HospitalInspections.org

Based on document review and staff interview, it was determined in 1 of 10 (pt #1) record reviewed for discharge planning, the Hospital failed to ensure a written request by the patient requesting discharge was obtained per policy.

Findings include:


1. The "Application For Voluntary Admission" was reviewed on 6/17/15. The document required " Rights of Voluntary Admittee *You have the right to request discharge from this facility. Your request must be in writing. *After you give request, the facility must discharge you at the earliest appropriate time ..."

2. The clinical record of Pt #1 was reviewed on 6/17/15 at approximately 2:00 PM. Patient #1 was admitted to the Emergency Department (ED) on 10/12/14 for a psychiatric evaluation. Diagnoses were noted as intermittent explosive disorder, mild to moderate mental retardation, history of traumatic brain injury, chronic constipation, hypothyroidism and seizure disorder. An Application For Voluntary Admission dated 10/17/14 and a Reaffirmation of Voluntary Admission dated 11/14/14 was signed by Pt #1 and legal guardian. The clinical record noted on 11/13/14, 11/15/14, 11/16/14, 11/17/14 and 11/18/14 Pt #1 was requesting to go home and she didn ' t want to stay at the facility. The clinical record lacked a written discharge request by Pt #1.

3. During an interview on 6/19/15 at approximately 9:30 AM, MD#1 (Psychiatrist/Medical Director of Inpatient Behavioral Health) stated Pt #1 was "demanding discharge."

4. During an interview on 6/18/15 at approximately 4:00 PM, E#3 (Director of Analytics and Accreditation) stated the record lacked documentation of Pt #1's written discharge request. E#3 stated a written request for discharge should have been obtained although it was documented by the social worker, nurses and physician.