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Based on record review and interview, it was determined that for 1 of 11 (Pt. #3) closed clinical records reviewed for discharge planning, the Hospital failed to ensure that the patient's family was notified of the time and mode of transportation on day of discharge.

Findings include:

1. On 10/22/2024, the Hospital's policy titled, "Patient/Family Discharge and Aftercare Plan" (dated 8/2023) was reviewed and required, "Discharge and aftercare planning is an important aspect of the patient's treatment beginning at admission and continuing through the patient's stay...RN completes discharge note, including date, time, type of discharge, manner in which patient left, destination, patient's status and who accompanied patient..."

2. On 10/22/2024, Pt. #3's clinical record (dated 8/20/2024 thru 8/30/2024) was reviewed and indicated:
-Pt. 3's initial psychiatric evaluation & treatment plan written by MD #2 dated 8/21/2024 noted, "Pt. #3 with a long history of psychiatric illness and extensive psychiatric hospitalizations, carries diagnosis of schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking and behavior), admitted due to increased aggression at home, shouting, seeing vampires not sleeping for the past several nights. Evidence of failure at or inability to benefit from a less intensive outpatient setting. Pt. #3 is oriented to person and place."

- Pt. #3's discharge order written by MD #2 dated 8/30/2024 noted "Discharge Pt. #3." Pt. #3's nursing discharge instructions written by the Registered Nurse (E #7) dated 8/30/2024 noted, "List of medications reviewed with Pt. #3. Copy of Crisis Safety Plan reviewed and given to Pt. #3. All belongings sent with Pt. #3 and Pt. #3 signed inventory form. Suicide prevention materials provided. Aftercare Plan reviewed with Pt. #3. Pt. #3 able to verbalize discharge instructions. Pt. #3 verbalize understanding of when/how to seek further treatment."

-Pt. #3's clinical record noted that on 8/29/2024, "E #6 attempted to contact Pt. #3's mother and sister to inform them of scheduled discharge for Pt. #3 tomorrow. There was no answer and E #6 was unable to leave VM (voice message) due to mailbox being full. Writer will attempt to contact family tomorrow prior to Pt. #3 discharging."

-Social service discharge note written by E #6 dated 8/30/2024 noted Pt. #3 was discharged back to Pt. #3's mother and sister's home. Method of transportation will be used to transport Pt. #3 at discharge - cab. The note did not include an attempt to contact Pt #3's family on 8/30/2024 prior to discharge.

3. On 10/23/2024 at 9:15 AM, an interview was conducted with the Registered Nurse (E #7). E #7 stated that E #7 discharged Pt. #3 on 8/30/2024. E #7 stated that E #7 did not know if Pt. #3's mother was notified regarding Pt. #3's discharge. E #7 stated that E #7 walked Pt. #3 down to the hospital lobby and gave Pt. #3 a bus card (that was provided by the social worker - E #6). E #7 stated that E #7 asked Pt. #3 if Pt. #3 knew what bus to take. E #7 stated that Pt. #3 refused assistance and walked out the hospital door.

4. On 10/22/2024 at 11:00 AM, an interview was conducted with the Director of Social Service (E #4) regarding the process for discharge planning. E #4 stated that this facility has an arrangement with the cab company that the cab company will transport patients "door to door." E #4 stated that if any problems arise during the transport to the discharge location, the cab company will notify E #4. E #4 stated that E #4 told E #6 that Pt. #3 was ok to take a cab. E #4 stated that E #4 talked to Pt. #3 about taking a cab, and Pt. #3 agreed to take a cab. E #4 stated that E #4 is not sure what happened on the day of Pt. #3's discharge. E #4 stated that Pt. #3 must have refused the cab and agreed to a bus pass.