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Based on staff interviews, medical record review, and review of facility policies, procedures, and documents, it was determined the facility failed to ensure patients assigned to a court appointed legal guardian are released to the guardian and failed to implement their protocols when a patient makes an allegation of abuse.

Findings include:

The facility failed to ensure the patient was discharged to the appointed legal guardian and failed to implement their protocols when a patient makes an allegation of abuse. (Cross-refer to Tag A-1103)

Based on staff interviews, review of one (1) out of one (1) medical record (#1), and review of facility policies, procedures, and documents, it was determined that the facility failed to release the patient to the appointed legal guardian upon discharge and failed to implement their policy when a patient makes an allegation of abuse.

Findings include:

Reference #1: The facility policy and procedure titled, "Guardianship Proceedings" states,"... .II. Permanent Guardianship: 1. Whenever a patient lacks capacity to participate in discharge planning or make discharge decisions, ... appointment of a Permanent Guardian shall be addressed through the following steps. ... . 8. ... . Case Management is responsible for ensuring that a copy of the order appointing the Guardian is placed in the patient's chart. 9. Case Management/Social Services is responsible for assisting the Guardian making arrangements for the patient, i.e. for discharge planning purposes. ... ."

Reference #2: The facility policy and procedure titled, "Victim Abuse and/or Neglect suspected," states, "... . Policy: 5. It is hospital policy that each victim will be offered, when appropriate, hospital and community resources that are available for counseling, information, and assistance. Current lists of public and private referral agencies and organizations are maintained for this purpose and appended to this policy. ... .7. Reporting: E. The employee who identifies a case of reportable suspected abuse should make the report to the appropriate agency and contact their supervisor immediately. ... .F. A Social Worker should be notified directly or through the Case Management Department to act as a continuing liaison. ... ."

Reference: #3: The facility policy and procedure titled, "Psychiatric Emergency Screening Services," states, "... .Procedure: 2. The treatment plan will be tailored to the patient according to age specific symptoms and least restrictive alternates and is corroborated with patient and their family/significant other... . 11. Patients discharged back to the community will have a plan for continuity of care. The screener has the opportunity to discuss with the patient and their family/significant other the plan toward wellness and recovery. ...."

1. On 8/24 and 8/25/2021, Staff #1 facilitated a review of Medical Record #1. The following was indicated:

a. Patent #1 arrived to the Emergency Department on 8/12/2021 via ambulance. The registration time was 6:52 PM. The triage exam was complete at 7:17 PM.

b. On 8/12/2021 at 7:59 PM, the Emergency Department Physician (Staff #9) Note states,"... . History of preset illness. Patient is a twenty-three (23) year old [male/female], who reports getting into a fight with [his/her] [parent] today. Patient states that [he/she] was supposed to fly to (Name of State) to marry a soldier. It is unclear whether they met in person or met online. [Parent] notes the patient was recently hospitalized at (name of Facility) for a while and that [he/she] was taking Geodon, Ativan, and Cogentin. Patient notes that during the altercation, the [parent] locked the door and [he/she] tried to jump out a one story window. [Parent] notes that [he/she] tried to grab the patient and was kicked. I spoke to the [parent] at length. ... Patient is medically cleared for a Psychiatric Evaluation. ... ."

c. On 8/12/2021 at 23:38 (11:38 PM), a Mental Health Screener (Staff #3) Note states, "... . Writer spoke to the patient's fiance, (Name), who is a soldier at (Name of City and State). Fiance reported that [he/she] witnessed on video chat where the patient's [parent] grabbed [him/her] and indicated that the patient was not going anywhere and became physically assault to the patient. Patient's fiance indicated the patient was supposed to fly out today and they were planing to get married on Monday. Patient's fiance reported the patient and [his/her] [parent] have a toxic relationship. Patient's fiance reported the [parent] has Power of Attorney over the patient ...."

d. On 8/13/2021 at 13:35 (1:35 PM), a Nursing (Staff #4) Note Addenda states, "... . Was very focused on not returning home as [he/she] has safety concerns with [parent], stating I don't want to go back there. Look [he/she] put bruises on me, and when the cops arrived, they saw that. Patient stated that [he/she] does not have any alternatives for housing except fiancé in (Name of State). Screener (Staff #5) (Name of Screener) is aware and spoke with [parent] about returning home. Patient denies suicidal ideation, homicidal ideation and Auditory/visual hallucination and discharged from the unit after verbalizing understanding of aftercare instruction. ... ."

e. On 8/13/2021 at 7:30 AM, a Mental Health Screener (Staff #5) Progress Note states, "writer spoke to patient's [name of parent], who stated the patient was recently admitted to (name of another facility) and discharged 3 weeks ago and is non-compliant with medications. Patient is linked to (name of day program.)." ... . 13:00 (1:00 PM), "Patient discharged by UBER home."

f. On 8/13/2021 at 15:24 (3:24 PM), a Psychiatric Evaluation Final Report note, written by Staff #6 (Psychiatrist), states, "patient is a twenty-three (23) year old [male/female] with a history of schizoaffective disorder; history of temporal lobe surgery in the past for seizures; reportedly patient's [parent] is [his/her] legal guardian ... . patient reports [his/her[ [parent] assaulted [him/her]; patient reported [he/she] did not want to go back to [his/her] [parent], but willing to return home for now... . At present time the patient does not meet criteria for civil commitment, thus will be discharged to [his/her] [parent]. ... "

g. The document titled, "State of New Jersey Essex County Surrogate's Court," dated April 3, 2017, was provided by Staff #1, confirming that Patient #1 was appointed a Guardian.

2. Upon staff interviews, the following was indicated:

a. On 8/24/2021 at 12:55 PM, Staff #2 stated upon interview that the facility staff usual practice to ascertain Guardianship is to request a copy of the Legal Guardian Document and upload to the medical record.

b. On 8/24/2021 at 13:55 (1:55 PM), Staff #5 stated upon interview that [he/she] spoke to Patient #1's parent to let them know that the Psychiatrist is discharging the patient to home. Staff #5 stated that [he/she] told the parent the patient would be discharging via an UBER. Staff #5 stated that the [Father/Mother] was unhappy with the decision to discharge and hung the phone up on Staff #5. Patient #1 was discharged via the UBER. Staff #5 stated that in hindsight [he/she] should have documented the details of the conversation.

(i) Staff #5 confirmed that he/she did not attempt any further contact with the parent after being hung up on.

(ii) Staff #5 confirmed that the transportation was not affiliated with the hospital transportation, it was a public UBER.

c. On 8/24/2021 at 15:00 (3:00 PM), Staff #6 (physician), stated upon interview that he/she performed the Psychiatric Evaluation and the Discharge. He/she did not discuss the discharge with the patient's Father/Mother (Legal Guardian) and that the Mental Health Screeners would discuss the discharge. He/she said the case sounded more like a domestic conflict than a case of suspected abuse.

d. On 8/24/2021 at 15:40 PM (3:40 PM), Staff #15 stated upon interview that if a patient expresses abuse or assault allegations, they would discuss this with the patient, discuss this with the alleged accused, contact the supervisor, and reach out to the Division of Aging to get a report on file.

e. On 8/25/2021 at 10:20 AM, Staff #1 stated upon interview that an allegation of abuse should be reported to social services, himself/herself, and a referral made to Adult Protective Services in order to research the allegation. He/She further reported that a member of their security team (Staff #19) attempted to reach out to the patient's fiance and confirmed that the patient is currently with him/her in (name of state).

3. On 8/30/2021 at 2:00 PM, Staff #1 was asked to provide education records for Staff #6 and Staff #9, both physicians.

(i) On 8/30/2021 at 3:43 PM, there was no evidence that Staff #6 or Staff #9 had completed orientation or annual on going training in abuse.

4. On 8/25/2021 at 2:40 PM, it was confirmed with Staff #1 that the Guardian was not involved in the discharge plan of care, that Patient #1 did not arrive home to his/her Guardian's house, and that the allegation of assault/abuse was not reported in accordance with facility policies and procedures.

These findings resulted in an Immediate Jeopardy (IJ) on 8/25/2021 at 2:40 PM. Staff #1 was informed of the IJ and the IJ template was provided to Staff #1 via email at 2:48 PM. An IJ removal plan was requested at that time. An acceptable IJ removal plan was provided by the facility on 8/27/2021 at 10:00 AM.

On 8/30/2021, a removal plan visit was conducted. It was determined that the facility implemented the following to remove the IJ: Staff #19 contacted Patient (#1) and his/her "significant other" to verify that the patient was safe. Adult Protective Services was called by Staff #2, who is following up to ensure that all information of the allegation of abuse/assault is communicated for completion of the referral. Hospital Leadership, Patient Care Service Management, and Risk Management will be notified of all patients who are under Guardianship Status. This process is being communicated to The ED [Emergency Department] and PESS [Psychiatric Emergency Screening Services] staff through verbal and written education. Staff are receiving inservice education on reporting suspected abuse/neglect and the procedure for patients under guardianship. All ED and PESS staff were sent a "mass text message" from "Send Word Now" to inform that prior to the start of their assigned shifts, they are to complete the immediate inservice education. Staff #2 followed up with their staff face-to-face through staff meetings and via Web-ex to educate on guardianship and reporting of suspected abuse procedures. An Algorithm was posted on the units for a visual guideline. Staff #14 followed up with staff during the start of shift "huddles" to reinforce that the education was required to be completed prior to starting their shifts. Staff #1 showed proof of in-service education through signage on rosters and read and sign Attestations. On 8/30/21, it was determined that the IJ removal plan was implemented and the IJ was removed at 2:58 PM.