HospitalInspections.org

Based on a review of documentation, observations, and interview, the hospital failed to protect and promote each patient's rights, as evidenced by:
* The facility failed to ensure patients the right to receive care in a safe setting, as evidenced by discharging a minor patient in an unsafe manner. Please refer to A0144.
* The facility failed to ensure patients have the right to be free from restraint or seclusion, of any form, imposed as a means of convenience. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others. Failure to ensure this right is evidenced by secluding child and adolescent patients behind 2 locked doors, due being physically prevented from leaving, with no staff present in the Access Unit, Child and Adolescent Waiting Room. Please refer to A0154.
* The facility failed to ensure seclusion may only be used for the management of violent or self-destructive behavior. Please refer to A0162.
* The facility failed to ensure that each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others was renewed in accordance with the following limits for up to a total of 24 hours: 2 hours for children and adolescents 9 to 17 years of age. Please refer to A0171.

Based on a review of documentation, observation, and interviews, the facility failed to ensure the patient right to care in a safe setting, by failing to provide a safe discharge of Patient #1. Facility discharge policies were not followed for this discharge. Documentation did not reflect this patient was stable or safe for discharge. There was risk of injury and even death to the patient, due to leaving this minor patient in an unsafe situation at closed CPS office.

Findings included:

Facility based policy entitled, "BH 009 - Discharge Planning Process" stated in part,
"4. On the day prior to discharge, psychiatrist conducts and documents face-to-face risk evaluation to include:
a. Assess for risk factors
b. Discontinue suicide/homicide precautions··
c. Enter discharge ongoing order
d. Document the patient's progress, readiness to discharge, and aftercare plan..."

Patient #1 (a 15- year-old minor patient) was discharged from the facility on 04/29/23 at approximately 1945.
* This minor patient was under the custody of Child Protective Services (CPS) while inpatient at the facility.
* On the date of this patient's discharge (04/29/23), this patient had multiple episodes of personal holds and seclusion, due to aggressive behavior, intermittently from 0934-1745. The continued use of seclusion due to aggressive behaviors indicated this patient's discharge may not have been appropriate.
* This patient also remained on precautions up until the time of discharge on 04/29/23 at 1945.
1. A physician observation level order for "1:1 Observation, Homicide Assault/Aggression" was placed on 04/29/23 at 1010 (and was discontinued on 4/29/23 at 1828).
2. Precaution orders for "Routine Elopement" remained in place from 04/28/23 at 1554-04/30/23 at 0605.
3. Review of Observation Checklist for 04/29/23 indicated (based on check marks on the form) that the patient was monitored 1:1 and Q 15 minutes for potential for suicide, potential for homicidal behaviors, potential for assaultive behavior, and potential sexual aggression from 0000-1945.
Per facility policy suicide/ homicide precautions should be discontinued the day prior to discharge. Suicide and homicide precautions were not discontinued, and the patient remained on precautions up until discharge.
* A discharge order by a physician was not placed for this patient until 4/29/2023 at 1010, not the day prior to discharge, per facility policy.
* This patient's medical record did not contain a documented face-to-face risk evaluation, assessing for risk factors, performed by a psychiatrist the day prior to discharge, per facility policy.
* On the date of discharge 04/29/23, an on-call CPS caseworker was driving from over 5 hours away to pick up the patient. The social worker (staff member #18) was aware that the caseworker was driving from a long distance to pick up the patient. However, the facility did not continue to keep the patient on the unit until the arrival of the CPS caseworker to take custody of this minor.
* Documentation by the social worker (staff member #18) reflected that patient #1 was discharged to the care of their CPS caseworker. A note by the social worker (staff member #18) on 04/29/23 at 2138 stated in part, "Pt was discharged today per the order of Dr. [name]. At the time of discharge, pt presented with a broad affect with congruent mood and voiced a readiness to return home. Pt's caseworker: - [name]was notified of the discharge and was present to assume care of the pt. At discharge, pt was transported by NWTH to CPS Amarillo and housing/shelter needs were appropriately met."
* A nursing note documented on 04/29/23 at 2050 stated, "Patient exited unit with staff to hospital transport. Patient was taken to CPS facility where two marked police cars were standing by. Patient exited car with three staff and front door of the facility was buzzed. No answer came this nurse called my house supervisor to get instructions on proper procedure. This nurse was notified to let APD know the hospital no longer had legal grounds to stay with the subject so APD would need to stand by with said subject, APD did instruct staff to stand by for further instructions, but hospital staff left subject in APD's care per orders received from house supervisor."
* Per Amarillo Police Reports, three staff members from this facility transported this 15-year old patient in a NWTH labeled vehicle to the Child Protective Services office on a Saturday evening (the CPS office was closed, its operational hours are only M-F 8 AM-5 PM). This office was closed, with no CPS representatives available to receive this adolescent patient. The staff members asked the police to take custody of the adolescent patient, the police told the staff members that Patient #1 remained in their custody, and that if they left the patient at the closed CPS office, it could be considered child abandonment. The 3 staff members refused to identify themselves to the officers and left the child with the police, prior to any CPS representatives arriving. Police stayed with the adolescent until the CPS caseworker arrived to pick up the patient.
* In interviews with staff members #1, 5, 6, and 18, they were all unaware the local CPS office was closed on weekends with coverage available. All 4 of these staff members were under the impression the local Amarillo CPS office was open and staffed 24 hours/7 days a week.

The above findings were verified on 05/11/23 with staff members #1, 2, 3, and 4.

Based on a review of documentation, observations, and interviews, the facility failed to ensure patients have the right to be free from restraint or seclusion, of any form, imposed as a means of convenience. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others. Failure to ensure this right is evidenced by secluding child and adolescent patients behind 2 locked doors, due to them being physically prevented from leaving, with no staff present in the Access Unit, Child and Adolescent Waiting Room.

Findings included:

Patient's Bill of Rights stated in part, "30. You have the right not to be physically restrained (restriction of movement of parts of the body by person or device or placement in a locked room alone) unless your doctor orders it and writes it in your medical record, in an emergency, you may be restrained for up to one hour before the doctor's order is obtained. If you are restrained, you must be told the reason, how long you will be restrained and what you have to do to be removed from restraint. The restraint has to be stopped as soon as possible."

The Teen's Bill of Rights also stated, "17: You have the right not to be physically restrained (restriction of movement of your body by person or by a device or by being locked in a room alone) unless your doctor says it's necessary. However, if there is a situation in which staff thinks you may hurt yourself or someone else if you aren't restrained right away, you can be restrained for up to an hour before the doctor's permission is gotten. Whenever you are restrained, staff has to tell you why you are being restrained, how long you'll be restrained, and what you need to do to be remove from restraint sooner."

Facility Based Policy entitled, "Title: BH 012- Proper Use and Monitoring of Restraint, Emergency Medications and Seclusion: Texas Acute" stated in part,
"Policy: It is the policy of Northwest Texas Healthcare System Behavioral Health to support
each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. The patient has a right to be free from restraint/ seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff. Restraint/seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing ...

This facility is committed to preventing, reducing, and striving to eliminate the use of restraints and seclusion, as well as preventing emergencies that have the potential to lead to the use of these interventions ...

Definitions: ...

Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not ..."

During a tour of the patient intake and admission area (referred to as the Access Unit by staff members) on 05/10/23 at 3:45 PM the following was observed:

The outside entrance to the facility admission area included 2 locked doors (opened via electronic key contained in a wristband staff members wear) which lead to an inner hallway that leads to a second entry point that has a sally port with 2 locked doors (also unlocked via electronic key). After passing through these two locked doors, you enter an open area that was previously the uniformed service unit. An enclosed nurse's station is located to the right as you enter the Access area. The patient bathroom was also located in this open area. A small hallway leads to the child and adolescent waiting area, labeled TG130. To enter the child and adolescent waiting area you enter through 2 more locked doors in a sally port arrangement. It was observed that these doors require a physical key to unlock them to enter the waiting area. Once inside the waiting area it was noted the door was locked and could not be opened from the inside. Staff member #1 demonstrated the 2 doors required a key to unlock both doors from the inside in order to be able to exit the waiting area.

The child and adolescent waiting room was observed to have phone on the wall that when picked up would dial directly into the nurse's station. Staff member #1 verified that patients would need to utilize the phone to request staff take them to the bathroom. Camera surveillance was also noted in the waiting area. Staff member #1 verified that staff perform every 15-minute rounding if a child is alone in the waiting area, "We watch them on the camera. We only put a staff member in this room if there is more than one child in the waiting area." Staff member #1 again verified that patients could not exit the waiting area on their own without staff members entering and unlocking both locked doors with a key.

Review of surveillance video for the Child and Adolescent Waiting Room in the Admission/Access area of Intake on 04/26/2023 from 1640-1938 revealed the following:
* A 15-year-old male patient and their CPS caseworker were placed into a waiting room (monitored via video surveillance, staff were not physically in this waiting room) in the admission area for approximately 3 hours prior to being admitted to the Child and Adolescent Unit, there are two doors (a sally port access) to this room with key locks present, requiring staff to open it with key access. There was no access to a bathroom in this room. The only way to be let out of this room is by utilizing a phone on the wall to contact nursing staff.
* Due to being unable to open the door on their own, this patient was physically prevented from leaving, creating a seclusion environment.
* There was no order for seclusion of Patient #1 during this time period on 04/26/23. This violates the patient right to be free of unnecessary seclusion.

Staff member #1 verified on 05/10/23 that child and adolescent patients are routinely placed in this room with 2 locked doors alone with no staff physically present unless there is more than one patient present in the room, this implies that all child and adolescent patients placed in this room alone were also secluded in this room, due being physically prevented from leaving, without an order.

The above findings were verified on 05/10/22 with staff member #1, 2, 3, and 4.

Based on a review of documentation, observations, and interviews, the facility failed to ensure seclusion may only be used for the management of violent or self-destructive behavior.

Findings included:

Facility Based Policy entitled, "Title: BH 012- Proper Use and Monitoring of Restraint,
Emergency Medications and Seclusion: Texas Acute" stated in part,
"Policy: It is the policy of Northwest Texas Healthcare System Behavioral Health to support
each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. The patient has a right to be free from restraint/ seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff. Restraint/seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing ...

This facility is committed to preventing, reducing, and striving to eliminate the use of restraints and seclusion, as well as preventing emergencies that have the potential to lead to the use of these interventions ...

Definitions: ...

Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not ..."

During a tour of the patient intake and admission area (referred to as the Access Unit by staff members) on 05/10/23 at 3:45 PM the following was observed:

The outside entrance to the facility admission area included 2 locked doors (opened via electronic key contained in a wristband staff members wear) which lead to an inner hallway that leads to a second entry point that has a sally port with 2 locked doors (also unlocked via electronic key). After passing through these two locked doors, you enter an open area that was previously the uniformed service unit. An enclosed nurse's station is located to the right as you enter the Access area. The patient bathroom was also located in this open area. A small hallway leads to the child and adolescent waiting area, labeled TG130. To enter the child and adolescent waiting area you enter through 2 more locked doors in a sally port arrangement. It was observed that these doors require a physical key to unlock them to enter the waiting area. Once inside the waiting area it was noted the door was locked and could not be opened from the inside. Staff member #1 demonstrated the 2 doors required a key to unlock both doors in order to be able to exit the waiting area.

The child and adolescent waiting room was observed to have a phone on the wall that when picked up would dial directly into the nurse's station. Staff member #1 verified that patients would need to utilize the phone to request staff take them to the bathroom. Camera surveillance was also noted in the waiting area. Staff member #1 verified that staff perform every 15-minute rounding if a child is alone in the waiting area, "We watch them on the camera. We only put a staff member in this room if there is more than one child in the waiting area." Staff member #1 again verified that patients could not exit the waiting area on their own without staff members entering and unlocking both locked doors with a key.

Review of surveillance video for the Child and Adolescent Waiting Room in the Admission/Access area of Intake on 04/26/2023 from 1640-1938 revealed the following:
* A 15-year-old male patient and their CPS caseworker were placed into a waiting room (monitored via video surveillance, staff were not physically in this waiting room) in the admission area for approximately 3 hours prior to being admitted to the Child and Adolescent Unit, there are two doors (a sally port access) to this room with key locks present, requiring staff to open it with key access. There was no access to a bathroom in this room. The only way to be let out of this room is by utilizing a phone on the wall to contact nursing staff.
* Due to being unable to open the door on their own, Patient #1 was physically prevented from leaving, creating a seclusion environment.
* There was no evidence in the video surveillance or medical record documentation, that this patient was engaging in violent or self-destructive behavior on 04/26/23, which could support the use of seclusion. Therefore, there was no management of violent or self-destructive behavior that could provide reasons for utilizing seclusion and preventing this patient from leaving this room.

The above findings were verified on 05/10/22 with staff member #1, 2, 3, and 4.

Based on a review of documentation, observations, and interviews, the facility failed to ensure that each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others was only renewed in accordance with the following limits for up to a total of 24 hours:
(A) 4 hours for adults 18 years of age or older;
(B) 2 hours for children and adolescents 9 to 17 years of age; or
(C) 1-hour for children under 9 years of age;

Findings included:

Facility Based Policy entitled, "Title: BH 012- Proper Use and Monitoring of Restraint, Emergency Medications and Seclusion: Texas Acute" stated in part,
"3.0 Physician Orders, Consultation, and Evaluation:

3.1 Restraint, seclusion, or emergency medications shall be used in emergency situations only and requires an order from a physician. Prior to initiation of restraint, seclusion, or emergency medications, the physician and nurse will be aware of any considerations that should be taken based upon the initial assessment completed at the time of admission

3.1.1 The physician/LIP orders are not written as standing or PRN orders ...

3.2 The physician's/LIP's order for use of restraint, seclusion, or emergency medication will be recorded in the medical record and include the following: ...

3.2.2 Time limits not to exceed 15 (fifteen) minutes for personal/manual restraints, or for mechanical restraints/seclusion: 4 hours for adults, 2 hours for children and adolescents ages 9 to 17, and 1 hour for children under age 9; (Northwest Texas Behavioral Health does not authorize the use of mechanical restraints) ...

3.3 If a physical restraint immediately goes into a seclusion and/or mechanical restraint, the total time for the restraint(s) and/or seclusion must not be more than the allowable time limits according to the regulatory standards (see 3.2.2). (Northwest Texas Behavioral Health does not authorize the use of mechanical restraints)

3.3.1 A physician/LIP's order is required for each separate restraint and seclusion episode that is not considered one continuous episode, i.e. a patient at some later time is determined to require the use of a restraint or seclusion to ensure his/her safety or the safety of others ..."

Based on physician orders and documentation on Restraint/ Seclusion Patient Observation Forms, Patient #1 had personal holds and seclusions as follows on 04/29/23:
Personal hold 0938-0935
Seclusion 0938-1100
Seclusion 1115-1245 (1245 noted door open patient wanted to remain in the room)
Seclusion 1345-1557- 1403 noted "eyes closed" 1557 noted "stated he wants to remain in seclusion"
Seclusion 1600-1745

Timeline for the review of surveillance video for the Child and Adolescent Seclusion Room on 04/26/2023 for Patient #1 revealed the following:
* 9:36 am - patient is standing in a corner of the unit, near the seclusion room
* 9:38 am - upright restraint/escort initiated by staff identified by administration as Staff member #15 and 16, patient is walked into the seclusion room and door is closed
* 9:42 - nursing staff enters room and administers an injection to the right deltoid
* 10:09 - door is opened and patient leaves the room
* 10:10 - patient is back in room and door is closed
* 10:54 - door opens, staff enters room & brings food to patient and leaves, closing door behind them
* 10:58 - door opens briefly & staff toss another snack item to patient and close door again
* 11:06 - staff enter room to remove patient's food trash
* 11:19 - door is opened and patient leaves room
* 11:22 - patient back in room and door closed
* 12:09 - staff opens door and brings patient food
* 12:31 - released from seclusion
* 12:40 - back in seclusion room, door remains open
* 12:50 - patient leaves seclusion room and immediately steps back in
* 1:27 - patient leaves seclusion room
* 1:44 - patient placed back into seclusion room and door is closed
* 3:55 - patient briefly leaves seclusion room
* 3:56 - patient back in seclusion room, door left open
* 3:59 - door to seclusion room closes
* 4:00 - patient stood on bench bolted to floor in middle of room and reaches above his head, pulling down a round, white, smoke detector. Smoke detector is dangling from a cord and the patient is swatting it back and forth.
* 4:03 - behavioral tech enters room
* 4:05 - tech rips smoke detector from ceiling and patient assaults another technician in the room, patient and technician are separated and the door to the seclusion room is closed again.
* 4:07 - while standing on bench, patient pulls another white object from above his head, security enters the room and takes item from patient
* 4:08 - patient picks up black object (measuring approximately 4" x 4") from floor and begins scratching anterior, left forearm with the object
* 4:09 - security enters room and takes object from patient
* 4:11 - Patient again stands on bench and reaches above his head; staff & security immediately enter room
* 4:12 - patient placed in brief hold to administer injection; staff & security leave and door closes
* 4:14 - patient stands on bench and reaches above his head; staff re-enter room
* 4:15 - staff identified as RN by facility staff stands on bench and yanks approximately 3-4 feet of white cord down from ceiling area; staff leaves and door closes
* 4:56 - patient back on bench, reaching hands above his head
* 5:07 - door opens briefly and staff hands patient snacks
* 5:17 - patient on bench, leaning towards corner where surveillance camera is and punching at it
* 5:20 - patient on bench, hitting ceiling with shoe
* 5:27 - patient on bench, striking camera with his shoe (at this moment, the camera view is out of focus)
* 5:50 - door opens and staff enters
* 5:51 - staff leaves and closes door
* 5:58 - staff enters with patient meal
* 6:11 - patient exits seclusion room and re-enters, door open
* 6:21 - patient walks out of seclusion room
Based on review of the above video surveillance from 1345-1745, Patient #1 only briefly left the seclusion room for less than a minute from 1555-1556 with the door closed after returning, the door was not opened to release the patient from seclusion until 1811. Documentation reflected a release from seclusion for this patient at 1557, this was not supported by review of the video surveillance. It appears patient #1 was in seclusion with the door closed from 1345-1811, this represents a seclusion episode lasting over 4 hours, well over the 2 hour limit prescribed by regulations and facility policy.

The above findings were verified with facility administrative staff on 05/11/23.

Based on review of documentation, observations, and interviews the hospital failed to have in effect a discharge planning process that includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plans did not ensure an effective transition of the patient from hospital to post-discharge care. As evidenced by:
* The facility failed to ensure the discharge planning process required regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan. The facility also failed to ensure that discharge plans were updated, as needed, to reflect these changes. Please refer to A0802.
* The facility failed to ensure that discharge planning evaluations were made in a timely basis to ensure the appropriate arrangements for post-hospital care were made before discharge. Please refer to A0805.

Based on a review of documentation and interviews, the facility failed to update Patient #1's discharge plan as needed to re-evaluate the patient's condition that could require modification of the discharge plan. The continued needed for suicide/homicide precautions and monitoring of this patient up until when they left the facility for discharge was not addressed in this patient's discharge plan, despite that, per facility policy, these precautions should have been discontinued the day prior to discharge. The discharge plan also did not reflect the patient's refusal to sign their discharge instructions. The discharge plan for this patient did not reflect why the facility did not wait for the CPS caseworker to arrive and instead discharged this minor patient to a closed CPS office.

Findings included:

Facility based policy entitled, "BH 009 - Discharge Planning Process" stated in part,
"4. On the day prior to discharge, psychiatrist conducts and documents face-to-face risk evaluation to include:
a. Assess for risk factors
b. Discontinue suicide/homicide precautions··
c. Enter discharge ongoing order
d. Document the patient's progress, readiness to discharge, and aftercare plan...

9. Discharge/Continuing Care Plan is developed prior to discharge with input from patient/family/natural support
a. Copy is provided to patient and family/natural support, and the signed original is placed in medical record
b. Documentation of securing of weapons and medication should occur at time of discharge with patient, family/natural supports ...

11. Aftercare plans are communicated to the patient and family, as appropriate, and documented in the medical record.

12. If patient refuses to complete any aspect of the discharge process, notify the Psychiatrist and Risk Manager. Document in the medical record patient refusal to participate in process.

13. Clinical review of discharge is performed by all members of treatment team on the day of discharge using the discharge process checklist."

Patient #1 (a 15- year-old minor patient) was discharged from the facility on 04/29/23 at approximately 1945.
* This minor patient was under the custody of Child Protective Services (CPS) while inpatient at the facility.
* On the date of this patient's discharge (04/29/23), this patient had multiple episodes of personal holds and seclusions, due to aggressive behavior, intermittently from 0934-1745. The continued use of seclusion due to aggressive behaviors indicate this patient's discharge may not have been appropriate. The use of personal holds and seclusion to manage this patient's ongoing aggression from 0934-1745 on the date of their discharge on 04/29/23 were not addressed in the discharge plan, nor was the discharge plan of this patient updated.
* This patient also remained on precautions up until the time of discharge on 04/29/23 at 1945.
1. A physician observation level order for "1:1 Observation, Homicide Assault/Aggression" was placed on 04/29/23 at 1010 (and was discontinued on 4/29/23 at 1828).
2. Precaution orders for "Routine Elopement" remained in place from 04/28/23 at 1554-04/30/23 at 0605.
3. Review of Observation Checklist for 04/29/23 indicated (based on check marks on the form) that the patient was monitored 1:1 and Q 15 minutes for potential for suicide, potential for homicidal behaviors, potential for assaultive behavior, and potential sexual aggression from 0000-1945.
Per facility policy suicide/ homicide precautions should be discontinued the day prior to discharge. Suicide and homicide precautions were not discontinued, and the patient remained on precautions up until discharge. The continued need for suicide/homicide precautions and monitoring of this patient up until they left the facility for discharge was not addressed in this patient's discharge plan, despite that per facility policy, these precautions should be discontinued the day prior to discharge.
* On the date of discharge 04/29/23, an on-call CPS caseworker was driving from 5 hours away to pick up the patient. The social worker (staff member #18) was aware that the caseworker was driving from a long distance to pick up the patient. However, the facility did not continue to keep the patient on the unit until the arrival of the CPS caseworker.
* The social worker (staff member #18) did not start discharge planning with this patient's guardian until 04/29/23 the date of discharge. A note by staff member #18 on 04/29/23 at 2136 stated, "Due to doctors' orders from Dr. [name] Patient: [Patient #1 name] was ordered for discharged as of 1010 on 4/29/23. As therapist on CAU I called [Patient #1's] caseworker [Name]to start discharge planning."
* Documentation by the social worker (staff member #18) reflected that patient #1 was discharged to the care of their CPS caseworker. A note by staff member #18 on 04/29/23 at 2138 stated in part, "Pt was discharged today per the order of Dr. [name]. At the time of discharge, pt presented with a broad affect with congruent mood and voiced a readiness to return home. Pt's casworker [sic]: - [name] was notified of the discharge and was present to assume care of the pt...At discharge, pt was transported by NWTH to CPS Amarillo and housing/shelter needs were appropriately met."
* A nursing note on 04/29/23 at 2050 stated, "Patient exited unit with staff to hospital transport. Patient was taken to CPS facility where two marked police cars were standing by. Patient exited car with three staff and front door of the facility was buzzed. No answer came. This nurse called my house supervisor to get instructions on proper procedure. This nurse was notified to let APD know the hospital no longer had legal grounds to stay with the subject so APD would need to stand by with said subject. APD did instruct staff to stand by for further instructions, but hospital staff left subject in APD's care per orders received from house supervisor."
* Based on several sources; including Amarillo Police Department reports and interviews, it was verified that Patient #1 was not discharged to the care of a CPS caseworker and was instead actually discharged via a NWTH (Northwest Texas Hospital) transport team to the local CPS office in Amarillo at 1945 on 04/29/23 (a Saturday).The local CPS office in Amarillo located at 3521 SW 15th Avenue Amarillo only has business hours from Monday-Friday 8:00 AM-5 :00 PM and is closed after hours an on weekends. The Amarillo CPS office hours were verified via a Website search, on-site visit, and interview of a receptionist at the Amarillo CPS office by surveyors.
* The discharge paperwork for Patient #1, including the Discharge Instructions, indicated "Patient Refuses to Sign" and "Patient Left Without Signing". There was no documentation that the Psychiatrist and Risk Manager were notified, per facility policy. The patient's refusal to participate in the process also was not documented in the medical record. The discharge plan also did not reflect the patient's refusal to sign their discharge instructions.

The continued need for observation, the continued use of seclusion, and the change in the discharge plan from discharging this patient to the care of their CPS caseworker and instead discharging Patient #1 to a closed CPS office, was not reflected in any kind of re-evaluation or update to the discharge plan for Patient #1.

The above finding were verified on 05/11/23 with staff members #1, 2, 3, and 4.

Based in a review of documentation and interviews, the facility failed to ensure that discharge planning evaluations were made in a timely basis to ensure the appropriate arrangements for post-hospital care were made before discharge.

Findings included:

Facility based policy entitled, "BH 009 - Discharge Planning Process" stated in part,
"4. On the day prior to discharge, psychiatrist conducts and documents face-to-face risk evaluation to include:
a. Assess for risk factors
b. Discontinue suicide/homicide precautions··
c. Enter discharge ongoing order
d. Document the patient's progress, readiness to discharge, and aftercare plan...

7. Discharge education is provided to patient, parent/guardian/spouse/natural supports and documented regarding
a. Suicide risk factors including increased risk for suicide immediately following discharge
b. Discharge/aftercare instructions including the importance of keeping aftercare appointments, continuing medication, dangers of drug and alcohol use, crisis line numbers, and how to contact healthcare providers in case of emergent signs/symptoms

8. Educational material regarding suicide risk factors and symptoms of relapse are provide to:
a. Patient
b. Parent/guardian/spouse/natural support
c. Documentation on the patient/family education form in medical record

9. Discharge/Continuing Care Plan is developed prior to discharge with input from patient/family/natural support
a. Copy is provided to patient and family/natural support, and the signed original is placed in medical record
b. Documentation of securing of weapons and medication should occur at time of discharge with patient, family/natural supports ...

11. Aftercare plans are communicated to the patient and family, as appropriate, and documented in the medical record.

12. If patient refuses to complete any aspect of the discharge process, notify the Psychiatrist and Risk Manager. Document in the medical record patient refusal to participate in process.

13. Clinical review of discharge is performed by all members of treatment team on the day of discharge using the discharge process checklist."

Patient #1 (a 15 year-old minor Patient) was discharged from the facility on 04/29/23 at approximately 1945.
* This minor patient was under the custody of Child Protective Services (CPS) while inpatient at the facility.
* A discharge order was not placed for this patient until 4/29/2023 at 10:10 AM, not the day prior to discharge.
* This patient's medical record did not contain a documented face-to-face risk evaluation, assessing for risk factors performed by a psychiatrist the day prior to discharge, per facility policy.
* On the date of discharge 04/29/23, an on-call CPS caseworker was driving from 5 hours away to pick up the patient. The social worker (staff member #18) was aware that the caseworker was driving from a long distance to pick up the patient. However, the facility did not continue to keep the patient on the unit until the arrival of the CPS caseworker.
* Documentation by the social worker (staff member #18) reflected that patient #1 was discharged to the care of their CPS caseworker. A note by social worker (staff member #18) on 04/29/23 at 2138 stated in part, "Pt was discharged today per the order of Dr. [name]. At the time of discharge, pt presented with a broad affect with congruent mood and voiced a readiness to return home. Pt's casworker [sic]: - [name] was notified of the discharge and was present to assume care of the pt. At discharge, pt was transported by NWTH to CPS Amarillo and housing/shelter needs were appropriately met."
* A nursing note documented on 04/29/23 at 2050 stated, "Patient exited unit with staff to hospital transport. Patient was taken to cps facility where two marked police cars were standing by. Patient exited car with three staff and front door of the facility was buzzed. No answer came. This nurse called my house supervisor to get instructions on proper procedure. This nurse was notified to let APD know the hospital no longer had legal grounds to stay with the subject so APD would need to stand by with said subject. APD did instruct staff to stand by for further instructions, but hospital staff left subject in APD's care per orders received from house supervisor."

Based on several sources; including Amarillo Police Department reports and interviews, it was verified that Patient #1 was not discharged to the care of a CPS caseworker and was instead actually discharged via a NWTH (Northwest Texas Hospital) transport team to the local CPS office in Amarillo at 1945 on 04/29/23 (a Saturday).The local CPS office in Amarillo located at 3521 SW 15th Avenue Amarillo only has business hours from Monday-Friday 8:00 AM-5 :00 PM and is closed after hours an on weekends. NWTH staff attempted to leave this patient in the custody of the Amarillo Police Department (APD), who had no obligation to take custody of this minor patient. NWTH staff members preceded to abandon this minor patient at this closed CPS office, knowing that APD was not taking the patient into custody. The hospital staff abandoned this minor patient at a closed CPS office, despite APD declining to take custody of the patient and the patient's CPS case worker not being present at the closed CPS location.

Discharging a minor patient to a closed and un-staffed CPS office, is not an appropriate arrangement for post-hospital care for this adolescent.

Review of the medical record for Patient #1 and 4 other child and adolescents patients (#2, 3, 4, and 5) recently discharged from the facility revealed that discharge instructions and the discharge process checklist were not being consistently completed.
* Patient #1's Discharge Instructions indicated both the "Patient Refuses to Sign" and "Patient left Without Signing". There was no documentation that the Psychiatrist and Risk Manager were notified, per facility policy. The patient's refusal to participate in the process also was not documented in the medical record, per facility policy. The Discharge Process Checklist subsections for the "Physician", "Discharge Nurse", "Discharge documented & provided", and "education material" portions were not completed. The Discharge Process Checklist for this patient also did not have signature present for the discharge planner, physician, or the discharge nurse.
* Patient #2's Discharge Process Checklist subsection for the "Physician" was incomplete. The Discharge Process Checklist for this patient also did not have signature present for the physician.
* Patient #3's Discharge Process Checklist subsection for the "Physician" was incomplete. The Discharge Process Checklist for this patient also did not have signature present for the physician.
* Patient #4's Discharge Process Checklist did not have signature present for the physician.
* Patient #5's Discharge Process Checklist subsection for the "Physician" was incomplete. The Discharge Process Checklist for this patient also did not have signature present for the physician.

The above findings were verified on 05/10/23 with staff members #1 and 2