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Based on interview and record review, the facility failed to complete a discharge evaluation that included the likelihood of the patient needing post-hospital services, and failed to evaluate the patient for his capacity for self-care. This deficiency affected 1 (#1) out of the 5 sampled patients. Findings include:

Admissions Evaluation

Review of patient #1's Admission Psychiatric Evaluation, dated 3/4/17, showed he was placed, by a court order, at the Montana State Hospital after he was discharged from a long-term care facility because of inappropriate sexual behaviors with other residents. The patient was at the hospital on a court ordered placement. The patient stated he was diagnosed with dementia about two years (2015) prior to the 3/4/17 Montana State Hospital admission. The Evaluation stated he had a history of suicidal and homicidal ideation, alcohol dependence, and his estimated length of stay was 90 days.

Treatment Plan Review and Progress Notes

Review of patient #1's Treatment Plan Review, dated 4/4/17, and review of the facility progress notes showed the patient was having continued behavioral struggles and was not ready for discharge. The Review and the progress notes showed the patient had the following behaviors:

- 3/7/17: patient was claiming to stop breathing while smiling, and stated has always wished he was dead
- 3/9/17: grabbed a peer's arm and licked at a nurses face
- 3/16/17: patient showed minimal insight as to why behaviors were inappropriate
- 3/18/17: patient smiling and making inappropriate gestures
- 3/21/17: patient made inappropriate sexual comment to another peer
- 3/22/17: exposed genitals in the hallway
- 3/25/17: tried to get a male peer to come into his room
- 3/28/17: multiple inappropriate comments, Paxil was increased
- 3/29/17: tried to get a peer into his room to lay down with him
- 3/31/17: sexually inappropriate words and comments to the psych tech, and refused to follow instructions
- 4/1/17 inappropriate during ADL cares of roommate and refused to redirect
- 4/4/17: observed by nursing office window walking slowly and stalking towards a resting peer. Approached and touched the peer with his fingernail and the tip of his finger. The peer told the patient to go away but patient refused to redirect. Patient #1 then was redirected by staff member D, patient smiled big and put his index finger over his mouth signaling "shhh" and focused his attention back to the peer.
- 4/12/17: patent urinated in his pants prior to a scheduled meeting with his treatment team, stating, "I like the warmth."
- 4/13/17: inappropriate sexual behaviors, refused to redirect, grabbed peer's hand and would not let go, tried to push through the locked double doors when staff was leaving the unit, yelling at others.
- 4/14/17: refused to use coping skills, refused to follow staff direction, poor ADL's (activities of daily living) and voiding in his room and demanding staff clean it up. Patient was targeting female staff and peer and making sexual gestures towards them.
- 4/15/17: following female peers and female staff around on the unit
- 4/16/17: staying up most of the night and standing by the control room window, staring at staff. Patient was incontinent in his room and there was urine all over his floor, continued to try to intimidate staff and continued to be inappropriate.
- 4/18/17: urinated on himself and refused to change his clothes, was rude to his peers, and was attempting to intimidate the nurse.
- 4/21/17: patient came out into the hallway smelling of urine, staff entered room and said the bed was saturated with urine
- 4/22/17: verbally inappropriate with staff, was coming around staff after he urinated on himself, would yell at staff with redirection, threatened staff. The patient doubled fists and came towards staff saying, "I am going to break your fucking nose."

Aftercare Plan

Review of patient #1's Aftercare Plan, dated 4/20/17, showed the patient was going to be traveling by bus to Minnesota, and would be provided a staff escort. The follow-up appointments were just listed as out of state. No times and dates were provided for follow-up. The Plan listed some contacts, including his sister, and a staff member at the [OMIT] Center. The note under the contact stated the resident "desired to seek admittance to the [OMIT] Residence" which was the long-term care "wet house."

The plan stated the staff member F was in contact with a staff member at the [OMIT] Residence, and informed the staff member that patient #1 planned on seeking admittance to the [OMIT] facility. The note also documented that patient #1 was not a resident of the county, and would have to begin the intake process at the [OMIT] Center and get his Montana Insurance transferred over to Minnesota insurance.

Discharge Instructions

Review of the facility Discharge Instructions, dated 4/24/17, showed the patient would be transported to the [OMIT] Center in Minnesota, by bus, with a "teamster" from the facility. The Instructions showed the patient was provided a resource list of services in the Saint Paul area, and the information had been communicated with his sister as well. The Instructions showed the patient was aware of all the discharge arrangements and instructions for his arrival in Saint Paul, was instructed to present himself to the [OMIT] Center upon arrival to St. Paul. He was instructed to complete an intake to utilize the [OMIT] Center for meals and shelter. The instructions stated there was a clinic, he would have to complete an intake, in the same building to help him manage his medication refills. The Instructions also stated that transitioning into the [OMIT] Residence may not be a quick process, though he could reside at the [OMIT] Center until a more permanent placement "came up."

Discharge Summary

Review of the facility Discharge Summary, dated 4/24/17, showed patient #1's reason for admission was that he was discharged from a long-term care facility for inappropriate behaviors. The Summary showed he had dependence on alcohol, had extended amounts of time incarcerated due to the alcohol-related crimes, and was relocated to Montana after being released from prison in Minnesota. The Summary documented that the patient was initially admitted to the Sprat (geriatric) Unit, where it was discovered he likely had a mixed personality disorder and a significant amount of malingering.

The Summary showed a note from staff member K and it stated, "based on the patient's sexually inappropriate, attention-seeking and preying-type behaviors, his clear ability to understand right from wrong, even though he presents as demented at times, his admittance to using medical problems and complaints in order to avoid evaluations, his childlike, helpless and long history of institutionalization, it seems more likely that the patient is malingering; complicated by his poor social skills and unspecified Cluster B personality traits." The summary also stated, the unit considered a possibility of using Depot Lupron to address the hypersexuality. The summary continued to state that staff member D elected not to use the medication for chemical castration, and was going to treat the patient with Paxil instead.

The Summary showed a conversation that was had with the patient's sister, who was living in Wisconsin. The sister stated her brother had a long history of inappropriate behaviors. She stated that the patient could not come live with her due to the risk he could implement on her family. She stated in the summary interview, "he will just try to do something to get back to prison" once he was discharged. The summary also documented the sister acknowledged the patient's behaviors may lead to rejection from the assisted living facility referrals currently pending. The sister was also noted as saying the patient had been neglecting to care for himself for the past several years and she had observed a pattern of volitional self-neglect.

The Summary documented the patient was unwilling to accept chemical dependency treatment and therefore it would have been difficult to place him at an assisted living facility. The patient expressed he wanted to go to a "wet house" closer to his relatives in Wisconsin. He was given information on the homeless shelter, then he could transition into the [OMIT] Residence wet house program. The summary stated the patient's mental status remained unchanged throughout and he responded to redirection regarding inappropriate leering behaviors, entering people's personal space, and also responded well to direct and firm instruction regarding grooming and self-care.

The discharge instructions, from staff member D on the discharge summary, were for the patient to attend all scheduled follow up available to the patient at the [OMIT] Center and [OMIT] Residence. Staff member D also wrote in the summary for the patient to "take a harm reduction approach to the alcohol use and reconsider treatments."

Interviews

During an interview on 10/10/17 at 12:12 p.m., NF1 stated the resident was on his way to a placement in St. Paul when he fell and hit his head. NF1 stated the emergency medical services and police arrived at the scene and patient #1 was transferred to the local hospital. NF1 stated the patient then stayed in the local hospital 100 days because he was waiting for his Montana insurance to be transferred to the Minnesota Insurance. NF1 stated, this is a timely process and the local hospital had to apply for a CADI (Community Access Disability Inclusion) to get him into a group home. NF1 stated she had some correspondence with the Montana State Hospital and was unsure if they looked into any waivers or alternative placements for the patient because she thought patient #1 was not capable of making self-decisions and being at the [OMIT] Center was not the best discharge plan for that patient. NF1 also questioned that if the patient was able to make his own decisions, why did the Montana State Hospital send a "teamster" with him.

During an interview on 10/10/17, at 1:55 p.m., staff member F stated patient #1 was safe and stable at the time of the discharge. She stated the social workers were not responsible for deciding when a patient was ready for discharge and that the facility doctors decided. Staff member F stated the patient wanted to relocate closer to his sister but the sister could not have the patient live with her due to his history of behaviors. Staff member F stated the patient came in on the Sprat unit and was transferred over to the B unit, where he would be around a less vulnerable population. Staff member F stated the patient was "kicked out of the nursing home due to sexualized behaviors," and at the time of discharge, the patient just wanted to go drink. Staff member F stated she tried to get him closer to his sister and also provided him with any resources that may have been helpful. Staff member F stated there were no shelters in Montana where the patient could reside and be an active drinker, so staff member D suggested [OMIT] Center and the [OMIT] Residence. Staff member F also stated there was some difficulties with the transfer because the patient's Social Security was not in place.

During an interview on 10/10/17, at 1:10 p.m., staff member C stated the staff at the facility talked as a team to see if patients were appropriate for discharge and at the time of discharge, the team thought patient #1 was ready for discharge. At the time of the interview, staff member C was asked to provide any documented information of an assessment or an evaluation that was completed showing the patient could care for himself. Staff member C referred to the progress notes for any information showing he could care for himself.

During an interview on 10/10/17, at 1:15 p.m., staff member D stated the patient was at the facility for several months and that he took over as the provider after the patient was transferred from the SPRAT unit. Staff member D shared he was encouraging the patient's sister to become the patient's power of attorney because he had been suffering from several issues and it may be helpful. Staff member D stated the patient was socially awkward, but was lucid in the 1:1 interviews with staff member D. Staff member D gave the example of patient #1 urinating in his pants in public on several occasions and the poor boundaries. Staff member D stated the team met to discuss the complexity of patient #1 and felt that his diagnosis of Alzheimer's was not accurate and when he was transferred to the B unit, he was presenting with personality disorder traits. Staff member D stated, "Sometimes he cares and was complaint, and some day's he was not compliant." Staff member D stated the patient responded better to set boundaries, and felt his behaviors were malingering.

Staff member D stated that when he took the call from staff member G, "he explained that the patient could not be restrained due to his behaviors in public. Staff Member D said he also had a conversation with staff member G prior to going on the trip with patient #1 and expressed that the patient could be difficult on the trip and that if the patient chose to walk away from the plan, there was nothing the facility or staff member G could do to manage the behaviors of the patient. Staff member D stated the patient was difficult to "pin down," and he stated he recalled getting a phone call from the "teamster" in Minnesota at the time patient #1 was on his way to the [OMIT] Center. Staff member D stated that he was called by staff member G and informed that the patient was acting out and that the emergency response team and the police were on the scene because patient #1 was laying down on the sidewalk and refusing to get up. Staff member D recalled staff member G stating he was not able to redirect the patient, and at that time staff member D encouraged staff member G to let the police handle the situation.

During an interview on 10/10/17 at 1:50 p.m., staff member G stated he did not complete an incident report of what had happened with the patient when he was on the ground in Minnesota, two blocks from the [OMIT] Center. He stated patient #1 was acting like he was having a heart attack and would not redirect. Staff member G stated his behaviors were consistent throughout the time of his hospitalization, and "he was doing what he always did at the facility. He was doing what Personality Disorders do, he was attention seeking. He was at [OMIT] Residence one day later anyway." Staff member G stated the patient was struggling behaviorally up until the day he discharged and was redirected by staff often up until the point of discharge for being hypersexual and inappropriate towards female staff. Staff member G stated that the patient would act in ways that he knew were not allowed, such as urinating in his pants on purpose.

During the exit conference on 10/10/17, at 3:15 p.m., staff members A, C, E, and J were asked if an assessment or evaluation was completed to show the patient was able to make rational self-choices. The staff members were encouraged to send any evaluation or assessments that showed the self-care assessments were completed, but the facility failed to provide adequate information that the patient was assessed in a formal way to show he was able to self-care.

Based on interview and record review, the facility failed to evaluate the patient's need for post-hospital needs, including evaluating the patient's risk of residing in a homeless shelter, in another state, based on his continued inappropriate behaviors. The facility failed to initiate the transfer of his Medicaid funding to Minnesota from Montana. Without insurance in the state he would be residing in, it would be difficult to find permanent housing. The deficiency affected 1 (#1) out of 5 sampled patients. Findings include:

Please refer to A806 for a detailed timeline of the patient's admission, stay at the facility, and discharge from the facility.

Review of patient #1's Aftercare Plan, dated 4/20/17, showed the patient was going to be traveling by bus to Minnesota, and would be provided a staff escort. The follow-up appointments were just listed as out of state. No times and dates were provided for follow-up. The Plan listed some contacts, including his sister, and a staff member at the [OMIT] Center. The note under the contact stated the resident "desired to seek admittance to the [OMIT] Residence" which was the long-term care "wet house."

Review of the facility Discharge Instructions, dated 4/24/17, showed the patient would be transported to the [OMIT] Center in Minnesota, by bus, with a "teamster" from the facility. The Instructions showed the patient was provided a resource list of services in the Saint Paul area, and the information had been communicated with his sister as well. The Instructions showed the patient was aware of all the discharge arrangements and instructions for his arrival in Saint Paul, was instructed to present himself to the [OMIT] Center upon arrival to St. Paul. He was instructed to complete an intake to utilize the [OMIT] Center for meals and shelter. The instructions stated there was a clinic, he would have to complete an intake, in the same building to help him manage his medication refills. The Instructions also stated that transitioning into the [OMIT] Residence may not be a quick process, though he could reside at the [OMIT] Center until a more permanent placement "came up."

Review of the Discharge Summary showed a note from staff member K and it stated, "based on the patient's sexually inappropriate, attention-seeking and preying-type behaviors, his clear ability to understand right from wrong, even though he presents as demented at times, his admittance to using medical problems and complaints in order to avoid evaluations, his childlike, helpless and long history of institutionalization, it seems more likely that the patient is malingering; complicated by his poor social skills and unspecified Cluster B personality traits." The summary also stated, the unit considered a possibility of using Depot Lupron to address the hypersexuality. The summary continued to state that staff member D elected not to use the medication for chemical castration, and was going to treat the patient with Paxil instead.

The Summary showed a conversation that was had with the patient's sister, who was living in Wisconsin. The sister stated her brother had a long history of inappropriate behaviors. She stated that the patient could not come live with her due to the risk he could implement on her family. She stated in the summary interview, "he will just try to do something to get back to prison" once he was discharged. The summary also documented the sister acknowledged the patient's behaviors may lead to rejection from the assisted living facility referrals currently pending. The sister was also noted as saying the patient had been neglecting to care for himself for the past several years and she had observed a pattern of volitional self-neglect.

During an interview on 10/10/17 at 12:12 p.m., NF1 stated the resident was on his way to a placement in St. Paul when he fell and hit his head. NF1 stated the emergency medical services and police arrived at the scene and patient #1 was transferred to the local hospital. NF1 stated the patient then stayed in the local hospital 100 days because he was waiting for his Montana insurance to be transferred to the Minnesota Insurance. NF1 stated, this is a timely process and the local hospital had to apply for a CADI (Community Access Disability Inclusion) to get him into a group home. NF1 stated she had some correspondence with the Montana State Hospital and was unsure if they looked into any waivers or alternative placements for the patient because she thought patient #1 was not capable of making self-decisions and being at the [OMIT] Center was not the best discharge plan for that patient. NF1 also questioned that if the patient was able to make his own decisions, why did the Montana State Hospital send a "teamster" with him.

During an interview on 10/10/17, at 1:10 p.m., staff member C stated the staff at the facility talked as a team to see if patients were appropriate for discharge and at the time of discharge, the team thought patient #1 was ready for discharge. At the time of the interview, staff member C was asked to provide any documented information of an assessment or an evaluation that was completed showing the patient could care for himself. Staff member C referred to the progress notes for any information showing he could care for himself.

During an interview on 10/10/17 at 1:50 p.m., staff member G stated he did not complete an incident report of what had happened with the patient when he was on the ground in Minnesota, two blocks from the [OMIT] Center. He stated patient #1 was acting like he was having a heart attack and would not redirect. Staff member G stated his behaviors were consistent throughout the time of his hospitalization, and "he was doing what he always did at the facility. He was doing what Personality Disorders do, he was attention seeking. He was at [OMIT] Residence one day later anyway." Staff member G stated the patient was struggling behaviorally up until the day he discharged and was redirected by staff often up until the point of discharge for being hypersexual and inappropriate towards female staff. Staff member G stated that the patient would act in ways that he knew were not allowed, such as urinating in his pants on purpose.

During the exit conference on 10/10/17, at 3:15 p.m., staff members A, C, E, and J were asked if an assessment or evaluation was completed to show the patient was able to make rational self-choices. The staff members were encouraged to send any evaluation or assessments that showed the self-care assessments were completed, but the facility failed to provide adequate information that the patient was assessed in a formal way to show he was able to self-care.

Based on interview and record review, the facility failed to include a discharge planning evaluation in the patient's medical record. The deficiency affected 1(#1) out of 5 sampled patients. Findings include:

Review of the patient's medical record on 10/10/17, showed the facility failed to complete a discharge evaluation for patient #1.

During an interview on 10/10/17, at 01:10 p.m., staff member C was asked for an evaluation completed by the facility to ensure patient #1 was able to care for himself. Staff member C suggested looking in the progress notes.

During the exit conference on 10/10/17, at 3:15 p.m., staff members A, C, E, and J were asked if an assessment or evaluation was completed to show the patient was able to make rational self-choices. The staff members were encouraged to send any evaluation or assessments that showed the self-care assessments were completed, but the facility failed to provide adequate information that the patient was assessed in a formal way to show he was able to self-care.

Based on interview and record review, the facility failed to reassess the appropriateness of the patient's discharge plan. The deficiency affected 1 (#1) out of 5 sampled patients. Findings include:

Review of patient #1's Treatment Plan Review, dated 4/4/17, and review of the facility progress notes showed the patient was having continued behavioral struggles and was not ready for discharge. The Review and the progress notes showed the patient had the following behaviors:

- 3/7/17: patient was claiming to stop breathing while smiling, and stated has always wished he was dead
- 3/9/17: grabbed a peer's arm and licked at a nurses face
- 3/16/17: patient showed minimal insight as to why behaviors were inappropriate
- 3/18/17: patient smiling and making inappropriate gestures
- 3/21/17: patient made inappropriate sexual comment to another peer
- 3/22/17: exposed genitals in the hallway
- 3/25/17: tried to get a male peer to come into his room
-3/28/17: multiple inappropriate comments, Paxil was increased
- 3/29/17: tried to get a peer into his room to lay down with him
- 3/31/17: sexually inappropriate words and comments to the psych tech, and refused to follow instructions
- 4/1/17 inappropriate during ADL cares of roommate and refused to redirect.
- 4/4//17: observed by nursing office window walking slowly and stalking towards a resting peer. Approached and touched the peer with his fingernail and the tip of his finger. The peer told the patient to go away but patient refused to redirect. Patient #1 then was redirected by staff member D, patient smiled big and put his index finger over his mouth signaling "shhh" and focused his attention back to the peer.
- 4/12/17: patent urinated in his pants prior to a scheduled meeting with his treatment team, stating, "I like the warmth."
- 4/13/17: inappropriate sexual behaviors, refused to redirect, grabbed peers hand and would not let go, tried to push through the locked double doors when staff was leaving the unit, yelling at others.
- 4/14/17: refused to use coping skills, refused to follow staff direction, poor ADL's (activities of daily living) and voiding in his room and demanding staff clean it up. Patient was targeting female staff and peer and making sexual gestures towards them.
- 4/15/17: following female peers and female staff around on the unit.
- 4/16/17: staying up most of the night and standing by the control room window, staring at staff. Patient was incontinent in his room and there was urine all over his floor, continued to try to intimidate staff and continued to be inappropriate.
- 4/18/17: urinated on himself and refused to change his close, was rude to his peers, and was attempting to intimidate the nurse.
- 4/21/17: patient came out into the hallway smelling of urine, staff entered room and say the bed was saturated with urine
- 4/22/17: verbally inappropriate with staff, was coming around staff after he urinated on himself, would yell at staff with redirection, threatened staff. The patient doubled fists and came towards staff saying, "I am going to break your fucking nose."

Discharge Instructions

Review of the facility Discharge Instructions, dated 4/24/17, showed the patient would be transported to the [OMIT] Center in Minnesota, by bus, with a "teamster" from the facility. The Instructions showed the patient was provided a resource list of services in the Saint Paul area, and the information had been communicated with his sister as well. The Instructions showed the patient was aware of all the discharge arrangements and instructions for his arrival in Saint Paul, was instructed to present himself to the [OMIT] Center upon arrival to St. Paul. He was instructed to complete an intake to utilize the [OMIT] Center for meals and shelter. The instructions stated there was a clinic, he would have to complete an intake, in the same building to help him manage his medication refills. The Instructions also stated that transitioning into the [OMIT] Residence may not be a quick process, though he could reside at the [OMIT] Center until a more permanent placement "came up."

Discharge Summary

Review of the facility Discharge Summary, dated 4/24/17, showed patient #1's reason for admission was that he was discharged from a long-term care facility for inappropriate behaviors. The Summary showed he had dependence on alcohol, had extended amounts of time incarcerated due to the alcohol-related crimes, and was relocated to Montana after being released from prison in Minnesota. The Summary documented that the patient was initially admitted to the Sprat (geriatric) Unit, where it was discovered he likely had a mixed personality disorder and a significant amount of malingering.

The Summary showed a note from staff member K and it stated, "based on the patient's sexually inappropriate, attention-seeking and preying-type behaviors, his clear ability to understand right from wrong, even though he presents as demented at times, his admittance to using medical problems and complaints in order to avoid evaluations, his childlike, helpless and long history of institutionalization, it seems more likely that the patient is malingering; complicated by his poor social skills and unspecified Cluster B personality traits." The summary also stated, the unit considered a possibility of using Depot Lupron to address the hypersexuality. The summary continued to state that staff member D elected not to use the medication for chemical castration, and was going to treat the patient with Paxil instead.

The Summary showed a conversation that was had with the patient's sister, who was living in Wisconsin. The sister stated her brother had a long history of inappropriate behaviors. She stated that the patient could not come live with her due to the risk he could implement on her family. She stated in the summary interview, "he will just try to do something to get back to prison" once he was discharged. The summary also documented the sister acknowledged the patient's behaviors may lead to rejection from the assisted living facility referrals currently pending. The sister was also noted as saying the patient had been neglecting to care for himself for the past several years and she had observed a pattern of volitional self-neglect.

The Summary documented the patient was unwilling to accept chemical dependency treatment and therefore it would have been difficult to place him at an assisted living facility. The patient expressed he wanted to go to a "wet house" closer to his relatives in Wisconsin. He was given information on the homeless shelter, then he could transition into the [OMIT] Residence wet house program. The summary stated the patient's mental status remained unchanged throughout and he responded to redirection regarding inappropriate leering behaviors, entering people's personal space, and also responded well to direct and firm instruction regarding grooming and self-care.

The discharge instructions, from staff member D on the discharge summary, were for the patient to attend all scheduled follow up available to the patient at the [OMIT] Center and [OMIT] Residence. Staff member D also wrote in the summary for the patient to "take a harm reduction approach to the alcohol use and reconsider treatments."

Interviews

During an interview on 10/10/17, at 1:55 p.m., staff member F stated patient #1 was safe and stable at the time of the discharge. She stated the social workers were not responsible for deciding when a patient was ready for discharge and that the facility doctors decided. Staff member F stated the patient wanted to relocate closer to his sister but the sister could not have the patient live with her due to his history of behaviors. Staff member F stated the patient came in on the Sprat unit and was transferred over to the B unit, where he would be around a less vulnerable population. Staff member F stated the patient was "kicked out of the nursing home due to sexualized behaviors," and at the time of discharge, the patient just wanted to go drink. Staff member F stated she tried to get him closer to his sister and also provided him with any resources that may have been helpful. Staff member F stated there were no shelters in Montana where the patient could reside and be an active drinker, so staff member D suggested [OMIT] Center and the [OMIT] Residence. Staff member F also stated there was some difficulties with the transfer because the patient's Social Security was not in place.

During an interview on 10/10/17, at 1:10 p.m., staff member C stated the staff at the facility talked as a team to see if patients were appropriate for discharge and at the time of discharge, the team thought patient #1 was ready for discharge. At the time of the interview, staff member C was asked to provide any documented information of an assessment or an evaluation that was completed showing the patient could care for himself. Staff member C referred to the progress notes for any information showing he could care for himself.

During an interview on 10/10/17, at 1:15 p.m., staff member D stated the patient was at the facility for several months and that he took over as the provider after the patient was transferred from the Sprat unit. Staff member D shared he was encouraging the patient's sister to become the patients power of attorney because he had been suffering from several issues and it may be helpful. Staff member D stated the patient was socially awkward, but was lucid in the 1:1 interviews with staff member D. Staff member D gave the example of patient #1 urinating in his pants in public on several occasions and the poor boundaries. Staff member D stated the team met to discuss the complexity of patient #1 and felt that his diagnosis of Alzheimer's was not accurate, and when he was transferred to the B unit, he was presenting with personality disorder traits. Staff member D stated, "Sometimes he cares and was complaint, and some day's he was not compliant." Staff member D stated the patient responded better to set boundaries, and felt his behaviors were malingering.

During an interview on 10/10/17 at 1:50 p.m., staff member G stated he did not complete an incident report of what had happened with the patient when he was on the ground in Minnesota, two blocks from the [OMIT] Center. He stated patient #1 was acting like he was having a heart attack and would not redirect. Staff member G stated his behaviors were consistent throughout the time of his hospitalization, and "he was doing what he always did at the facility. He was doing what Personality Disorders do, he was attention seeking. He was at [OMIT] Residence one day later anyway." Staff member G stated the patient was struggling behaviorally up until the day he discharged and was redirected by staff often up until the point of discharge for being hypersexual and inappropriate towards female staff. Staff member G stated that the patient would act in ways that he knew were not allowed, such as urinating in his pants on purpose.

During the exit conference on 10/10/17, at 3:15 p.m., staff members A, C, E, and J were asked if an assessment or evaluation was completed to show the patient was able to make rational self-choices. The staff members were encouraged to send any evaluation or assessments that showed the self-care assessments were completed, but the facility failed to provide adequate information that the patient was assessed in a formal way to show he was able to self-care.