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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 (medical record) documentation for P1 indicated on 4/30/24 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. On 5/4/24 indicated P1 was wanting out of H1 but was told not until Tuesday (5/7/24). On 5/5/24 indicated P1 expressed a desire to go home. On 5/6/24 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 an 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 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 (power of attorney), 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 MR for P1 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 x 4, medication compliant without side effects, no medication changes, and denied SI (suicidal ideation)/HI (homicidal ideation). LEVEL OF CARE JUSTIFICATION indicated the patient was doing well on current regimen, was noted to be psychiatrically stable, and was cleared for discharge to appropriate setting. This note serves as provider order for discharge.
b. P1 was discharged to home in stable condition on 5/8/24.

3. 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.
b. P3 was not discharged at the time of this survey on 5/15/24.

4. P4's MR indicated the patient was voluntarily admitted to H1 from 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.
b. Interdisciplinary Discharge Plan documentation indicated the patient was discharged to home on 5/8/24 at 11:00 am in stable condition.

5. 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.
b. Discharge Summary documentation indicated P4 was discharged to a skilled nursing facility in stable condition on 5/14/24.

6. P6's MR indicated the patient was admitted to H1 from 4/30/24 on an EDO. 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.


7. 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.
b. Discharge Summary documentation indicated P8 was discharged home in stable condition on 5/8/24.


8. 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.
b. Discharge Summary documentation indicated P10 was discharged to home in stable condition on 5/12/24 .


9. In an interview on 5/16/24 at approximately 12:10 pm with L1 (Licensed Staff) confirmed remembering P1 as alert and oriented, 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.

10. 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.

11. In a telephone interview on 5/20/24 at approximately 2:10 pm with L3 (Licensed Staff) confirmed A1 (Chief Executive Officer) puts a cap of 5 discharges a day, A1 is the final say if someone can be discharged is 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.

12. 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 has instructed providers not to tell patients the date of their discharge.