HospitalInspections.org

Based on a review of documents and interviews the facility failed to ensure the patient (or patient's representatives) had the right to participate in the development and implementation of his or her plan of care.

Findings included:

Facility based policy entitled "TREATMENT PLANNING; INTEGRATED/MULTIDISCIPLINARY" stated in part,
"o Documenting specific plan for family/significant other involvement in treatment and continuing care.
o Coordinating documentation of the treatment plan reviews and revisions to reflect patient progress and any discharge/continuing stay criteria every seven (7) days (31 days lOP) or at key decision points with multi-disciplinary treatment ...
o Finalizing the discharge process and reviewing Continuing Care Plan within 48 hours of discharge with patient (and patient's family if indicated). Continuing Care Plan includes names, dates, times, addresses, and phone numbers of all providers and services needed to support individual post discharged. Continuing medication regime and education is provided and documented for the patient. A written copy of the plan is given to the patient, significant other, and/or patient's guardian. Any needed adaptation or education is rendered.
o Coordinating all internal and external care, treatment and services, as well as care between providers and settings."

Review of the the medical records for 5 child/adolescent patient in Child Protective Custody (CPS) care revealed the following:
* 2 of the 5 medical record (Patients #2, and 3) revealed that there was no documentation that the CPS caseworker was notified of the treatment plan meeting or content. The Integrated Treatment Plan for each patient only noted "CPS" for "LAR Notified" with no date or time indicated.
* In an interview on 07/18/19 staff member #6 was asked how they notifies families and guardians of children and adolescents about treatment planning. The staff member replied, "I create treatment plan for social services for that patient. I notify the family or guardian of the treatment plan and what that looks like and entails. Ask if they have any questions and that's about it ...typically over the phone." This staff member verified that this was not documented in medical record for the above 2 patients.
* One of the 5 CPS custody child/adolescent patients was inpatient at the facility for over 30 days. Patient #1 was inpatient at the facility for over 30 days. There was note that the CPS caseworker had been notified of the initial treatment plan on 06/03/19. In an interview on 07/17/19, staff member #6 verified that they had not notified the CPS case worker of subsequent treatment plan meetings, which occur every 7 days per facility policy.

Based on the above findings the facility failed to ensure that the patient's representatives had the right to participate in the development and implementation of his or her plan of care, by failing to notify the representative of when the treatment team meetings occurred and asking for input in the planning.

Based on a review of documentation and interview, the facility failed to ensure that as needed, the patient and family members or interested persons must be counseled to prepare them for post-hospital care.

Findings included:

Facility based policy entitled "DISCHARGE PLANNING: TRANSITION RECORD" stated in part,
"PURPOSE:
To establish guidelines for assisting patients to the appropriate level of psychosocial/ physical care, treatment and services for post-treatment placement/follow-up and/or transfer.

POLICY:
Discharge planning commences upon admission to any program. Tentative discharge plans are established and reviewed and modified throughout treatment ...

Treatment Team Members
1. Updates/Reviews post discharge plans during weekly treatment team meetings or more frequently to be determined if the discharge plan meets treatment needs of the patient.
2. Discharge planning should encompass the following areas:
a. Review of the precipitating events and stressors which led to current treatment and what resources the patient will need to deal with these events/stressors post -discharge.
b. Review of any daily living changes (need for nursing home, group home, home health, etc.) patient may need to decrease relapse potential.
c. Review of community resources needs of patient post-discharge and availability of same (i.e. vocational rehabilitation, private therapist, educational, etc.)
d. Family's needs post discharge.
e. Patient/family's continued education needs.
f. Cost feasibility of plan.
g. Orders for continuing care to meet physical and psychosocial needs for discharge or transfer ...

Social Services:
1. Participates/Facilitates discharge planning and develops mechanisms for exchanging information with services outside the facility: ...
3. Contacts the post-discharge referral source to ascertain the suitability of placement, schedule any appointments, and to facilitate coordination of transfer ...
6. Meets the referral agencies and establishes communication with referral sources as needed to promote optimal transition of care, treatment, and services."

Based on a review of documentation the facility was providing conflicting information to the pateint representative regarding discharge plans for an adolescent/child patient that was in CPS custody. Review of the medical record for Patient #1 revealed the following:

Physician notes indicated a plan to discharge to another hospital, including the following:
On 07/16/19 stated in part, "Pt waiting for hospital."
On 07/15/19 at 1200 stated in part, "Waiting for state bed. Pt gets secured."
On 07/11/19 stated in part, "Pt locked self in bathroom yesterday and tried to self-harm ...Pt attempted to grab and physically harm a medical student ...Awaiting state hospital bed."

There were no discharge orders present in the patient's medical record as of 07/17/19.

In an interview with the patient's physician on 07/17/19 he was asked what the discharge plan was for this patient. The physician replied, "She's on the waiting list for the state hospital. I don't know where else to send her or she's going to kill herself. I can't see discharging her to any other level of care."

However, case management notes reflected the following:
06/21/19 a social services note at 1600 stated in part, "Explained OBH could not meet the therapeutic needs of the pt ...Jennifer asked if pt was a danger to self and others which Amber and I both said yes to, but OBH was not able to meet there [sic] needs..."
07/16/19 at 1120 AM "Called and spoke to [CPS caseworker] letting her know my provider and admin are wanting pt to discharge. At this time I had gotten word from NTSH that they still needed CPS to send additional paperwork. I let [CPS caseworker] know, she said she would check on it as we had discussed sending this info a week ago."
07/16/19 at 5:00 PM "Spoke to {Name} at NTSH and we are waiting to see if papers from CPS came through. They have Dr ready for review. Unofficially she is #2 on wait list."
07/17/19 at 8:10 AM "Received call from [CPS caseworker], she said that the paperwork for pt has been sent, I then transferred the call to my supervisor [Name] because [CPS caseworker]was saying they 'may not come' and needed help to explain she needed to go today."
07/17/19 at 08:10 AM "This writer informed [CPS caseworker] that [Patient #1] was no longer appropriate for this hospital and would be discharged today. She stated she would have to notify 'higher ups' because they didn't have placement. I explained the danger of this patient being here for other pts, herself, and staff members. [CPS caseworker]said she would call us back."
07/17/19 at 10:00 AM "This writer received a call from {Name] with CPS placement [phone number] explained the above information to here. This writer also notified [CPS worker] that we had a conference call with CPS on 06/24/19 explaining other hospitalizations needed to be done because pt was no longer appropriate here and the only progress from that meeting was what our CM has been trying (Austin and North TX). CPS did not fax info to NTX until yesterday 07/16/19. [Name] will call back."

In an interview with staff member #3 on 07/17/19 they were asked if the current plan at the facility was to discharge this adolescent child to CPS custody today. They replied, "That's what I was told we were going to be doing. This is the third time we've called and she needs to go today and nothing." They were asked if Patient #1 was stable, this patient was last restrained 2 days prior. The staff member replied, "Right it's all behavior...Right now we're waiting to get that call to see what the doctor said for Northwest Texas other than that I think the doctor wrote discharge orders. I had heard they were written yesterday but I haven't seen them."

In an interview on 07/17/19 the patient's physician and staff member #2 both verified that the facility was currently waiting to hear about placement at a state hospital for this patient and this was the safest discharge plan for Patient #1. However the case worker notes indicated that on 07/17/19 the case worker notified the CPS caseworker that the patient would be discharged directly to their care without a placement plan. This patient would not be safe to be discharged direct to CPS care without a higher level of care placement arranged.

Based on the above findings the facility failed to ensure that the patient's representative was effectively counseled to prepared for post-hospital care. Currently Patient #1's CPS caseworker was receiving conflicting information regarding discharge placement plans. At the time of this survey exit on 07/17/19, Patient #1 was still inpatient at the facility waiting for safe placement at a state hospital facility if it become available.