HospitalInspections.org

Based on hospital policy, medical record reviews, staff and physician interviews, the hospital failed to secure a safe discharge for a patient in 1 of 11 medical records reviewed (Patient #2).

Findings included:

Review of the hospital policy titled Admission and Discharge Criteria BHU (Behavioral Health Unit ) Procedure, last reviewed 02/2022, revealed ".... Discharge criteria ...Treatment plan goals and objectives have been substantially met and/or a safe, continuing care program can be arranged ...Support systems that allow the patient to be maintained in a less restrictive treatment environment have been thoroughly explored and/or secured ...."

Review of the hospital policy titled Behavioral Safety and Risk Assessment and Intervention, last reviewed 11/2021, revealed ".... Phone use: Patient will have telephone access. Calls to be monitored ...."

Review of the hospital policy titled Discharge Planning Policy, last reviewed 05/2021, revealed ".... The discharge planning screening will include .... The ability of the patient to return to the pre-admission environment .... The case management initial discharge planning evaluation will include the high-risk screening for: 1. The pre-admission environment ....6. The ability of the patient being cared for in the environment from which they entered .... Procedure .... Case Management Department .... B. The Case Management department discharge planning evaluation results including patient/caregiver discussion, the patient/caregiver agreed upon discharge plan, the name of the individual notified they may request a re-evaluation of the discharge plan at any time and any follow up notes will be placed in the medical record .... The discharge planning screening will include: The ability of the patient to return to the pre-admission environment .... If the following circumstances occur, a case management consult will need to be completed to update the discharge plan .... A change in the ability of the caregiver to resume the previous level of care prior to admission ...."

Closed medical record review on 11/28/2022 of Patient #2 revealed a 38-year-old female who was admitted to the hospital on 10/13/2022 at 1330 with Suicidal Ideation (ideas of suicide/suicidal thoughts) with a plan to cut herself. Review of the BHU (Behavioral Health Unit)-V2 Psychiatric Evaluation and History and Physical, 10/23/2022 at 0718 by Medical Doctor (MD) #5 revealed Patient #2 was admitted under Involuntary Commitment ( A legal process through which an individual who is deemed by a qualified agent to have symptoms of a severe mental disorder is detained in a psychiatric hospital where they can be treated involuntarily) on admission. Review of a Provider Progress Note dated 10/14/2022 1115 by MD #5 revealed that Patient #2 agreed to a voluntary admission. Review of the Nurses Note on 10/19/2022 at 0730 by RN (Registered Nurse) #1 "10/18/22 evening-Patient was on the phone and started crying and stated that she was unable to go back to where she was living before discharge because she was a harm to herself and others ... She was very anxious and upset and wanted us to let the SW (social worker) know because she feared being discharged to the street..." Record review revealed Patient #2 informed RN #1 on 10/18/2022 that she could not return to the same shelter due to harming self and others. Review of BHU-Discharge Summary dated 10/19/2022 at 0952 by PA (Physicians Assistant) #6, revealed ".... She is not sure about the Shelter that she is supposed to go to. She does not want to be put on the streets, she has no where [sic] else to go .... although the stress of not being house [sic] could become overwhelming which could lead to hospitalization. But we have no where [sic] else to discharge the patient to wear [sic] discharge her back to where she came from which was a Shelter (named city) we have not heard back from after multiple calls that we have placed ...." Review of the BHU-Discharge Instructions SW (Social worker), dated 10/18/2022 at 0935 by DCP (Discharge Planner) #2 revealed Patient #2 "...Will be discharged back to the (named) homeless Shelter ." Review of BHU-Discharge Instructions Phys (Physician) by PA #6 on 10/19/2022 at 0900 revealed ".... will be discharged back to the homeless Shelter ....we have tried repeatedly to get a whole [sic] of somebody at the (named) Shelter to assure that she can come back there. They have not returned our calls .... the main risk would come if they do not allow her back into the (named Shelter) and she is homeless in (named city) and without anywhere to go she might end up in the emergency room ...." Review of the medical record failed to reveal documentation of attempts to call the (named) homeless Shelter and to set up discharge placement or verify that Patient #2 was allowed to return. Record review failed to reveal hospital reevaluation of Patient #2's discharge plan after learning on 10/18/2022 she could not return to the (named) Shelter. Record review revealed Patient #2 was discharged on 10/19/2022 at 1015 to the (named) Shelter accompanied by Law Enforcement Officers.

Telephone interview on 11/28/2022 at 1650 with the Manager of the (Named) Shelter revealed the house committee had met and decided Patient #2 could not return due to self-harm behaviors. During the interview, the Shelter Manager stated she "personally relayed this to 3 different hospital staff members while Patient #2 was in the hospital but could not recall names of who (she) spoke to." Interview revealed on 11/19/2022 Patient #2 arrived to the (named) Shelter transported by Law Enforcement Officers. Interview revealed the Shelter Manager "personally drove Patient #2 to (a local) emergency room that the patient asked to be taken to", because Patient #2 could not stay at the (named) Shelter. Interview revealed that the Shelter Manager spoke with 3 people at the hospital prior to the discharge of Patient #2 to tell them she could not return, but Patient was still discharged to the Shelter.

Interview on 12/07/2022 at 1407 with RN #1 revealed RN #1 remembered Patient #2 after reviewing the chart. Interview revealed RN #1 "felt ... that after the event on the phone with Patient #2 was able to go back to the shelter." Interview with RN #1 revealed when there wass a change in the discharge plan for a patient, it was discussed with the social worker. RN #1 stated she "is sure she spoke with a Social Worker about ( Patient #2's) statement that she could not return to the Shelter." Interview revealed that RN #1 did not remember who she told. Interview revealed RN #1 did not document the conversation in the medical record. RN #1 stated "It is both the patient and our responsibility to find placement." Interview revealed the discharge plan was not re-evaluated after new information identified that Patient #2 could not return to her prior living arrangement and before discharging Patient #2, as per policy.

Interview on 12/07/2022 at 1500 with DCP #2 revealed the following: DCP #2 starts discharge planning on the first day of a patient's admission and "I talk with facilities every day and document this in a progress note under clinical notes." Interview revealed DCP #2 did not talk with the Shelter. Patient #2 was discharged to because "...we called them for days and left messages, but no one would call us back..." Interview revealed DCP #2 was unable to locate any documentation of the attempts to call the Shelter because, ".... I was training during this time and didn't document the attempts ...." When asked if it was the hospitals responsibility to find every patient somewhere to go, DCP #2 stated ".... It is our responsibility to make sure discharge is safe. I believe Patient #2's discharge was explored and secured. We called multiple times trying to clarify the patient's statement 'that she could not go back', but no one at the Shelter would call us back ...." Interview revealed the DCP staff member never spoke with the shelter to verify Patient #2 could not return.

Interview on 12/08/2022 at 1100 with the Director of BHU/Director of SW and DCP, RN #3 revealed ".... the expectation was that every phone call and every interaction with a patient is to be documented in the patient's record. I expect to see progression/plan for the patient. There should have been documentation of contact with the shelter." Interview with RN#3 revealed there should have been documentation of phone calls to the Shelter in the medical record of Patient #2. Interview revealed there was no documentation in the medical record of phone calls to the (named) Shelter or re-evaluation of discharge plan for Patient #2, as per Hospital policy.

Telephone interview on 12/08/2022 at 1040 with the MCO (Managed Care Coordinator) assigned to Patient #2, Care Coordinator (CC) #4, revealed: CC #4 had "spoken with hospital staff at least the day before the discharge of Patient #2" and told them that the "patient could not return to the Shelter however they discharged her to the Shelter anyway." Interview revealed CC #4 had spoken with hospital staff to alert them Patient #2 could not return to the named Shelter .

Telephone interview on 12/07/2022 at 1435 with MD #5, Attending Physician for Patient #2 revealed MD #5 communicated that Patient #2 "Stated she wanted to go back to the Shelter, and no one could confirm to us that she could not return. The patient had learning issues and IDD (Intellectual or Developmental Disability) and you could not be sure she understood correctly what was said to her on the phone call. We wanted to hear straight from the Shelter whether she could return but no one would call us back ...." Interview revealed the MD #5 did not fully believe the patient's statement that she could not return to the Shelter due to her disability but did not confirm that patient was accepted back to Shelter prior to discharge.

Interview on 12/09/2022 at 1020 with PA #6 revealed after PA #6 reviewed the Nursing Notes of RN #1 and his notes, he stated ".... if the statement that she could not return was made by the patient, we should have verified it before sending her back to (named) Shelter. We messed up then. She shouldn't have been sent back there (Shelter) ...." Interview revealed PA #6 did not remember Patient #2 and that "the Social Workers set up all the inpatient discharges." Interview revealed PA #6 felt the discharge for Patient #2 was not appropriate if acceptance at the (named) Shelter could not be confirmed.
NC00194372