Suicidal patient released too early despite voicing concerns

Cypress Creek Hospital was cited by the Centers for Medicare and Medicaid Services (CMS) for failing to uphold a patient’s right to participate in her plan of care by not taking her concerns into consideration.

CMS found that the patient, who was admitted involuntarily at the facility, had expressed concerns in group therapy about her fragile mental state. Documentation from the group therapy session (which was co-signed by the therapist) noted that the patient said she was “too vulnerable to go home” and that “Pt. said she thinks that if she goes home today she will probably harm herself before the flight on Monday…” The patient’s family therapy notes from that same day read “…tearful, poor insight and judgment; anxious; disheveled…” Despite the serious nature of these statements, this information was not communicated to her physician and she was released.

In an interview, the patient’s physician said that had he known about her concerns, he would have delayed the discharge. The physician added that he often wrote discharge orders in the morning, but expected to be informed of any significant patient changes prior to discharge. However, CMS surveyors found that “the facility did not have a policy that addressed informing physicians of significant patient information.”

The facility was also cited by CMS for failing to document a nurse’s assessment of the patient upon discharge. The facility was unable to locate the actual time of discharge or a nursing assessment of the patient, which was required to be performed by an RN upon discharge.

The facility was required to submit a plan of correction to address its cited deficiencies and deficient policies.