HospitalInspections.org

Based on staff interview, medical record review, review of reports submitted by a patient advocacy group, and review of hospital policy and procedure, it was determined the hospital failed to ensure all discharge planning requirements were met. There lacked evidence of a valid and safe discharge for 1 of 10 sample patients (#9) (A820), This system failure resulted in the inability of the hospital to meet all of the necessary requirements for the Discharge Planning Condition of Participation.

Based on staff interview, medical record review, review of reports submitted by a patient advocacy group, and review of hospital policy and procedure, the hospital failed to ensure a valid and safe discharge occurred for 1 of 10 sample patients (#9). The finding's were:

Review of the 4/4/14 physician's discharge summary showed patient #9 was admitted to the hospital on 2/24/14 with a diagnosis of Schizophrenia Chronic Paranoid Type. The report showed the patient was homeless, had no problem solving skills, and was not based in reality. In addition, the patient was suicidal with a plan. The patient was admitted on a court ordered mental health detention. Review of the physician progress notes throughout the patient's hospitalization showed staff attempted to work with the patient in preparing a discharge plan. However, the treatment team felt the patient's plan for discharge was not viable. Nonetheless, the patient was discharged on 4/4/14 to his/her own reconnaissance to go to the local mission. The following concerns with discharge planning were identified:
a. Review of the discharge plan showed the patient stated s/he would not continue to take medications as ordered after discharge. Review of the physician's 4/4/14 discharge summary showed the patient's prognosis was poor due to non-compliance. Further review of the discharge plan showed it was recommended the patient continue treatment because s/he was not ready for discharge but had to leave because s/he was "discharged by [the] court." Review of the court paperwork, however, showed the court ordered detention was not dismissed until 4/9/14 indicating the patient was still on involuntary detention on the day of discharge. Interview with the director of medical records on 7/2/14 at 2:30 PM verified the court orders instructed the patient must "remain in detention at [the hospital] for a period not to exceed ten (10) days. This detention period may be extended at the request of the proposed patient or his attorney. DATED this 27th day of March, 2014." Ten days from 3/27/14 was 4/6/14 and the patient was discharged on 4/4/14. Further, the discharge plan indicated the patient declined to remain in the hospital on a voluntary basis, however, review of the medical record showed no evidence the patient was offered that option. Interview with the director of nursing (DON) on 7/2/14 at 2:40 PM verified there was no evidence to indicate the patient was offered the option of continuing hospitalization on a voluntary basis.
b. Review of reports submitted by a patient advocacy agency on 5/20/14 revealed the hospital called a family member on the day of discharge, 4/4/14, and said the patient was being discharged and asked the family member to pick the patient up at the hospital. The family member said s/he lived out of town and was currently at work and was unable to transport the patient on such short notice. Review of the physician's progress notes dated 3/31/14 showed the discharge date anticipated was 4/9/14. Continued review of the patient advocacy group reports showed the family member asked if the patient could remain one additional night to give her time to travel to the hospital. The family member was told the patient could not stay in the hospital. The hospital gave the patient a bus ticket and s/he was dropped off near the rescue mission on 4/4/14. The patient got lost and ended up in a motel located in a bad part of the city where the patient stayed overnight until the family member could pick him/her up the following day. Review of the 4/3/14 physician's progress note, showed the patient's affect was poorly-related, his/her mood was irritable, the thought process was illogical and thought content was notable for paranoia. In addition, the patient's judgment was severely impaired as was his/her insight. Further review of these notes showed the patient was gravely disabled and unable to care for him/herself. Review of the 4/4/14 discharge summary revealed the patient's discharge mental status examination showed the patient was paranoid, had illogical thing, and his/her judgment ad insight remained significantly impaired. Finally, the 4/3/14 physician's progress notes indicated the anticipated discharge date was still 4/9/14, though the actual discharge date was 4/4/14 (5 days earlier than planned). Interview with the DON and the clinical director, on 7/2/14 at 2:40 PM revealed they were unsure why the discharge date was 5 days earlier than the planned discharge date of 4/9/14.
c. Review of the hospital policy and procedure on discharge planning, #1000.17, reviewed 3/14, showed "Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care...In developing discharge aftercare plans, the following areas must be assessed according to the specific needs of the patient:..Patient safety issues...In developing discharge aftercare plans, the following areas may be assessed according to the specific needs of the patient:...Housing needs and/or placement issues;...Personal support systems,...The discharge/aftercare plan should define the following:...Where the patient will live following discharge, With whom the patient will live and in what circumstances, All professionals who will follow-up with the patient, including medical follow-up to monitor medications;...Referrals to self-help groups, support groups, or community resources..." Review of the discharge plan showed the patient was discharged to a rescue mission with no scheduled appointment with a local provider for outpatient therapy or for medication management or referral resources after discharge.