HospitalInspections.org

Based on a review of facility policy, documents, and staff interview [EMP], the facility failed to provide a safe environment by failing to follow their adopted policy regarding identification of an adult who presents to discharge a minor in one of one patient (MR1).

Findings include:

1. Review of facility patient admission packet, The Meadows Parent Handbook for the Child/Adolescent revealed, "Welcome to 'The Meadows!' ... This guide is to help answer some questions you may have ... 'I was given a Patient ID Number on a small card, why do I need this?' To visit or call and talk with your child, you need to tell our staff this ID number. This 'ID' is like a password to protect those who stay with us; calls or visits cannot be allowed for anyone who does not have this number. ... ."

2. Review of facility policy Discharge of Patients, revised September 2013, revealed, "... E. Discharge of Minors (under 18 yrs. Old ) [sic] - Providing ID. 1. An adult who comes for a minor is required to provide identification. ... ."

3. A review was conducted of MR1 dated March 20, 2013, and revealed no documented evidence that the patient ID number was requested by the staff and/or provided by parents. Documentation of MR1 revealed, "0300 - Pt discharged AMA to parents."

4. A review of facility Visitor Sign-In Sheet, dated March 18, 2013, through March 20, 2013, was conducted. The Visitor Sign-In Sheet revealed no documented evidence that the patient's parents signed the Log, when they presented to the facility to take the patient home.

5. Review of electronic documentation from EMP1, dated June 22, 2015, revealed, "... we do not have a policy specific to the Log. There is not a separate Log on each of the Units as all visitors have to come through the Lobby. ... unfortunately it is not documented anywhere."