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Based on record review and interview the facility staff failed to ensure that the patient's legal guardian was kept informed regarding the treatment plan and discharge instructions as per policy in 1 of 10 medical records reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure #15-008-0221 titled, "Patient Rights and Responsibilities" effective 02/01/2021 revealed, "You (Patient) or your representative (Legal Guardian) shall receive information about your illness, course of treatment and prognosis for recovery..."

Review of policy and procedure #CLI-PCS-102 titled, "Treatment Planning" last reviewed 02/27/2023 revealed the following:
- "The treatment plan is an ongoing reflection of the patient's changing progress toward goals and requires updates to the treatment plan including possible changes to the IPOC (Interdisciplinary Plan of Care)...and to the Master Treatment Plan."
- "Evaluation is based, not only on team members observation about patient functioning, but on feedback from the patient/guardian/support system."
- "The Treatment Plan Signature Sheet (HIM-139) should be signed by the patient, parent/guardian."
- "If the parent/guardian if not available in person, a member of the care team will review care plan updates, document verbal consent, and sent the parent/guardian form HIM-139 for physical signature."

Review of policy and procedure #CLI-PCS-110 titled, "Aftercare/Continued Care Planning" effective date 05/01/2022 revealed the following:
- "Discharge plans and final disposition will be recorded on the 'Discharge Instructions' form in the patient's electronic health record. The course of treatment, improvement during treatment, prognosis, and any problems foreseen for the patient, as well as recommendations made, will be recorded by a member of the treatment team..."
- "The treatment team will complete discharge instructions and review these instructions with the patient prior to or at the time of discharge. A member of the treatment team will obtain signatures verifying this review at the time of discharge."
- "The EHR (Electronic Health Record) Depart (Departure) and the Discharge Medication Reconciliation must be reviewed with the parent/guardian for signatures and a copy is provided to the patient/guardian."

Review of Pt #1's medical records revealed Pt #1 is 37 years old admitted to the behavioral health facility under a Chapter 51 Emergency Detention (involuntary admission) on 06/12/2024 at 2:51 AM; Pt #1 was discharged home on 07/05/2024 at 3:36 PM.

Review of Pt #1's Psychiatric Evaluation dated 06/12/2024 at 2:51 PM, revealed that Pt #1 has a history of schizophrenia spectrum disorder, bipolar mood disorder, PTSD (post traumatic stress disorder), developmental delay and anxiety.

Per review of Pt #1's medical record revealed, "Letters of Guardianship" Circuit Court documents dated 08/18/2004, Family A (Pt #1's mother) was appointed "Permanent" legal guardian as Pt #1 was deemed "incompetent" per court documents.

Review of the Treatment Plan Signature Sheet (HIM-139) form revealed by "Signing this document, I have been informed of the services within the treatment plan and have participated in treatment planning and care." The Treatment Plan Signature Sheet revealed, "To not delay necessary treatment, when a parent/guardian cannot attend...staff will obtain verbal consent from the parent or guardian to initiate immediate service and will work toward getting written consent within 10 days--this applies to minors and adults with legal guardians."

Review of Pt #1's Treatment Plan Signature Sheet revealed Pt #1 initialed as having reviewed his/her Treatment Plan with staff on 06/13/2024, 06/20/2024, 06/24/2024, 06/28/2024, and 07/01/2024. Review of Pt #1's Treatment Plan Signature Sheet revealed that the "Parent/Guardian" sections were not signed by Family A (guardian) to show evidence of staff reviewing the Treatment Plan updates with Family A as per policy.

During interview with Director of Clinical Services D on 08/21/2024 beginning at 2:45 PM, Director D stated that the patient and patient's legal guardian should sign the Treatment Plan as an acknowledgement and consent of the Treatment Plan. Director D confirmed that there was no documented evidence of staff updating Pt #1's legal guardian on the Treatment Plan meetings and Family A signing as per policy.

Review of Pt #1's Patient Summary Documents revealed that Registered Nurse (RN) E discussed the Discharge Instructions with Pt #1 on 07/05/2024 beginning at 3:21 PM, and Pt #1 signed and acknowledged the Discharge Instructions on 07/05/2024 at 3:24 PM. Review of Pt #1's Patient Summary Documents revealed the "Patient/Representative Written Consent Signature" showing the legal guardian was informed of Pt #1's Discharge Instructions was documented as "Declined."

Interview with Family A (Legal Guardian) on 08/20/2024 beginning at 6:28 PM revealed that Pt #1 called Family A after Pt #1 was discharged. Per Family A, Pt #1 stated that he/she was discharged with no transportation. Family A stated that Pt #1 showed up to Family A's house 3 hours after calling Family A and stated that Pt #1 took the bus home and did not have any money but the bus driver let Pt #1 ride anyway. Per Family A, the hospital did not call and inform Family A that Pt #1 was being discharged on that day. Family A stated that if Pt #1 had not called her, Family A would not have known that Pt #1 was discharged. Family A stated that Pt #1 was not discharged with medication prescription.

Per interview with RN E on 08/22/2024 beginning at 9:40 AM, when asked if legal guardians are included in the review of the patient's discharge instructions, RN E stated that he/she has never run into a situation of having to include the legal guardian with an adult patient. RN E stated that the discharge instructions are shared with the legal guardian if they are present at discharge. RN E stated that he/she was not aware that Pt #1 had a legal guardian and did not review the discharge instructions with Pt #1's legal guardian.

During interview with Director of Nursing (DON) C on 08/21/2024 beginning at 2:05 PM, while reviewing Pt #1's medical records; DON C confirmed the findings and stated that the discharge instructions should be discussed with the patient's legal guardian and should be signed by the legal guardian as per policy.

Based on record review and interview staff failed to implement a preventative action plan based on a comprehensive root cause analysis for all adverse events as per policy in 1 of 3 adverse events reviewed (Patient (Pt) #1), in a total sample of 3 adverse events reviewed.

Findings Include:

Review of policy and procedure #COM-REG-105 titled, "Incident Reporting" effective 01/01/2022 revealed the following:
- "Primary Investigator Responsibilities: 1. Evaluate the incident and assist in providing support as necessary. 2. Investigate the incident and document the following within the incident report: a. who was involved in the incident? b. When did the incident occur? c. Where did the incident occur? d. What happened? e. Was policy followed? f. How can this be prevented from occurring in the future? 3. Initiate any needed action plan, staff re-training, human resources involvement, care delivery process or policy changes, or treatment plan modifications. 4. Sign off on the incident report as completed."

Review of Pt #1's medical records revealed Pt #1 is 37 years old admitted to the behavioral health facility under a Chapter 51 Emergency Detention (involuntary admission) on 06/12/2024 at 2:51 AM; Pt #1 was discharged "home" on 07/05/2024 at 3:36 PM.

Review of Pt #1's Psychiatric Evaluation dated 06/12/2024 at 2:51 PM, revealed that Pt #1 has a history of schizophrenia spectrum disorder, bipolar mood disorder, PTSD (post traumatic stress disorder), developmental delay and anxiety.

Review of Pt #1's Incident Report completed by Clinical Services Manager (CSM) I, revealed an Incident Date of 07/05/2024 and Time of Incident at 3:40 PM. Per review of the Incident Summary, "Therapist (H) communicated to first shift nurses that patient was not to be discharged until everything was set in place for the group home...At 341 (3:41 PM) (H) came to (CSM I) office and stated that the second shift nurse (RN E) just discharged (Pt #1) without checking to see if things were set. (Pt #1) did not have any medications faxed to preferred pharmacy and no ride was set up for the patient to take him to his group home. Patient is on a stipulation agreement for (Pt #1's) emergency detention and housing was a stipulation to his agreement. Writer went to ask (RN E) if he/she got any hand off from 1st shift nurse (RN F) and he/she stated 'No. I just saw the DC (discharge) order and discharged him...'"

Per interview with Psychiatrist G on 08/21/2024 beginning at 3:40 PM, Psychiatrist G stated that he/she mistakenly put an order for Pt #1 to discharge home instead of to the group home. Psychiatrist G stated that it was a miscommunication and stated that the nurse saw the order to discharge "home" and figured it was ok to discharge. Psychiatrist G stated that the discharge orders automatically default to "home" and he/she should have changed this.

Per interview with RN E on 08/22/2024 beginning at 9:37 AM, RN E stated that he/she came in as 2nd shift RN and took shift report from the first shift RN F that Pt #1 was "packed up and ready to go." RN E stated he/she reviewed the physician order and discharged Pt #1. RN E was not aware that Pt #1 had a legal guardian and was not aware of the discharge plan to discharge to a group home with transportation. RN E stated that he/she should have coordinated with the treatment team to ensure all steps were completed prior to discharging Pt #1.

Review of the Primary Investigator Summary of Pt #1's Incident Report revealed, "(Registered Nurse E) was educated/reminded via a coaching note..."

Review of Registered Nurse (RN) E's Coaching Form signed by RN E on 07/18/2024 revealed, "Before discharging a patient, make sure that both Therapist and CTS (Care Transition Specialist) have completed their documentation. This is notated under discharge forms in Cerner-result will state 'yes' once their forms are complete. If there are any delays from the clinical team in completing their paperwork, please reach out to them directly to coordinate discharge. Nursing may not discharge a patient until the clinical documentation is complete."

Per review of Pt #1's Incident Report there was no documented evidence of a comprehensive investigation, including interviewing all staff involved to determine the root cause and implementing a preventative action plan based on all contributory factors.

Per interview with Director of Nursing (DON) C on 08/21/2024 beginning at 2:20 PM, DON C stated that staff determined that Pt #1's adverse event was caused by a lack of communication by RN E and he/she was re-educated on reviewing notes and communication. DON C stated that the investigation and action plan did not address the physician's order being inaccurate or the nursing shift report provided to RN E. Per DON C, no other staff were re-educated or provided with a coaching. If a discharge happens during shift change, DON C stated that it is not in the RN's discharge process to review progress notes from previous days, the RN will review the physician order for discharge and rely on nursing shift report.

Based on record review and interview the facility staff failed to ensure that the patient's legal guardian was informed of the discharge instructions as per policy in 1 of 10 medical records reviewed (Patient (Pt) #1); and failed to provide a safe discharge as per the treatment plan in 1 of 10 medical records reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed.

Findings Include:

Facility staff failed to ensure that the patient's legal guardian was informed of the discharge instructions as per policy. See Tag A-808.

Facility staff failed to provide a safe discharge as per the treatment plan. See Tag A-813.

Based on record review and interview the facility staff failed to ensure that the patient's legal guardian was informed of the discharge instructions as per policy in 1 of 10 medical records reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure #CLI-PCS-110 titled, "Aftercare/Continued Care Planning" effective date 05/01/2022 revealed the following:
- "Discharge plans and final disposition will be recorded on the 'Discharge Instructions' form in the patient's electronic health record. The course of treatment, improvement during treatment, prognosis, and any problems foreseen for the patient, as well as recommendations made, will be recorded by a member of the treatment team..."
- "The treatment team will complete discharge instructions and review these instructions with the patient prior to or at the time of discharge. A member of the treatment team will obtain signatures verifying this review at the time of discharge."
- "The EHR (Electronic Health Record) Depart (Departure) and the Discharge Medication Reconciliation must be reviewed with the parent/guardian for signatures and a copy is provided to the patient/guardian."

Review of Pt #1's medical records revealed Pt #1 is 37 years old admitted to the behavioral health facility under a Chapter 51 Emergency Detention (involuntary admission) on 06/12/2024 at 2:51 AM; Pt #1 was discharged home on 07/05/2024 at 3:36 PM.

Review of Pt #1's Psychiatric Evaluation dated 06/12/2024 at 2:51 PM, revealed that Pt #1 has a history of schizophrenia spectrum disorder, bipolar mood disorder, PTSD (post traumatic stress disorder), developmental delay and anxiety.

Per review of Pt #1's medical record revealed, "Letters of Guardianship" Circuit Court documents dated 08/18/2004, Family A (Pt #1's mother) was appointed "Permanent" legal guardian as Pt #1 was deemed "incompetent" per court documents.

Review of Pt #1's Patient Summary Documents revealed that Registered Nurse (RN) E discussed the Discharge Instructions with Pt #1 on 07/05/2024 beginning at 3:21 PM, and Pt #1 signed and acknowledged the Discharge Instructions on 07/05/2024 at 3:24 PM. Review of Pt #1's Patient Summary Documents revealed the "Patient/Representative Written Consent Signature" showing that the legal guardian was informed of Pt #1's Discharge Instructions was documented as "Declined."

Interview with Family A (Legal Guardian) on 08/20/2024 beginning at 6:28 PM revealed that Pt #1 called Family A after Pt #1 was discharged. Per Family A, Pt #1 stated that he/she was discharged with no transportation. Family A stated that Pt #1 showed up to Family A's house 3 hours after calling Family A and stated that Pt #1 took the bus home and did not have any money but the bus driver let Pt #1 ride anyway. Per Family A, the hospital did not call and inform Family A that Pt #1 was being discharged on that day. Family A stated that if Pt #1 had not called her, Family A would not have known that Pt #1 was discharged. Family A stated that Pt #1 was not discharged with medication prescription.

Per interview with RN E on 08/22/2024 beginning at 9:40 AM, when asked if legal guardians are included in the review of the patient's discharge instructions, RN E stated that he/she has never run into a situation of having to include the legal guardian with an adult patient. RN E stated that the discharge instructions are shared with the legal guardian if they are present at discharge. RN E stated that he/she was not aware that Pt #1 had a legal guardian and did not review the discharge instructions with Pt #1's legal guardian.

During interview with Director of Nursing (DON) C on 08/21/2024 beginning at 2:05 PM, while reviewing Pt #1's medical records; DON C confirmed the findings and stated that the discharge instructions should be discussed with the patient's legal guardian and should be signed by the legal guardian as per policy.

Based on record review and interview the facility failed to provide a safe discharge as per treatment plan in 1 of 10 medical records reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed.

Findings include:

Review of policy and procedure #15-008-0221 titled, "Patient Rights and Responsibilities" effective 02/01/2021 revealed, "You (Patient) or your representative (Legal Guardian) shall receive information about your illness, course of treatment and prognosis for recovery..."

Review of policy and procedure #CLI-PCS-110 titled, "Aftercare/Continued Care Planning" effective date 05/01/2022 revealed the following:
- "Discharge plans and final disposition will be recorded on the 'Discharge Instructions' form in the patient's electronic health record. The course of treatment, improvement during treatment, prognosis, and any problems foreseen for the patient, as well as recommendations made, will be recorded by a member of the treatment team..."
- "Verify attending provider's written discharge order and discharge plan."
- "The treatment team will complete discharge instructions and review these instructions with the patient prior to or at the time of discharge. A member of the treatment team will obtain signatures verifying this review at the time of discharge."
- "Discharge instructions shall contain the following: a. A complete description of arrangements with treatment and other community resources for the provision of follow-up services...c. Description of community housing/living arrangement..."
- "At the time of discharge, patients will receive a patient summary of information that outlines:...b. Treatment needs that will continue at the next level of care...d. Living arrangements..."
- "The EHR (electronic health record) Depart (Departure) and the Discharge Medication Reconciliation must be reviewed with the patient/guardian for signatures and a copy is provided to the patient/guardian."

Review of Pt #1's medical records revealed Pt #1 is 37 years old admitted to the behavioral health facility under a Chapter 51 Emergency Detention (involuntary admission) on 06/12/2024 at 2:51 AM; Pt #1 was discharged "home" on 07/05/2024 at 3:36 PM.

Review of Pt #1's Psychiatric Evaluation dated 06/12/2024 at 2:51 PM, revealed that Pt #1 has a history of schizophrenia spectrum disorder, bipolar mood disorder, PTSD (post traumatic stress disorder), developmental delay and anxiety.

Per review of Pt #1's Letters of Guardianship Circuit Court documents dated 08/18/2004, Family A (Pt #1's mother) was appointed "Permanent" legal guardian as Pt #1 was deemed "incompetent" per court documents.

Review of Pt #1's Social Worker Progress Notes completed by Social Worker (SW) H revealed the following:
-06/26/2024 at 11:34 AM: "Pt reports concern that he does not have stable housing...Writer to follow up with CM (case manager)."
-06/26/2024 at 12:51 PM: "Pt's (Pt #1's) mother (Family A) reports return to apartment is not option at this time."
-06/26/2024 at 4:58 PM: "Writer met with pt to discuss housing following d/c (discharge) from IP (inpatient)...Pt reports (Pt #1) was not aware that (Pt #1) was unable to return to former living arrangement...Pt reports anxiety surrounding unstable housing..."
-06/28/2024 at 11:22 AM: "Writer provided pt with update regarding housing. (Pt #1) stated 'I will just be homeless.' Writer reassured pt that voicemails have been left for Family Care to assist with placement."
-07/02/2024 at 2:11 PM: "Writer received email from...Granny's House informing writer pt has been accepted for housing."
-07/02/2024 at 4:13 PM: "Writer met with pt and informed of acceptance to Granny's House (group home). Pt is agreeable. MD (physician) in process of completing intake paperwork..."

Review of Pt #1's Physician Progress Note completed by Psychiatrist G dated 07/05/2024 at 2:58 PM revealed, "...(Pt #1) was alerted to discharge, told that he would be going to (Pt #1's) new group home today...Discharge orders were completed relative to (Pt #1) going to his new group home. Medications were transmitted to pharmacy electronically. SW/therapist was in the process of arranging for transportation for (Pt #1)."

Review of Pt #1's Patient Summary Documents including the Discharge and Aftercare Instructions, signed by Registered Nurse (RN) E on 07/05/2024 at 3:21 PM revealed, "(Pt #1) to discharge to Granny's House." Discharge Instructions were signed by the patient on 07/05/2024 at 3:24 PM. The Aftercare and Discharge Instructions were not signed indicating that staff reviewed the final treatment plan and discharge instructions with the legal Guardian (Family B) as per policy.

Review of Pt #1's Physician orders revealed that Psychiatrist G wrote an order on 07/05/2024 at 2:53 PM to discharge Pt #1 "Home", this was inconsistent with Pt #1's treatment plan to discharge to a group home.

Review of Pt #1's Incident Report completed by Clinical Services Manager (CSM) I, revealed an Incident Date of 07/05/2024 and Time of Incident at 3:40 PM. Per review of the Incident Summary, "Therapist (H) communicated to first shift nurses that patient was not to be discharged until everything was set in place for the group home...At 341 (3:41 PM) (H) came to (CSM I) office and stated that the second shift nurse (RN E) just discharged (Pt #1) without checking to see if things were set. (Pt #1) did not have any medications faxed to preferred pharmacy and no ride was set up for the patient to take him to his group home. Patient is on a stipulation agreement for (Pt #1's) emergency detention and housing was a stipulation to his agreement. Writer went to ask (RN E) if he/she got any hand off from 1st shift nurse (RN F) and he/she stated 'No. I just saw the DC (discharge) order and discharged him...'"

Interview with Family A (Legal Guardian) on 08/20/2024 beginning at 6:28 PM revealed that Pt #1 called Family A after Pt #1 was discharged. Per Family A, Pt #1 stated that he/she was discharged with no transportation. Family A stated that Pt #1 showed up to Family A's house 3 hours after calling Family A and stated that Pt #1 took the bus home and did not have any money but the bus driver let Pt #1 ride anyway. Per Family A, the hospital did not call and inform Family A that Pt #1 was being discharged on that day. Family A stated that if Pt #1 had not called her, Family A would not have known that Pt #1 was discharged. Family A stated that Pt #1 was not discharged with medication prescription.

Per interview with Psychiatrist G on 08/21/2024 beginning at 3:40 PM, Psychiatrist G stated that he/she mistakenly put an order for Pt #1 to discharge home instead of to the group home. Psychiatrist G stated that it was a miscommunication and stated that the nurse seen the order for "home" and figured it was ok to discharge. Psychiatrist G stated that staff realized the mistake after Pt #1 was discharged and Psychiatrist G drove around in car looking for Pt #1 but could not locate him/her. Psychiatrist G stated that he/she assumed Pt #1 took the bus to Family A's house.

Per interview with RN E on 08/22/2024 beginning at 9:37 AM, RN E stated that the RN should print out the discharge medication list, discharge instructions, and aftercare instructions and review with the patient prior to discharge. RN E stated that he/she came in as 2nd shift RN and took shift report from the first shift RN F that Pt #1 was "packed up and ready to go." RN E stated he/she reviewed the physician order and discharged Pt #1. RN E was not aware that Pt #1 had a legal guardian and was not aware of the discharge plan to discharge to a group home with transportation. RN E stated that he/she should have coordinated with the treatment team to ensure all steps were completed prior to discharging Pt #1.