HospitalInspections.org

Based on record review, interviews and hospital policy review, the hospital failed to ensure all discharge materials including transition record, medications, and instructions were reviewed with the Patient and/or representative of 1 (#2) of 3 patients sampled.
Findings:

Review of the hospital policy #PC-18 titled "Discharge Planning: Transition Record" last revised on 10/01/2024 revealed in part:
"Purpose: To establish guidelines for assisting patients to the appropriate level of psychosocial/physical care, treatment and services for post-treatment placement, follow-up, and/or transfer.
Policy: Discharge planning commences upon admission to any program. Tentative discharge plans are established, reviewed, and modified throughout treatment.
Procedure: 4. Social Services/Case Management personnel shall: -Notifies patient and family of the date discharge will occur; -When feasible, prior to discharge or transfer to a lower level of care, conducts a discharge conference with patient (family/significant others, as appropriate to: ~Finalize living arrangement and post-treatment care plans to meet ongoing needs for care and services; ~Review patient progress in treatment; ~Discuss patient and family's expectations of patient's behavior and participation in recommended therapies post-discharge. 5. The Nurse shall: -Review patient's medication regimen and educate on medications; -Upon discharge, provide the patient recommendations for anticipated continuing care, treatment, and services and discharge medication interventions. 6. The Treatment Team members will complete a crisis safety plan, if applicable, and document the final discharge plans on the Transition Record. This information shall include at a minimum: -Reason for inpatient admission; -Principal diagnosis at discharge; -Current medication list; - Studies pending at discharge; -Patient self-management instructions; -Contact information for obtaining results of studies pending at discharge, if indicated; -Plan for follow-up care including primary physician, other health care professional, or site designated for follow up, any/all follow-up appointments and aftercare services; -Patient signatures of acceptance/understanding of recommendations and Transition Record being provided."

Review of Patient #2's medical record revealed she was admitted to the hospital on 09/06/2025 at 2:30 a.m. from an outside emergency room facility on a PEC and subsequently a CEC for psychosis with suicidal and homicidal ideations with hallucinations and delusions.

Review of Patient #2's Consent for Treatment document revealed she herself signed the document and also provided authorization for her daughter in law to be contacted, updated and provided information regarding her care at any point during her hospitalization. Patient #2 did not revoke this authorization at any point during her hospitalization.

Review of Patient #2's Transition Record revealed the following in part:
Transition Record:
Discharge Date and Time - 09/20/2025 at 10:00 a.m.
Discharge Status - Scheduled
-Provided education to patient or family member on diagnosis
Discharge to - Home
Mode of transportation to discharge location - home with family member in private vehicle
Follow-Up Appointments:
PCP Appointment Scheduled
Psychiatry Appointment Scheduled
Neurologist Appointment Scheduled
Medical:
Are there any lab or X-Ray results pending at discharge? "No"
- Patient #2 did have a pending potassium lab result at her time of discharge, which was called to her daughter in law, which had resulted after she had been discharged, and the facility instructed the daughter-in-law to bring Patient #2 to the ER or after-hours lab to get her potassium level checked.
Discharge Plan Education:
Patient Understanding of Discharge Plan-
Patient/Family able to verbalize discharge instructions (checked); Patient verbalizes understanding when/how to seek further treatment (checked)
Discharge medication reconciliation-
Medication reconciliation is completed by provider and copy of medication list with discharge education is given to patient by nursing (checked)
Patient Authorization and Signature:
The patient has received a copy of the following-
Discharge Orders (checked); Crisis Safety Plan (checked); Discharge Medication Reconciliation (checked)
Patient Signature:
Patient refuses or is unable to sign (checked) Date: 09/18/2025 Time: 3:22 PM
Social worker/therapist/case manager signature:
S3CM Date: 09/18/2025 Time: 3:22 PM
No additional SocialWorker/Therapist/Case Manager or Nurse signature or Patient legal guardian/representative signature is found on the document.

Review of Patient #2's medical record revealed an official discharge date of 09/19/2025 at 11:55 a.m. to home with her daughter in law.

Review of Patient #2's multidisciplinary team notes involving communication with Patient #2's daughter in law immediately following discharge revealed the following in part:
On 09/19/2025 at 4:34 PM - DON spoke with Patient #2's daughter-in-law, attempted to notify her of medication changes while inpatient. Patient #2's DIL stated that she did not get a medication list printed. I also notified her of the pt's high potassium which resulted after her leaving our building and that we recommend getting her to an ER or an after-hours that does labs. Signed at 4:56 PM by S2DON.

On 11/24/2025 at 4:10 PM, an interview was conducted with S1VPCS. S1VPCS said the expectation would be if the patient was unable to sign or refused to sign their transition record at discharge and had a representative who the patient had given authorization to be a part of their treatment and discharge planning process, the expectation would be the transition record should be reviewed with the patient's representative and they would sign on behalf of the patient as having received the information and confirmed understanding. S1VPCS reviewed Patient #2's transition record and confirmed it revealed documentation on 09/18/2025 at 3:22 p.m. of Patient #2 being unable to or refusing to sign and/or documentation within the transition record or other multidisciplinary notes that the transition guide was reviewed in its entirety with Patient #2's daughter-in-law prior to Patient #2's discharge on 09/19/2025.