary patient, upon his request pursuant to state law. Further review indicated that Patient #1 was admitted to the facility's behavioral health voluntarily on 4/1/2024 and signed an Application for Voluntary Admission at approximately 1:58 PM. Patient #1 was at all times a voluntary patient. Patient #1 requested discharge from the facility on 4/2/24 at approximately 1:10 PM and again on 4/3/24 at 08:15 AM in accordance with Patient #1's records. However, Patient #1 was not discharged until 4/6/24, four days after his initial request.

Patient #1 requested discharge from the Behavioral Health facility on at least two occasions, however the hospital failed to follow proper discharge procedure pursuant to the Mental Health Code. Upon Patient #1's initial request on 4/2/24, the facility's staff should have assisted Patient #1 in putting this request in writing for him to sign and then notified the physician of this request. However, there is no evidence in Patient #1's records that staff assisted him in putting the request in writing. There also is no evidence that a physician evaluated Patient #1 to determine whether he met criteria for court-ordered mental health services. If the treating physician determined Patient #1 met criteria for commitment, the facility had an affirmative duty to submit the appropriate application and obtain the necessary order from the court in order to keep Patient #1 hospitalized. The hospital did not do so. Without a court order, the facility should have; at the latest, discharged Patient #1 on 4/3/24 at 1:10 PM. Because the facility failed to discharge Patient #1 upon request and did not obtain a court order to continue his hospitalization, the facility violated Patient #1's rights as a voluntary patient.

Interview with Patient #1 on 5/8/25 at 7:00 PM stated the following, in part;
He was transferred from their facility - A to their behavioral health facility - B, "to get help" that they told him he would be able to see a therapist. He had never been to a psychiatric facility or had previously been treated for a psychiatric diagnosis. He said during the admission assessment they told him he could be there a "little bit," or he could be there "longer." He said he told them at that time that he was "okay, nothing is going on anymore." He said he had already snapped himself out of the situation, was not suicidal, and had worked through it. He reported to the admission staff that he wanted to go home and that his wife was on her way; that he needed to work and provide for his family. Patient #1 said he went there voluntarily and then they took him to the back and would not let him out until he talked to the Doctor. He said he kept telling any staff that would talk to him to please let him out, "please, I am begging you. Let me out of here." He said that any staff he talked to just kept telling him that he needed to talk to the Doctor and then they put him in a room where staff would come in every 30 minutes to an hour to check in on him and then would tell him the Doctor was not available and had not shown up yet. He said they then told him it would be the "next day" and that he could talk to the Doctor then. He then spoke to the Doctor and told him he had a family that he needed to support, he was not suicidal and he knew his reason to live was for his family; that being locked in the facility was "stressing me out, loosing even more money" not being able to work. He said he did everything asked of him and was compliant because he wanted out. He said that on the 4th day of being locked in and not allowed to leave, that another patient told him about the "4-hour letter." He said that no one had every told him about it prior to the other patient telling him. He said that he felt the Doctor (Staff -A) "tried to trigger" him when there was a meeting "with all of these Doctor's, I was doing well and then the Doctor [Staff-A] attempted to trigger" him and said, "You look sad." He said he had been doing everything that he had been asked to do so that he could get out, "I was there voluntary and kept asking can I get out." He said the staff kept trying to give him "medication," but he didn't need any because he was cooperative and felt fine. He said that the Therapist (Staff- B) that he saw told him "it's up to you when you get out, we can keep you up to 30 days; unless he [Doctor] gave the ok, you can't get out." He said I was "happy, upbeat" and even helping other patients that were in there until he started to keep to himself, because he did not want to do anything wrong that would give them a reason not to let him out. He said that he was not given any information or a pamphlet regarding his rights; that he was only given a paper "about the rules while you're there." He was asked to "sign here, you're voluntary." He said he would tell the staff; "with the white coats that ask you how you're feeling and any thoughts of suicide today" that he was okay, no thoughts, and to please let him go. He said the whole experience has affected him, his family, and kids; because he has always been there for them and they fear him leaving, not knowing if he will be coming back.

Review of Patient #1's records revealed the following:
Psychiatric evaluation completed 4/2/24 at 10:20 AM by Doctor/Psychiatrist -A indicated "Patient is admitted after he attempted suicide. Patient attempted suicide by wrapping an electric cable around his neck. Patient said that when the police came to his car he already had taken away the cable. Patient said he did that because he has been very upset about losing $10,000 in his stock. He says that he been trying to recuperate and keep gambling and he spent the money from many family members. He says he does that on the side and he has his own private business. Patient said that he regrets what he did and that he is not suicidal. He believes he should be going home because his family needs him. Patient said that he is not depressed despite of having this financial stressors and not sleeping. Patient denies any past psychiatric history. Patient does not have any medical problems. Patient denies hallucination. He does not use drugs or alcohol he does not smoke. He said that he lives with his wife and his 3 children. He says that there are no marital problems. Patient says he is not suicidal."

Justification for Hospitalization:
"No Justification for Hospitalization documented."

"I certify that the inpatient psychiatric facility admission was medically necessary for treatment which could reasonably be expected to improve the patient's condition. Based upon the available information, I expect that this patient will require medically necessary care beyond two (2) midnights."

Medications: Scheduled: 0, Continuous: 0, PRN: Olanzapine 5mg Dis Tab (Zyprexa) 5 mg 1 tab oral, q 6 H

INITIAL DISCHARGE PLAN:
Discharge home when psychiatrically stable.

There was not any documentation or discussion by the Psychiatrist/Doctor-A that Patient #1 had requested to be discharged.

BH Discharge Planning Note dated 4/2/24 at 1:10 PM by staff -D, Therapist/Social Services documented, "met with patient to complete 24-hour introduction. Patient was agreeable and cooperative during interaction; however asking for discharge."

Bio-Social Assessment completed 4/3/24 at 08:15 AM by Therapist-B indicated Patient #1 denies being suicidal or homicidal ideations, denies auditory/visual hallucinations. Patient states he felt a little depressed, missing his family. Patient stated he "made a big mistake and ask if he can leave but was denied by doctor." Treatment team will reevaluate patient's progress tomorrow. Patient does not have history of inpatient or outpatient psychiatric treatment. Employment Barriers: Pt. stated inpatient is a barrier as he cannot leave.

There was not any further documentation that Therapist -B or any other facility staff assisted Patient #1 with his request to discharge, or a subsequent physician assessment after the initial psychiatric evaluation by Doctor/Physician-A.

4/3/24 at 1:43PM, Treatment Plan, Discharge Criteria:
No suicidal or homicidal ideation, Improvement in mood, thinking, and/or behavior, Verbal commitment for aftercare, appointment arranged with psychiatrist and/or therapists, Reduction of target symptoms.

Review of the "Progress Note-Physician" completed by Nurse Practitioner- C on 4/3/24 at 2:50 PM, on 4/4/24 at 12:30 PM, and 4/5/24 at 12:45 PM all documented the same information, in part:

"Met with the patient this morning. Patient is calm and cooperative. The patient is reporting no symptoms of depression and anxiety. The patient is reporting no symptoms of auditory hallucinations and visual no hallucinations. Denies suicidal ideation. Denies homicidal ideation _ The patient is not prescribed medication at this time. Reports that his sleep is good and appetite is good. Patient reports not having suicidal thoughts and states that he is now understanding that he needs to speak to his wife and let her know what is happening and not keep secrets from her wife is aware of what is going on and they have been talking about it.

Assessment: The patient is calm and cooperative. The patient continues to report no suicidal ideation. The patient is denying auditory and visual hallucinations. Thought content is circumstantial. The patient's ADLs are good."

Discharge Planning: Discharge Home with Family, Saturday

Review of Patient #1's records revealed he was not administered any medications.

Patient #1 signed his discharge information on 4/4/24 at 7:48 PM.

Interview on 3/26/25 at 4:20 PM with the facility's Director of Accreditation and Regulatory Services stated the following, in part; The two staff that were verbally told that the patient wanted to leave, did not document any follow up, or escalate the patient's request to leave. There was not a 4-hour letter completed. The Discharge planners begin the process after admission and if the patient states they want to leave, then it needs to be escalated. Patients are supposed to be provided with a booklet upon admission that includes their rights and information for requesting discharge if voluntary.

Interview on 3/26/25 at 4:35 PM with Therapist -B, who was the Licensed Professional Counselor (LPC) Supervisor stated the following, in part; he most likely told the patient he was there for a reason and explained to him why he was there; because he was minimizing the situation. Therapist -B stated, "I don't discharge, the doctor has the final say and we error on the side of caution." The doctor was going to probably say no if we asked him or would ask for a four-hour letter. We usually ask the patient's to give us five to seven days for treatment; usually for mood. Therapist - B stated we usually do not do a discharge on the first day; rule of thumb, to explain the process. Therapist - B vaguely remembered this patient. If he asked to leave, the rationale was that he could no longer be a danger. If he was asking the doctor to discharge, then he would have given us the information and we'd submit it to the doctor after the treatment team reviewed and we would provide the information. The team wants collateral from the family; to find out what happened, and if he's safe. We try to do due diligence. The patient's intake was voluntary. The doctor sees them within 24 hours. The Therapist/LPC will see them within 72 hours for the treatment plan and then somewhere along the line he requested to leave. The nurses will tell them about having to complete a four-hour letter and that request; 4-hour letter is from the nurse and they help them to complete it. The patient stated he was denied from the doctor he saw. The doctor saw him a day after admission, the doctor usually will reevaluate the next day.

Interview on 3/26/25 at 4:50 PM with the Risk Management Director confirmed there was not a 4-hour letter, a grievance, an internal [midas] report, or an AMA [Against Medical Advice] completed for Patient #1.

Review of the facility's policy/procedure titled, Discharge Against Medical Advice 4 Hour Letter, last revised 4/1/2023 indicated the following in part;

Procedure:
A, 2. Any patient admitted on a voluntary basis has the right to request discharge.

C. Licensed staff will provide the patient with paper and appropriate writing instrument to use in filing the request for discharge and assist with completing the request if the patient is unable to do so independently.

E. Staff will notify the attending psychiatrist, or psychiatrist on-call, of the patient's request for discharge, as soon as possible, so a resolution may be obtained within 4 hours of the request.

F. The psychiatrist will determine if the patient meets the criteria for regular discharge, involuntary commitment, or discharge AMA.

G. (i) A voluntary patient is entitled to leave an inpatient mental health facility in accordance with this section after a written request for discharge is filed with the facility administrator or the administrator's designee. The request must be signed, timed, and dated by the patient or a person legally responsible for the patient and must be made a part of the patient's clinical record. If a patient informs an employee of or person associated with the facility of the patient's desire to leave the facility, the employee or person shall, as soon as possible, assist the patient in creating the written request and present it to the patient for the patient's signature.

(ii) The facility shall, within four hours after a request for discharge is filed, notify the physician responsible for the patient's treatment. If that physician is not available during that period, the facility shall notify any available physician of the request.

(iii) The notified physician shall discharge the patient before the end of the four-hour period unless the physician has reasonable cause to believe that the patient might meet the criteria for court-ordered mental health services or emergency detention.

(iv) A physician who has reasonable cause to believe that a patient might meet the criteria for court-ordered mental health services or emergency detention shall examine the patient as soon as possible within 24 hours after the time the request for discharge is filed. The physician shall discharge the patient on completion of the examination unless the physician determines that the person meets the criteria for court-ordered mental health services or emergency detention. If the physician makes a determination that the patient meets the criteria for court-ordered mental health services or emergency detention, the physician shall, not later than 4 p.m. on the next succeeding business day after the date on which the examination occurs, either discharge the patient or file an application for court-ordered mental health services or emergency detention and obtain a written order for further detention. The physician shall notify the patient if the physician intends to detain the patient under this subsection or intends to file an application for court-ordered mental health services or emergency detention. A decision to detain a patient under this subsection and the reasons for the decision shall be made a part of the patient's clinical record.

Texas Administrative Code, Title 26, Part 1, Chapter 320, Subchapter A, Rule §320.13(a)(2)
If an individual informs a person associated with or employed by the department facility, community center, or psychiatric 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.