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Based on a review of facility records, policies and procedures, Medical Executive meeting minutes, and staff interview, it was determined that the governing body failed to take immediate actions for patient safety following the suicides within 48 hours of discharge of three (3) patients (#1, #2 and #3).

Finding include:

Cross reference A0115 as it relates to the facility's failure to protect and promote the patient's rights.

Cross reference A0142 as it relates to the patient's right for a safe transition of care after discharge from the hospital.

Cross reference A0396 as it relates to the failure of the facility to implement a complete nursing plan.

Cross reference A0405 as it relates to licensed nurses conducting the proper transcription of physician orders to ensure that patients receive their prescribed medication upon discharge from the hospital.

Cross reference A0799 as it relates to the facility's failure to implement a discharge planning plan that ensures patient safety after discharge.

Cross reference A0837 as it relates to communicating about follow-up appointments at the time of patients discharge, and to the hospital transferring or referring patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.

Based on a review of medical records, facility policies and procedure and staff interview the facility lacked an effective system to ensure that patients received post discharge follow-up treatment and failed to provide a safe discharge for Patient #1, Patient #2, and Patient #3, resulting in harm to the patients who committed suicide 48 hours after discharge from the facility.

Findings include:

Cross reference A0142 as it relates to the patient's right for a safe transition of care after discharge from the hospital.

Based on a review of medical records, facility policies and procedure and staff interview the facility lacked an effective system to ensure that patients received post discharge follow-up treatment and failed to provide a safe discharge for Patient #1, Patient #2, and Patient #3, resulting in harm to the patients who committed suicide 48 hours after discharge from the facility.

Findings include:

The facility failed:

1. To provide a complete safety plan and post-discharge medication information for Patient #1.
2. To provide post-discharge medication information and complete home health care services and medical follow-up referral for Patient #2.
3. To include a medication prescribed by the physician in the discharge instructions for Patient #3.

Review of facility's policy # PC 115 entitled "Discharge Planning", revealed the following:
a. Hospital discharge planning involves determining the appropriate post-hospital discharge destination for a patient.
b. Identifying what the patient requires for a smooth and safe transition from the hospital to his/her destination and meeting discharge needs.
c. The patient's readiness to discharge should be linked to discharge goal achievement, although some goals continue at another level of care following discharge.

Policy # PC115 further provided that all patients' post-discharge needs are identified and evaluated. All patients have a discharge plan developed prior to their discharge, including a scheduled aftercare appointment.

Policy # PC115 also included information concerning identifying the responsibility for making sure the follow-up is accomplished.

Facility policy number CTS-112 entitled "Suicidal/Homicidal Patient Management: Risk Reduction Guidelines" last reviewed 6/16, revealed the following:

5.0 Prior to the discharge of, or the granting of a therapeutic leave to a patient with suicidal tendencies, the physician must provide evidence/proof in the medical record that suicide potential no longer exists, or exists at a level that can be safely managed at a lower level of care. A complete discharge summary is documented in the medical record. A second opinion will be considered if the patient is being discharged to a less than twenty-four-hour supervised setting with one or more of the following conditions:

a. History of "surprise suicide attempts" with significant lethality (for example, the patient made a serious suicide attempt following a clinical assessment that he/she was not suicidal.)

b. Persistent suicidal ideation with a possible/easy plan.
c. Patient presents suicidal ideation at discharge with significant symptoms of depression, alcohol/substance abuse, schizophrenia, or persistent panic/anxiety disorder or refuses post-discharge assistance.

Policy number RC-007 entitled "Transcription of Physicians Orders Inpatient" last reviewed 6/2016, revealed that licensed nursing staff would be responsible for transcription of physician orders. The licensed nurse would review (note) the order and all accompanying documents and signify the accuracy with a signature, date and time on the order from time of seeing the order to carrying out the order.

If the physician thinks that the clinical indicators do not justify a second opinion, a notation is made on the pre-discharge suicide risk assessment, which outlines the reason for this decision.

Policy number CTS-165 entitled "Discharge and /Aftercare Planning" last reviewed 7/2016, revealed:
1.0 As a part of the assessment process, treatment recommendations are made. These recommendations include the various levels of care needed to assure patients are treated at the appropriate level of care.
Procedure: 2.5- Identify the responsibility for ensuring that the prescribed follow-up is accomplished.
2.5- Including timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care.

Review of the medical record of Patient #1 revealed that the 25-year-old was admitted to the facility on 3/13/17 with diagnoses of methamphetamine and heroin dependence (uncomplicated), intentional overdose, alcohol dependence (in remission) and cocaine dependence.

A therapist's note dated 3/15/17 at 12:37 revealed that Patient #1 had refused a family session and that his/her safety plan was incomplete.

Patient #1's ITP (interdisciplinary treatment plan) lacked information of physician and nursing focused interventions, with described intended outcomes and what the physician and nurse would do to assist the patient in achieving his/her goals.

Patient #1 was discharged on 3/23/17. The discharge summary in Patient #1's medical record was completed on 4/28/17, more than thirty days after Patient #1 was discharged from the facility.

Further review of Patient #1's medical record revealed that before discharge, Patient #1 was alert and oriented. Patient #1 planned to return home to stay with a friend and promised to remain cooperative with all medications moving forward, and to remain sober. Patient #1 denied suicidal ideations (thoughts of harming self) and homicidal ideations (thoughts of harming others). Patient #1 had no reports of any behavioral, visual or auditory (hearing) disturbances, neither had he/she problems with sleep or appetite.

Review of Patient #1's discharge care plan and home medications form revealed that Patient #1 was being discharged on 3/23/17 with a mental health appointment at a health and rehabilitation facility on 3/24/17 at 8:00 a.m.
Patient #1's home medication reconciliation discharge sheet failed to reveal a list of medications to be taken after discharge.

Review of the medical record of Patient #2 revealed that the 82-year-old patient lived alone had been referred from an acute care hospital to the facility on an involuntary status. Patient #2 was found unresponsive at home on 5/25/17 with a blood sugar of 29. Patient #2's psychiatric diagnoses included major depressive disorder, (recurrent, severe), without psychotic features, as well as a medical diagnosis of insulin-dependent diabetes.

The suicide risk assessment-intake form indicated that Patient #2 lived at home with family.

On 5/29/17 at 3:28 p.m., the therapist completed the psychiatric suicide assessment (PSA) with Patient #2, and spoke with the Patient #2's adult child about the patient's management and whether there were weapons in the home.

The discharge plan and home medication form information were faxed to an out-patient center for Patient #2's walk-in appointment for 6/7/17 at 2:00 p.m.

Physician #3's discharge orders for Patient #2 included psychiatric home health care services and a provision for a medical follow-up.

The home medication reconciliation discharge medication sheet for Patient #2 failed to reveal post-discharge medications and was not signed by any licensed staff. Review of the discharge care plan and home medications form had a mental health /intake appointment but had no evidence that a therapist or nurse had contacted a psychiatric home health service or had made a medical appointment.

The physician's discharge progress note on 6/6/17 indicated that the patient was being discharged to home. Patient #2's prognosis (likely course of disease or ailment) was described as "fair". Patient #2 had refused nursing home placement offered by the physician.

During an interview at 10:00 a.m. on 6/21/17 in the facility's training room, Physician #3 reviewed Patient #2's record and stated that he/she had met with Patient #2 daily and the nurse practitioner (an advance practice nurse with special training and additional responsibilities for providing patient care) saw Patient #2 on some weekends. Patient #2 had chronic risk factors and had experienced some losses. Patient #2 had overdosed on insulin at home but did not formally admit a suicide attempt. Patient #2 had memory problems, thoughts of death in general, and had no interest in going to a nursing home. Patient #2 had no suicidal plan, so Physician #3 "thought the patient was safe." Physician #3 stated that he/she wrote the physician order for both psychiatric and medical follow-up and also wrote a prescription for Patient #2 to receive psychiatric home health services and medical follow-up.

Physician #3 searched and was unable to produce documented evidence in Patient #2's medical record that a therapist or nurse had contacted a psychiatric home health service or had made a medical appointment for Patient #2 for post-discharge follow-up treatment.

Physician #3 stated that it was the RN who would communicate with the social worker/therapist to set up home health care.

In a subsequent interview on 6/23/17 at 9:30 a.m., Physician #3 acknowledged that the provisions of policy #CTS-112 were relevant to Patient #2 and that said policy provided that prior to the discharge of a patient with suicidal tendencies, the physician must provide evidence in the medical record that suicide potential no longer exists, or exists at a level that can be safely managed at a lower level of care, and that a second opinion will be considered if the patient is being discharged to a less than twenty-four hour supervised setting.

Physician #3 admitted that he/she had not requested a second opinion from a different psychiatrist regarding Patient #2's discharge, had not documented a notation on the pre-discharge suicide risk assessment, which outlined that suicide potential no longer exists, or exists at a level that can be safely managed at a lower level of care. Physician #3 further stated that it was his/her expectation after writing the discharge orders, that the nurse or therapist would set up the appointments as needed for the patient.

During an interview on 6/21/17 at 2:00 p.m., in the training room Therapist #4 stated that he/she was Patient #2's treating therapist and discharge planner along with the intern therapist.

Therapist #4 acknowledged that Patient #2's had a prescription for psychiatric home health services and medical follow-up. Therapist #4 stated that a call was made to a counseling facility and a referral fax had been sent to a home health service. Therapist #4 stated that he/she usually called them and then wait for 24 to 48 hours afterward because it takes time for them to respond.

Therapist #4 stated further that there was no documentation about a referral request in Patient #2's record. The therapist stated that "The information had been discussed in treatment team". Therapist #4 stated that he/she did not coordinate or normally set up medical appointments.

During an interview on 6/22/17 at 12:18 p.m., the House Supervisor (RN#16) acknowledged that Patient #2's treatment plan lacked a signature of an RN signifying a nurse's involvement. In addition, that there was no RN signature verifying that Patient #2's discharge order had been picked up or that a psychiatric home health or medical appointment had been made.

Review of policy number MMM-014 entitled "Medication Reconciliation" last reviewed 6/2016 revealed- that to prevent medication errors related to failed communication about prescribed medications, it is the policy of the facility to provide a process for the accurate and complete reconciliation during the course of the patient's care. The process includes obtaining the most accurate list possible of the patient's current medication at the time of admission, prescribing new medications, prescription change for long-term medication in behavioral health settings, reconciling, and resolving any discrepancies, reconciling again upon transfer and /or discharge, and communicating the complete list of the patient's medications to the next provider.

Review of the medical record of Patient #3 revealed that the 41-year-old was admitted on an involuntary basis from an area hospital emergency room on 1/20/17. Patient #3 had diagnoses of bipolar disorder, severe depression with psychosis, fibromyalgia (a condition where the person had widespread muscle and skeletal pain, tiredness that comes and goes.) Patient #3's past medical history included migraines after a head injury due to a car accident in 2008. Patient #3 had a history of a prior suicide attempt in 2013 and was experiencing the recent loss of his/her sibling who reportedly overdosed on patient #3's medication.

A suicide risk assessment was performed with Patient #3 on 1/20/17 at 12:00 p.m. At that time Patient #3 admitted to having daily (SI) with an unclear plan.

Physician #5 wrote a discharge order on 1/27/17 at 11:00 for Patient #3 and Gabapentin 1200 mg, to take in the morning, noon, 5 p.m., and 9:00 p.m. Patient #3's discharge medications did not include Gabapentin 1200 mg.

The physicians discharge progress note was completed on 1/27/17 at 11:00 a.m., and indicated that Patient #3 planned to stay with his/her family and to cooperate with a therapy facility.

During an interview with Physician #5 at 11:03 a.m. on 6/21/17 he/she stated that he/she patients daily and last saw Patient #3 on 1/27/17 around 11:40. At the time Patient #3 stated that he/she slept well the previous night. Physician #5 stated further that Patient #3 was patient was alert and oriented. Patient #3 denied feeling suicidal of homicidal and stated that his/her plan was to go for long-term opioid rehabilitation in another state. Patient #3 requested a Toradol (a drug used to treat pain) injection, but Physician #5 stated that he/she did not provide the medication because Patient #3 had strong cravings for Opioid and did not have an expression of pain on his/her face. Physician #5 stated he/she increased Patient #3's prescription of Gabapentin (used to treat seizures and pain) to 1200 mg and wrote the same in the progress notes in Patient #3's medical record on 1/27/17. Physician #5 reviewed Patient #3's record and failed to locate a copy of Patient #3's prescription for Gabapentin and also acknowledged that Gabapentin was not on Patient's #3's discharge medication list.

According to the health information manager (Employee #9) at 11:27 a.m., on 6/21/17 in the training room, the nurses are supposed to copy the patient's prescription, write the discharge medications on the medication reconciliation sheet, and place a copy of the prescription in the patient's medical record.

During an interview on 6/22/17 at 10:17 a.m., in the training room RN #1 stated that he/she worked the day shift on the Transitional Unit and was acquainted with Patient #3. RN #1 further stated that he/she had been involved with Patient #3's discharge plan and documented the discharge note in the record. RN #1 acknowledged that there was no copy of the discharge prescription for Patient #3 in the patient's chart. RN #1 also acknowledged and that the nursing discharge note that he/she had written did not include where Patient #3 was being discharged to as per facility policy. RN #1 acknowledged that the physician's discharge order dated 1/27/17 read as follows-: 'discharge today, discontinue Gabapentin as scheduled, Gabapentin 1200 mg PO, AM, 5 PM, and 9 PM" , but the Gabapentin was not on the list of medications written on the sheet entitled 'Current Medication-Discharge Medications with Dosage Changes'.

During the second interview on 6/23/16 at 9:14 a.m., Physician #5 stated that nurses often failed to put a copy of patients' prescriptions on the records and when he/she sees patients in the office it is difficult to tell what medications the patients are taking.

Review of five (5) personnel files (#1, #2,#4, #7 and #10) revealed that all had participated in the patient's treatment planning and discharge, had attended orientation; had annual training which included topics related to discharge/aftercare planning and prevention of patient abuse and neglect.

Review of three (3) credential files (#3, # 5, and #6) revealed that Physician #3 had not been recredentialed, had no evidence of current malpractice insurance or drug enforcement agency certification. Physician #6 file had a governing body approval letter dated 6/3/16 but lacked a signature.

Based on review of records, policies and procedures and interview it was determined that nursing staff failed to keep current the interdisciplinary treatment plan (which was considered the same as the nursing care plan) for three (3) of (3) patients.

Finding include:

Review of patients Interdisciplinary Care Plan/ Nursing Care Plans revealed that patients (#1, #2, and #3) lacked a description of the interventions the nurse would do to assist the patient in achieving goals.

In an interview at 12:18 p.m., on 6/22/17 in the training room RN #16 acknowledged the findings.

Based on review of records, policy and procedures and staff interview, it was determined that nursing staff failed to adhere to the transcribing of physicians orders in accordance to professional standards of practice or facility policy.


Finding include:

Review of policy number RC-007 entitled "Transcription of Physicians Orders Inpatient" last reviewed 6/2016, revealed that licensed nursing staff would be responsible for transcription of physician orders. The licensed nurse would review (note) the order and all accompanying documents and signify the accuracy with a signature, date and time on the order from time of seeing the order to carrying out the order.

Review of policy number MMM-014 entitled "Medication Reconciliation" last reviewed 6/2016 revealed-
To prevent medication errors related to failed communication about prescribed medications, it is the policy of the facility to provide a process for the accurate and complete reconciliation during the course of the patient's care. The process includes obtaining the most accurate list possible of the patient's current medication a the time of admission, prescribing new medications, prescription change for long-term medication in behavioral health settings, reconciling, and resolving any discrepancies, reconciling again upon transfer and /or discharge, and communicating the complete list of the patient's medications to the next provider.

Physician #5 wrote a discharge order on 1/27/17 at 11:00 for Gabapentin 1200 mg for Patient #3 to take in the morning, noon, 5 p.m., and 9:00 p.m.

· The physician's note on the discharge progress note indicated 'see the prescription'.
· Patient #3's current medications/discharge medications with dosage changes sheet did not include Gabapentin 1200 mg.

Patient #1's home medication reconciliation discharge medication sheet was blank at the bottom portion following the wording, 'attention patients: the following are a list of medicines to take after discharge'.

During an interview at 10:17 a.m. on 6/22/17 in the training room RN #10 acknowledged that there was no copy of a discharge prescription in Patient #3's chart. RN #10 also acknowledged the Physician's progress note dated 1/27/17, which read, 'see prescription'. RN #10 further acknowledged the physician's discharge order dated 1/27/17 which included instruction that Patient #3 be discharged on that day, with an addition of Gabapentin 1200 mg PO, AM, 5 PM, and 9 PM, to be taken at home after discharge.
RN #10 also acknowledged that Gabapentin was not on the list of medications written on the sheet entitled 'Current Medication-Discharge Medications with Dosage Changes'.

Based on review of records, policies and procedures and staff interview, it was determined that the facility failed to have an effective discharge planning process resulting in the facility's failure to communicate information for psychiatric home health services and to set up a medical appointment for Patient #2 at discharge from the facility, resulting in harm to Patient #2 who committed suicide two (2) days after discharge from the facility.

Findings include:

Cross reference A-0837 as it relates to the facility's failure to transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.

Based on review of records, policies and procedures and staff interview it was determined that the facility failed to set up an appointment for follow-up psychiatric home health services and a medical appointment for Patient #2 at discharge from the facility.

Finding include:

Review of facility's policy # PC 115 entitled "Discharge Planning", revealed the following:
a. Hospital discharge planning involves determining the appropriate post-hospital discharge destination for a patient.
b. Identifying what the patient requires for a smooth and safe transition from the hospital to his/her destination and meeting discharge needs.
c. The patient's readiness to discharge should be linked to discharge goal achievement, although some goals continue at another level of care following discharge.

All patients post discharge needs are identified and evaluated. All patients have a discharge plan developed prior to their discharge- Scheduled aftercare appointment.

The discharge policy also included information concerning identifying the responsibility for making sure the follow-up is accomplished.

Copies of the discharge prescriptions written by the physician included orders for psychiatric Home Health Care services and for a medical follow-up.

The physician's order written on 6/6/17 at 10:10 and a copy of prescription pad revealed - 'discharge patient with both psychiatric and medical follow-up.'

Review of the discharge care plan and home medications form had a mental health /intake appointment but had no evidence that a therapist or nurse had contacted a psychiatric home health services or made a medical appointment.

During an interview on 6/21/17 at 2:00 p.m., in the training room Therapist #4 stated that he/she was Patient #2's treating therapist and discharge planner along with the intern therapist.

Therapist #4 acknowledged that Patient #2 had a prescription for psychiatric home health services and medical follow-up. Therapist #4 stated that a call was made to a counseling facility and a referral fax had been sent to a home health service. Therapist #4 stated that he/she usually called them and then waited for 24 to 48 hours afterward because it takes time for them to respond.

Therapist #4 stated further that there was no documentation about a referral request in Patient #2's record. The therapist stated that "The information had been discussed in treatment team".