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Based on documentation review and interview, facility staff failed to include a patient in his/her plan of care for 1 of 10 medical records reviewed. (P1)

Findings include:

1. The facility policy titled, "Patient Discharge - AMA", PolicyStat ID 13916075, last revised 06/2023, indicated under POLICY: Patients will be discharged only upon the orders of the attending licensed practitioner. A competent, adult patient cannot be detained from leaving the hospital.

2. The facility policy titled, "Patient Rights and Responsibilities", PolicyStat ID 13517670, last revised 09/2021, indicated under PROCEDURE:
1. Receive considerate ethical behavior and respectful care in treatments, services, and business practices. You have the right to be made comfortable and treated with dignity. You have the right to be respected for your personal values and beliefs including cultural, psychosocial, and spiritual values and beliefs.
5. Receive information about your health status, course of treatment, prospects for recovery and outcomes of care, including unanticipated outcomes, in terms you can understand, tailored to the patient's age and language; have your family and/or agent, when appropriate, be informed of your care, including unanticipated outcomes, in order to participate in current and future decisions affecting your care and to participate in the development and implementation of your plan of care. During your hospitalization, information concerning your condition, medication, treatment, and discharge plans may be shared with your personal friends and family through your designated spokesperson.

3. MR review for P1 indicated on 4/30/24, patient was noted to be alert, quiet, compliant with medications. P1's child and sibling called several times to request a transfer to a facility closer to P1's home and the patient indicated he/she wanted out of H1 (Psychiatric Hospital). On 5/4/24 indicated P1 was wanting out of H1 but was told not until Tuesday (5/7/24). On 5/5/24 nursing note indicated P1 expressed a desire to go home. On 5/6/24 MR note indicated the patient was cleared for discharge, was doing well and wanted to go home, A&O (alert and oriented) x (times) 4, medication compliant without side effects, no medication changes, and denied SI (suicidal ideation) / HI (homicidal ideation). LEVEL OF CARE JUSTIFICATION dated 5/5/2024, indicated the patient was doing well on current regimen, was noted to be psychiatrically stable, and was cleared for discharge to appropriate setting. P1's MR lacked education and/or discussions with P1 on transferring to another psychiatric facility closer to home and or discharging AMA (Against Medical Advice) when he/she expressed the desire to go home and/or be transferred. P1 was held after 5/5/24 clearance for discharge, with a discharge date of 5/8/2024. MR lacked documentation that discharge was a result of patient request and/or practitioner recommendation.

4. In interview on 5/16/24 at approximately 1:50 pm with A5 (Patient Advocate) confirmed he/she did not speak with P1 nor was he/she called to speak with P1 as the patient advocate.

5. In a telephone interview on 5/20/24 at approximately 2:10 pm with L3 (Licensed Staff) confirmed was not notified that P1 was wanting to leave H1 AMA by nursing staff.

Based on document review and interview, nursing administration failed to provide adequate staffing for 8 of 14 days reviewed on unit 200.

Findings Include:

1. The facility policy titled, "Clinical Staff (Nurse) Staffing Plan", PolicyStat ID 12279065, last revised 08/2022, indicated under PROCEDURE: Staffing Plan: B. Core Staffing Matrix per unit: Inpatient Programs for Days (7 am-11 pm). One clinical staff member for every four (4) patients.

2. Staffing Pattern Worksheets review indicated unit 200 was not adequately staffed per facility policy. Unit number, dates, number of clinical staff member(s) lacked and patient census are indicated as follows:
a. Unit 200:
4/21/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a patient census (PC) of 15. 4 clinical staff members needed but only 2 clinical staff members were present.
4/22/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present.
4/23/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present.
4/24/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present.
4/26/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present.
4/27/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present.
4/28/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
4/29/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present.

3. In interview on 5/15/24 at approximately 2:15 pm with staff member A1 (Chief Executive Officer) confirmed unit 200 was not adequately staffed per policy and should have been.

Based on documentation review and interview, facility nursing staff failed to follow diet order policy and/or procedure in 1 of 10 medical records reviewed. (P1)

Findings include:

1. The facility policy titled, "Transmission of Diet Orders", PolicyStat ID 12511884, last revised 01/2020, indicated under PROCEDURE: 2. Changes to diet orders, supplements will be communicated via physician orders and sent via fax or written communication.

2. P1's MR Diet Orders & Communication documentation dated 4/29/24 at 2:00 am indicated the nursing staff changed the diet for P1 from a Regular Diet to a Controlled Carbohydrate and initiated an Oral Nutrition Supplement of 2 liters of water per day and did not notify/confirm with a provider.

3. In an interview on 5/15/24 at approximately 2:10 pm with A1 (Chief Executive Officer) confirmed diet order changes for P1 should have been confirmed by a practitioner when the order was changed by nursing staff and was not.

Based on documentation review and interview, facility staff failed to discharge patients in a timely manner based on admission criteria and/or provider orders in 7 of 10 MRs (medical records) reviewed. (P1, P3, P4, P5, P6, P8, and P10)

Findings include:

1. The facility policy titled, "Discharge Planning", no policy number, last revised 03/2022, indicated under POLICY: Discharge planning begins at the time of admission. Based on input from the patient/family/Guardian/POA, physician, and members of the multidisciplinary team, a discharge plan is developed. Under DOCUMENTATION: The Social Worker documents discharge information on social service notes and the Master Treatment Plan utilized by the multidisciplinary team.

2. Review of P1MR indicated patient voluntarily admitted to H1 (Psychiatric Hospital) on 4/27/24.
a. Psychiatric Progress Note documentation indicated on 5/6/24 that P1 was cleared for discharge, was doing well and wanted to go home, A&O (alert and oriented) x (times) 4, medication compliant without side effects, no medication changes, and denied SI (suicidal ideation) / HI (homicidal ideation). LEVEL OF CARE JUSTIFICATION dated 5/5/2024, indicated the patient was doing well on current regimen, was noted to be psychiatrically stable, and was cleared for discharge by provider to appropriate setting.
b. P1 was discharged to home in stable condition on 5/8/24.

4. P3's MR indicated the patient was voluntarily admitted to H1 on 5/3/24 and is currently inpatient awaiting discharge. P3's medical record was reviewed and indicated the following:
a. Psychiatric Progress Note indicated on 5/13/24 P3 was cleared for discharge by provider.
b. P3 was not discharged at the time of this survey on 5/15/24.

5. P4's MR indicated the patient was voluntarily admitted to H1on 4/27/24. P4's medical record was reviewed and indicated the following:
a. Psychiatric Progress Note documentation dated 5/6/24 indicated P4 was cleared for discharge by provider.
b. Interdisciplinary Discharge Plan documentation indicated the patient was discharged to home on 5/8/24 at 11:00 am in stable condition.

6. P5's MR indicated the patient was admitted to H1 from 4/27/24 on an EDO (Emergency Detention Order). P5's medical record was reviewed and indicated the following:
a. Psychiatric Progress Note documentation dated 5/8/24 indicated the patient was cleared for discharge by provider.
b. Discharge Summary documentation indicated P4 was discharged to a skilled nursing facility in stable condition on 5/14/24.

7. P6's MR indicated the patient was admitted to H1 from 4/30/24 on an EDO (Emergency Detention Order). P6's medical record was reviewed and indicated the following:
a. Psychiatric Progress Note documentation dated 5/9/24 indicated P6 no longer required inpatient psychiatric treatment and was cleared for discharge per psychiatry.
b. Discharge Summary documentation indicated P6 was discharged to home in stable condition on 5/11/24.


8. P8's MR indicated the patient was admitted to H1 from 5/1/24 by his/her POA/Guardian. P8's medical record was reviewed and indicated the following:
a. Psychiatric Progress Note documentation dated 5/6/24 indicated P8 was noted to be psychiatrically stable and was cleared to discharge by provider.
b. Discharge Summary documentation indicated P8 was discharged home in stable condition on 5/8/24.


9. P10's MR indicated the patient was admitted to H1 from 5/1/24 on an EDO. P10's medical record was reviewed and indicated the following:
a. Psychiatric Progress Note documentation dated 5/9/24 indicated P10 was noted to be psychiatrically stable and was cleared to be discharged by provider.
b. Discharge Summary documentation indicated P10 was discharged to home in stable condition on 5/12/24 .


10. In an interview on 5/16/24 at approximately 12:10 pm with L1 (Licensed Staff) confirmed remembering P1 as alert and oriented. L1 did not interpret, from nursing notes reviewed, that the patient's desire to go home was a request to leave AMA, P1's medications were adjusted last on 4/29/24 and if there were no signs or symptoms of mania, SI (suicidal ideation), and/or HI (homicidal ideation) after a medication adjustment (which could take up to 72 hours), P1 should have been cleared for discharge on 5/2/24.

11. In a telephone interview on 5/17/24 at approximately 11:42 pm with L2 (Licensed Staff) confirmed he/she was a telehealth provider for P1, cannot clear patients for discharge because he/she does not work in person at H1, telehealth providers cannot clear patients for discharge.

12. In a telephone interview on 5/20/24 at approximately 2:10 pm with L3 (Licensed Staff) confirmed A1 (Chief Executive Officer) puts a limit of 5 discharges a day, A1 is the final say if someone can be discharged if not made by providers, it takes several days for patients to get discharged after being cleared by a provider, patients not experiencing SI/HI/adverse medication side effects would be cleared for discharge, providers are instructed by administrators not to tell patients when they are cleared for discharge, and was not notified that P1 was wanting to leave H1 AMA by nursing staff.

13. In a telephone interview on 5/23/24 at approximately 2:10 pm with L4 (Licensed Staff) confirmed providers at H1 have no control over the ongoing issue of delayed discharges of patients, after patients are cleared for discharge the hospital says they need to complete a safety plan and discharge process, discharge process for patients can take up to three days, he/she feels that H1 staff wait until the last minute to start discharge planning, delays in discharge happen frequently which puts providers in an uncomfortable situation and administration have instructed providers not to tell patients the date of their discharge.