HospitalInspections.org

Based on policy review, medical record review, and staff interviews the hospital failed to identify behavioral health patients who are at high risk for adverse health consequences on discharge for 1 of 1 medical records reviewed. (Patient #7)

Findings included:

Review on 06/24/2025 of the hospital policy, High Risk Assessment for Discharge Planning, effective 02/2024, revealed "...PURPOSE: To identify the mental, physical, social, discharge and/or educational needs of those patients meeting high risk criteria and to implement a discharge plan in a timely manner. DEFINITION(S): High Risk: Those patients identified by the organization based on diagnosis, age, debility, or social and financial needs that are at risk for post hospital continuity of care. ... PROCEDURE: All RN [registered nurse] Care Coordinators and Medical Social Workers are responsible for identifying patients for high-risk discharge and appropriately completing the Discharge Planning Screen in [named software program]. ...Chart Screen Step One NOTE: This will be performed with each admission chart review. ... TWO Perform Discharge Planning Screen. ... THREE Establish a discharge Plan...After assessment interview, discuss discharge needs and potential options for disposition with the patient/caregiver. ...FOUR Communicate plan to Provider and Multidisciplinary Team. ...NOTE: If there is no variation of this policy at the site, NONE is indicated. ... [Hospital A] None. HIGH RISK SCREENING CRITERIA ... The following criteria is helpful in identifying patients that need a discharge planning evaluation and possible Care Coordination Services: ...Home Environment: Geriatric, age 65 or older, lives alone; no support system, Guardianship/POA (power of attorney) status, ... Transfer from another facility (Acute;...) ...Social Problems: ...Psychiatric/emotional disturbances, ... Lack of family support/dysfunctional family issues...Mental and /or Physical Impairments: High Risk Diagnoses: Dementia [decline in cognitive abilities]/Alzheimer's Disease [a disease that destroys memory and mental functions]/Parkinson's Disease [disorder of the central nervous system that affects movement] ..." Review revealed this policy did not have variations, and did not exclude any admitted inpatients who met criteria.

Review of the policy on 06/24/2025, Admission & Discharge Criteria BHU [behavioral health unit] Procedure effective date 03/2025 revealed, " ... Discharge Criteria ... 6. Support systems that allow the patient to be maintained in a less restrictive environment have been thoroughly explored and/or secured. ..."

Closed medical review on 6/24/2025 revealed Patient #7, a 75-year-old female who was transferred from Hospital B, an acute care hospital emergency department under involuntary commitment [IVC] to the behavioral health unit [BHU] at Hospital A for psychosis and neurocognitive disorder [a mental health disorder that affect cognitive abilities including learning, memory, perception, and problem solving.] on 02/08/2024 at 1214. Review of the BHU Psychiatric Evaluation & History & Physical dated 02/08/2024 at 1819 by Medical Doctor [MD] #1 revealed "...documented history of major neurocognitive disorder presents on IVC petition by son who is her legal guardian. IVC reads: Ms. [named Patient #7] has been diagnosed with dementia with additional psychosis. Which at this time is taking no meds for and has become more aggressive towards her 2 sons who are her guardians. She has become physical towards them. Saturday she threw a drink at her son [named] while he was driving up [named road] hitting him in the head breaking his glasses. [Named Patient #7] believes that her sons are breaking into her home stealing. .... She has threatened to kill herself. She is not allowing the brother to do the things needed to secure her safety in the home at this time. Patient has declined since her husband passed away in December. Sons have already spoken to [named post discharge facility] for community placement and they liked the facility. ... Diagnosis -major neuro cognitive disorder with psychotic features. ... Patient meets criteria for hospitalization for safety reasons.... There is clearly a disconnect here and the best place for this patient is on our unit as it is locked, and visitor access is controlled. I suspect that if we discharge her, she will just land in another hospitalization for the same allegations. Patient does meet criteria for hospitalization. ...Plan of Care ... Based on my clinical assessment, the patient would be at risk if discharged from the unit. ...A mental health clinician team will assist in coordinating the discharge plan. ... Addendum 02/09/2024 at 0910 ... spoke with hospital attorney. No IVC criteria met upon my exam, must convert to voluntary and appointed guardian must provide paperwork. ..." The initial BHU Nursing Note by RN #2 revealed " ...Patient is a moderate fall risk due to her weakened gait [a change in the way a person walks, often due to their nervous system, muscles, joints ...]" The next day 02/09/2024 at 1517 LCMHC [licensed mental health counselor] #3 completed a SLUMS [St. Louis University Mental Status /score 20 or below is indicative of dementia] assessment. " ...Patient scored 19. Normal score is between 25-30. Patient score indicates major cognitive disorder." At 02/09/2024 at 1517, LCMHC #3 documents, "Discharge Planning Update: Plan to discharge home, tentatively Thursday, 2/15/2024. No other changes noted in treatment team. Clinician [having direct contact with and responsibility for patients] will continue to support patient in progressing toward treatment plan goals for discharge." On 02/09/2024 at 1754, RN #2 documents Patient #7 was now voluntary status. On 02/12/2025 at 1002, LCMHC #4 documents "Pt. [patient] discussed in treatment team. No change to d/c [discharge] plan. On 2/13/2024 at 1034 LCMHC #4 wrote "I spoke with pt's guardian [named], regarding sending documentation to [named nursing facility]. ... He is aware her discharge date is 2/15/2025." On 02/14/2024 at 1045 by LCMHC #4 documented "Pt. discussed in treatment team today. No change to discharge plan." No mention of the conversation with guardian, and information sent to [named nursing facility]. Review of BHU Physician Notes dated for 2/14/2024 at 1049 summarized notes from MD #6, 02/11/2024: " ...patient with ongoing paranoia [unrealistic distrust of others], delusions [an altered reality belief]. Accusing nursing of stealing her jewelry from her home." ...02/12/2024: "impaired insight and judgement regarding memory issues and safety rt [related to] going home ..." 02/13/2024: new medication: " ...transition to Risperdal [an antipsychotic medication used to treat mental health conditions] to avoid extra sedation, 2 milligrams po [oral] qhs [bedtime]." 02/14/2024: " ...she continues to have delusions regarding her sons, ..." Review of the BHU Physician's Progress note dated for 02/15/2024 at 1136 by MD #6 revealed " ...Medical Necessity for continued Stay: Risk of harm to self/others;, Cognitive impairment poses high risk; as evidenced by : Poor insight and grossly poor judgement, inability to keep self and/or others safe in outpatient, despite the efforts of social work the patient does not have a safe place to discharge to and step down efforts have been unsuccessful or are ongoing/patient cannot keep self-safe in outpatient setting without safe aftercare. ..." On 02/15/2024 at 1313 by LCMHC #4 documented "Pt. will discharge on 2/16/2024. [Named assisted living facility] here today to assess for placement there. Pt. will either be discharged to [named assisted living] (they will provide transport) or to her son/guardian." New note dated 02/16/2024 at 0954 by LCMHC #4 revealed " ...tentative date for discharge has been moved to 2/19/2024 in the hope that bed at [named assisted living] will be ready." An additional note on 2/16/2024 at 1500 by the MHC [mental health counselor] #5 was documented about a phone call with the guardian regarding planned discharge for 2/19/2024. The son/guardian asked if Patient #7 could qualify for outpatient rehabilitation. The son voiced his discontent with the communication about his mother, and the son asked to speak to the provider. MHC #4 explained that rehab wasn't something that could be arranged on a Friday at 3:00 PM, and not sure [named Patient #7] would meet that criteria for rehab. The phone was handed to LCMHC #4 to set up plans to discuss discharge with son/guardian on Monday morning, discharge day. Review of the record revealed plans for the assisted living facility was not discussed in the documentation on Friday 02/16/2024. On 2/16/2024 at 1516 LCMHC #4 documented they received a call from [named assisted living facility] needing more information for Patient #7. " ...I've called twice today and left message containing my email address. I requested that Pt's guardian also call and provide this information. I have not received these forms to complete or a return phone call. As such, I assume they will not be receiving [patient #7] on 2/19/2024. Pt.'s guardian is aware that she will be discharged to him on 2/19/2024." Review failed to reveal any further communication/follow-up to the assisted living facility who visited Patient #7. On 2/19/2024 at 1227 LCMHC #4 documented "Met with pt's guardian [named], nurse manager, and unit director to review discharge instructions prior to pt's discharge to her son/guardian. Guardian signed all documents except for social work discharge instructions; he reported that the [named nursing post discharge facility] had agreed to take patient but needed additional documents from us. We confirmed that I would contact [named nursing post discharge facility] to provide needed information. I made it clear that if they were unable to accept her or provide transportation that he would need to transport her. Immediately after the meeting, I contacted the [named nursing post discharge facility] who reported that pt. did not meet criteria for admission and also that they had lock-down presently and couldn't admit anyone. I immediately contacted [named son/guardian] to let him know that we would arrange transportation, likely with [named county law enforcement officer transportation] and I would let the guardian know what time she would be retrieved. (Pt did not want to be transported by guardian and guardian did not want to transport pt.) [Named]LEO could not guarantee that they could retrieve her today; if they did it, might not be until later today. Due to this uncertainly and the fact that pt's dementia worsens in the evenging [sic], it was determined to be a safer discharge if she were transported by the hospital's contracted transport company. Pt. agreed to be transported by this service and asserted, again, that she didn't want guardian to pick her up. I phoned pt's son/guardian to let him know the time that she would be leaving this facility, as promised. He was angry and accusatory . I asked if I should send Pt's belongings with pt or if he'd prefer to get them when he came to sign updated social work discharge instructions. He indicated I should send them with her because he refused to 'set foot at his hospital ever again.' He agreed to have me email it to him and that he would sign, scan and return. I also emailed him the documents that he signed this morning. Guardian continued to be angry and accusatory. I told him I was going to hang up, and I did." On 2/19/2024 at 1410 LCMHC #4 documents he has filed a report with [named] adult protective services ...." A treatment meeting note was entered on 2/19/2024 at 1456 [sic] by LCMHC #4 "Pt. discussed in treamtent [sic] and will discharge today as planned. Discharge instructions and safety plan completed. Review of the Discharge Instructions Physician was signed by MD #6 on 02/19/2024 at 0852 before the Son's/guardian's meeting. The guardian refused to sign all of the discharge instructions on learning Patient #7 was going home alone. The BHU discharged Patient #7 with a hospital contracted public transportation service, home unaccompanied on 02/19/2024 at 1230. The medication instructions were reviewed with Patient #7 and sent electronically to a pharmacy. The medical record did not reveal a plan/transportation for Patient #7 to obtain her new prescription of Risperdal from the pharmacy. The medical record failed to reveal a high-risk screening was performed for Patient #7 to discover discharge needs for: Home Environment: Geriatric, age 65 or older, lives alone; no support system, Guardianship/POA (power of attorney) status, ...Psychiatric/emotional disturbances, ... Lack of family support/dysfunctional family issues...Mental and /or Physical Impairments: High Risk Diagnoses: Dementia ..." The medical record failed to reveal a BHU medical provider was notified that the guardian did not agree with the discharge plan on 02/19/2024 before Patient #7 was discharged to home setting.

Summary: The medical record revealed Patient #7 did not receive a high-risk assessment for discharge planning. Patient #7 scored a 19 on the SLUMS screening indicative of dementia. Patient #7's guardian was requesting placement for his mom, who had documented "impaired insight and judgement, memory issues, and safety risks for going home alone" by MD #6. Patient #7 was documented as needing assistance with medications at home. The BHU was asked by the guardian to follow up with two named post discharge nurse facilities starting on 02/13/2024. The guardian was present on 2/16/2024 and 2/19/2025 and did not agree to the discharge plan. The medical record failed to reveal the physician was notified of the guardian's disapproval of the discharge plan on 02/19/2024 prior to discharge at 1230. Discharge instructions for medication were given to Patient #7 and did not include the guardian. Patient #7 was sent home early in the day on 02/19/2024 "because patient's dementia worsens in the evening" by LCMHC #4. Patient #7 was sent home unaccompanied with public transportation contracted by the hospital. The guardian lived in a different state from Patient #7.

Interview request for LCMHC #3 revealed they were unavailable during the survey.

Interview on 06/25/2025 at 1405 by BHU discharge RN #8 revealed they reviewed discharge instructions with Patient #7 and escorted them to the pharmacy to pick up medications received at admission. Patient #7 signed for the envelope, and RN #8 accompanied her to the entrance and assisted her in the transportation vehicle to go home. The interview revealed RN #8 did not review discharge instructions/medications with the guardian prior to discharging Patient #7 from the behavioral health unit .

Interview on 06/25/2025 at 1425 with the BHU Nurse Manager revealed the discharge registered nurse should review any discharge instructions/ and new medications with the patient and/or guardian. The interview revealed this did not occur. Further, the interview revealed the BHU meets daily at 0800 M-F [Monday through Friday] to discuss patient discharge needs. The hospital's case management team does not cover BHU patients. BHU patients are covered by 3 [named] licensed mental health counselors who completed the discharge screening for BHU patients. "The son was adamant he wanted her placed ..." Interview on 06/27/2025 at 1045 with BHU Nurse Manager revealed "We are not doing high-risk screening; we don't use that. BHU patients are not followed by case management, but by master's level LCMHC, and social worker. The interview revealed a social worker did not see Patient #7.

Interview on 06/26/2025 at 1100 with LCMHC #4 revealed there was no tool to screen BHU patients for high/low discharge risks. We would fax documents to seek placement when indicated. " ...I do not sign medication instructions, that is not within my scope of practice. The medication was escribed [sent electronically] to the preferred pharmacy. The guardian demanded he would make the arrangements for a discharge facility and patient did not meet criteria. We are unable to treat chronic conditions here. She had a guardian that was engaged in her care. I can't recall if I updated the physician after the son's meeting on 2/19/2024. I don't think we offered a choice list. We have to get a release of information. He [the son/guardian] would only sign those two and we sent them. The first one [named] I never received the forms to complete, the second [named] were on lockdown, so I did not ask further. ..." The interview revealed LCMHC #4 did not recall if he notified the physician after the son's meeting on 2/19/2024, when he refused to sign discharge paperwork and did not agree to the discharge plan for Patient #7, sending Patient #7 home alone without resources in place .

Telephone interview on 06/26/2025 at 1626 with the BHU Medical Director revealed " ...If a safe discharge plan changes it should be addressed. I would expect the treatment team to reach out to the MD for guidance to ensure a safe discharge plan was in place . ..."

NC00215382