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Based on staff interview, medical record review, 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 3 of 7 sample patients (#2, #4, #6) (refer to 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, and review of hospital policy and procedure, the hospital failed to ensure a valid and safe discharge occurred for 3 of 7 sample patients (#2, #4, #6). The findings were:

1. Review of the 9/29/14 admission history and physical (H & P) showed patient #4 was admitted to the hospital on 9/28/14 for acute stabilization after s/he attempted suicide by taking pills. The patient stated s/he ingested Percocet (narcotic pain medication), Flexeril (muscle relaxant), Tegretol (anticonvulsant), and Lisinopril (blood pressure medication). The patient had a significant past history of suicide attempts and major depressive disorder. Currently the patient was grieving the demise of his/her long term marriage. The patient was discharged on 10/1/14. The following concerns with the lack of discharge planning were identified:
a. Review of the physician's progress note written on 9/30/14 showed the patient continued to be depressed, despondent, and anhedonic (loss of interest in normal activities). In addition the patient was described as excessively anxious, worried, and feeling on the edge with increased muscle tension. Review of the mental status examination showed the patient was in acute distress with poor eye contact, a fixed facial expression, and was down cast. The patient's insight and judgement continued to be "very poor." The plan was to continue with the antidepressant Lexapro at 10 mg with an anticipated increase to 20 mg, group therapy and to contact the patient's support system. However, an order for discharge of the patient was written at 9:15 AM the following morning. Review of the entire medical record showed no evidence the patient was ready for discharge. Interview with the psychiatrist on 10/2/14 at 3:10 PM revealed she did not feel the patient was ready and safe for discharge.
b. Review of the discharge plan showed the patient would benefit from continued work on current stressors including the grief/loss issues and stress related to the current separation from his/her spouse. Interview with the psychiatrist on 10/2/14 at 3:10 PM revealed she did not feel the patient was ready and safe for discharge but the court dropped the involuntary hold so she felt discharge was mandatory. Interview further revealed the patient was not offered the option of signing in on a voluntary basis for continued therapy and stabilization. In addition, interview at 3:10 PM on 10/2/14 with the two psychiatrists who both testified at the patient's court hearing, to make a determination of the patient's status, had differing opinions about the patient's safety and readiness for discharge. Interview revealed they had not conferred with each other prior to the hearing to discuss the patient's status or to plan for his/her continued care and/or discharge planning.

2. Review of the 9/29/14 H & P showed patient #2 was admitted to the hospital on 9/28/14 for acute stabilization after s/he had ingested Buspirone (antianxiety medication) with concurrent acute alcohol intoxication. The police found the patient unresponsive with a nearby empty bottle of whiskey and a near empty (1 pill left) bottle of Buspirone lying next to him/her. The patient's admitting diagnoses included mood disorder and anxiety disorder. The patient was discharged on 10/1/14. The following concerns with the lack of discharge planning were identified:
a. Review of the 9/30/14 physician progress notes showed the patient continued to be depressed, despondent, and anhedonic. Further review showed the patient was excessively anxious, worried and in acute distress. The patient was described to have poor eye contact, was down cast and had a fixed facial expression. The patient's insight and judgement were still "very poor." However, an order for discharge of the patient was written at 9:30 AM the following morning. Review of the entire medical record showed no evidence the patient was ready for discharge.
b. Review of the discharge plan showed the patient would benefit from continued treatment on how to deal with current stressors in a healthy manner without the benefit of alcohol and drugs. The patient continued to have significant stressors in regard to his/her mother's serious illness. Finally, the patient needed to identify triggers and coping mechanisms to prevent a similar situation from occurring. The discharge order was "Pt [patient] discharged by the judge." Interview with the patient's psychiatrist and the psychiatrist who testified at the court hearing on the patient's involuntary status on 10/2/14 at 3:10 PM revealed they had not spoken with each other or collaborated on an appropriate discharge plan for the patient prior to the court hearing. Review of the medical record showed no evidence the patient was offered the option of signing in on a voluntary basis for continued therapy and stabilization.

3. Review of the admission face sheet showed patient #6 was admitted to the hospital on 9/19/14 on a voluntary basis with diagnoses including major depressive disorder, acute stress reaction, generalized anxiety disorder, and cannabis abuse. Review of the 9/21/14 admission H & P showed the patient had posted an apology video to anyone s/he had hurt or done wrong which was interpreted as a suicide note. The patient was admitted for his/her safety. Review of the medical record showed the patient was placed on an involuntary hold on 9/21/14 at 3:35 PM because of "very poor" insight, impulse control, and judgement. The patient was depressed and feeling guilty about a friend's recent suicide. The patient was considered to be a risk to him/herself. However, the patient was discharged home the following day, 9/22/14 at 5 PM. The following concerns with the lack of discharge planning were identified:
a. Review of the medical record showed no evidence a discharge plan for aftercare was in place prior to the patient's discharge on 9/22/14. The patient's psychiatric evaluation was not performed until 9/22/14 at 7:41 AM the day of discharge. According to the evaluation the plan included admission to the acute psychiatric unit under close observation, structured milieu and safety precautions. Approximately nine hours later, the patient was discharged home without evidence of improvement in his/her mental status.
b. Review of the discharge paper work showed the patient needed to work on learning to positively express his/her emotions and feelings and to continue to build and improve coping skills on his/her ability to handle stress levels. The patient would benefit from additional therapy in a structured environment. Review of the discharge notes showed the patient and family had developed a significant distrust with the hospital and was discharged because of that, however, the patient was not transferred to another inpatient setting and no discharge plans were developed prior to the discharge. Interview with the admitting psychiatrist for this patient on 10/2/14 at 3:10 PM revealed she believed the patient was a danger to him/herself and was not ready for discharge and wrote an extensive note to that effect.

4. Review of the hospital policy on Care of Patients/Discharge Planning, revised 9/14 showed the discharge plan should "Prepare through counseling, the patient and family for the transition to the next level of care...All patient cases in which the court dismisses their involuntary detention or commitment, will be reviewed by the Treatment Team for risk of discharge. If the Team recommends continued treatment, the patient will be given the option to sign in voluntarily for continued stay. The offering of this option will be documented in the medical record, along with the patient response. In those cases when a patient refuses to sign in voluntarily, and the Team feels they are at risk to discharge, the physician will then assess for criteria for placing the patient on an involuntary hold. In those cases when a patient is assessed as not meeting criteria for an involuntary hold, the patient and family or support person(s) will be contacted to review and participate in creating a safe discharge plan."