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Based upon review of 1 of 7 medical records (#1), review of policy and procedure and interviews, the hospital failed to ensure Patient #1's change in condition triggered a reassessment of the patient's Discharge Plan. This was evidenced by the failure of S5Psychiatrist to reassess patient #1 after the patient exhibited physical aggression and homicidal threats against family members on the morning of his discharge on 9/28/15. Findings:

Review of patient #1's medical record revealed the patient was admitted to the hospital on 9/18/15 for suicidal ideation, stating he wanted to kill himself after exhibiting violent behavior in his home when told by his parents he was not allowed to smoke. Review of the Discharge Criteria implemented on 9/19/15 revealed the patient was to have a reduction of life-threatening or endangering symptoms to within safe limits and improved stabilization in mood, thinking and/or behavior.

Review of the Summary Note written by S4Social Worker on 9/28/15 at 9:35 a.m. revealed "...met with patient and parents (via phone) to discuss plans for discharge. Parents reported that patient had a negative attitude and was very disrespectful during family visit last evening. Patient who presents with blunted affect, growing irritable mood and agitation began cursing parents and made verbal threat of killing both parents if discharged. Patient stated 'I'm gonna kill both of ya'll when I get out of here". Patient repeated threat several times, then pulled phone from the wall, threw phone to the floor and began jumping up and down on the phone. Patient then threw the phone against the wall next to the desk used for session and walked out of the room..." "At 9:43 a.m. Mother and Father called SW (Social Worker) to discuss outburst. Both parents identified patient's outburst as a temper tantrum and talked about past incidents of outbursts that have caused patient admission into aftercare facilities and parents unwillingness for patient's return to home setting. SW discussed critical responsibility of duty to warn with both parents. Because both parents were present on phone when threats were made, SW encouraged parents to inform the police of threat as SW would also be making a report...Soon after, SW and nursing supervisor consulted with attending physician who advised to continue with plans for discharge and that patient's behavior was tantrum aimed at seeking attention. Later, SW received call from mother indicating patient could discharge to (local rescue mission), however, felt that patient may actually try to follow through on threat. Several minutes later, both parents called SW back to express concern about physician's intention to discharge despite patient's threats....Later, nursing staff informed by intake staff that mother had contacted the Caddo Parish Coroner's Office and Deputy Coroner called hospital. SW uncertain of exact message from Deputy Coroner as to what actions to take. However, upon further investigation, SW informed that coroner's request was for Dr and staff to look into the matter. At that point, SW consulted unit social services supervisor, nursing house supervisor, and nursing staff. After meeting, attending physician notified that Coroner's Office had been contacted and Deputy Coroner had called. Physician again advised to continue with plans for discharge."

Review of the S5Psychiatrist progress note dated 9/28/15, dictated at 7:41 a.m., revealed "Assessment of Progress and Response to Treatment: The patient has reached maximum inpatient service benefit and it was felt by the treatment team that the patient was ready for discharge to outpatient therapy. Precautions were discontinued without problems reported or noted by staff. There were no side effects noted from medication. The patient is overall improved..." Review of S5Psychiatrist's Discharge Summary for patient #1 revealed "...By the time of discharge, he was able to identify triggers and verbalize healthy coping skills. He denied any suicidal ideation, homicidal ideation, or auditory or visual hallucinations. He signed a contract for safety and medication compliance. He tolerated medications well with no side effects. On September 28, 2015, it was felt the patient had reached maximum therapeutic benefit from this hospitalization, had been acutely psychiatrically stabilized, and was ready for a trial period of outpatient follow-up."

Interview with S5Psychiatrist on 10/30/15 at 10:15 a.m. revealed when asked if he evaluated patient #1 prior to his discharge, he replied "no".

Review of policy # CC.001 titled Discharge Planning, review/revised 3/15 revealed "Purpose: 8.0 The discharge plan must be reassessed and updated whenever, warranted by a change in the patient's condition or needs."

There failed to be documented evidenced S5Psychiatrist conducted an evaluation of the patient prior to discharge even though the patient had made homicidal threats against his family and exhibited physical aggression just prior to discharge.

Review of the emergency department record from Hospital A revealed on 9/28/15 at 5:34 p.m. patient #1 was taken by police to the ED on an order of protective custody due to homicidal ideation. The emergency department physician placed the patient on a Physician Emergency Certificate and admitted the patient to the hospital's behavior unit.

Based upon review of 1 of 7 medical records (#1) and interviews, the hospital failed to ensure each patient received an evaluation by the psychiatrist prior to discharge. This was evidenced by the failure of S5Psychiatrist to conduct an evaluation of patient #1, prior to his discharge on 09/28/15, after the patient exhibited violent behavior and voiced homicidal threats against his parents. Findings:

Review of patient #1's medical record revealed the patient was admitted to the hospital on 9/18/15 for Suicidal Ideation after an outburst of violent behavior at his home. On 9/28/15, at 2:20 p.m., the patient was discharged to the local rescue mission.

On the morning of his discharge, 9/28/15 at 9:35 a.m., S4 Social Worker held a meeting with the patient and his mother and father via telephone. During the meeting the patient learned from his parents that he would not be allowed to return home upon discharge and began making homicidal threats against his parents stating "I'm going to kill ya'll when I get out of here". The patient then tore the phone out of the wall, jumped up and down on it and threw it towards a desk. The patient walked out of the room to the Adult Psychiatric Unit irritable and agitated.

Interview with S7RN/Nursing Supervisor on 10/30/15 at 11:40 a.m. revealed the treatment team met to discuss patient #1's violent outburst and homicidal threats. S5Psychiatrist was called and informed of the incident and he instructed the treatment team to continue with the discharge.

Review of the S5Psychiatrist progress note dated 9/28/15, dictated at 7:41 a.m., revealed "Assessment of Progress and Response to Treatment: The patient has reached maximum inpatient service benefit and it was felt by the treatment team that the patient was ready for discharge to outpatient therapy. Precautions were discontinued without problems reported or noted by staff. There were no side effects noted from medication. The patient is overall improved..." Review of S5Psychiatrist's Discharge Summary for patient #1 revealed "...By the time of discharge, he was able to identify triggers and verbalize healthy coping skills. He denied any suicidal ideation, homicidal ideation, or auditory or visual hallucinations. He signed a contract for safety and medication compliance. He tolerated medications well with no side effects. On September 28, 2015, it was felt the patient had reached maximum therapeutic benefit from this hospitalization, had been acutely psychiatrically stabilized, and was ready for a trial period of outpatient follow-up."

Interview with S5Psychiatrist on 10/30/15 at 10:15 a.m. revealed when asked if he evaluated patient #1 prior to his discharge, he replied "no"