HospitalInspections.org

Based on a review of facility documents, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to adequately develop and implement a safe discharge plan for one of ten medical records reviewed (MR1).

Findings include:

Review on April 24, 2014, of facility document "Discharge Planning," dated December 2010, revealed " All patients admitted to the services of Brooke Glen Behavioral Hospital shall have a discharge and aftercare plan which ... minimize the likelihood of relapse. ... Social Worker 1. The assigned social worker shall negotiate an aftercare plan in coordination with the patient, family ... Nursing ... 2. The nurse shall review both the Discharge Order/Summary and the Aftercare plan with the patient and/or family members at the time of discharge. 3. The nurse shall provide any necessary patient-family education regarding medications or follow-up to medical problems at the time of discharge. ..."

Review on April 24, 2014, of MR1 revealed that the patient was to be discharged to a family member's residence.

Interview on April 24, 2014, at 10:00 AM, with EMP1 confirmed that the patient was instructed to call a family member to notify them of the discharge. The patient reported that the family member was not able to transport the patient from the facility to home. EMP1 revealed that the facility provided the patient with eleven dollars and written directions how to get home utilizing public transportation. EMP1 revealed that on April 15, 2014, the facility became aware that the patient was missing and never made it home after being discharged from the facility on April 10, 2014. EMP1 suggested to the patient's family to file a missing persons report.

Review of "Admission Psychiatric History and Evaluation," dated April 15, 2014 revealed that the patient arrived to another psychiatric facility. Further review of the assessment revealed " unknown psychiatric history, patient with severe blocking; petrified stare; severe Bradykinesia visible u.e. (upper extremity) shaking, afraid, and needs to be admitted."

Review on April 24, 2014, of MR1 revealed no documented evidence that the facility notified and educated the patient's family of the patient's aftercare needs, and the date and time that the patient was to be discharged. There was no documented evidence that the facility adequately developed and implemented a safe discharge plan for this patient to minimize the risk of relapse.

Based on a review of facility documents, medical records (MR) and interviews with staff(EMP), it was determined that the facilty failed to ensure that there was a mechanism in place for ongoing reassessment of its discharge planning process.

Findings include:

Review on April 24, 2014, of MR1 revealed that the patient was discharged to home via public transportation on April 10, 2014.

Review on April 24, 2014, of facility document "2014 Plan for Performance Improvement and Patient Safety," did not reveal any evidence of a program to review outcomes for patients discharged via public transportation to determine if patients are arriving safely at planned destinations.

Interview on April 24, 2014, at 10:00 AM, with EMP1 confirmed that a patient was discharged from the facility on April 10, 2014; and that the patient was instructed to take public transportation to place of residence. EMP1 confirmed that the family notified the facility on April 15, 2014 that the patient never arrived home. EMP1 confirmed that the facility has not integrated into its QAPI program a mechanism for verifying if patients discharged from facility to home or other post - hospital setting, and utilizing public transportation as the mode of transport, have safely reached their destination. No assessment is being done to validate if public transportation is a safe and reliable option for patient discharge.