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Based on medical record review, review of policies and procedures, and interviews with hospital staff and staff at the shelter, the facility failed to ensure an appropriate post-hospital discharge destination was provided for 1 of 4 sample patients discharged to a location that was not home. In addition, the facility failed to develop policies, procedures, and guidelines for more complex and individualized discharge planning. The findings were:

Review of the medical record showed patient #1 was admitted on 5/2/17 under legal detainment due to mental status changes. Further review showed the patient received medical stabilization and reality orientation; and the detainment was terminated on 5/19/17. Review of the 5/2/17 nursing and physician admission assessments showed the patient was blind, had a stroke in the past that affected his/her right upper extremity, and had a history of not taking medications as prescribed.

Review of the 5/6/17 to 5/19/17 nursing care plan showed the following interventions for discharge planning: "Identify barriers to discharge with patient and caregiver. Arrange for needed discharge resources and transportation as appropriate. Identify discharge learning needs (meds [medications], wound care, etc.). Refer to Case Management Department for coordinating discharge planning if patient needs post-hospital services based on physician order or complex needs related to functional status, cognitive ability or social support system." Further review of this care plan showed the goal was to discharge to home or other facility with appropriate resources and discharge needs to be met by the time of discharge.

Review of the 5/16/17 progress notes documented by physician #1 showed "Current medications working and feeling fine. Denies any needs or requests today." Filed notice with district court that conditions justifying hospitalization no longer exists. Will therefore plan for discharge 5/19/17. Review of the 5/18/17 progress notes completed by physician #1 showed "Patient reports doing better. Concentration, appetite, focus and energy good." Still wanting to go home 5/19/17. Will continue current medications at current doses and plan on discharge on 5/19/17.

Review of the 5/16/17, 5/17/17, and 5/18/17 nursing progress notes showed "Patient blind," requires 1 to 1 sitter for safety. Further review of the 5/18/17 nursing notes revealed the patient continued "to meet medical necessity at this time. Treatment team working on medication stabilization and skills acquisition, as well as safety, as patient presents with continued risk and few protective factors."

Review of the 5/16/17 notes documented by licensed clinical social worker #1 showed family member #1 talked about the patient returning to family member #1's home as a last resort due to safety concerns and inability to be with the patient 24 hours a day 7 days a week. This family member was worried about the patient being left alone.

Review of the 5/17/17 interdisciplinary team note "Patient's [family member #1] will only take patient as a last resort." Patient is compliant with mediations. Does continue to meet medical necessity at this time.

Review of the 5/17/17 documentation by licensed professional counselor (LPC) #1 showed the facility received a message from family member #2, who resided with family member #1, stating the patient could not be discharged to family member #1's home. Met with patient to work on discharge planning and told patient about the message received from family member #2. The patient refused to allow staff to contact family member #3.

Review of the 5/18/16 documentation by LPC #2 showed the patient completed a discharge safety plan with the LPC's assistance and the patient agreed to allow staff to contact family member #3. The LPC then had a telephone conversation with family member #3 who stated patient could not be discharged to his/her home because no one was available to stay with the patient.

Review of the 5/19/17 progress note showed LPC #1 contacted family member #1. At that time this family member confirm the patient could not be discharged to his/her home. According to the documentation, LPC #1 told family member #1, if family member #3 was unwilling to take the patient; the patient "will be discharged to a shelter today due to there is no medical reason to continue to hold the patient." LPC #1 then tried to contact family member #3, but was unsuccessful. LPC #1 contacted the case manager at the shelter. LPC #1 discussed the patient's blindness and family member #3's plans for making arrangements for the patient to stay with family member #4 at a future date.

Review of the 5/19/17 discharge progress notes showed the following actions were implemented: The administrator and lead case manager were consulted regarding the patient's discharge. Discussed needs and additional support services that could be put in place. Talked about patient's clinical presentation. Not able to detain because the medical necessity "expired today, and patient declined to sign in voluntary when offered in team meeting this morning." Follow-up appointments with support agencies and the physician were made. An additional list of support services were read to patient and the written copies were given to him/her. LPC #1 talked with the case manager at the shelter about the patient's medications. The arrangement was that staff at the shelter would keep the medications behind the desk, get them out when the patient requested, read the labels to the patient, then give the container to the patient to self-administer the pills. A taxi took the patient to the pharmacy for the prescribed medications; then to the shelter. Pills were not bubble-packed because this could not be provided until 3 days later. The discharge medications included Cogentin (anticholinergic and antihistaminergic drug), Valium (anxiolytic and sedative), Ritalin (central nervous system stimulant), Seroquel (antipsychotic), Tramadol (as needed pain medication), and Trazadone (antidepressant).

Interview with the case manager at the shelter on 6/16/17 at 11:50 AM revealed prior to admission to the shelter the hospital reported the patient was independent. At the shelter, the patient required assistance, monitoring and care that the staff at the shelter were not trained to provide. The patient did not have assistive devices. The patient was reliant on the other residents at the shelter to assist him/her to the bathroom and when no one was available the patient was incontinent. At times the patient went outside to smoke and could not find his/her way back into the shelter. Staff and residents had to search outside for the wandering patient. The shelter did not have a monitoring system for medication distribution to ensure the patient was taking medications as prescribed. At night the only person on duty was one security person. The case manager called the hospital on 5/22/17 and 5/23/17, and reported the staff at the shelter were unable to provide the care the patient needed. The hospital was unable to help. Additional phone inquiries were made to other agencies in an attempt to find a more appropriate place to send the patient.

Interview with the unit administrator and LPC #1 on 6/16/17 at 1 PM revealed the following information: The medical necessity had expired and the patient was her/his own responsible person. The plan was to discharge to home, but the patient's family did not want this. Staff tried to convince the patient to remain at the facility, but s/he was determined to leave the facility. Therefore, staff made arrangements for the patient to go to the shelter. The discharge planning policy and procedures did not address these types of issues. Interview with the administrator on 6/21/17 at 10:40 AM revealed staff tried to talk the patient into delaying the discharge because staff wanted time to find a more permanent discharge destination. Staff did not know how to respond to a patient who wanted to leave despite their attempts to get him/her to remain at the facility. The administrator further stated staff education was needed to provide knowledge of how to address this type of situation.

Review of the current discharge policy and procedure dated, 5/15/17, showed the following procedural steps in the discharge process: "Discharge in collaboration with patient, family, and/or significant other and personnel involved in ongoing treatment. Comprehensive integrated notes reflect patient involvement and agreement with plan. Authorization for release of information should be obtained. If refused, document refusal in the patient's medical record. Referrals are made by the attending psychiatrist in conjunction with clinical staff and approval of patient. The discharge planner coordinates the referral. If court involved, staff will contact an officer of the court about referrals." Further review of the policy and procedure revealed no references to an evaluation or assessment of the post-hospital discharge destination's ability to meet the patient's needs.

The following concerns were identified during interview with the unit administrator on 6/16/17 at 1 PM and review of the discharge planning notes:
a. Staff were aware of the possibility that the family members were unable to care for the patient 3 days prior to discharge; however, there was no evidence staff pursued other post hospital discharge destinations or provided the patient with options other than the shelter.
b. Staff did not complete a thorough safety assessment of the post-hospital discharge destination prior to discharge.
c. There was no evidence of staff providing the patient with information about the safety risks associated with residing at the shelter.