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Based on interview and record review, it was determined the hospital did not ensure that each patient or the patient's representative was given information on the patient's health status for 1 of 10 sampled patients who had a full medical review completed by the survey team. Specifically, one patient was held for more than 24 hours after a courts mandate to release her was received. (Patient identifier: 8.)

Findings Included:

Patient 8 was admitted to the hospital on 3/4/2023 for suicidal ideation with a plan to shoot herself. Her primary diagnoses included major depressive disorder with recurrent episodes and severe psychosis, post-traumatic stress disorder, generalized anxiety disorder, history of anorexia and borderline personality disorder.

Patient 8's medical record from 3/4/2023 through 3/10/2023 was reviewed. Patient 8 was a 39-year-old married female. She presented at the Provo Canyon Behavioral Hospital with her husband after experiencing escalating suicidal ideation with visual and olfactory hallucinations. Patient reported being sexually assaulted at work 6 months ago and then sexually assaulted again 2 weeks ago. She reported significant sexual, physical, and emotional abuse and domestic violence from an ex-spouse. She was concerned about HIV, herpes, and a yeast infection.

Documentation revealed that an application for involuntary commitment for patient 8 was filed with the 4th district court -Provo Utah County, State of Utah on 3/7/2023.

In a ruling dated 3/7/2023 it stated "Proceedings for the involuntary commitment of the above-named proposed patient have been filed with this Court on March 7, 2023. It appears from said application and reported facts that there is a reasonable basis to believe that the proposed patient has a mental illness which poses a substantial danger to the proposed patient, others, or property, requiring involuntary commitment pending examination and hearing. THEREFORE, IT IS HEREBY ORDERED, pursuant to the provisions of Utah Code Annotated 62A15-631 (2013), that such proposed patient shall be placed in the custody of the Local Mental Health Authority or in a temporary emergency facility to be detained for the purpose of examination."

Documentation further revealed that a release from order of detention from 4th district court -Provo Utah County, State of Utah had been emailed and received on March 9, 2023, at 2:22 PM, it stated "This matter comes before the court for involuntary commitment hearing. The patient has met with two court appointed examiners and both examiners find (patient 8, name redacted) does not meet the criteria for an order of commitment. After consideration of reports and all evidence, (patient 8, name redacted) is ordered to be released from the order of detention and this case is dismissed."

In an interview on 4/20/2023 at 3:13PM, with the licensed clinical social worker (LCSW), she stated that Patient 8 was released on 3/10/2023 at 5:00 PM after opening the email. She further stated "I made a mistake. I did not check my email and I feel terrible about that. This is not the doctor's fault. The responsibility is mine, the doctor does not recieve court documents." Patient 8 was held more than 24 hours past the court mandate release sent and recieved on 3/9/2023 due to the email remaining unopened until 3/10/2023 at 4:30 PM.