HospitalInspections.org

Based on interview, clinical record review and document review, the facility failed to ensure an effective governing body was legally responsible for the conduct of the hospital. (A-0043) The governing body failed to ensure the medical staff was accountable to the governing body for the quality of care provided to patients. (A-0043) The governing body failed to ensure there was an effective discharge planning process that applied to all patients. (A-0799)

The governing body failed to identify at an early stage of hospitalization patients who were likely to suffer adverse consequences upon discharge without an adequate discharge plan.
(A-0800) The governing body failed to ensure patients were provided with a discharge panning evaluation and needs assessment on a consistent basis in accordance with facility policies and procedures. (A-0806)

The governing body failed to ensure a discharge planning evaluation was included in patient's medical records according to facility policies and procedures. (A-0811) The governing body failed to ensure arrangements were made by hospital staff for the initial implementation of patient's discharge plans. (A-0820)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutory mandated care to patients.

Based on interview, clinical record review and document review, the facility failed to ensure the medical staff was accountable to the governing body for the quality of care provided within the hospital and upon discharge for two (2) out of thirty (30) psychiatric patients sampled. (Patients #1 and #11)

Findings include:

Patient #1

Patient #1's medical record indicated the patient was admitted to the facility on 02/09/13 to the POU (psychiatric observation unit) on a Legal 2000 (72 hour hold for psychiatric evaluation) due to symptoms of psychosis, auditory hallucinations and suicidal ideation. The patient's diagnoses included psychotic disorder, polysubstance abuse, opoid abuse, mild mental retardation, chronic pain. The patient had several congenital bone and joint defects and used a wheelchair to assist in mobility. The patient was homeless. The patient was placed on psychiatric medication that included Thorazine for a psychotic disorder, Klonopin for an anxiety disorder and Cymbalta for depression.

A review of Patient #1's Psychosocial Assessment dated 02/10/13 documented the patient was homeless and unable to care for himself. Patient #1 reported he did not have the ability to focus or concentrate, and had physical limitations and restrictions with mobility. The patient's ability to learn was below average and the patient exhibited a high risk for psychosocial problems which included housing, living situation, isolation and social problems.

Patient #1 requested group home placement due to forgetfullness and lack of orientation to get home. The patient previously stayed at an assisted living facility in Las Vegas, Nevada for one year and wanted to return. The patient requested a referral to the assisted living facility facility for discharge planning. The Social Worker was to assist the patient with possible discharge to the assisted living facility with follow-up for after care at the facility's out-patient clinic.

A Psychiatric Evaluation dated 02/10/13 at 1:50 PM by Physician #2 documented the patient reported trouble caring for himself and had trouble with his memory. The patient reported hearing voices in his head and feeling sad and depressed. The patient had no reasonable plan for self care besides wanting to find a group home to live in.

The initial treatment plan included the following:

1. "Evaluate the patient for any concerning psychosis or mood symptoms.
2. Evaluate for suicidal/homicidal ideation and response to medication.
3. Social Worker to assist with dispositional needs. Patient could benefit from group home placement. Perhaps assisted living as he has been to this facility in the past. Will also need case worker.
4. Will start Thorazine 10 mg PO TID, Cymbalta 30 mg PO QD,(daily) Klonopin 1 mg PO BID (twice a day) for anxiety.
5. Medical consult.
6. Consider in-patient admission for psych testing and more dispositional needs that cannot be provided in the psychiatric observation unit setting."

A Psychiatric Progress Note dated 02/11/13 included the patient had lost his identification and Medicare card and reported when he is stressed out he hears voices. The patient reported being off his psychiatric medication 6 days prior to admission to the facility. The patient reported having Alzheimer's disease and had been slow in learning programs but could function all right if he had a safety net. The patient wanted to go to California to find a group home. There was no city in California documented as a discharge destination. The patient's mood was upset. The patients affect was anxious. The patient was hearing voices telling him to smash computers. The patient's insight and judgment was poor.

Physician Orders dated 02/11/13 at 9:50 AM documented to discharge the patient to the Greyhound bus station by taxi at 1:00 PM with a three day supply of Thorazine, Klonopin, Cymbalta and to send ensure and snacks with the patient for a 15 hour bus ride. The physician's order lacked documentation as to how the patient could access continued mental health care, medication clinic, or the name of a psychiatrist and medical physician for follow-up care in Sacramento, California.

On 03/06/13 at 1:00 PM an interview was conducted with the patients psychiatrist, Physician #1 who reported he wrote a discharge order for the patient to be discharged to Sacramento California with a three day supply of prescribed psychiatric medication, ensure and snacks for a 15 hour bus ride. The physician gave orders for the patient to follow-up with mental health services, narcotic anonymous meetings and a medical physician for any medical problems in Sacramento, California. Physician #1 acknowledged being aware the patient was homeless and had no family or contacts in Sacramento California.

Physician #1 acknowledged the patient should have been provided with specific referrals for mental health services, medication clinic, narcotic anonymous, shelter, psychiatrist and a medical physician by the Social Worker assigned to the patient in order for the discharge to be considered safe. Physician #1 acknowledged he was not familiar with the facility's discharge policy and procedure that had been approved by the governing body. The physician could not articulate what the discharge policy said regarding the services and support systems that were required to be provided to a patient for a safe discharge. Physician #1 acknowledged the patient never received a medical consult documented in the initial treatment plan by Physician #2 prior to the patient being discharged from the facility.

On 03/08/13 at 4:00 PM, an interview was conducted with the facility Administrator who reported at discharge you would want the client to have housing, directions for how to get to the housing, and have the skill to find the housing. The client should have reasons to go to the discharge destination. If the client is incapable of geographically negotiating in the intended area, then someone should receive the individual on the other end.

Patient #11


Patient # 11 was admitted with diagnoses which included a history of polysubstance abuse, overdose attempt, bipolar disorder and diabetes. Patient #11 was from Oklahoma and had been in Las Vegas since 12/12.


The clinical record contained physician's order dated 2/10/13, for the patients blood sugar to be checked at 7:00 AM, 11:00 AM and 4:00 PM. The documentation in the clinical record indicated the patient's blood sugar at 7:00 AM, was 237 (normal blood sugar 70-120) and at 11:00 AM, was 218. On both occasions the patient received sliding scale insulin coverage. According to the clinical record the patient refused to have her blood sugar checked at 4:00 PM on 2/11/13.


The clinical record contained physician's order dated 2/11/13 for discharge today. Greyhound bus to Oklahoma at 8:20 PM. Ensure for 2 day trip. The physician's order lacked documentation as to the quantity of Ensure to be provided to the patient for the trip to Oklahoma. The physician's order for discharge did not address medication or equipment for the patient's type 2 diabetes.



The facility's pharmacy logs lacked documentation the patient received medication for her diabetes upon discharge. The pharmacy logs indicated the patient had been discharged with Ensure.


On 3/7/13 at 1:50 PM, a Registered Nurse (RN) stated Patient #11 had a diagnoses of diabetes mellitus type 2 and a history of bi-polar. The patient had a physician's order for sliding scale insulin and the patient had received insulin on 2/13/13, twice for blood sugars of 237 and 218. The RN verbalized the documentation indicated the patient had refused the finger stick blood sugar check at 4:00 PM, on 2/11/13. The RN indicated the patient should not have been provided Ensure for travel because as a diabetic the patient should be on Glucerna. The RN confirmed the medical physician had not seen the patient while at the facility. The RN stated it was not an unfair statement to say the discharge plan did not address the patients type 2 diabetes. The RN was asked if it was typical for a patient to be discharged via bus to Oklahoma with out medications. The RN stated no, it was unusual.

Based on record review, interview and document review, the facility's nurses failed to ensure physicians' orders were followed for a patient's observational monitoring status (Patient #1), failed to clarify physicians' orders for the quantity of Ensure provided at discharge for 8 of 30 patients (Patient #1, #11, #12, #20, #30, #22, #25, and #26), and failed to obtain consents for 4 of 30 patients (Patient #11, #22, #25, and #26).

Findings include:

Patient #1

On 2/9/13, Patient #1 was admitted with diagnoses of psychotic disorder new onset, unspecified hypothyroidism, delusions or hallucinations, and rule out schizoaffective disorder.

On 2/9/13 at 2:15 AM, a physician ordered every 15 minute observation monitoring to ensure safety.

On 2/10/13 at 3:25 PM, a physician ordered every 5 minute observation monitoring for sexually inappropriate behavior. This order remained in effect for the remainder of the stay.

On 2/11/13 on page 2 of the facility's monitor board, Patient #1's photo and order for every 5 minute checks was present at the top of the monitor sheet. The sheet covered from 11:00 AM through 2:30 PM. Patient #1 had a discharge time of 1:40 PM written in ink by his name on the sheet. The monitor board showed personnel documented observation monitoring every 15 minutes instead of every 5 minutes.

On 3/8/13, a review of Patient #1's file showed no documented rationale for changing the observational monitoring frequency from 5 minutes back to 15 minutes from 11:00 AM until discharge at 1:40 PM on 2/11/13.

On 3/8/13, at 1:20 PM, the Medical Director indicated an observational monitoring status change should be accompanied by a progress note.

On 3/8/13 at 4:00 PM, the Administrator indicated a change in any observational monitoring status should be documented with an accompanying order and rationale.

According to the facility's policy Special Observation of Patients, last revised 6/21/11 by the Director of Nursing II, "...All changes in observation level should be accompanied by a progress note specifically stating the rationale for the change. Orders for a change in observation must be entered in the patient's chart..."

On 3/8/13 at 5:00 PM, Physician #1 indicated staff did not ask to change the observational monitoring status on the morning of 2/11/13.

On 2/11/13 at 9:00 AM, Physician #1 ordered Ensure for a 15 hour bus ride. Physician #1's order did not specify the quantity of Ensure.

Patient #12

On 1/12/13, Patient #12 was admitted to the facility with diagnoses of major depression, anxiety disorder, cannabis dependence, and personality disorder.

On 1/15/13, a physician ordered "Ensure for trip x 3 days."

On 3/8/13 at 11:00 AM, Patient #12's social worker indicated the pharmacy supplied the Ensure, the doctor wrote down how long the trip was, and the order did not specify the quantity.

Patient #20

On 2/24/13, Patient #20 was admitted to the facility with diagnoses of psychotic disorder and chronic obstructive asthma.

On 2/26/13, a physician ordered "provide 2 days worth Ensure for nutrition."

On 3/8/13 at 11:25 AM, Patient #20's social worker indicated the physician's order did not specify the quantity of Ensure.

Patient #30

On 1/8/13, Patient #30 was admitted to the facility with diagnoses of substance induced psychotic disorder (amphetamine dependence).

On 1/9/13, a physician ordered "Ensure for trip, 6 HR trip."

On 3/8/13 at 11:00 AM, Patient #30's social worker indicated the pharmacy supplied the Ensure, the physician wrote down how long the trip was, and the order did not specify the quantity.


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Patient #11

Patient # 11 was admitted to the facility with diagnoses which included a history of polysubstance abuse, overdose attempt, bipolar disorder and diabetes. Patient #11 was from Oklahoma and had been in Las Vegas since December 2012.

The Medication Administration Record documented on 2/11/13, Patient #11 received Ambien 10 milligram (mg) orally times 1 dose, Klonopin 1 mg orally times 1 dose now, and Zyprexa 15 mg orally times 1 dose now for psychotic agitation.

The clinical record lacked documentation consents were signed by the patient for the medications Ambien, Klonopin and Zyprexa.

On 3/7/13 at 1:50 PM, a Registered Nurse (RN) confirmed consents were not signed by the patient for Ambien, Klonopin or Zyprexa.

The clinical record contained a physician's order dated 2/11/13 for discharge today. Greyhound bus to Tulsa, Oklahoma at 8:20 PM. Ensure for 2 day trip. The physician's order lacked documentation as to the quantity of Ensure to be provided to the patient for the trip to Tulsa, Oklahoma.



Patient # 22

Patient #22 was admitted to the facility on 1/31/13, with diagnoses of mood disorder and alcohol dependence. The clinical record indicated the patient verbalized he wanted to return home to Boston, Massachusetts.

The Medication Administration Record dated February 2013 indicated the patient received Seroquel 200 mg as a now order "for mood."

The clinical record lacked documentation Patient #22 signed a consent for for the medication Seroquel.

The clinical record documented a physician's order for Patient #22 to be discharged to the bus station and provide 3 days of Ensure. The physician's order lacked documentation regarding the quantity of Ensure to be provided to the patient for the trip to Boston, Massachusettes.


On 3/7/13 at 2:30 PM, a Registered Nurse (RN) confirmed there was no signed consent for the medication Seroquel. The RN verbalized the facility's policies had not been followed for consents. The RN verbalized the physician's order lacked documentation as to the quantity of Ensure to be provided to the patient for the trip to Boston, Massachusettes.


Patient # 25

Patient #25 was admitted to the facility on 1/13/13 and discharged on 1/14/13, with diagnoses that included paranoid schizophrenia. The documentation indicated the patient lived in California.

The Medication Administration Record documented the patient received Klonopin 0.5 mg orally times 1 dose now, Risperdal 2 mg times 1 now for psychosis, and Celexa 20 mg one dose now for depression on 1/13/13.

The clinical record lacked documented evidence the patient signed the consent form for the medications Klonopin, Risperdal and Celexa.

A physician's order dated 1/14/13, documented the patient was to have Ensure for the trip. The physician's order lacked documentation regarding the quantity of Ensure to be provided to the patient for the trip.

The clinical record lacked documented evidence the patient was provided with nourishment for the trip. The pharmacy logs lacked documentation the patient received the Ensure in accordance with the physician's order.

On 3/11/13 at 12:30 PM, a Mental Health Counselor confirmed there was no documented evidence the patient signed a consent for the medications Klonopin, Risperdal and Celexa. The Mental Health Counselor confirmed there was no documented evidence the patient received Ensure in accordance with the physician's orders. The Mental Health Counselor stated the physician needed to order the quantity of Ensure required for the trip.

Patient # 26

Patient #26 was admitted on 12/12/12 and discharged on 12/13/12 to California. The patient had diagnoses that included mood disorder, alcohol abuse and a self reported history of bipolar disorder. The documentation indicated the patient had been in Las Vegas a few days and wanted to go back to Los Angeles, California.

The patient was prescribed Seroquel 200 mg orally at night for mood and Ativan 1 mg orally every 4 hours as needed for anxiety/alcohol withdrawal (received 3 doses of Ativan) while at the facility.

The clinical record lacked documentation the patient signed a completed informed consent form for the administration of Seroquel and Ativan medications.

On 3/11/13 at 12:20 PM, a Mental health Counselor II stated it was the responsibility of the physician or the nurse to obtain the complete informed consent for the medications.

The clinical record contained a physician's order dated 12/13/12, to provide enough Ensure for a 6 hour trip. The physician's order lacked documentation as to the quantity of Ensure to be provided to the patient for the trip.

On 3/7/13 at 1:10 PM, a Registered Nurse (RN) stated the facility needed a patient's permission for the medications Seroquel and Ativan and the patients still have a right to refuse medications unless it was an emergency or their rights had been taken away. The RN confirmed there was no documentation a signed consent was obtained for the medications. The RN verbalized the facility's policy for consents had not been followed. The RN stated the physician should have written how much Ensure to provide the patient with for the trip. The RN verbalized the facility's policy on travel nourishment protocol was not followed.

The facility's policy entitled, Medications: Informed Consent for Administration and Protocol for Involuntary Administration dated effective August 2011, documented:

"..II. Purpose: To establish procedures for obtaining and documenting the receipt of informed consent/authorization from patients for the voluntary use of medications as a prescribed component of their multi-disciplinary treatment at the facility.

IV. Procedures: A. 3: The consent must be given voluntary.
Attachment A; indicated in part the patient had been informed of the recommendation to receive medication (s) marked below for the treatment of the illness, informed of the benefits, risks, and side effects of the medications to be utilized in my treatment.."

Documentation entitled Travel Nourishment Protocol, indicated the facility provided non-perishable nourishment for patients who do not have the monetary resources to purchase food or beverages when traveling back to their home communities. Ensure plus was a healthier choice than most meals or snacks. The number of bottles of Ensure Plus needed was based on the length of travel. "The physician shall write an order for the quantity of Ensure Plus requested..."


Complaint # NV00034829

Based on interview, clinical record and document review, the facility failed to ensure a comprehensive discharge plan was implemented, policies and procedures, and established standard of care were followed for patients discharged from the facility.
(A-0799)

The facility failed to identify patients who were likely to suffer adverse health consequences upon discharge without an adequate discharge plan. (A-0800)

The facility failed to provide an appropriate safe discharge plan for patients according to the physicians orders. The facility failed to ensure a discharge planning evaluation was completed on patients that included the likelihood of patients needing post hospital services and the availability of the services. (A-0806)

The facility failed to include a discharge planning evaluation for patients' medical records that established an appropriate discharge plan. (A-0811)

The facility failed to arrange for the initial implementation of patients' discharge plans. (A-0820)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutory mandated care to patients.

Based on interview, clinical record review and document review, the facility failed to identify patients who were likely to suffer adverse health consequences upon discharge without an adequate discharge plan for 2 out of 30 patients sampled. (Patients #1 and #11).


Findings include:


Patient #1

Patient #1's medical record indicated the patient was admitted to the facility on 02/09/13 to the POU (psychiatric observation unit) on a Legal 2000 (72 hour hold for psychiatric evaluation) due to symptoms of psychosis, auditory hallucinations and suicidal ideation. The patient's diagnoses included psychotic disorder, polysubstance abuse, opioid abuse, mild mental retardation and chronic pain. The patient had several congenital bone and joint defects, chronic back pain and used a wheelchair to assist in mobility. The patient was homeless. The patient was placed on psychiatric medication that included Thorazine for a psychotic disorder, Klonopin for an anxiety disorder and Cymbalta for depression.

A review of Patient #1's Psychosocial Assessment dated 02/10/13, documented the patient was unable to care for himself. The patient did not have the ability to focus or concentrate and had physical limitations and restrictions with mobility. The patient's ability to learn was below average and the patient exhibited a high risk for psychosocial problems which included housing, living situation, isolation and social problems.

The patient reported he wanted to go to a group home because he forgot where he was or how to get home. He previously stayed at an assisted living facility in Las Vegas Nevada for a year and would like to go back there to live. The patient requested a referral to the assisted living facility for discharge planning. The Social Worker was to assist the patient with possible discharge to the assisted living facility with follow-up for after care at the facility's (psychiatric hospital) out-patient clinic.

A Psychiatric Evaluation dated 02/10/13 at 1:50 PM, by Physician #2 documented the patient reported trouble caring for himself and had trouble with his memory. The patient reported hearing voices in his head and feeling sad and depressed. The patient had no reasonable plan for self care except a desire to find a group home to live in.

The initial treatment plan included the following:

"..1. Evaluate the patient for any concerning psychosis or mood symptoms.

2. Evaluate for suicidal/homicidal ideation and response to medication.

3. Social Worker to assist with dispositional needs. Patient could benefit from group home placement. Perhaps assisted living as he has been to this facility in the past. Will also need case worker.

4. Will start Thorazine 10 mg PO TID (by mouth three times a day), Cymbalta 30 mg PO QD (daily), Klonopin 1 mg PO BID (twice a day) for anxiety.

5. Medical consult.

6. Consider in-patient admission for psych testing and more dispositional needs that cannot be provided in the psychiatric observation unit setting..."

A Nursing Note dated 02/11/13, included the patient was exhibiting sexually inappropriate behavior and was delusional. The patient stated there were worms in his head and wanted more medication. The patient complained that his medications were only half the dose of what he regularly took.

A Psychiatric Progress Note dated 02/11/13, included the patient lost his identification and Medicare card and reported when stressed out he heard voices. The patient reported being off his psychiatric medication 6 days prior to admission to the facility. The patient reported having Alzheimer's disease and had been slow in learning programs but could function all right if he had a safety net. The patient wanted to go to California to find a group home. There was no city in California documented as a discharge destination. The patient's mood was upset. The patient's affect was anxious. The patient was hearing voices telling him to smash computers. The patient's insight and judgment were poor.

Physician Orders dated 02/11/13 at 9:50 AM, documented to discharge the patient to the Greyhound bus station by taxi at 1:00 PM, with a three day supply of Thorazine, Klonopin and Cymbalta medication as well as to send Ensure and snacks with the patient for a 15 hour bus ride.

A Social Worker's Note dated 02/11/13, documented the following:

"Discharge to California via Greyhound bus. Affect and mood within normal limits. Denies suicidal, homicidal ideation."

A Nursing Note dated 02/11/13, indicated the psychiatrist saw the patient and signed the discharge order.

Discharge procedure included discharge to the Greyhound bus station via taxi with a three day supply of medication. Discharge instructions were explained to the patient especially on medications.

There was no documented evidence in the medical record of instructions provided to the patient that included appointments made, addresses, phone numbers, and names of physicians or how the patient could access any services. There was no documented evidence in the medical record that indicated how the patient could access mental health services, narcotic anonymous meetings, medication clinic, name of a psychiatrist and medical physician for follow-up and a list of housing or shelters where the patient could stay.

A review of the facility's Discharge Planning and Aftercare Plan Policy and Procedure, effective 06/2012, included the following:

"..Procedure: It shall be the procedure of (Facility) social services to provide discharge planning to all patients in the Psychiatric Observation Unit (POU) and on all inpatient units.

Purpose: The purpose of the discharge planning and aftercare is to identify and describe the services and support systems that are appropriate to meet the patient's psychosocial needs and that will be effective on the day of discharge.

Social Workers shall provide each patient with a copy of the Discharge Instructions. Instructions shall include appointments made and /or how the patient can access services.

Social Workers shall complete prior to discharge date and document in weekly progress notation all contacts and referrals with intra agency and community programs and shall document the discharge planning process with the patient and multidisciplinary treatment team, in weekly treatment plan up-dates as well as in weekly Progress Notes.

Staff shall provide client with information and appointment when appropriate for mental health services available in the home community.

If nourishment is required for the length of travel, program or unit staff shall contact the Pharmacy for providing nourishment until clients arrive at their destination.

Social Workers shall write a discharge summary that day or the next working day, in the progress notation following patient discharge which shall include:

a. Complete description of referrals to treatment and community resources including dates and times and addresses of service providers.

b. Description of community based housing arrangements and prior communication and exchange of information.

c. Transportation resources provided, day bus passes given, bus schedules, and map quest to get to referral appointments.

In addition to a discharge progress note, the social worker shall complete a Locus and SSAP (date and core measure tab) in Avatar.

A review of the facility's Client Discharge Transportation Policy and Procedure effective 08/2011 included the following:

a. Staff shall confirm client has housing /shelter available and a support system available to meet client at destination..."

The facility's Standards of Care for Discharge Planning included the following:

a. Joint Commission Interpretive Guide for Discharge Planning.

b. CMS Standards for Discharge Planning

CMS Standards for Discharge Planning included the following:

"..482.61 (e) the record for each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient's hospitalization. This summary includes the reason for admission, treatment achieved during hospitalization, a baseline of psychiatric, physical and social functioning of the patient at the time of discharge, and evidence of the patient/family response to treatment interventions.

The record of each patient who has been discharged should indicate the extent to which goals established in the patient's treatment plan have been met.

As part of the discharge planning, staff considers the discharge alternatives addressed in the psychosocial assessment and the extent to which the goals in the treatment plan have been met.
482.61(e) Recommendations from appropriate services concerning follow-up or aftercare.

The patient's discharge summary should describe the services and supports that are appropriate to the patient's needs and will be effective the day of discharge.

A complete description of arrangements with treatment and other community resources for the provision of follow-up services. Reference should be made to prior verbal and written communication and exchange of information.

A plan outlining psychiatric, medical/physical treatment and medication regimen as applicable.

a. Specific appointment dates and times and addresses of the service providers.

b. Description of community housing/living arrangement.

c. Economic/financial status or plan.

d. A complete description of the involvement of family and significant others with the patient after discharge.

482.61(e) A brief summary of the patient's condition non discharge. The patient's discharge planning process should address anticipated problems after discharge and suggested means for intervention i.e., accessibility and availability of community resources and support systems including transportation, special problems related to the patient's functional ability to participate in the discharge plan..."

Joint Commission Interpretive Guide for Discharge Planning last updated 09/02/12 included the following:

"..Social service staff responsibilities include, but are not limited to participating in discharge planning, arranging for follow-up care, and developing mechanisms for exchange of information with sources outside the hospital.

Prior to discharge, the hospital arranges or assists in arranging the services required by the patient after discharge in order to meet his or her ongoing needs for care and services.

The hospital educates the patient about how to obtain any continuing care, treatment, and services the patient will need.

The facility's required LOCUS Adult Assessment Level of Care Documentation indicated the following information should be documented on all patients discharged from the facility. The documentation included the following;

1. Risk of harm.
2. Functional status.
3. Co-Morbidity.
4. Recovery Environment.
5. Recovery Environment Support.
6. Treatment and Recovery History.
7. Engagement..."

On 03/06/13 at 9:46 AM, the Director of Social Services reviewed Patient #1's medical record and confirmed that the Social Worker assigned to the patient's case failed to follow the facility's Discharge Planning and Aftercare Policy and Procedure and the facility's Standard of Care which included CMS (Center For Medicare Services) Standards for Discharge Planning and Joint Commission Interpretive Guide for Discharge Planning. There was no written or verbal discharge instructions that included information on how the patient could access mental health care, medication clinic, narcotic anonymous meetings, housing or shelter and the name of a psychiatrist and medical physician for follow-up care in Sacramento, California.

The Director confirmed the patient's Social Worker failed to complete a (LOCUS) (Level of Care Utlization System) documentation that included an assessment of the patient's functional status, risk of harm, recovery environment and treatment and recovery history. The patient's Social Worker failed to thoroughly explore whether the patient had any family or friends to act as a support group or any patient programs to help meet the patient's discharge goals.

On 03/06/13 at 10:30 AM, Patient #1's (CSW) Clinical Social Worker acknowledged responsibility for implementing the patient's discharge plan. The CSW indicated the patient expressed a desire to return to an assisted living facility or a group home in Las Vegas, Nevada upon discharge. The CSW reported he called an assisted living facility in Las Vegas for possible placement of the patient but the facility refused to accept the patient. The CSW acknowledged no other group homes or assisted living facilities were contacted for possible placement in Las Vegas, Nevada prior to the decision made to discharge the patient to Sacramento, California.


On 03/06/13 at 1:00 PM, an interview was conducted with Patient #1's psychiatrist, Physician #1 who reported the patient had diagnoses that included psychotic disorder, polysubstance abuse, opioid abuse, mild mental retardation, chronic pain and rule out malingering. The patient's medications included Thorazine for the treatment of a psychotic disorder. Physician #1 reported he spoke with the patient who expressed a desire to be discharged to California for out-patient treatment even though the patient reported having no family members or contacts there. Physician #1 reported the patient wanted to be discharged to California to find a group home.

Physician #1 reported he wrote a discharge order for the patient to be discharged to Sacramento, California with a three day supply of prescribed psychiatric medication, Ensure and snacks for a 15 hour bus ride, orders for the patient to follow-up with mental health services, narcotic anonymous meetings and a medical physician for any medical problems in Sacramento, California. Physician #1 acknowledged he was aware the patient was homeless and had no family or contacts in Sacramento, California. Physician #1 acknowledged the patient should have been provided with specific referrals for mental health services, medication clinic, narcotic anonymous, shelter, psychiatrist and medical physician by the Social Worker assigned to the patient in order for the discharge to be considered safe.




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Patient #11

Patient #11 was admitted to the facility with diagnoses which included a history of polysubstance abuse, overdose attempt, bipolar disorder and diabetes. Patient #1 was from Oklahoma and had been in Las Vegas since December 2012.

The clinical record contained a physician's order dated 2/10/13, for the patient's blood sugar to be checked at 7:00 AM, 11:00 AM and 4:00 PM. The documentation in the clinical record indicated the patient's blood sugar at 7:00 AM, was 237 (normal blood sugar 70-120) and at 11:00 AM, was 218. On both occasions the patient received sliding scale insulin coverage. According to the clinical record, the patient refused to have her blood sugar checked at 4:00 PM on 2/11/13.

The clinical record contained a physician's order dated 2/11/13, "for discharge today. Greyhound bus to Oklahoma at 8:20 PM. Ensure for 2 day trip." The physician's order lacked documentation as to the quantity of Ensure to be provided to the patient for the trip to Oklahoma. The physician's order for discharge did not address medication or equipment for the patient's type 2 diabetes.

The discharge note documented the patient was discharged to a treatment center in Tulsa, Oklahoma. There was no documented evidence the patient was provided with the address or directions for the treatment center in Tulsa, Oklahoma.

The clinical record lacked documentation the patient was discharged with medication to treat diabetes or equipment needed to check blood sugar levels during the trip.

The clinical record lacked documentation the medical physician saw the patient while at the facility.

The facility's pharmacy logs lacked documentation the patient received medication for diabetes upon discharge. The Pharmacy logs indicated the patient was discharged with Ensure.

On 3/7/13 at 1:50 PM, a Registered Nurse (RN) stated Patient #11 had diagnoses of diabetes mellitus type 2 and a history of bi-polar. The patient had a physician's order for sliding scale insulin and the patient received insulin twice on 2/13/13 twice for blood sugars of 237 and 218. The RN verbalized the documentation indicated the patient refused the finger stick blood sugar check at 4:00 PM, on 2/11/13. The RN indicated the patient should not have been provided Ensure for travel because as a diabetic the patient should be on Glucerna. The RN confirmed the medical physician had not seen the patient while at the facility. The RN was asked if it was typical for a patient to be discharged via bus to Oklahoma without medications. The RN stated no; it was unusual.


Complaint # NV00034829

Based on interview, clinical record review and document review, the facility failed to provide a discharge planning evaluation upon the request of a physician that included the likelihood of the patient needing post hospital services and the availability of the services for three (3) out of thirty (30) patients sampled (Patient #1, #3, and #11). The facility failed to ensure there was an adequate discharge planning evaluation that included the patient's capacity for self care upon discharge in two (2) out of thirty (30) patients sampled. (Patient's #1 and #11).


Findings include:


Patient #1

Patient #1's medical record indicated the patient was admitted to the facility on 02/09/13, to the POU (psychiatric observation unit) on a Legal 2000 (72 hour hold for psychiatric evaluation) due to symptoms of psychosis, auditory hallucinations and suicidal ideation. The patient's diagnoses included psychotic disorder, polysubstance abuse, opioid abuse, mild mental retardation and chronic pain. The patient had several congenital bone and joint defects, chronic back pain and used a wheelchair to assist in mobility. The patient was placed on psychiatric medication that included Thorazine for a psychotic disorder, Klonopin for an anxiety disorder and Cymbalta for depression.

A review of Patient #1's Psychosocial Assessment dated 02/10/13, documented the patient was homeless and unable to care for himself. The patient did not have the ability to focus or concentrate and had physical limitations and restrictions with mobility. The patient's ability to learn was below average and the patient exhibited a high risk for psychosocial problems which included housing, living situation, isolation and social problems.

A Psychiatric Evaluation dated 02/10/13 at 1:50 PM, by Physician #2 documented the patient reported trouble caring for himself and had trouble with his memory. The patient reported hearing voices in his head and feeling sad and depressed. The patient had no reasonable plan for self care except a desire to find a group home to live in.

The initial treatment plan included the following:

"..1. Evaluate the patient for any concerning psychosis or mood symptoms.

2. Evaluate for suicidal/homicidal ideation and response to medication.

3. Social Worker to assist with dispositional needs. Patient could benefit from group home placement. Perhaps assisted living as he has been to this facility in the past. Will also need case worker.

4. Will start Thorazine 10 mg PO TID (by mouth three times a day), Cymbalta 30 mg PO QD (daily), Klonopin 1 mg PO BID (twice a day) for anxiety.

5. Medical consult.

6. Consider in-patient admission for psych testing and more dispositional needs that cannot be provided in the psychiatric observation unit setting..."

A Psychiatric Progress Note dated 02/11/13, included the patient lost his identification and Medicare card and reported when stressed out he heard voices. The patient reported being off his psychiatric medication 6 days prior to admission to the facility. The patient reported having Alzheimer's disease and had been slow in learning programs but could function all right if he had a safety net. The patient wanted to go to California to find a group home. There was no city in California documented as a discharge destination. The patient's mood was upset. The patient's affect was anxious. The patient was hearing voices telling him to smash computers. The patient's insight and judgment were poor.

Physician Orders dated 02/11/13 at 9:50 AM, documented to discharge the patient to the Greyhound bus station by taxi at 1:00 PM, with a three day supply of Thorazine, Klonopin and Cymbalta medication as well as to send Ensure and snacks with the patient for a 15 hour bus ride.

A Nursing Note dated 02/11/13, indicated the psychiatrist saw the patient and signed the discharge order.

A Patient Discharge Form dated 02/11/13, documented the patient was discharged to the Greyhound bus station by taxi to Sacramento, California with a three day supply of medication and instructions to follow up with mental health, narcotics anonymous and follow-up with a medical doctor in California for medical concerns.

There was no documented evidence in the medical record of instructions provided to the patient that included appointments made, addresses, phone numbers, and names of physicians or how the patient could access any services. There was no documented evidence in the medical record that indicated how the patient could access mental health services, narcotic anonymous meetings, medication clinic, name of a psychiatrist and medical physician for follow-up and a list of housing or shelters where the patient could stay in accordance with the facility's Discharge Planning and Aftercare Plan Policy and Procedure, effective 06/2012.

On 03/06/13 at 1:00 PM, an interview was conducted with Patient #1's psychiatrist, Physician #1 who reported the patient had diagnoses that included psychotic disorder, polysubstance abuse, opioid abuse, mild mental retardation, chronic pain and rule out malingering. The patient's medications included Thorazine for the treatment of a psychotic disorder. Physician #1 reported he spoke with the patient who expressed a desire to be discharged to California for out-patient treatment even though the patient reported having no family members or contacts there. Physician #1 reported the patient wanted to be discharged to California to find a group home.

Physician #1 reported he wrote a discharge order for the patient to be discharged to Sacramento, California with a three day supply of prescribed psychiatric medication, Ensure and snacks for a 15 hour bus ride, orders for the patient to follow-up with mental health services, narcotic anonymous meetings and a medical physician for any medical problems in Sacramento, California. Physician #1 acknowledged he was aware the patient was homeless and had no family or contacts in Sacramento, California. Physician #1 acknowledged the patient should have been provided with specific referrals for mental health services, medication clinic, narcotic anonymous, shelter, psychiatrist and medical physician by the Social Worker assigned to the patient in order for the discharge to be considered safe.







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Patient #3

Patient #3 was admitted to the facility with suicidal ideation on 2/10/13 and discharged on 2/11/13. The patient's diagnoses included mood disorder, psychotic disorder, polysubstance abuse and Alcohol dependence. The patient was to follow up with the facility (Psychiatric Hospital) as an outpatient and attend AA (Alcohol Anonymous) and NA (Narcotics Anonymous) meetings.

The clinical record lacked documentation the patient received information regarding AA/NA meeting locations or a telephone number.

On 3/11/13 at 9:25 AM, a Registered Nurse confirmed there was no documented evidence the patient received information regarding AA/NA meeting locations or a telephone number.


Patient #11

Patient #11 was admitted with diagnoses which included a history of polysubstance abuse, overdose attempt, bipolar disorder and diabetes. Patient #1 was from Oklahoma and had been in Las Vegas since December 2012.

The clinical record contained a physician's order dated 2/10/13, for the patient's blood sugar to be checked at 7:00 AM, 11:00 AM and 4:00 PM. The documentation in the clinical record indicated the patient's blood sugar at 7:00 AM, was 237 (normal blood sugar 70-120) and at 11:00 AM, was 218. On both occasions the patient had received sliding scale insulin coverage. According to the clinical record, the patient refused to have her blood sugar checked at 4:00 PM on 2/11/13.

The clinical record contained a physician's order dated 2/11/13, "for discharge today. Greyhound bus to Oklahoma at 8:20 PM. Ensure for 2 day trip." The physician's order lacked documentation as to the quantity of Ensure to be provided to the patient for the trip to Oklahoma. The physician's order for discharge did not address medication or equipment for the patient's type 2 diabetes.

The discharge note documented the patient was discharged to a treatment center in Tulsa, Oklahoma. There was no documented evidence the patient was provided with the address or directions for the treatment center in Tulsa, Oklahoma.

The clinical record lacked documentation the patient was discharged with medication to treat diabetes or equipment needed to check blood sugar levels during the trip.

The clinical record lacked documentation the medical physician saw the patient while at the facility.

The facility's pharmacy logs lacked documentation the patient received medication for diabetes upon discharge. The Pharmacy logs indicated the patient had been discharged with Ensure.

On 3/7/13 at 1:50 PM, a Registered Nurse (RN) stated Patient #11 had diagnoses of diabetes mellitus type 2 and a history of bi-polar disorder. The patient had a physician's order for sliding scale insulin and the patient received insulin twice on 2/13/13 twice for blood sugars of 237 and 218. The RN verbalized the documentation indicated the patient refused the finger stick blood sugar check at 4:00 PM, on 2/11/13. The RN indicated the patient should not have been provided Ensure for travel because as a diabetic the patient should be on Glucerna. The RN confirmed the medical physician had not seen the patient while at the facility. The RN stated it was not an unfair statement to say the discharge plan did not address the patient's type 2 diabetes. The RN was asked if it was typical for a patient to be discharged via bus to Oklahoma without medications. The RN stated no; it was unusual.



Complaint # NV00034829

Based on interview, clinical record review and document review, the facility failed to ensure a discharge planning evaluation used for establishing an appropriate discharge plan was completed and entered into the patients medical record for one of thirty (30) patient's sampled. (Patient #1).


Findings include:

Patient #1

Patient #1's medical record indicated the patient was admitted to the facility on 02/09/13, to the POU (psychiatric observation unit) on a Legal 2000 (72 hour hold for psychiatric evaluation) due to symptoms of psychosis, auditory hallucinations and suicidal ideation. The patient's diagnoses included psychotic disorder, polysubstance abuse, opioid abuse, mild mental retardation and chronic pain. The patient had several congenital bone and joint defects, chronic back pain and used a wheelchair to assist in mobility. The patient was homeless. The patient was placed on psychiatric medication that included Thorazine for a psychotic disorder, Klonopin for an anxiety disorder and Cymbalta for depression.

A review of Patient #1's Psychosocial Assessment dated 02/10/13, documented the patient was homeless and unable to care for himself. The patient did not have the ability to focus or concentrate and had physical limitations and restrictions with mobility. The patient's ability to learn was below average and the patient exhibited a high risk for psychosocial problems which included housing, living situation, isolation and social problems. The patient was homeless and unable to care for himself. The patient's ability to focus and concentrate was impaired.

The patient reported he wanted to go to a group home because he forgets where he is or how to get home. The patient requested he previously stayed at an assisted living facility in Las Vegas, Nevada for a year and would like to go back there to live. The patient was requesting a referral to the assisted living facility for discharge planning. The Social Worker was to assist the patient with possible discharge to the assisted living facility with follow-up for after care at the facility's (psychiatric hospital) out-patient clinic.

A Psychiatric Evaluation dated 02/10/13 at 1:50 PM, by Physician #2 documented the patient reported trouble caring for himself and having trouble with his memory. The patient reported hearing voices in his head and feeling sad and depressed. The patient had no reasonable plan for self care besides wanting to find a group home to live in.

The initial treatment plan included the following:

"..1. Evaluate the patient for any concerning psychosis or mood symptoms.

2. Evaluate for suicidal/homicidal ideation and response to medication.

3. Social Worker to assist with dispositional needs. Patient could benefit from group home placement. Perhaps assisted living as he has been to this facility in the past. Will also need case worker.

4. Will start Thorazine 10 mg PO TID (by mouth three times a day), Cymbalta 30 mg PO QD (daily), Klonopin 1 mg PO BID (twice a day) for anxiety.

5. Medical consult.

6. Consider in-patient admission for psych testing and more dispositional needs that cannot be provided in the psychiatric observation unit setting.."

A Social Workers Note dated 02/11/13 documented the following:

"Discharge to California via Greyhound bus. Affect and mood within normal limits. Denies suicidal, homicidal ideation."

On 03/06/13 at 9:46 AM, the Director of Social Services reviewed Patient #1's medical record and confirmed that the Social Worker assigned to the patient's case failed to follow the facility's Discharge Planning and Aftercare Policy and Procedure and the facility's Standard of Care which included CMS (Center For Medicare Services) Standards for Discharge Planning and Joint Commission Interpretive Guide for Discharge Planning. There was no written or verbal discharge instructions that included instructions and information on how the patient could access mental health care, medication clinic, narcotic anonymous meetings, housing or shelter and the name of a psychiatrist and medical physician for follow-up care in Sacramento, California.

There was no documented evidence in the medical record that indicated the patient's Social Worker completed a discharge planning summary and evaluation that established an appropriate and safe discharge plan for the patient.

Complaint # NV00034829

Based on interview, clinical record review and document review, the facility failed to take steps to arrange the initial implementation of discharge plans necessary for post hospital services and care for three (3) out of thirty (30) patients sampled. (Patients #1, #3 and #11).


Findings include:

Patient #1

Patient #1's medical record indicated the patient was admitted to the facility on 02/09/13, to the POU (psychiatric observation unit) on a Legal 2000 (72 hour hold for psychiatric evaluation) due to symptoms of psychosis, auditory hallucinations and suicidal ideation. The patient's diagnoses included psychotic disorder, polysubstance abuse, opioid abuse, mild mental retardation, chronic pain. The patient had several congenital bone and joint defects, chronic back pain and used a wheelchair to assist in mobility. The patient was homeless. The patient was placed on psychiatric medication that included Thorazine for a psychotic disorder, Klonopin for an anxiety disorder and Cymbalta for depression.

A review of Patient #1's Psychosocial Assessment dated 02/10/13, documented the patient was homeless and unable to care for himself. The patient did not have the ability to focus or concentrate and had physical limitation and restrictions with mobility. The patient's ability to learn was below average and the patient exhibited a high risk for psychosocial problems which included housing, living situation, isolation and social problems. The patient was homeless and unable to care for himself. The patient's ability to focus and concentrate was impaired.

The patient reported he wanted to go to a group home because he forgets where he is or how to get home. The patient reported he previously stayed at an assisted living facility in Las Vegas, Nevada for a year and would like to go back there to live. The patient requested a referral to the assisted living facility for discharge planning. The Social Worker was to assist the patient with possible discharge to the assisted living facility with follow-up for after care at the facility's (psychiatric hospital) out-patient clinic.

A Psychiatric Evaluation dated 02/10/13 at 1:50 PM, by Physician #2 documented the patient reported trouble caring for himself and having trouble with his memory. The patient reported hearing voices in his head and feeling sad and depressed. The patient had no reasonable plan for self care besides wanting to find a group home to live in.

The initial treatment plan included the following:

"..1. Evaluate the patient for any concerning psychosis or mood symptoms.

2. Evaluate for suicidal/homicidal ideation and response to medication.

3. Social Worker to assist with dispositional needs. Patient could benefit from group home placement. Perhaps assisted living as he has been to this facility in the past. Will also need case worker.

4. Will start Thorazine 10 mg PO TID (by mouth three times a day), Cymbalta 30 mg PO QD (daily), Klonopin 1 mg PO BID (twice a day) for anxiety.

5. Medical consult.

6. Consider in-patient admission for psych testing and more dispositional needs that cannot be provided in the psychiatric observation unit setting. .."

A Social Workers Note dated 02/11/13 documented the following:

"Discharge to California via Greyhound bus. Affect and mood within normal limits. Denies suicidal, homicidal ideation."

A Patient Discharge Form dated 02/11/13, documented the patient was discharged to the Greyhound bus station by taxi to Sacramento, California with a three day supply of medication and instructions to follow up with mental health, narcotics anonymous and follow-up with a medical doctor in California for medical concerns.

There was no documented evidence in the medical record that indicated the patient's Social Worker completed a discharge planning summary and evaluation that established an appropriate and safe discharge plan for the patient.

There was no documented evidence in the medical record of instructions provided to the patient that included appointments made, addresses, phone numbers, and names of physicians or how the patient could access any services. There was no documented evidence in the medical record that indicated how the patient could access mental health services, narcotic anonymous meetings, medication clinic, name of a psychiatrist and medical physician for follow-up and a list of housing or shelters the patient could stay at.

On 03/06/13 at 9:46 AM, the Director of Social Services reviewed Patient #1's medical record and confirmed the Social Worker assigned to the patient's case failed to follow the facility's Discharge Planning and Aftercare Policy and Procedure and the facility's Standard of Care which included CMS (Center For Medicare Services) Standards for Discharge Planning and Joint Commission Interpretive Guide for Discharge Planning by failing to provide Patient #1 with written or verbal discharge instructions that included instructions and information on how the patient could access mental health care, medication clinic, narcotic anonymous meetings, housing or shelter and the name of a psychiatrist and medical physician for follow-up care in Sacramento, California.

On 03/06/13 at 10:30 AM, Patient #1's Clinical Social Worker (CSW) acknowledged being responsible for implementing the patients discharge plan. The CSW indicated the patient expressed a desire to return to an assisted living facility or a group home in Las Vegas, Nevada upon discharge. The CSW reported he called an assisted living facility in Las Vegas for possible placement of the patient, but the facility refused to accept the patient. The CSW acknowledged no other group homes or assisted living facilities were contacted for possible placement in Las Vegas, Nevada prior to the decision being made to discharge the patient to Sacramento, California.

The CSW reported his participation in the patient's discharge plan was not adequate and there was a failure to follow the facility's established discharge planning policy and procedure. The faciity failed to make proper discharge arrangements and provide the patient with a written description of arrangements made for the provision of follow-up services that indicated how the patient could access mental health services, narcotic anonymous meetings, medication clinic, name of a psychiatrist and medical physician for follow-up and a list of housing or shelters the patient could stay at in Sacramento, California. The CSW acknowledged there were no appointment dates, names or addresses of service providers provided to the patient for out-patient mental health services, narcotic anonymous meetings, medication clinic, shelter, psychiatrist or medical physician.





29140

Patient #3

Patient #3 was admitted to the facility with suicidal ideation on 2/10/13 and discharged on 2/11/13. The patient's diagnosis included mood disorder, psychotic disorder, polysubstance abuse and Alcohol dependence. The patient was to follow up with the facility (Psychiatric Hospital) as outpatient and attend AA (Alcohol Anonymous) and NA (Narcotics Anonymous) meetings.

The clinical record lacked documentation the patient received information regarding AA/NA meeting locations or a telephone number.

On 3/11/13 at 9:25 AM, a Registered Nurse confirmed there was no documented evidence the patient received information regarding AA/NA meeting locations or a telephone number.


Patient #11

Patient #11 was admitted with diagnoses which included a history of polysubstance abuse, overdose attempt, bipolar disorder and diabetes. Patient #11 was from Oklahoma and had been in Las Vegas since December 2012.

The clinical record contained a physician's order dated 2/10/13, for the patient's blood sugar to be checked at 7:00 AM, 11:00 AM and 4:00 PM. The documentation in the clinical record indicated the patient's blood sugar at 7:00 AM, was 237 and at 11:00 AM, was 218. On both occasions the patient had received sliding scale insulin coverage. According to the clinical record, the patient refused to have her blood sugar checked at 4:00 PM on 2/11/13.

The clinical record contained a physician's order dated 2/11/13 for discharge today. Greyhound bus to Oklahoma at 8:20 PM. Ensure for 2 day trip. The physician's order lacked documentation as to the quantity of Ensure to be provided to the patient for the trip to Oklahoma. The physician's order for discharge did not address medication or equipment for the patient's type 2 diabetes.

The discharge note documented the patient was discharged to a treatment center in Tulsa, Oklahoma. There was no documented evidence the patient was provided with the address or directions for the treatment center in Tulsa, Oklahoma.

The clinical record lacked documentation the patient was discharged with medication to treat diabetes or equipment needed to check blood sugar levels during the trip.

The clinical record lacked documentation a medical physician had seen the patient while at the facility.

The facility's pharmacy logs lacked documentation the patient received medication for her diabetes upon discharge. The Pharmacy logs indicated the patient had been discharged with Ensure.

On 3/7/13 at 1:50 PM, a Registered Nurse (RN) stated Patient #11 had diagnoses of diabetes mellitus type 2 and a history of bi-polar disorder. The patient had a physician's order for sliding scale insulin and the patient had received insulin on 2/13/13 twice for blood sugars of 237 and 218. The RN verbalized the documentation indicated the patient had refused the finger stick blood sugar check at 4:00 PM, on 2/11/13. The RN indicated the patient should not have been provided Ensure for travel because as a diabetic the patient should be on Glucerna. The RN confirmed the medical physician had not seen the patient while at the facility. The RN stated it was not an unfair statement to say the discharge plan did not address the patients type 2 diabetes. The RN was asked if it was typical for a patient to be discharged via bus to Tulsa, Oklahoma without medications. The RN stated no; it was unusual.


Complaint # NV00034829