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Based on observation, interview, and record review, the hospital failed to provide direct observation and supervision for two of two sampled patients (Patient 21 and Patient 22) in the adolescent unit, when Patient 22 was seen exiting Patient 21's room. This failure had the potential for staff being unaware if Patient 21 was in distress or danger.

Findings:

During an interview on 9/18/24 at 10:35 a.m. with Chief Executive Officer (CEO), CEO stated Patient 22 snuck out of her room and entered Patient 21's room and hid behind a door. CEO stated she stressed to the patients the goal was to keep them safe while in the hospital. CEO stated Patient 21 was getting ready for bed. CEO stated Patient 21 told Patient 22 to leave the room.

During a concurrent interview and review of hospital's video hallway recording at 11:20 a.m. on 9/18/24 with CEO and Interim Chief Nursing Officer (ICNO), the video recording dated 9/6/24, indicated, Patient 21 went to his room. Patient 22 entered into Patient's 21 room at 7:43 p.m.. At 7:52 p.m. Mental Health Worker (MHW) 4 was doing observation rounds to check on Patient 21's room, and without entering room closed Patient 21's and Patient 22's door. At 8:10 p.m. MHW 4 without entering the room, opened and closed Patient 22's door. At 8:17 p.m. Patient 22 left Patient 21's room. ICNO stated Patient 22 went into Patient 21's room in-between every-five-minute observation rounds.

During an interview on 9/18/24 at 11:25 p.m. with ICNO, ICNO stated MHW 4 did not monitor Patient 22.

During an interview on 9/18/24 at 2:10 p.m. with MHW 3, MHW 3 stated the process for direct observation monitoring a patient in the bathroom with the door closed was to call out to the patient and have the patient respond to the staff.

During a review of Patient 22's, "Observation Rounding Precautions (ORP)," dated 9/6/24, the ORP indicated, Patient 22's location was in the bathroom.

During a review of Patient 22's "Signed Statement (SS)," dated 9/6/24, the SS indicated, "[Patient 21 and Patient 22] went into the shower for 20 minutes."

During a review of the facility's policy and procedure (P&P) titled, "Rounds of Patient Observation," approved 7/27/22, the P&P indicated, "Every 5 minute Observations. Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress. Staff will be vigilant for potential risk factors identified for specific patients (levels of precautions)."

Based on interview and record review, the facility failed to reevaluate the discharge plan for one of 10 sampled patients, (Patient 11), when the facility was informed that Patient 11 was not welcome to return to family member (FM) 1's home at discharge. This failure resulted in the facility attempting to discharge Patient 11 to a shelter with no available beds, and discharging to an unsafe location.

Findings:

During an interview on 9/16/24 at 9:40 a.m. with Director of Clinical Services (DCS), DCS stated when the facility discharges a patient that is homeless, the staff must make sure it is a safe discharge. DCS stated a safe discharge would be to a homeless shelter (HS).

During an interview on 9/17/24 at 8:38 a.m. with FM 1, FM 1 stated he pleaded with the facility not to discharge Patient 11 to his residence. FM 1 stated he told the facility that he was not a safe discharge plan; that he worked two jobs and could not ensure Patient 11 to be safe. FM 1 stated on the day Patient 11 was discharged, he was at work when he got a call from someone at the facility who told him he had to accept Patient 11 into his home. FM 1 stated he had to leave his job and go to his residence to accept Patient 11. FM 1 stated he had to take Patient 11 to the emergency department (ED) where she was placed on a 5150 hold (a temporary involuntary hospitalization for a person experiencing a mental health crisis). FM 1 stated Patient 11 was transferred from the ED and admitted to another psychiatric hospital.

During an interview on 9/18/24 at 8:35 a.m. with DCS, DCS stated there was a multidisciplinary team (MDT a group of people from different disciplines who work together to achieve a common goal) discussion about Patient 11's discharge plan. DCS stated they knew FM 1 did not want Patient 11 to be discharged to his home and was asking the facility about a discharge to a Board and Care or another facility. The facility did not have a confirmed bed at a shelter. DCS stated when medical doctor (MD) 2 discharged Patient 11, MD 2 was adamant about discharging Patient 11 on 8/26/24. DCS stated the MDT did not believe Patient 11 was ready for discharge.

During a concurrent interview and record review on 9/18/24 at 9:45 a.m. with Case Manager (CM) 2, Patient 11's "Social Service Progress Notes (SSPN)," dated 8/26/24, were reviewed. The first "SSPN" indicated, "8/26/24 4:30 pm (CM) met with patient [11] to go over discharge plan ...CM informed [Patient 11] that she was being discharge [sic] today and her two options are to discharge back to [FM 1] home, but [FM 1] does not welcome you back into the home or the [HS]. Patient 11 stated that she would go to the HS. CM informed Patient 11 that [transport company (TC)] will be transporting her to [HS 1]." The second "SSPN" indicated, "8/26/24 4:41 pm [CM] spoke to [MD 2] to inform him that HS was full and no viable placement was available for Patient 11. [MD 2] stated that Patient 11 needs to be discharged today to the HS. CM agreed to arrange the transportation." The third "SSPN" indicated, "8/26/24 6 pm [CM] messaged [TC] to change Patient 11's discharge address to home address [address in Santa Maria] as it is patients last home address. HS are full, and no viable placement was found." CM 2 stated she met with Patient 11 to discuss the discharge plan. CM 2 stated the patient told her she would go to the shelter. CM 2 stated she called HS 1 and was told, "there may be a bed." CM 2 stated she called TC to transport Patient 11 to Santa Maria. CM 2 stated she called HS 1 at 3 p.m. and was told they did not have any available beds. CM 2 stated she notified MD 2 of the bed situation and MD 2 told her patient [11] had to be discharged to her home address. CM 2 stated she notified TC to change the discharge address from HS 1 to Patient 11's home.

During a concurrent interview and record review on 9/18/24 at 9:54 a.m. with CM 1, an email sent by CM 1 to the CM group, [undated], was reviewed. The email indicated, "[Patient 11] was estimated for [discharge] on 8/23, but was canceled. [FM 1] had major concerns over the stability of [Patient 11] and did not feel safe [with] her return. [FM 1] expresses that he does not have the means to take care of [Patient 11] and feels that she will decompensate further if discharged .CM l stated he sent out this email to the CM group in case [Patient 11] was discharged while he was on time off. CM 1 stated FM 1 was very clear that he could not take care of Patient 11.

During an interview on 9/18/24 at 10:26 a.m. with MD 2, MD 2 stated, "This was a very difficult placement issue." MD 2 stated he had to discharge Patient 11 because she did not meet the criteria for a hold, Patient 11 was not a danger to self (DTS), not a danger to others (DTO), and not gravely disabled (GD) because Patient 11 was willing to accept placement in a shelter. MD 2 stated the facility was required to use the least restrictive environment and a "psych hospital" is extremely restrictive. MD 2 stated FM 1 was required to let Patient 11 return to her place of residence because FM 1 had not legally "evicted" (move out of one's home) Patient 11.

During an interview on 9/18/24 at 12:05 p.m. with Director of Utilization Review (DUR), DUR stated she received a call from the facility on 8/26/24, that Patient 11 had been discharged and transported to a shelter in Santa Maria and there were no available beds. DUR called FM 1 and asked him to go to his residence and receive Patient 11. DUR stated FM 1 agreed and said, "O.K., but I'm just gonna take her to the ER."

During a review of Patient 11's "Face Sheet (FS)," dated 8/18/24, the FS indicated Patient 11's address was a residence in Santa Maria.

During a review of Patient 11's "Discharge Summary (DS)." dictated 8/30/24, the "DS" indicated, "Patient was homeless ...patient was discharged to [HS 1] at Santa Maria."

During a review of Patient 11's "Discharge Aftercare Plan (DAP)." dated 8/26/24, the DAP indicated, "Discharge Address: [address of HS 1]."

During a review of Patient 11's "Physician Progress Note (PPN)," [undated], the "PPN" indicated, "[Discharge] failed due to family refuse to pick up pt [patient] ...Although pt is delusional [a fixed false belief that a person holds despite evidence to the contrary] willing to accept shelter [FM 1] refuse [sic] to pick her up."

During a review of the facility's policy and procedure (P&P) titled, "Discharge of Patients," approved date 7/27/22, the P&P indicated, "PURPOSE: To ensure a smooth transition to the next level of care ...and to ensure continuity of the treatment modalities selected for the patient."

During a review of the facility's P&P titled, "Discharge Planning," Approved 4/27/22, the P&P indicated, "2. To aid in the achievement of maximum post hospital adjustment through the identification of the etiology of environmental stressors past and present and to offer recommendations for resolution or at least lessening of these stressors. 3. To preserve and or strengthen family relationships by providing emotional support and interpretation to family members so that they will become more accepting and aware about the patient's problems and goals. 4. To involve the relatives in planning for the patients current and ongoing care and recognition of the necessity for change in their living patterns. 5. To assist patients and their families in making the transition and adjustments from hospital to home or to another facility."

Based on interview and record review, the hospital failed to ensure the Director of Competency Restoration Program (DCRP) provided oversight for a Doctoral Student (DS) in the discharge planning/transfer request documentation for one of one sampled patient (Patient 1), who was under the care of DCRP. This failure had the potential for insufficient planning and inadequate information, which could result in Patient 1's discharge to be incomplete and ineffective for continuity of care.

Findings:

During the initial tour of the Competency Restoration Unit (Incompetent To Stand Trial (IST) Unit in units 500, 600, and 700) on 9/16/24 at 10:07 a.m. with Program Coordinator (PC) and Medical Doctor (MD) 1, PC stated Patient 1 was discharged/transferred to another Department of State Hospital (DSH). PC stated Patient 1 failed to complete the 90-120-day competency evaluation to stand trial. PC stated Patient 1 was discharged at 5:30 a.m. and picked up by the transportation DSH arranged and designated.

During a concurrent interview and record review on 9/16/24 at 10:30 a.m. with PC, Patient 1's discharge planning documents were not in Patient 1's medical records (MR). PC stated the documentation was in a secured electronic mail.

During a concurrent interview and record review on 9/16/24 at 11:06 a.m. with Registered Nurse (RN) 3, Patient 1's "Redirect Request (RR-a transfer request to the program management unit responsible for all DSH transfers)," dated 9/5/24 was reviewed. The RR indicated, "Patient 1 has been unable to demonstrate a complete knowledge of his charges or an ability to assist his counsel in a rational manner." RN 3 stated the DS completed the RR. RN 3 was unable to provide documentation of the DCRP in Patient 1's MR to verify DS documentation and demonstrate supervision of DS discharge planning/transfer request.

During an interview on 9/16/24 at 2:42 p.m. with DCRP and Interim Chief Nursing Officer (ICNO), DCRP stated the hospital had doctoral students in psychology completing their clinical rotation. DCRP stated the doctoral students were working "under my license." DCRP stated she reviewed their documentation, met with the students weekly, and conducted face-to-face sessions with the students to go over their documentation. DCRP stated she did not document she reviewed and co-signed DS documentation nor wrote a progress note of approval of DS RR for Patient 1.

During a review of the facility's "Clinical Documentation Training Manual," dated 2024-2025, the Training Manual indicated, "Staff shall provide all services within the scope of practice of the individual delivering the service. Clinicians will follow the specific scope of practice requirements determined by regulations, including those of the governing boards of the applicable licenses . . . Notes requiring co-signatures must be submitted to a supervisor within two business days for review and authorization. Upon authorization, the staff requiring the co-signature must finalize the note to claim the service. If the supervisor is not available, the providing staff must coordinate with the program director or other designated supervisors to review notes and other clinical documents for co-signatures."