The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on interview, record review, policy review, and document review, the facility failed to ensure notification of the physician was appropriately documented when a patient exhibited suicidal ideations upon discharge for 1 of 30 sampled patients (Patient #20).

Findings include:

The facility policy titled, "Special Precautions" (PC.104, revised 3/2013), stated in part, "Special Precautions are defined as an intensified level of staff awareness and attention to patient safety/security needs required the initiation of specific protocols and supplement documentation. It is the policy of Spring Mountain Treatment Center to provide a safe, secure environment for patients. Special Precaution procedures can be initiated by the physician or R.N. (registered nurse). When there is change (sic) of condition and/or behavioral change in the patient, staff will notify the RN who will assess the patient and report the findings/change to the Physician. This assessment may warrant an addition of a special precaution as listed below. Special Precautions include the following: -Suicide...".

Patient #20 was admitted to the facility on [DATE], with diagnoses that included bipolar, depressed episode, suicidal ideations, and a history of non-compliance with medical treatment.

Patient #20's clinical record was reviewed on 03/19/2013 through 03/20/2013. The patient's Discharge Summary, dated 11/21/2012, stated in part:

"Reason for hospitalization : The patient is a [AGE]-year-old male admitted to (name of facility) for evaluation of complaints of suicidal thoughts. The patient states that he has not been in the right mindset. He also states that he has unstable housing and that his rent was too high. He has been homeless and living on the streets and states that he has been out of his medications..."

"Hospital Summary: The patient was admitted for evaluation of symptoms of suicidality in the context of having bipolar disorder and having severe social stress with housing, disability and limited finances. He states that he had been robbed and had his medications and his money stolen...Near the time of discharge the patient had improvement in his mood. He had improvement in his range of affect. He was not having any medication side effects...

Discharge Plan: The patient will be staying at (name of shelter) until he is able to identify stable housing. His psychiatric follow up will be at (Clinic #1) on November 26, 2012".

This document, Patient #20's Discharge Summary, was signed and dated by his physician (Physician #1) on 11/21/2012, at 12:00 PM.

Patient #20's Nursing Progress Note, dated 11/21/2012, at 1:30 PM, was written by Employee #5, a Registered Nurse. The document stated:

"(Patient) compliant (with medications) but refused group this am. All paperwork was done and signed by (patient) all the while he continued to yell that he wasn't ready. Wanted to stay 1 more day. When (Physician #1) said no, he yelled that he would leave here and run into traffic, we could get sued if we discharged him like that. (Patient) was angry and upset that he couldn't stay 1 more day so he started yelling suicidal ideations. After staff started getting his belongings together and had him sign papers, he stopped yelling and eventually left on bus pass".

There was no documentation that the patient's physician or social worker were notified of the suicidal ideations by Patient #20. Patient #20's Observation Rounds Record indicated he was last observed on 11/21/2012 at 12:45 PM, and that his behavior was "agitated".

Employee #5's Job Description stated in part:
-"Admissions, discharges and transfers adequately documented".
-"Communicates pertinent information to administrator and managers/directors in timely manner".

Physician #1 (Patient #20's physician) was interviewed via telephone on 03/20/2013 at 4:30 PM. She stated she did not recall the incident, however, if she had been aware a patient was exhibiting suicidal ideations upon discharge, that before the patient were discharged , she would reassess the mental status of the patient and determine the safety of the planned discharge. She stated she would review Patient #20's clinical record when she was at the facility at a later date.

On 03/21/2013, the Director of Nursing (DON) was interviewed via telephone. She stated Employee #5 (Patient #20's discharging nurse) stated to her that she remembered the patient and the incident. The employee indicated to the DON that the Patient's physician was aware of the suicidal ideations, but told the nurse he was manipulating. The nurse said the patient later apologized for being upset. The DON stated she also spoke with (Physician #1). She indicated the physician stated she believed the nurse would have spoken to her about the patient.

The Director of Nursing stated there was no documentation of the conversation between Employee #5 and #6, and no documentation of a reassessment by the physician.

Complaint #NV 915

Based on interview, record review, and policy review, the facility failed to 1) ensure safe discharge planning for 3 of 30 sampled patients (Patient #10, #1, #3) which included an evaluation to provide the patient's return to a reasonably safe and appropriate environment; and 2) assist with making the follow up psychiatric appointment in accordance with facility policy for 1 of 30 sampled patients (Patient #15).

Findings include:

Patient #10

Patient #10 was admitted [DATE] with a diagnosis of bipolar disorder.

The Comprehensive Assessment Tool by a registered nurse (RN) dated 1/19/13 indicated 5 times in which Patient #10 stated threats to burn the group home down (the home where he had lived at prior to admission). Statements included, in part: "If I have to go there, I'm going to do something to go to jail instead."; and "The voices told me to burn the house down."

The Psychosocial Assessment by the licensed social worker (Employee #6) dated 1/20/13 at 12:45 PM indicated, "Pt (patient) admitted on a L2K (Legal 2000) due to aggressive, threatening behaviors, threatening to burn group home down. Pt reports A/H (active hallucinations). Pt reports that group home staff took his food stamps & SSI (Social Security Income), did not buy food or get his medication."

The facility's Discharge Summary by Physician #2 dated 2/5/13 indicated, "HISTORY OF PRESENT ILLNESS: The patient is a [AGE] year old man admitted on a Legal 2000. He was threatening to burn down the group home that he had been living at. He said they were not caring for him properly. He said he was hearing voices telling him to burn the house down. He had a lighter and he was going to do it. In the emergency room he threatened that if he went back to the group home he would do something and go to jail...HOSPITAL SUMMARY...He was willing to go back to the group home that he had been at. It was clear that it probably wouldn't last if he went there. Finally he came up with a plan that he seemed to have laid out very well. He didn't want to live in Las Vegas anymore. He wanted to go to California...DISCHARGE REFERRAL: The patient will contact mental health services in Los Angeles County if he does go to California. Otherwise, he was advised to seek treatment at (Clinic #1)..." (Note: Clinic #1 is a state psychiatric clinic for outpatient services.)

The Individual & Family Progress Note by the social worker (Employee #3) documented on 1/24/13 a telephone call was made to the placement agent (who had previously placed the patient in group homes), and stated, "Discharge Plan Update: He can return to last independent home".

The Individual & Family Progress Note by the social worker (Employee #3) dated 2/5/13 indicated Patient #10 was being "discharged today", and, "He has $779.00 on Soc Sec (Social Security) debit card & says plane ticket is less than $200..."

The Patient Continuing Care Plan dated 2/5/13 and signed by the physician, discharge nurse (RN), and the social worker (Employee #3) indicated placement at "home".

Patient #10 was discharged from the facility on 2/5/13 at 12:35 PM.

Patient #10 was admitted to Acute Care Facility #2 on 2/7/13. The Emergency Department History and Physical Examination indicated, "Chief Complaint: 'I should not have left (Facility #1)...This is a [AGE] year old male with a history of psychosis who presents with hallucinations and delusions. He states he was at (Facility #1) up until 3 days ago. He states that he was released, but states that he did not have his home medications which includes Cymbalta and Thorazine. He states that he forgot his way back to (Facility #1) and was forced to stay in a hotel last night, and then the voices told him that he should 'call the ambulance and the cops' and here he is. The patient at this point, feels as though he wants to relocate to California because the mental health is better there...Patient does state, 'My brain is gyrating a 1/4 inch in my head.' When asked whether he feels suicidal, he says, 'Maybe', that if he is unable to get his head right, then he will think about suicide. In the past he has tried to commit suicide by police. When asked me (sic) whether he is homicidal, he says, 'Maybe' and states that he does not want to wither and die on the street and that if he has to go that way he wants to go out with a bang...Neuro/Psych (Neurological/Psychiatric): He is alert and oriented at this time. He does endorse auditory hallucinations. He denies any overt delusions. He does endorse some wild fleeting suicidal ideation, as well as potential homicidal ideation...CLINICAL IMPRESSION: 1. Psychosis. 2. Suicidal ideation..."

On 3/20/13 at 3:00 PM, the social worker (Employee #3) indicated she was not aware Patient #10 had threatened to burn down the group home. She indicated Patient #10 was given a $5.00 bus pass on 2/5/13 at 12:35 PM, and that the plan was for Patient #10 to go back to the group home. If the patient decided to go to California, he could take the local bus to the group home to get his debit card and his belongings. The discharge plan was that he said he wanted to go to California, had researched Helping Hands, and wanted to go home to get his belongings at the independent living group home. Employee #3 verbalized, "I don't know anything about him saying he was going to light the house on fire. I did not ask how much money he had on his debit card."

Employee #3 verified she documented that Patient #10 could return to his last home, and indicated, "When I talked to (name of referral agent) she didn't tell me about him threatening to burn down the group home. She only told me about all of his stays at other group homes. We didn't talk about where he was going to live."

On 3/20/13 at approximately 3:00 PM, the DON and Employee #3 verified that the inventory and discharge documentation listed that Patient #10 was only discharged with clothing and a medication card to fill the prescriptions.

Patient #15

Patient #15 was admitted [DATE] at 6:30 PM with a diagnosis of mood disorder. Patient #15 was discharged on [DATE] at 3:30 PM to her home in California with psychiatric diagnoses of psychosis NOS (not otherwise specified) and anxiety. The Patient Continuing Care Plan indicated the Psychiatric Appointment was "not scheduled by (name of health insurance company)". The Aftercare Goals indicated, "Contact insurance for additional resource if necessary"; however, there was no phone number and contact information provided.

On 3/20/13 in the morning, the Director of Nursing and the social worker (Employee #3) verified Patient #15 was not given a prescription for the Prozac and there was no documentation the facility assisted Patient #15 with making a follow-up psychiatric appointment.

Patient #3

Patient #3 was admitted [DATE] with diagnoses including psychoses, schizo-affective, cannibus abuse, noncompliance with treatment, social maladjustment, and inadequate material resources. Patient #3 was discharged [DATE] (no time indicated).

The Patient Continuing Care Plan dated 11/20/13 indicated, "Placement - Other: (name of the homeless shelter in San Francisco). First pt will d/c (discharge) to Greyhound, 2005 S. (south) Main Street...". The physician's Discharge Summary dated 12/1/12 also indicated that discharge planning included referral to a mental health clinic in San Francisco.

There was documentation of a prescription for Patient #3's discharge medications; however, there was no evidence of how the patient was going to pay for the medications.

The Nursing Progress Note dated 11/20/13 indicated, "...Refused to take Seroquel & Haldol. Says he is D/C'ing (discharging) today & these meds (medications) make him sleepy. So he wants to wait until he talks to his dr (doctor) first. Edu (education) provided on prescriptions, f/u (follow up) appointments & suicide/crisis prevention resources. Awaiting cab to D/C to Greyhound bus station...". There was no documented evidence the physician was notified of Patient #3's refusal to take his medications.

On 3/19/13, interview with the DON and the social worker revealed they were not aware if Patient #3 had any money upon discharge. They indicated the patient had told them he had a round trip ticket to San Francisco, but it was not listed on the inventory list. They further indicated they did not know where the patient's debit card was and how much money he had, and that the inventory did not show a debit card.

Patient #1

Patient #1 was a [AGE] year old male initially admitted on [DATE]. Diagnoses included bipolar disorder and conduct disorder. Patient #1 had the following admitted s:

Admission #1: 1/22/13 through 1/29/13
Admission #2: 2/3/13 through 2/6/13
Admission #3: 2/16/13 through 2/21/13

The Social Services Director indicated on 03/21/2013 at 3:10 PM, she reviewed the Discharge Summaries of Patient #1's three admissions with the inspector. She acknowledged the following:

Admission #1's Discharge Summary, dated 01/29/2013, stated in part, "Chief Complaint: 'My parents couldn't handle me'... Discharge Plan: The patient was discharged for outpatient therapy with (name deleted) on January 31, 2013 at 4:00 PM. Outpatient appointments for medication management will be determined by the patient's insurance. At the time of discharge, the patient and family were provided with a copy of the Patient Continuing Care Plan that contained addresses and phone numbers of providers for continuity of care. A discharge packet was provided to Patient #1 and family including education about the diagnosis, medications and community resources.

Admission #2's Discharge Summary, dated 02/06/2013, stated in part, "Reason for hospitalization : "...This patient is a [AGE]-year-old white male whose parents brought him to (name of facility) last month for mood issues and was discharged on Abilify. Parents did not follow through with outpatient appointments and the patient ran out of Ability one week ago... The patient cries describing overhearing family describing him as a 'devil child' on the phone with other friends and mom stating she 'wished I never had you'... Discharge Plan: The patient is discharged to his home. He will see (name deleted) for outpatient medication management...".

(At this point, the Social Services Director stated he probably did not run out of Abilify when he was discharged after Admission #1, because he would have been given a prescription for thirty days.)

Admission #3's Discharge Summary, dated 02/21/2013, stated in part, "Reason for hospitalization ...The patient was playing with paint in the house and spilled it. The patient had a fight with his mother and claims his mother threatened to send him to jail 'where you will get f'd in the a--'. The patient was arrested one week prior, three days in a row for assaulting his stepfather, the patient states in self-defense and after that he brought a knife in his room in case he was arrested again and he would kill himself. The patient was in (name of facility) in January 2013. He states that he was on medication but 'did not get any when I went home' ...Discharge Plan: The patient was discharged to his home...".

After the three Discharge Summaries were reviewed between the inspector and the Social Services Director; the Social Service Director was asked whether it was appropriate to send the patient home with his family after the parents did not follow through with treatment (i.e., medications and follow up appointments) and the comments made to him by his mother. The Social Service Director explained that the facility did not dictate the discharge plan because Child Protective agencies were involved, and those agencies would dictate the discharge plan.

There was no documented evidence of an evaluation with communication or coordination of information (discharge status and home situation) between the facility social worker and the Child Protective agency representative upon each discharge to ensure that Patient #1's home was a safe placement.

The policy and procedure ("Patient Continuing Care Plan, Discharge Planning, Interdisciplinary", revised 3/2013) indicated as follows:

4. The Therapist will be responsible to do the following:
d. Refer for outpatient treatment, and assist with scheduling first appointment.
e. Assist with living arrangements...
j. Initiate entries in the following sections on the Patient Continuing Care Plan. f. Psychiatric & Therapist Appointments...
5. The Nursing Department will be responsible to do the following:
...Review and complete the following sections on the Patient Continuing Care Plan upon discharge:
k. Other Aftercare: Medical follow up, Medical Appointments, Medical care..."

Complaint #NV 915