HospitalInspections.org

Based on the hospital policy review, clinical record review and staff interviews the hospital failed to implement discharge plan for 1 of 10 sampled patients (Patients #2). The hospital failed to provide Patient #2 with prescription for an antidepressant medication (Zoloft) or to provide the patient with Zoloft medications to cover the days until the first scheduled psychiatric appointment after discharge from the hospital.

The findings include:

Review of the Hospital Behavioral Health Service policy titled "Behavioral Multidisciplinary Discharge Process" revealed the policy specifies, on the day of discharge: 1) The psychiatrist issues the order for discharge and also writes prescriptions to accompany the patient. 2) Discharge planning shall address the availability of, and access to prescribed psychotropic medications in the community. Such prescribed psychotropic medications, prescriptions for psychotropic medications or a combination thereof, shall be provided to the patient when discharged to cover the intervening days until the first scheduled psychotropic medication after care appointment, or for a period of up to 21 calendar days, whichever occurs first.

Clinical record review revealed Patient #2 was admitted on 9/20/12 under the Baker Act due to severe depression, suicidal thoughts, and poor coping skills.
Psychiatric evaluation on 9/21/12 determined the patient is competent to provide express and informed consent for voluntary admission and treatment.
On 9/21/12 a Licensed Clinical Social Worker (LCSW) therapist documented in a social worker progress notes, Therapist provided supportive therapy to assist patient in expressing feelings. Patient spoke about being depressed because she is in a psych unit. Spoke about being stressed at work and telling her boss that she rather commit suicide than work. Patient states she was just saying that because she was frustrated not because she actually had any intention of hurting herself. Patient spoke about significant sadness regarding being hospitalized at the end of the session the patient was able to improve mood and speak about positive aspects of her life. Patient denies any suicidal ideation.
The physician order and Medication Administration records revealed the patient was given Zoloft 50 mg orally daily on 9/22/12 at 10:00AM and on 9/23/12 at 9:48 AM.

A psychiatrist documented on 9/23/12, patient is deemed ready for discharge at this time since the patient denies suicidal or homicidal thoughts, denies any side effect with medications and is stable for outpatient treatment. The psychiatrist discharge medication reconciliation order on 9/23/12 revealed the patient is to resume Zoloft 50 mg =1 tablet orally daily. A Psychiatric discharge record dated 9/23/12 documents the patient is discharged with prescription, however, the record failed to identify the prescription provided to the patient upon discharge .

The patient discharge instruction dated 09/23/12 at 1:35PM documents, "No instructions were provided." A social worker documented on 9/23/12 at 09:46AM, patient being discharged per Dr D..., patient being discharged home via own car as car is in hospital parking lot and she has keys in possession. Patient being discharged with prescription and crisis number, Therapist will contact patient tomorrow and provide therapy appointment and psychiatrist appointment when offices are open.
In an interview with the LCSW Social Work Manager, on 10/10/12 at 10:30 AM, the manager stated upon discharge the patient is given prescription or a supply of medication to last the patient until the follow up appointment. Further review of the clinical record revealed there is no documented evidence to verify the patient was given a supply of Zoloft tablets or a prescription for Zoloft.
In an interview with the Behavioral Unit Nurse manager, on 10/10/12 at 12:30 PM, the manager stated the Psychiatrist does not write prescription upon discharge, the prescription is faxed to the pharmacy from the psychiatrist office. The surveyor requested written evidence of the faxed prescription sent to the pharmacy. The Nurse manager stated she called the psychiatrist office and was told they have no record that the prescription for Zoloft or any other medications were sent to a pharmacy for the Patient (#2).
During interview with Patient (#2) on 10/11/12 at 1:50 PM, the patient denies taking an antidepressant medication prior to the hospital admission on 9/20/12. She received Zoloft, an antidepressant medication for two days at the hospital, but was not given a prescription for Zoloft on discharge from the hospital. The patient was instructed to see the primary care physician to get a prescription for Zoloft. A social worker contacted the patient two days after the hospital discharge and provided an appointment with a psychiatrist. The patient chose a different psychiatrist and is currently receiving counseling. The patient states, at discharge the hospital staff provided a prescription for Keflex to treat a urinary tract infection. No other prescription or medication was provided.

Based on clinical record review and staff interviews and hospital policy review the hospital staff failed to implement a discharge plan to ensure the patient's needs are provided for 1 of 10 sampled patients (Patient #1). Failure to discharge Patient #1 to an Assisted Living Facility as per the physician discharge order.

The findings include:

Clinical record review revealed Patient #1 was admitted to the hospital on 7/25/12 from an Assisted Living Facility (ALF) with chief complaint of non-resolving diarrhea. Admitting diagnoses were bilateral pneumonia, diarrhea and dehydration.
The medical history discloses the patient has altered mental status and is not able to make decisions. The patient's condition returned to the usual state of health and remained stable. On 8/08/12 a physician wrote an order to discharge the patient to an Assisted Living Facility.

A Registered Nurse /case manager documented on 7/27/12, the ALF did not want the patient back, case manager will try to send the patient to other facilities but all are out of beds.
On 8/01/12 Case management informed the patient's family the ALF did not want the patient back. The family was informed of several agencies that help the hospital find ALF placements for patients. The family agreed to the case manager contacting S---- F------ placement services for placing the patient.
A social worker documented on 8/6/12 and 8/7/12 an ALF placement was not found. On 8/8/12 at 2:28 PM a social worker documents receiving confirmation from a placement agency that the patient is accepted at " S... C... ALF " . The necessary paper work was completed and the patient was discharged ambulatory, accompanied by a family member, on 8/08/12. "Medication reconciliation list given to the patient."

In an interview with the Director of Case management on 10/09/12 at 12:30 PM, the Director stated the hospital use a placement agency to find placement for Patients. The placement agency informed the hospital social worker the patient (#1) was accepted at an assisted living facility and the patient was discharged to the facility. At the time, the social worker was unaware the placement agency had placed the patient in a halfway house. She stated "we don't check the facility because we depend on the placement agency to find the appropriate facility to meet the patient needs."
In an interview with a social worker on 10/09/12 at approximately 2:30 PM, the social worker stated she is unaware the facility is not an ALF because "the placement agency told her it is an ALF." The social worker acknowledge she did not communicate with the facility staff to ensure the facility is able to provide the patient's assessed needs. The social worker also stated an Adult Protective Service (APS) investigator informed the hospital case managers, the patient had been inappropriately discharged on 8/08/12 to a halfway house. The patient's sister removed him from the halfway house the next day and kept the patient at her home until APS placed him in an ALF facility. The social worker stated she now verifies facility type before a patient is discharged to make sure the facility is able to provide the patient's needs.
The hospital discharge /transfer policy specifies: The attending physician is responsible for ordering the release of a patient from the facility and any subsequent care. The individual responsible for discharge planning (i.e. case manager, discharged planner social worker) is responsible for implementation of the discharge order.

Based on the hospital policy review, clinical record review and staff interviews the hospital failed to implement discharge plan for 1 of 10 sampled patients (Patients #2). The hospital failed to provide Patient #2 with prescription for an antidepressant medication (Zoloft) or to provide the patient with Zoloft medications to cover the days until the first scheduled psychiatric appointment after discharge from the hospital.

The findings include:

Review of the Hospital Behavioral Health Service policy titled "Behavioral Multidisciplinary Discharge Process" revealed the policy specifies, on the day of discharge: 1) The psychiatrist issues the order for discharge and also writes prescriptions to accompany the patient. 2) Discharge planning shall address the availability of, and access to prescribed psychotropic medications in the community. Such prescribed psychotropic medications, prescriptions for psychotropic medications or a combination thereof, shall be provided to the patient when discharged to cover the intervening days until the first scheduled psychotropic medication after care appointment, or for a period of up to 21 calendar days, whichever occurs first.

Clinical record review revealed Patient #2 was admitted on 9/20/12 under the Baker Act due to severe depression, suicidal thoughts, and poor coping skills.
Psychiatric evaluation on 9/21/12 determined the patient is competent to provide express and informed consent for voluntary admission and treatment.
On 9/21/12 a Licensed Clinical Social Worker (LCSW) therapist documented in a social worker progress notes, Therapist provided supportive therapy to assist patient in expressing feelings. Patient spoke about being depressed because she is in a psych unit. Spoke about being stressed at work and telling her boss that she rather commit suicide than work. Patient states she was just saying that because she was frustrated not because she actually had any intention of hurting herself. Patient spoke about significant sadness regarding being hospitalized at the end of the session the patient was able to improve mood and speak about positive aspects of her life. Patient denies any suicidal ideation.
The physician order and Medication Administration records revealed the patient was given Zoloft 50 mg orally daily on 9/22/12 at 10:00AM and on 9/23/12 at 9:48 AM.

A psychiatrist documented on 9/23/12, patient is deemed ready for discharge at this time since the patient denies suicidal or homicidal thoughts, denies any side effect with medications and is stable for outpatient treatment. The psychiatrist discharge medication reconciliation order on 9/23/12 revealed the patient is to resume Zoloft 50 mg =1 tablet orally daily. A Psychiatric discharge record dated 9/23/12 documents the patient is discharged with prescription, however, the record failed to identify the prescription provided to the patient upon discharge .

The patient discharge instruction dated 09/23/12 at 1:35PM documents, "No instructions were provided." A social worker documented on 9/23/12 at 09:46AM, patient being discharged per Dr D..., patient being discharged home via own car as car is in hospital parking lot and she has keys in possession. Patient being discharged with prescription and crisis number, Therapist will contact patient tomorrow and provide therapy appointment and psychiatrist appointment when offices are open.
In an interview with the LCSW Social Work Manager, on 10/10/12 at 10:30 AM, the manager stated upon discharge the patient is given prescription or a supply of medication to last the patient until the follow up appointment. Further review of the clinical record revealed there is no documented evidence to verify the patient was given a supply of Zoloft tablets or a prescription for Zoloft.
In an interview with the Behavioral Unit Nurse manager, on 10/10/12 at 12:30 PM, the manager stated the Psychiatrist does not write prescription upon discharge, the prescription is faxed to the pharmacy from the psychiatrist office. The surveyor requested written evidence of the faxed prescription sent to the pharmacy. The Nurse manager stated she called the psychiatrist office and was told they have no record that the prescription for Zoloft or any other medications were sent to a pharmacy for the Patient (#2).
During interview with Patient (#2) on 10/11/12 at 1:50 PM, the patient denies taking an antidepressant medication prior to the hospital admission on 9/20/12. She received Zoloft, an antidepressant medication for two days at the hospital, but was not given a prescription for Zoloft on discharge from the hospital. The patient was instructed to see the primary care physician to get a prescription for Zoloft. A social worker contacted the patient two days after the hospital discharge and provided an appointment with a psychiatrist. The patient chose a different psychiatrist and is currently receiving counseling. The patient states, at discharge the hospital staff provided a prescription for Keflex to treat a urinary tract infection. No other prescription or medication was provided.

Based on clinical record review and staff interviews and hospital policy review the hospital staff failed to implement a discharge plan to ensure the patient's needs are provided for 1 of 10 sampled patients (Patient #1). Failure to discharge Patient #1 to an Assisted Living Facility as per the physician discharge order.

The findings include:

Clinical record review revealed Patient #1 was admitted to the hospital on 7/25/12 from an Assisted Living Facility (ALF) with chief complaint of non-resolving diarrhea. Admitting diagnoses were bilateral pneumonia, diarrhea and dehydration.
The medical history discloses the patient has altered mental status and is not able to make decisions. The patient's condition returned to the usual state of health and remained stable. On 8/08/12 a physician wrote an order to discharge the patient to an Assisted Living Facility.

A Registered Nurse /case manager documented on 7/27/12, the ALF did not want the patient back, case manager will try to send the patient to other facilities but all are out of beds.
On 8/01/12 Case management informed the patient's family the ALF did not want the patient back. The family was informed of several agencies that help the hospital find ALF placements for patients. The family agreed to the case manager contacting S---- F------ placement services for placing the patient.
A social worker documented on 8/6/12 and 8/7/12 an ALF placement was not found. On 8/8/12 at 2:28 PM a social worker documents receiving confirmation from a placement agency that the patient is accepted at " S... C... ALF " . The necessary paper work was completed and the patient was discharged ambulatory, accompanied by a family member, on 8/08/12. "Medication reconciliation list given to the patient."

In an interview with the Director of Case management on 10/09/12 at 12:30 PM, the Director stated the hospital use a placement agency to find placement for Patients. The placement agency informed the hospital social worker the patient (#1) was accepted at an assisted living facility and the patient was discharged to the facility. At the time, the social worker was unaware the placement agency had placed the patient in a halfway house. She stated "we don't check the facility because we depend on the placement agency to find the appropriate facility to meet the patient needs."
In an interview with a social worker on 10/09/12 at approximately 2:30 PM, the social worker stated she is unaware the facility is not an ALF because "the placement agency told her it is an ALF." The social worker acknowledge she did not communicate with the facility staff to ensure the facility is able to provide the patient's assessed needs. The social worker also stated an Adult Protective Service (APS) investigator informed the hospital case managers, the patient had been inappropriately discharged on 8/08/12 to a halfway house. The patient's sister removed him from the halfway house the next day and kept the patient at her home until APS placed him in an ALF facility. The social worker stated she now verifies facility type before a patient is discharged to make sure the facility is able to provide the patient's needs.
The hospital discharge /transfer policy specifies: The attending physician is responsible for ordering the release of a patient from the facility and any subsequent care. The individual responsible for discharge planning (i.e. case manager, discharged planner social worker) is responsible for implementation of the discharge order.