HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for discharge planning, the Hospital failed to ensure that the discharge plan was implemented in accordance with the discharge planning evaluation.

1. On 8/22/2022, the Hospital's policy titled "Assessment and Reassessment for Discharge Planning and Referrals" (revised on 4/2018) was reviewed and required, "Purpose: To provide a referral methodology for hospitalized patients to be evaluated by a... Social Worker... in collaboration with the Multidisciplinary team... A needs assessment will be performed... and an individualized discharge plan will be implemented..."

2. On 8/22/2022, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 7/6/2022 with a diagnosis of psychosis (a mental disorder characterized by a disconnection from reality). The clinical record included:

- E #1's (Social Worker) progress notes on 7/11/2022 indicated that E #1 met with Pt. #1 to discuss the discharge plan/instructions. The discharge plan indicated that Pt. #1 would be discharged to his parent's home and that Pt. #1 would be picked up by his parents.

- E #1's progress notes on 7/12/2022 included, "(E #1, E #3/Advanced Practice Nurse) and (Pt. #1's) parents had a conference call to discuss (Pt. #1)... Parents happy with (the) plan. (Pt. #1) to be discharged today."

- E #2 (Registered Nurse) and Pt. #1 signed the patient discharge instructions on 7/12/2022 to indicate that the plan was to discharge Pt. #1 to his parent's home and that Pt.1 would be picked up by his parents.

3. On 8/23/2022 at approximately 10:55 AM, an interview was conducted with E #1 (Social Worker/Discharge Planner). E #1 stated, "I prepared and discussed the discharge plan and instructions with (Pt. #1). The plan was for (Pt. #1) to be discharged to his parent's home and (Pt. #1) will be picked up by his parents. (Pt. #1) agreed with the plan. It was my understanding that did not happen. (Pt. #1's) mom called my office phone and left a message that they were waiting in the Hospital, but (Pt. #1) was released on his own. A day or two later, I heard (from E #5/Assistant Vice President) that (Pt. #1) was reported as missing." E #1 explained that the plan was based on the discharge planning evaluation.

4. On 8/23/2022 at approximately 1:49 PM, an interview was conducted with E #5 (Assistant Vice President). E #5 stated, "I saw the news that Pt. #1 was missing. We realized that we need to have a better discharge process and handoff. We discussed in our huddles that there should be a "warm-handoff" to whoever the patient will be discharged to." E #5 could not provide documentation that Pt. #1 wanted to be discharged on his own and disagreed with the discharge plan.