HospitalInspections.org

Based on interview the facility failed to:

1. have adequate numbers of trained staff to engage in safe patient discharges.

Refer to Tag A1688

2. ensure that Nursing Services was adequately staffed in order to provide safe care on 3 out 3 units (Unit 300 Acute Adult, Unit 400 Adult, and Unit 600 Adolescent).
3. ensure that Nursing Services were up to date on training and competencies in 4 (Staff #14, #17, #27, and #34) of 4 employee files reviewed.

Refer to Tag A1704

4. ensure Social Services had policies and procedures to ensure the staff were providing safe discharges and patients were able to obtain aftercare and appropriate sources outside the facility.
5. ensure discharge planning was monitored in the facility's quality department to maintain optimal discharge planning.
6. ensure staff participated in an appropriate discharge planning, providing a safety plan with numbers to call for assistance or places to go for safety, and ensure patients had safe transportation before discharge 2(#16 and 25) of 4 (#16, 14, 17, and 25).

Refer to Tag A1717

Based on review of records and interview, the facility failed to ensure that patient grievances were properly documented and investigated in 1 out 1 (Patient #9) reviewed.

Findings included:

On the morning of 6-16-2020, Staff #26 (Patient Advocate) was interviewed about Patient #9's discharge. Patient #9 was an 18-year-old male who had been involuntarily admitted to the facility on June 8, 2020 and released the next day. Staff #26 confirmed that the mother of Patient #9 had come to the facility on the day of discharge, June 9, 2020. The mother had stated she had received a call from the patient stating that he was going to be released that day. The patient's mother complained that no one from the facility had called her to discuss plan for the patient's upcoming discharge, to include the timeframe for discharge, post-discharge aftercare, or housing. The patient was released without anyone there to pick him up. The patient's mother was on her way to discuss his discharge with the facility when she found her son on the side of the road with the police and intervened. Staff #26 confirmed that the mother was very upset and concerned that this was an unsafe discharge. Staff #26 confirmed that Patient #9 had given permission for his mother to be involved in his treatment and receive information about his care.

Review of the Grievance log on 6-16-2020 showed that there was no record of a grievance being filed on the behalf of Patient #9. Staff #26 stated she had not completed a grievance form or document the grievance. Staff #26 stated she had met with the CEO to discuss the allegations and concerns. Staff #26 stated she had been told it would be handled through the Medical Staff for review and that she took no further action. No records of a Grievance Committee or records of a committee meeting conducted to consider the patient grievance were ever alleged or provided. Staff #26 was not aware of, nor was monitoring, any investigation of the grievance.

A review of the Patient Grievance/Complaint Policy and Procedure 1800.23 was as follows:

Page 3 of 4, item 2 and 3

"2. The Patient Advocate will convene a meeting with the Grievance Committee to consider the patient's grievance that ware received. Composition of the Grievance Committee may include any of the following:
CEO
Director of Nursing
Director of Compliance
Director of Clinical Services
Patient Advocate
Other Leadership as applicable to the grievance

3. The Grievance Committee will review and further investigate the substance of the patient's grievance to assist in the provision of a response and resolve any deeper, systemic problems indicated by the Grievance."

Page 4 of 4, item E. 2.

"2. All grievances will be logged in a database maintained at facility. The log will include patient identifiers, date of grievance, and the date of the written response."


The policy failed to address how investigations involving allegations of patients being placed in immediate danger, such as Patient #9 being released without appropriate discharge plans in place that resulted in law enforcement intervention, would be identified for swift investigation and resolution, the time frame for initiating the investigation, or the process of documenting the investigation.

Based on interview the facility failed to have adequate numbers of trained staff to engage in safe patient discharges.


An interview was conducted with Staff #4 on 6/18/20. Staff #4 reported that there was not enough trained staff in the facility to make sure discharge planning was adequate or even attainable at times.

Staff #4 reported that she was the new interim clinical services director. Staff #4 stated that the licensed clinician staff included herself and three other social workers. Staff #4 stated one of those clinicians was brand new and still in orientation. Staff #4 reported that she did not work full time hours and she not only had to perform groups, therapeutic meetings, and monitor staff that she was unable to get to everything and everyone.

Staff #4 reported that she knows some patients have been discharged during weekends and after hours, but she was not able to follow up on those patients. Staff #4 reported that she was not sure if all the patients had been active in the Interdisciplinary process. Staff #4 was not sure if there was a policy and procedure for the patient involvement and was unable to speak to any such process.

Based on review of records and interview, the facility failed to:

A. ensure that Nursing Services was adequately staffed in order to provide safe care on 3 out 3 units (Unit 300 Acute Adult, Unit 400 Adult, and Unit 600 Adolescent).

B. ensure that Nursing Services were up to date on training and competencies in 4 (Staff #14, #17, #27, and #34) of 4 employee files reviewed.

Findings A. included:

On June 12, 2020 at 3:25 PM, the facility submitted a plan of correction for previous deficient practices that had existed since first identified on 4-16-2020. The plan was signed by Staff #2 on 6-12-2020. All items on the plan of correction regarding staffing had been annotated with a "Completion Date" of 6-11-2020, with the responsible person listed as the Director of Nursing (DON).

Under the Plan for Correcting the Specific Deficiency, the facility stated:

"A. State standards for a staffing plan and staffing committee were reviewed in a planning meeting by the Director of Nursing, VP of Nursing, and the Director of Quality, Compliance, & Risk Management on 6/5/20.

B. Revised policies related to staffing plan, staffing committee, and reassessment of the patients were approved by the Governing Board on 6/11."

Interview was conducted with Staff #31 by phone on 6-16-2020. Staff #31 stated that she had worked with Staff #6 and Staff #10, reviewing the standards for a Nurse Staffing Advisory Committee, but that Staff #10 had provided the revised Nurse Staffing Plan policy. Staff #31 provided copies of a Nurse Staffing Plan policy from corporate that referenced a facility in Kingsport, Tennessee. The document contained the changes that showed references to the Kingsport facility and unit names had been changed. The Nurse Staffing Plan policy had not been developed for Rock Prairie Behavioral Hospital; but it had been copied and edited from a plan developed to meet the requirements of a facility in Tennessee.

Staff #31 stated she had reviewed the state standards for the nurse staffing committee requirements with another Director of Nursing from a corporate facility in Texas but had not worked on the Staffing Plan Policy.

Staff #31 advised that she had been on home quarantine since May 26, 2020, due to exposure to a COVID-19 positive staff member. Staff #31 advised that she returned on Monday, June 8, 2020 and resigned the morning of Thursday, June 11, 2020.

Interview was conducted with Staff #10. Initially Staff #10 stated that Staff #31 had developed the policy, incorporating the Texas State requirements with the assistance of a DON from another corporate facility in Texas. When told about the information Staff #31 had provided, Staff #10 confirmed that Staff #10 did make those changes to the Tennessee policy and sent it to Staff #31. Staff #10 stated that the expectation was that each facility was to customize corporate policies to the specific needs in the state they were located. Staff #10 stated that she was not aware that Staff #31 had not done that.

Staff #10 was reminded that Staff #31 had resigned the morning of June 11, 2020 and that the plan had been submitted on the afternoon of June 12, 2020. Staff #10, who provided corporate oversight to Staff # 31, confirmed that she had not reviewed any of the documents or tasks that had been assigned to Staff #31 prior to submitting the plan of correction to remove immediacy on the afternoon of June 12, 2020.

The Nurse Staffing Plan did not include, nor was any other documentation provided to show that the plan was developed to ensure safe staffing for the Rock Prairie Behavioral Hospital facility. Nursing Supervisors (also known as House Supervisors) were not included in the plan. The plan did not address the challenges of unit locations being isolated and without any remote monitoring so that staff in other parts of the building could monitor for safety incidents. The plan did not include information on nurse-sensitive safety indicators such a rate of patient falls, use of restraints, and patient/staff injuries.

Under the Plan for Correcting the Specific Deficiency, the facility stated:
"C. Staffing plan was modified to be in alignment with standards of care and with the approval of the Nurse Staffing Committee."

During interview, Staff #10 confirmed that the Nurse Staffing Committee had last met in May and that a functioning committee had not been fully developed. Staff #10 confirmed that the Staffing Committee had not met, reviewed and/or approved the Nurse Staffing Plan. Staff #13 was present during the interview. Staff #13 confirmed that he was one of 3 members of the Nurse Staffing Committee and that he had not been provided a copy of the Nurse Staffing Plan for review and approval at any time.

When asked how the plan had been modified and what standard of care was used to align the plan with, Staff #10 was not able to provide any information on any changes that were made as a result of a standard of care reviewed. When asked what standard of care the plan of correction was referring to, Staff #10 stated the Medicare Conditions of Participation and Joint Commission Standards. Staff #10 confirmed that the facility had not used any nationally recognized nursing standards of care such as the American Nurses Association Standard of Practice or the American Psychiatric Nurses Association's Psychiatric-Mental Health Nursing Scope and Standards of Practice.

Under the Plan for Correcting the Specific Deficiency, the facility stated:
"D. The DON will monitor the staffing levels and is responsible and accountable to ensure consistent staffing standards are used throughout the facility."

The previous DON had resigned on the morning of June 11, 2020. The plan had been submitted on the afternoon of June 12, 2020. Interview with Staff #10 and the Quality Director confirmed that no provisions had been made for anyone in the facility to pick up the tasks assigned to the DON until a new DON had been secured. Additionally, the facility had not secured an interim DON and had left the nursing staff without any nursing leadership for 6 day until this was pointed out. Review of the nurse staffing schedules and assignment sheets from May 29, 2020 to June 16, 2020 showed that every day had incomplete records and it was not possible to determine if consistent staffing standards had been used. Staff #10 was identified as the Interim DON and spent June 17th and June 18th in the building. Originally Staff #10 submitted a schedule stating that she would be available by phone when off site on June 19th, 20th, and 21st. The schedule indicated that Staff #13 would be available by phone to answer general questions and was acting as the staffing coordinator. Staff #13 was on light duty and was not able to assist on the units. Staff #10 left the state on June 18th without securing nursing leadership that could be on-site if needed.

A phone interview was conducted with Staff #13 on the morning of 6-19-2020 to determine his understanding of his role over the weekend. Staff #13 stated he had stepped down from the Nurse Manager and Staffing Coordinator role as of 9:15 AM that morning. Staff #13 explained that he had previously told Administration that he could not fulfill the time requirements as an interim DON. Staff #13 stated that he could not be available by phone over the weekend for any type of assistance due to family commitments. An interim DON from a corporate facility in New Mexico was scheduled to arrive on Monday, 6-22-2020. Until then, nursing staff were left without any on-site nursing leadership.

Under the Plan for Improving the Processed that Led to Deficiency Cited, the facility stated:
"A. The staffing plan developed included factoring in acuity and number of patients per unit. A contingency plan was also addressed for calling in extra staff when necessary. Definitions of acuity situations where extra staff are needed were delineated in writing. The Staffing Plan policy 1300.10"

Interview was conducted with Staff #1 on June 16, 2020. Staff #1 confirmed that the facility did not have any active contracts with staffing agencies. Review of staffing schedules and staffing assignment sheets, along with interview, showed that units were not able to obtain extra staff as necessary to include staff necessary to monitor an adolescent patient who was placed on a 1:1 (one staff member to one patient) level of observation.

Review of staffing schedules and staffing assignment sheets showed that on June 7, 2020, during the dayshift, Mental Health Technicians (MHT) assigned to the adolescent unit were scheduled to leave at 11:00 AM. An MHT on the Acute Adult Unit was a no-show to work. This left the 1:1 patient without appropriate monitoring and left the Acute Adult Unit with 1 MHT to 10 patients when it should have been 1:8.

The patient on the Adolescent Unit who was on a 1:1 was reported to have swallowed a battery from the television remote control on June 7, 2020. The patient had an X-Ray on June 8, 2020 that did not show any foreign bodies.

Interview on June 16, 2020 with Staff #6 confirmed that all incidents were either on the incident log or the paper copy of the incident was provided. Nursing Staff failed to fill out an incident report. Staffing was never evaluated for this incident to explain how the patient could access a remote control that contained batteries.

Under the Procedures for Implementing Acceptable Plan of Correction, the facility stated:
"A. A revised assignment sheet will be used to demonstrate adherence to the staffing plan and policy by clarifying the assigned nurses and MHT's for each patient on each unit. Assignment sheets are expected to show a planned time for the clinician's meal break as well as any code team assignments."

Review of the Nurse Staffing Binders for April, May, and June showed that the Nurse Schedule and Nurse/Patient Assignment sheets were the same that had always been used. No revisions to the forms being used had been implemented.

On June 15, 2020, Staff #1 and Staff #2 both stated that Staff #9 was the Staffing Coordinator and that Staff #13 was going to be helping her. Staff #13 only worked 3 days out of the week on 12-hour shifts. During interview with both, neither had received any instructions what the new forms were and how they were to be implemented. Zoom learning classes had been conducted between May 16, 2020 and May 20, 2020 that included a section to discuss a revised Assignment Form and Staffing Grid. There was not a policy or procedure that went with the discussion for the staff to fall back on. A form identified as Creekside Behavioral Health Shift Assignment & Handoff Sheet was attached as the example used. No evidence of a form developed for Rock Prairie Behavioral Health, with policy or written procedures was presented. A new form had never been implemented.

Staff #9 was interviewed on 6-16-2020 at approximately 2:00PM. Staff #9 stated she had been assigned as Staffing Coordinator in April 2020. Staff #9 stated that she was no longer the Staffing Coordinator and had been relieved of those duties on 6-15-2020. She as asked about any training received or processes clarified with scheduling staffing and completion of staffing sheets. Staff #9 stated she had never been given any initial training, policies or written procedures for the staffing process; and she had not been given any new instructions or new forms.

Under the Monitoring/Tracing Procedures/Sustaining Compliance, the facility stated:
"A. On a weekday basis at morning meeting (on Monday a review of Friday through Sunday occurs), leaders review the staffing from the prior day or days to monitor for proper coverage of staff per the staffing plan."

Staff #6 and Staff #10 confirmed during their respective interviews, this could not be done properly. Nurse Staffing Schedules and Nurse Staffing Assignments were missing or incomplete in the staffing books. Without properly completed schedules and assignment sheets, it was impossible to determine if nursing staff had been safely assigned.

"B. On a weekday basis at morning meeting, the DON would report on any current staffing needs based on acuity and patient mix."

This was not being done, as there was no DON, no interim DON, or anyone identified to complete the responsibilities assigned to the DON in this plan. In addition, this plan was submitted after the DON resigned and the facility had never reassigned the DON responsibilities.

"C. Trends about staffing and feedback from the Nurse Staffing Committee will be reported on a monthly basis to QAPI and MEC and quarterly to the Governing Board."

An interview was conducted with Staff #6 on 6-18-2020. Staff #6 confirmed that the Nurse Staffing Committee only met on a quarterly basis. Staff #6 was asked what staffing indicators would be trended, how they would be collected and aggregated, and who on the Nurse Staffing Advisory Committee would be responsible for collecting the data, analyzing it for trends, and preparing a report. Staff #6 stated he did not know exactly what indicators would be trended. Staff #6 stated he would provide the data report to the committee. Staff #6 was asked how that would work since the committee only met once every quarter. Staff #6 was asked why he would provide the data on trends so that the Staffing Committee could provide the report directly back to him since he oversaw Quality. Staff #6 did not have an explanation for how this monitoring process would work.

Staffing schedule and assignment sheets were reviewed for the period of May 29, 2020 through June 16, 2020. Each of the 19 days reviewed had missing and/or incomplete staffing schedules and assignment sheets.

Review of June 14th Staffing and Chemical Restraint

Interview conducted with Staff #27 on the evening of June 16, 2020 revealed that the previous Sunday, June 14, 2020, she had been on Unit 300 with 10 patients and only 1 MHT. One of the patients had been newly admitted and was going into other patient's rooms, dumping their clothing baskets, and being disruptive. This resulted in a chemical restraint. Staff #27 stated that the hospital was still trying to admit another patient, even though she was short an MHT. The anticipated admission fell through and she did not receive that patient. An incident report was completed by Staff #27 for the patient requiring a chemical restraint.

Review of the Nurse Staffing Schedule showed that Staff #27 was supposed to be assigned to Unit 400. Unit 300 was scheduled to have 2 MHTs. No Nursing Staff/Patient Assignment sheets for Units 300 and 400 were in the books. It's evident from the staff interview an incident report that the Nurse Scheduling sheet was incorrect.

Review of June 7th Staffing and Patient Incident

As previously reviewed in the above findings, the staffing sheets show that Unit 600 was understaffed with enough MHTs to watch a 1:1 level of observation. The Nurse Manager's report showed that Patient #3 was able to gain possession of the remoted control for a television, remove the battery, and swallow it. The patient received an X-Ray as a result. No foreign body was seen on the X-Ray. No incident reports or investigations were initiated. It was unknown if Patient #3 swallowed the battery at that time, if the battery was ever located, or if Patient #3 hid the battery to ingest later. The patient could potentially still be in possession of the battery and be able to harm herself at a future date by ingesting it.

Review of June 2nd Staffing and Staff Injury

Interview was conducted with Staff #17 on June 15, 2020. Staff #17 stated that on June 2, 2020, Patient #17 had wrapped some books in a t-shirt and hit Staff #17 in the head. Staff #17 did not fill out an incident report because she was not feeling well after being hit and went home. No one from Administration initiated an incident report. Review of nurse schedules and assignment sheets for June 2, 2020 showed that the assignment sheets were missing for Unit 300. The nursing schedule showed that Staff #17 was assigned to the unit with 11 patients, 2 MHTs, and an extra MHT for a patient being on a Line of Sight (LOS) observation level.

Cameras in the hallways record (are not available for staff to remotely monitor). Review of the recording of events from June 2, 2020 showed that only 2 MHTs were present on the Unit. Both MHTs left the unit to take patients to the cafeteria. Staff #17 was left alone on the unit with Patient #17. This was when she was assaulted by the patient. A nurse from Unit 400 had to abandon her patients to go onto Unit 300 when she heard Staff #17 yelling. Unit 300 and Unit 400 share a nursing station. If the Unit 400 nurse had not been in the nursing station, Staff #17 may not have gotten help so quickly, as there was no Nurse Manager (House Supervisor) or nursing leadership in the building on that Tuesday.

The Staffing Schedule showed that the Infection Control Nurse was assigned to the Nurse Manager role and as the Medication Nurse. An interview with the Infection Control Nurse was conducted on June 19, 2020. She confirmed that she had never been told she was being scheduled in these slots and had never been trained as a Nurse Manager. She confirmed that she did not act in the capacity of those two roles on that day.

An investigation was never conducted into this staff injury that resulted in a nurse having to leave work or why a nurse was left along on a unit with an acute patient.


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Findings for B. include:

An interview was on 6/17/2020 after 11:00 AM. Staff #17 was asked if additional training and competencies had been completed since the last survey with an exit date of 5/28/2020. Staff #17 stated, "We were given a packet of tests and competencies and told sign off each other." Staff #17 was then asked if each competency was demonstrated, observed, or tested at the time it was initialed by the Supervisor or Trainer. Staff #17 stated, "No, it was not done that way. We were just told that we needed to sign each other off because we had worked with each other at some time. We did not actually see them perform all the competencies on the day that they were signed. We just dated and initialed the documents."


A review of the document titled, "Registered Nurse Competency Checklist" dated 5/31/2020 for Staff #17 revealed Staff #14 had initialed all competencies for Staff #17 as demonstrated and/or observed. Staff #14 was the Supervisor/Trainer. Staff #14 confirmed Staff #17 had not demonstrated each competency he initialed on 5/31/2020 on that date. Staff #17 confirmed the findings.

A review of the document titled, "Registered Nurse Competency Checklist" dated 5/30/2020 for Staff #27 revealed Staff #34 had initialed all competencies for Staff #27 as observed on 5/30/2020. During an interview on 6/16/2020 at 9:15 PM, Staff #27 confirmed Staff #34 did not observe all competencies being performed on 5/30/2020. Further review of the training packet given to Staff #27 revealed competencies and/or tests for Vital Signs, Oxygen Administration, Portable Suction Machine, Dietary & Food Allergy Test, Safety Tub Competency, Health and Medication Safety, Restraint & Seclusion Test failed to list a trainer name and signature or a graded test if one was required. Staff #6 confirmed the findings.

A review of the document titled, "Registered Nurse Competency Checklist" dated 5/30/2020 for Staff #34 revealed Staff #35 had signed the competencies for Staff #34 as observed. Staff #14 confirmed Staff #35 had not observed Staff #34 complete all the competencies he initialed on 5/30/2020.

A review of the document titled, "Registered Nurse Competency Checklist" dated 5/31/2020 for Staff #14 revealed Staff #24 had initialed all competencies for Staff #14 as demonstrated/observed. Staff #24 was the Supervisor/Trainer. Staff #14 confirmed Staff #24 had not observed Staff #14 complete the competencies on 5/31/2020.

An interview was conducted on 6/16/2020 after 9:00 AM with Staff #2 and Staff #6. Staff #6 was asked if packets were passed out to the staff for competency verifications. Staff #6 replied, "Yes, they were passed out to staff and the staff were instructed to sign each other off." Staff #6 was then asked if he realized when a nurse signs a competency for a peer, that nurse is verifying that the nurse was competent in the skill or knowledge on that day. Staff #6 replied, "I thought it was ok if they had seen the peer perform the skill at any time, it was ok for that peer to confirm the competence of that nurse." Staff #6 was asked then, how do you ensure the nurse doing the training or signing the competencies was competent to do so. Staff #6 replied, "Well I guess you don't know." Staff #2 confirmed this was how they instructed the nursing competencies to be completed.

Based on review and interviews Social Services failed to:
A. have policy and procedures to ensure the staff was providing safe discharges and patients were able to obtain aftercare and appropriate sources outside the facility.
B. ensure discharge planning was monitored in the facility's quality department to maintain optimal discharge planning.
C. participate in an appropriate discharge planning, providing a safety plan with numbers to call for assistance or places to go for safety, and ensure patients had safe transportation before discharge 2(#16 and 25) of 4 (#16, 14, 17, and 25).

1.
Review of Patient #16's chart revealed he was admitted to Rock Prairie on 3/23/20 under an Emergency Detention Warrant (EDW).

Review of the physician discharge summary on 3/30/20 reveled he was found wandering around in the road in Brenham Texas. He was homeless and showing signs of delusional thinking. He refused his medications while in the hospital and got into several altercations with other patients. An Order of Protective Custody was filed to force medications. The patient was able to have enough clarity for the judge and was released by the court.

During an interview with Staff #5 on 6/17/20 revealed the patient was able to convince the judge that he was not psychotic or a danger to himself or others. Staff #5 stated the patient wanted to leave even though he was given the option to stay as a voluntary patient.

Review of the discharge safety plan revealed the LCSW had the patient initial a statement that if he felt alone to call one of these numbers, but the page was blank. The patient was told to contact family if he had any problems but documented that he had no family.

Review of the "Therapy Discharge Note" dated 3-30-20 at 1220 stated the patient refused any aftercare appointments so none were made. There was no information given to the patient on who to call or what to do as a follow up or referral.

Review of the AMA Discharge Note dated 3/30/20 at 1145 had the following blank information:
Describe in the patient words or events leading to request for discharge.
Patients plan after discharge.
Assessment of patient's mental status
Notifications
Diagnosis
Vital signs
Recommended follow ups/referrals
All belongings returned to and signed by the patient.
The nurse documented in the discharge note, "Discharged in stable condition AMA. Calm- alert- oriented x3. Denies SI-HI- hallucinations."

The facility failed to give the patient a safety plan with numbers to call for assistance or places to go for safety. There was no information in the chart that stated the patient returned to the facility and was denied admission.



2.
Review of Patient #25 chart revealed she was admitted on 5/19/20 as a voluntary patient. There was no discharge progress note, physician progress notes, nurse's notes, or therapy notes in the chart. The surveyor asked medical records for the notes and they were not provided.

Review of the psychosocial assessment dated 5/20/20 under summarize current symptoms stated, "friend states that pt. has been hearing voices and has been acting oddly- moving and fidgeting constantly. Pt reports she has not been sleeping, eating, or drinking water."

Review of the Mental Health Technicians note dated 5/20/20 "1st shift" stated, "pt. woke up anxious. Pt kept requesting to sign "paperwork". Pt has been isolated and observed talking to herself. Pt refused to eat dinner.

Review of the Mental Health Technicians note dated 5/20/20 "2nd shift" stated, "Pt was talking to herself about the bible most of the shift. Went to sleep late."

Review of the Mental Health Technicians note dated 5/21/20 "1st shift" stated, "patient did not eat any of her breakfast the whole 30 minutes. Pt stared out in space and drank juice."

There was no documentation from the RN on any unusual behavior or when the patient wanted to leave the facility. The patient signed a 4-hour discharge request on 5/20/20 at 2209. The patient was discharged "AMA" on 5/21/20 per Staff #5 at 11:00AM.

An AMA safety plan was found in the chart dated 5/21/20 at 11:00AM. Pt was provided a referral to the community MHMR.

An interview was conducted with Staff # 2 and #6 on 6/15/20. They were asked about the allegation of Patient # 25 locking herself in the bathroom after discharge and hallucinating. Staff #2 stated the patient had locked herself in the bathroom and had been there for some time. He was not aware how long. He stated the patient could reason but was still having some hallucinations. The patient was safely removed from the bathroom and she was picked up by a friend. Staff #2 denied that the patient was ever reevaluated to see if she was safe to go home. Staff #6 stated that there was not an incident report done.

On 6/16/20 an incident report was supplied to the surveyor dated 6/16/20 and the incident had happened on 5/21/20. The receptionist filled out the incident report. The incident report stated the patient had locked herself in the lobby bathroom and did not come out of the bathroom until 1315 (2 hours later) after the door was removed. Summary of the incident stated, "Patient discharged and I noticed she went to the bathroom. 30 minutes have gone by and she was still in the bathroom. I called the nurses station no one answered, went over the walkie and told a tech to have them called me. No one answered me. So, I called ____ (Staff #2) who was here and let him know. Himself, ___ ( Staff #31), and _____ (sw) came out and handled it. (sic)" At the bottom of the incident report Staff #6 wrote "6/16/20 1245 Tracking of AMA data will be noted referring this case for ____ (Staff #32) to do a review on Staff #5 discharge of this case. All reception staff being reeducate on timely submission of incident reports."

An interview with Staff #2 6/16/20 revealed the patient had locked herself in the lobby bathroom and Staff #2 stated the door had to be removed. The patient was discharged by the physician and unless the police wanted to come back and write a APPOW to keep the patient she was free to go. Staff #2 stated the physician was aware but had refused to readmit the patient, so she was discharged with a family member.

An interview was conducted with Staff #5 on 6/17/20 concerning the patients discharge. Staff #5 stated he was sure he had written a discharge summary. He stated he remembers seeing the patient and felt she was at her baseline and could safely be discharged. Staff #5 stated that he was never told the patient had locked herself in the bathroom and was hallucinating.

An interview was conducted with Staff # 31 on 6/17/20. Staff #31 stated the patient had been discharged and there had been no transportation set up. The patient had gone to the lobby bathroom and had approximately been in there for two hours before she was found. Staff #31 stated the door had to be removed. The patient stated Jesus was going to pick her up and had no idea who to call. SW called a friend and had the friend come pick her up but was very upset when she got there. The friend stated we had done nothing to help her and she was worse than before. Staff #2 talked to the friend and she left with the patient.


An interview was conducted with Staff #33 on 6/11/20 concerning her complaint allegations and the event around Patient # 25. Staff #33 stated that this patient was very psychotic and Staff #5 had came in and discharged her. He would not go for an OPC. She was found locked in the bathroom in the waiting room and had been there for two hours. They had to break into the bathroom to get her out. She was unable to hold a conversation and was unable to give a name of family that would pick her up. Staff #33 talked with Staff #2 and Staff #5 to have the patient readmitted and treated properly. Staff #5 refused to take the patient back in. Staff #33 asked if AR could reassess her and at least find alternative treatment. Staff #2 stated that he would call the police and have them assess her and if they will write a APPOW then maybe. The police department told Staff #2 that they are tired of them calling for APPOW's when they have people there to assess the patients and refused. A friend final came to pick up the patient but was very upset that the facility refused to help the patient.

Review of the chart revealed there was no therapy notes in the chart to determine the role the social worker provided in the incident and medical records was unable to provide them.

An interview was conducted with Staff #4 on 6/18/20. Staff #4 reported that there was not enough trained staff in the facility to make sure discharge planning was adequate or even attainable at times.

Staff #4 reported that she was the new interim clinical services director. Staff #4 stated that the licensed clinician staff included herself and three other social workers. Staff #4 stated one of those clinicians was brand new and still in orientation. Staff #4 reported that she did not work full time hours and she not only had to perform groups, therapeutic meetings, and monitor staff that she was unable to get to everything and everyone.

Staff #4 reported that she knows some patients have been discharged during weekends and after hours, but she was not able to follow up on those patients. Staff #4 reported that she was not sure if all the patients had been active in the Interdisciplinary process. Staff #4 was not sure if there was a policy and procedure for the patient involvement and was unable to speak to any such process. Staff #4 stated she had not provided any information to QAPI.