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Based on medical record review, policy review, and staff and patient family interview, the facility failed to have a discharge process that focuses on patient goals and treatment preferences to ensure an effective transition of the patient to post-discharge care, and reduce the factors leading to a preventable hospital readmission. The condition of participation is not met, affecting two patients (Patient #1 and #2) of three patients reviewed for discharge planning. See A802.

Based on medical record review, review of the hospitals policy and staff and patient interview it was determined the hospital failed to ensure re-evaluation of patient condition and needs to identify changes that required modification of the discharge plan. This affected two (Patient #1 and Patient #2) of three medical records reviewed. The census was 513.

Findings include:

1. Review of Patient (Pt) #1's medical record revealed the 14 year old arrived to the hospital on 09/09/25 at 7:07 PM via emergency medical services (EMS) and law enforcement after she ran away from home and tried to throw herself in the road. Review of the patients Behavioral Health Crisis Intervention assessment dated 09/10/25 at 5:55 AM completed by a licensed independent social worker (LISW) revealed the patient reported that she got upset and went on walk like her safety plan allows but she wandered too far looking for glass to harm herself. She stated her anxiety was unmanageable, she was in high distress and no safety skills were effective in that moment. She stated she has frequent thoughts of self harm, denied true intent to harm herself but she struggles when she is in distress. The patient stated she needs ways to manage high distress moments and wants to go home to her foster family. The LISW noted the patient had an extensive history of suicide attempts. The LISW noted the patients suicide risk was moderate reported he felt safe to discharge while she was limited in her ability to prevent another similar episode. LSW L completed the second portion of the Behavioral Health Crisis Intervention assessment on 09/10/25 at 10:42 AM with Pt #1's Franklin County Children Services Case Manager (FCCS CM), the Buckeye Ranch Case Manager (BR CM) and her foster mother. She noted the foster mother reported the patient had became frustrated and wanted to go for a walk. The mother noted the patient was going further than allowed and her foster father followed and at one point her foster sister had to push her out of traffic to keep her from getting hit. The police were called and brought her to the hospital. LSW L noted the patient had been in the foster home since July 2025 with incidents of self harm a behavioral escalations and the foster family expressed concerns regarding whether the patients current level of care/treatment was appropriate to address her ongoing needs. The Psychiatrist assessed the patient on 09/10/25 at 12:36 PM and noted the patient became upset and began walking to find glass to cut herself as her urge to harm herself was very intense. She noted the patient got so lost in this plan that she didn't realize she got off her normal path until her sister found her and informed her that her foster father had wrecked his bike trying to find her. This made her more upset and she decided things would be easier if she was dead and her only thought due to her location was to get hit by a car. She noted the patient denied suicidal intent at the time prior to when she tried to throw herself in traffic and she denied suicidal intent at the time of the assessment or upon returning home. She reported having feelings of guilt, self doubt and worthlessness due to concerns of letting her foster family down. She noted the safety plan was reviewed and the patient felt safe going home. The psychiatrist noted the patient did not appear to require inpatient hospitalization. The psychiatrists diagnosed the patient with major depressive disorder (mdd), post traumatic stress disorder (PTSD) and child in foster care. The disposition was to discharge the patient to home with intensive home based services and medication management later on 09/10/25. Further review of the medical record revealed on 09/10/25 at 2:46 PM Pt #1 verbalized frustration to mental health staff and requested to speak with someone from the treatment team. On 09/10/25 at 2:46 PM the patient was informed by the hospital staff that she was going to a group home and was discharged with FCCS CM. There was no mention the psychiatrist was aware or that the patient was reassessed to ensure safety after being informed that she would not be going home with her foster family. Further review of the medical record revealed the patient presented to the hospital on 07/06/25 through 07/14/25, 08/10/25, 08/27/25 and 09/02/25 for suicide attempts.

Interview on 09/15/25 at 11:08 AM with Clinical Lead SV (oversee's clinicians and discharge planners) revealed they determine a patient is safe and stable for discharge by having an ongoing conversation with the psychiatrist, who ultimately determines a patient is safe to discharge. They work with the patient and their family to develop a safety plan, they assist in locating outpatient community services to ensure the family feels empowered to take child home if another crisis were to arise. She stated outpatient appointments are scheduled prior to discharge. These may include psychiatric, therapy and ensuring they are linked with services if they are not already linked. She stated they make sure they have these appointments scheduled and no one leaves without these services secured. The latest timeframe for these appointments should be within 30 days but they are usually within week or two of the discharge date. She stated her staff works with patients to ensure they are able to notice signs and symptoms (s/s) of their illness and to help identify triggers precipitating events. They help the patients identify things that make them feel calm and safe and things that do not and outline those with patients to see what they can do when those s/s arise. They ensure patients and their families are sufficiently stable to manage their symptoms by providing psycho-education with multiple family sessions throughout the stay. They are educated on the diagnosis, symptom presentation, and coping strategies. Patient's are provided with this education on their discharge paperwork. The discharge paperwork contains the safety plan, and things the patients can do or the people they can call if the patient is feeling stressed out. They ensure the families are aware of outpatient home services. She stated they ensure patients have access to ongoing treatment and medication management by setting up appointments, having the hospitals pharmacy call in a 30 day supply of medications, and ensuring medication management is managed by outpatient providers, if the patient is not linked to psychiatrist to ensure they have management. She stated for patients that are discharged to a group home or in different residential treatment they ensure that the home staff can meet the patient in person or via zoom to provide them with safety plans and a strong hand off. They have phone calls and conferences to ensure they are aware of the support that the patient needs. They make sure the caretaker is informed of the safety measures, plans and triggers of the patient. They make the patients, families or caretakers aware of the crisis line at the hospital in case of an emergency to allow them to talk to someone they don't know to help talk them through a crisis, give coping mechanisms or direct them to the Psychiatric Crisis Department (PCD).

Interview on 09/16/25 at 2:16 PM with LSW L, revealed she was the clinician that spoke with Patient #1's foster mother, the Franklin County Children's Services Case Manager and the Buckeye Ranch Case Manager prior to Pt #1's discharge for a discharge care planning meeting. She stated they were discussing finding more intensive services and getting extra help in the home. She stated the foster family did not feel that they could keep the patient safe in their home, so Franklin County Children's Services had to find alternative placement. She stated during Pt #1's visit, hospital staff reviewed her safety plan to see if the plan was effective anymore. She stated the patient stayed in the extended observation area during her stay, she interacted with the metal health specialists (MHS), and she was assessed by a clinician and the psychiatrist. She stated Pt #1 had chronic behavioral health issues which is a challenge to deal with. She stated the patient has had frequent admissions and that has not stopped the behavioral health issues. She stated they try to see how they can keep the patient safe in the community. She verified that when the patient was told that she would not be going back to her foster home there should have been a reassessment and there was none documented.

Interview on 09/16/25 at 2:51 PM with the Director of Clinical Services verified the discharge summary for Pt #1 the psychiatrist noted that the patient was being discharged home with her family with interventions to follow up with outpatient services but the discharge location changed to a group home. She stated any changes in the patients discharge status should be reported to the psychiatrist to ensure the discharge instructions are still appropriate for a safe discharge. She stated the psychiatrist should be made aware of changes before the discharge disposition is set. She verified patients would be at increased risk for harm when their living environment changes. She stated she was unaware that when the FCCS CM picked up Pt #1, she ran into the busy traffic on Livingston Avenue immediately after being discharged from the hospital.

Interview on 09/16/25 at 3:00 PM with Patient #1's foster mother revealed prior to the patient running into traffic on 09/10/25, she had done it before a month prior on 08/09/25. She stated her husband picked the patient up from Nationwide Children's Hospital Behavioral Health and once she made it to the door she ran towards traffic. She stated someone from the hospital came out, but they did not do anything to help. She said for the 09/10/25 visit the patient was not ready to come home. She stated she; the Franklin County Children Services and Buckeye Ranch Case managers met with the hospital and told them that. She stated she wanted the patient to come back to her home, but the Buckeye Ranch Case Manager would not allow her to take the patient because she did not feel the patient had received appropriate treatment to be safe. She stated she does not remember the name of the clinician that they met with from the hospital via a Zoom meeting. She stated the patient ran once she was discharged and then was admitted to Riverside Hospital. She stated Riverside staff informed her that this was the second 14 year old in three days that was discharged from Nationwide Children's Behavioral Health that ended up at their hospital. She stated the patient is now at Sun Behavioral Health awaiting placement in a 21-day treatment facility. She stated she is going to get the patient back after her treatment. She stated, "that is my daughter".

Interview on 09/16/25 at 3:51 PM with Psychiatrist W revealed if a patient with a history of suicidal ideation was set to be discharged to their home and the discharge summary had been completed but the discharge location changed to group home she would expect to receive communication from the team. She stated this is important because she would need to ensure the previous outpatient follow up is still feasible with the new location, and to see if the initial plan should be revised. She stated she would expect that the patient be reassessed to get their perspective and consider their new feelings to ensure they do not have increased thoughts of suicidal ideation with intent.

Interview on 09/16/25 at 4:17 PM with Pt #1's Franklin County Children Services Case Manager (FCCS CM) revealed prior to Patient #1's discharge she, the foster mother and the Buckeye Ranch (BR) Foster Agency Case Manager had a meeting with Licensed Social Worker (LSW) L. She stated in that meeting she informed the hospital that she did not feel that Pt #1 was safe to return home because she needed more treatment. She said the foster mother was willing to take the patient back but wanted the hospital to ensure the patient was safe to return home first. The BR Foster Agency Case Manager requested that the hospital provide more treatment before the foster family would be able to safely take the patient back. The hospital refused to provide further treatment and informed her that if they did not come to pick up the patient they would call Franklin County Children's Services to file "some sort of action" (she could not remember what the hospital employee called it). She then informed her supervisor who eventually told her to go pickup Pt #1. The BR Foster Agency Case Manager stated they would not allow the foster family to take the patient without proper behavioral health treatment so she would have to go to a group home. The FCCS CM stated she asked the hospital not to tell Pt #1 that she was not going to her foster home because she has history with Pt #1 and knew she was in a cycle and would be extremely upset and try to hurt herself again. She said she wanted to tell Pt #1 once she got her back to the agency safely. She stated she took a co-worker because she needed assistance with the patient as she did not want the patient to hurt herself or her while she was driving. When she arrived, she was made aware that the patient already knew she was not going back to her foster family even though she asked the hospital staff not to tell her. She asked the patient if she was okay and she said she was fine, but she could tell that she was not. The FCCS CM stated she knew the patient would try to run once she got out of the hospital, so she stayed close to her side, and her co-worker was on the patient's other side. She stated as soon as they got to the door by the yellow parking garage the patient took off running. She stated she ran after her and yelled to her co-worker to go get help. She stated the patient ran in and out of the busy traffic on Livingston Avenue trying to get hit and then she sat in traffic. She stated she sat in traffic with the patient trying to comfort her and the patient got back up and proceeded to run. People were stopping in the cars and calling the police. Finally, the police and EMS arrived and took the patient to Riverside Hospital. The patient was admitted for a few days and then transferred to Sun Behavioral. After discharge she is going to a 21-day treatment facility.

2. Review of Patient #2's medical record revealed the 13 year old patient arrived to the hospital on 09/08/25 at 7:23 PM via emergency medical services (EMS) from another hospital after being treated for self injurious behavior (SIB) to her forearm. The patient had broken a mirror and cut her left lower wrist. The patient reported thoughts of suicidal ideation with a plan and stated she felt like no matter what she said she felt like no one would one was taking her serious. She reported she was unable to keep herself safe at home. The patient stated, "I feel like I can't trust anyone. I feel like no matter what I say, people don't want to taken me in." Her mother stated, "You guys have labeled her hospital dependent and she keeps getting ignored. She was at Grady (hospital) last night for threatening to stab herself in the neck with a knife. She is saying no one is taking her serious." The triage nurse noted the patient had suicidal ideation's without a plan.

Review of the patients Behavioral Health Crisis Intervention assessment dated 09/08/25 at 8:40 PM revealed the patients mother reported the patient has been treated by an outside hospital for SIB three times in the past couple weeks, with the most recent being earlier today. The clinician noted the patient has an extensive mental health history with multiple acts of SIB and suicidal ideation. On 07/06/25 the patient held scissors up to her mothers throat and spat on a police officer. He noted the patient has received extensive outpatient and inpatient treatment and is currently linked with I Am Boundless (organization that offers center and community based behavioral health services) and OhioRise (a medicaid managed care program that offers specialized behavioral healthcare for youth). Pt #2's mother reported that outpatient services is seeking residential treatment but they are having trouble finding placement due to her autism spectrum disorder diagnosis. The patient reported that she would be better off if she was no longer alive and her mother reported she is not comfortable maintaining the patient in the home. The clinician noted the patient was a moderate suicide risk and he recommended that another psychiatric admission would not be beneficial at this time due to concerns for secondary gain and her outpatient team recommending residential treatment.

On 09/08/25 at 10:53 PM the patient was admitted to the Extended Observation Unit (EOS) for observation. On 09/09/25 at 8:49 the nurse noted while doing the C-SSRS (Columbia Suicide Severity Rating Scale), the patient disclosed feeling suicidal. The RN asked the patient if she had a plan, and the patient disclosed using a spork to hurt herself with. The nurse retrieved the spork and asked doctor to change her diet order to finger foods. On 09/09/25 at 1:15 PM the psychologist noted an unsuccessful attempt to contact Pt #2's mother and a voicemail message was left requesting a call back.

Review of the after visit summary provided to the mother upon discharge revealed the only appointment that was set up for the patient was for 09/24/25 with the LSW Care Coordinator. On 09/09/25 at 3:50 PM the advance practice nurse set the patients disposition to discharge and at 8:59 PM the patient was discharged to her mother. On 09/10/25 the patient presented to a neighboring hospital after cutting her wrist.

Interview on 09/17/25 at 4:45 PM with Accreditation and Regulatory Consultant C revealed Pt #2 arrived on 09/08/25 at 7:23 PM from the hospital after self injurious behavior (SIB) to one of her forearms. She verified Pt #2's mom stated she could not keep the patient safe in her home as she has another smaller child and the patient was reporting that she was going to stab herself in the throat with a knife on 09/07/25 prior to cutting herself. She verified that on 09/09/25 at 8:49 AM the patient was trying to hurt her wrist with a spork and told the nurse that she wanted to kill herself with it and there was no notation the mother or doctor was made aware of this. She stated the doctor must have been aware of the spork incident because Pt's #2 meals were changed to finger foods after the incident by the advanced care practice nurse. She verified that no therapy or psychiatry appointments had been set up for Pt #2 prior to discharge but stated staff reached out to OhioRise and left messages for I Am Boundless. She also verified that Pt #2's mother was upset with the decision to discharge her daughter stating she did not feel she was safe to return home.

Interview on 09/17/25 at 4:51 PM with the Medical Director of the Behavioral Health Service Line revealed in regard to Pt #2 stating she was suicidal the day of discharge, she only threatened to do it with a spork which could hurt her but would not cause death. That was low risk for suicide. He stated for patients with chronic issues and repeated inpatient stays, they are probably always going to have suicidal thoughts and he has to determine if a hospital stay would decrease the risk for suicide. He stated the patient may just want to be hospitalized and admission could just make things worse. He verified that Patient #2 would have more access to sharper more harmful objects outside of the hospital at home and that she had a history of cutting herself. He stated she has never cut herself to the point of suicide and that in her safety plan they went over it with her mother to lock up harmful objects. This surveyor stated the patient had previously cut herself with a piece of a mirror that she broke out and some things in the home are hard to safe proof like forks, mirrors and windows. He stated they discussed having someone with the patient 1:1 and having increased psychiatric help in the home. He verified that neither of these interventions were set up for the patient prior to discharge and stated they take some time to get the services financed and set up. He verified that there was no documentation evidencing that Pt #2's mother was made aware of the patient stating that she wanted to kill herself with a spork on 09/09/25 at 8:49 AM and even though her mother requested more treatment for the patient the hospital discharged the patient on 09/09/25 at approximately 3:50 PM. He verified on 09/10/25 the patient presented to a neighboring hospital after cutting her left wrist. He stated the psychiatrist recommended that the patient follow up with I Am Boundless but verified staff tried to reach out to them but was unable to make contact prior to the patients discharge. He verified that the mother informed staff that the I Am Boundless therapist was hard to get in contact with on 09/09/25 and that the psychiatrist discharged the patient stating her self injurious behaviors had improved even though the patient had just tried to cut herself with a spork the morning of her discharge.

Review of the hospitals policy titled, Discharge Planning revealed discharge planning is an ongoing process initiated on admission and reassessed as needed based on patient changing conditions. The discharge plan will consider as appropriate follow up care, the need for community resources/referrals and safety and accessibility of the home environment. Patients with unplanned readmissions within 30 days require documentation that includes the reason for readmission, caregivers understanding of the care needs any community services being utilized and access to other needed resources and supplies. The after visit summary (AVS) provided to the patient and caregiver at minimum includes: treatments as appropriate and follow up care/appointments.