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Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Chief Executive Officer (CEO), appointed by the Board of Trustees/Governing Body, was effectively managing the facility. Review of the facility's policy revealed the CEO was accountable for the effective management, executive direction and operation of the hospital. However, the CEO failed to identify and monitor hospital discharge procedures from the Behavioral Health Unit (BHU) of the facility to ensure patient safety during the discharge process.

Patient #1 was admitted to the BHU on 06/29/2020 with suicidal and homicidal ideations and with a diagnosis of Chronic Paranoid Schizophrenia. The patient also had a history of attempted suicide by drug overdose in 2019. The patient, who had an appointed guardian, was discharged on 07/07/2020 via public transportation back to the Personal Care Home (a licensed home for residents who need assistance with basic health and health related services but are able to manage most of the activities of daily living) where the patient previously resided. Hospital staff filled the patient's discharge medications in the hospital pharmacy and gave the medications to the patient upon discharge. The medications included a month supply of BuSpar (antianxiety), Lamictal (anticonvulsant), and Wellbutrin (antidepressant). The Personal Care Home (PCH) staff were not able to locate the patient's Wellbutrin medication and the patient denied ever being given these medications. The patient was discovered in cardiorespiratory arrest on 07/08/2020, at approximately 10:30 AM, and was transported to the local hospital and pronounced dead at 11:14 AM. The hospital Emergency Department note revealed the patient had multiple Wellbutrin pills on his/her person.

Refer to A0057.

Based on interview and review of the facility's policy it was determined the facility's Chief Executive Officer failed to ensure the hospital effectively monitored/reviewed the practice of discharging patients with medications to ensure the safety of the patients. Patient #1 was admitted to the Behavioral Health Unit (BHU) on 06/29/2020 with suicidal and homicidal ideations and with a diagnosis of Chronic Paranoid Schizophrenia. The patient also had a history of attempted suicide by drug overdose in 2019. The patient, who had an appointed guardian, was discharged on 07/07/2020 via public transportation back to the Personal Care Home (a licensed home for residents who need assistance with basic health and health related services but are able to manage most of the activities of daily living) where the patient previously resided. Hospital staff filled the patient's discharge medications in the hospital's pharmacy and gave the medications to the patient upon discharge. The medications included a month supply of BuSpar (antianxiety), Lamictal (anticonvulsant), and Wellbutrin (antidepressant). The Personal Care Home (PCH) staff were not able to locate the patient's Wellbutrin medication and the patient denied ever being given this medication. The patient was discovered in cardiorespiratory arrest on 07/08/2020, at approximately 10:30 AM, and was transported to the local hospital and pronounced dead at 11:14 AM. The hospital Emergency Department note revealed the patient had multiple Wellbutrin pills on his/her person.

The findings include:

Review of the facility's policy, "Board of Trustees, Policies and Procedures," revised date November 2015, revealed the Chief Executive Officer (CEO) was accountable for the planning, executing, controlling, and monitoring of the programs and activities of the healthcare system. The policy further revealed the CEO had the specific accountability for the effective management, executive direction, and operation of the hospital.

Review of Patient #1's medical record revealed the facility admitted him/her to the BHU on 06/29/2020 with a diagnosis of Paranoid Schizophrenia, chronic. The patient presented to the Emergency Department from a Personal Care Home with a report of suicidal and homicidal ideations and auditory hallucinations.

Review of the Inpatient Psychiatry History and Physical (H&P), dated 06/30/2020, revealed Patient #1 had a history of multiple hospitalizations and reported one previous suicide attempt by overdose in 2019.

Review of the Order of Appointment of Guardian, dated 01/14/2015, revealed Patient #1 was placed under full State Guardianship.

Review of the Inpatient Master Treatment Plan for Patient #1, dated 06/30/2020, revealed an admission diagnosis of Paranoid Schizophrenia. The plan also stated the patient had limited degree of insight, education/cognition, and motivation. The identified problems listed included the psychiatric diagnosis of Paranoid Schizophrenia and the medical issue of Substance Abuse Disorder.

Review of the Social Services Progress Note, dated 06/30/2020, revealed communication with the State Guardian and agreement that Patient #1 could return to the personal care home upon discharge from the BHU. Further review revealed a progress note, dated 07/07/2020, stating the patient would return to the personal care home on "this date" and was to receive therapy and medication management. The note also stated the state guardian was notified of this information. Review of the Discharge Instructions, dated 07/07/2020, revealed the patient had received medications and general instruction on dosage, route, scheduling, medication generic/brand names, purpose, medication precautions, side effects, food/drug interaction, smoking cessation, and when to call a care provider.

Interview with the Kentucky Medication Aide (KMA) at the PCH on 07/13/2020 at 8:42 AM, revealed Patient #1 returned to the Personal Care Home between 1:00 PM and 1:30 PM on 07/07/2020. She stated the hospital had called and informed the home the patient was returning and no further instructions were provided. The KMA stated the residents would usually return from the hospital with a discharge packet and hard copy prescriptions for their medications.

Interview with Registered Nurse (RN) #1 on 07/14/2020 at 10:40 AM, revealed she was the nurse who discharged Patient #1 on 07/07/2020. She stated she sent the discharge information packet with the patient and he/she was discharged with the medications that included BuSpar, Lamictal, and Wellbutrin. Follow-up interview on 07/16/2020 at 11:40 AM, revealed she did not speak to the State Guardian upon discharge of this patient. She further stated that to her knowledge she had never been instructed to contact the State Guardian regarding medications.

Interview with RN #4 on 07/14/2020 at 11:17 AM, revealed on 07/07/2020 she transported Patient #1 to the pharmacy where the patient obtained the medications BuSpar, Lamictal, and Wellbutrin. She stated she also assisted the patient to the transportation van. RN #4 stated Patient #1 had the discharge information and medications with him/her when leaving the hospital.

Interview with the Pharmacist on 07/14/2020 at 11:40 AM, revealed Patient #1 would have left the hospital on 07/07/2020 with four (4) bottles of medications, BuSpar 15 mg (milligrams), 30 pills, BuSpar 10 mg, 60 pills, Lamictal 25 mg, 60 pills, and Wellbutrin 100 mg, 90 pills, as well as a box of 28 Nicotene patches.

Review of the Emergency Department medical record, dated 07/08/2020, revealed Patient #1 was brought in by emergency medical services at 11:03 AM after responding to a call from the Personal Care Home. The patient was intubated and cardiopulmonary resuscitation (CPR) was in progress. Further review of the record revealed the patient was pronounced dead at 11:14 AM and the diagnosis of Cardiac Arrest, cause unspecified-drug abuse was documented.

Interview with RN #3 on 07/14/2020 at 10:55 AM, revealed she was the nurse in the Emergency Department of the local hospital where Patient #1 was transported on 07/08/2020. She stated the patient arrived in cardiac arrest with resuscitative measures being performed. Per the RN, they never got any cardiac activity and the patient was pronounced (had expired) at 11:14 AM. She further stated the patient was noted to have pills in the pockets of his/her clothing and a sock was found with two (2) rocks and more pills. The hospital pharmacist identified two (2) of the pills as Lipitor and Wellbutrin. She stated there were multiple Wellbutrin pills, more than ten (10). RN #3 also stated that a drug screen (blood or urine) was not performed.

Interview with the State Guardian/Complainant on 07/13/2020 at 2:35 PM, revealed she was the appointed guardian of Patient #1 and had been the patient's guardian since February 2020. A follow-up interview with the guardian on 07/15/2020 at 11:42 AM, revealed that she had spoken to the Discharge Planner/Social Worker on 07/07/2020 and was told Patient #1 was returning to the Personal Care Home, but she was not informed the patient was leaving with medications. She added that if the hospital staff had told her the patient was being discharged with the actual medications, it would have been of great concern to her, due to not only the patient's substance abuse but other residents at the Personal Care Home as well.

Interview with the Social Worker/Discharge Planner on 07/13/2020 at 4:20 PM and on 07/15/2020 at 11:00 AM, revealed if a patient admitted to the BHU had a State Guardian, she initiated contact with the guardian as soon as possible. She stated that upon discharge, the guardian should be notified of the patient leaving the BHU and how they were being transported. Per the Social Worker/Discharge Planner, she does not inform the guardian that the patient is leaving with medications. She stated she believed the nurses were to notify the guardians regarding medications.

Interview with the Nurse Manager on 07/14/2020 at 1:33 PM, revealed he was familiar with Patient #1. He stated the physician made the decision of whether to discharge a patient with medications. He also stated he was aware the patient had an identified substance abuse disorder.

Interview with the Physician on 07/14/2020 at 1:20 PM, revealed he was familiar with Patient #1 and during this last admission the Nurse Practitioner had treated him/her. He stated everyone was discharged with medications so they would have medicine until they could get in for an appointment. He added that if there were any doubts related to the safety of this practice, this would be addressed through the state guardian. The physician also stated the patient had discharged with medications before and had not been shown to abuse prescribed medications in the past.

Post survey interview with the CEO on 07/27/2020 at 11:00 AM, revealed he was not aware of the practice of discharging patients with medications in hand. He further stated he was not involved in the decisions related to this, as he was not involved in the clinical aspect. He then stated this was an opportunity for process improvement and, had the incident and subsequent investigation not occurred, the hospital may not have been aware of the issue.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to conduct appropriate discharge planning for one (1) of ten (10) sampled patients (Patient #1). The facility admitted Patient #1 to the Behavioral Health Unit (BHU) on 06/29/2020 with suicidal and homicidal ideations and hallucinations. The patient, who had an appointed State Guardian, had a history of substance abuse and attempted suicide by overdose. On 07/07/2020, Patient #1 was discharged from the Behavioral Health Unit (BHU) with a one (1) month supply of the medications that included Nicotene patches (for smoking cessation), BuSpar (anti-anxiety), Lamictal (anti-convulsant), and Wellbutrin (antidepressant). However, the State Guardian was not informed the patient was discharged and given these medications in hand. The patient was transported by public transportation back to the Personal Care Home (licensed facility for residents who need assistance with basic health and health related services but are able to manage most of the activities of daily living) where the patient previously resided. Upon arrival at the Personal Care Home, the patient denied receiving medications from the hospital other than the Nicotene patches. After a search, the staff at the Personal Care Home were able to locate the BuSpar and the Lamictal, but they never located the Wellbutrin. On 07/08/2020, the patient was discovered on the floor of the Personal Care Home, unresponsive, and was transported to the local Emergency Department. Patient #1 was pronounced dead at 11:14 AM, approximately twenty-one (21) hours after discharge. The patient's cause of death was documented to be cardiac arrest, cause unknown-drug abuse. The Emergency Department records revealed three (3) different types of pills were found on the patient. According to the patient's guardian, the patient was not safe to have medication in his/her possession and the guardian was unaware that the facility was discharging the patient with any medications.

Refer to A0808.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure that the results of a discharge plan for one (1) of ten (10) sampled patients (Patient #1) were fully discussed with the patient's legal guardian. Patient #1 was admitted to the hospital's Behavioral Health Unit (BHU) on 06/29/2020 with suicidal and homicidal ideations and hallucinations. The patient, who had an appointed State Guardian, had a history of substance abuse and attempted suicide by overdose. On 07/07/2020, Patient #1 was discharged from the Behavioral Health Unit (BHU) with a one (1) month supply of medications that included Nicotene patches (for smoking cessation), BuSpar (anti-anxiety), Lamictal (anti-convulsant), and Wellbutrin (antidepressant); however, the State Guardian was not informed that the patient was discharged carrying these medications. The patient was transported by public transportation to the Personal Care Home (licensed facility for residents who need assistance with basic health and health related services but are able to manage most of the activities of daily living) where the patient previously resided. Upon arrival at the Personal Care Home, the patient denied receiving medications from the hospital other than the Nicotene patches. After a search, the staff at the Personal Care Home were able to locate the BuSpar and the Lamictal, but never located the Wellbutrin. On 07/08/2020, the patient was discovered on the floor of the Personal Care Home, unresponsive and was transported to the local Emergency Department and pronounced dead at 11:14 AM, approximately twenty-one (21) hours after discharge. The patient's cause of death was documented to be cardiac arrest, cause unknown-drug abuse. The Emergency Department records revealed three (3) different types of pills were found on the patient and many of the pills were identified by the hospital's pharmacist as Wellbutrin.

The findings include:

Review of the facility's policy, "Discharge Planning," revision date of January 2018, revealed each patient on the Behavioral Health Unit (BHU) will receive discharge planning which will aid the patient's transition into another phase of recovery. The policy further stated the patient, family, or legal guardian will participate and/or be able to verbalize the discharge plan.

Review of the medical record revealed Patient #1 was admitted on 06/29/2020 with a diagnosis of Paranoid Schizophrenia, chronic. The resident presented to the Emergency Department, from a Personal Care Home (PCH) with a report of suicidal and homicidal ideations and auditory hallucinations. Further review revealed the patient had a blood alcohol level of 74 mg/dl (milligrams per deciliter), with a reference range of 3 mg/dl or less.

Review of the Inpatient Psychiatry History and Physical (H&P), dated 06/30/2020, revealed Patient #1 required inpatient psychiatry for protection of self, observations, and medication management. The H&P also revealed the patient had a history of multiple hospitalizations and reported one previous suicide attempt by overdose in 2019.

Review of the Order of Appointment of Guardian, dated 01/14/2015, revealed Patient #1 was placed under full State Guardianship. Further review of the document revealed the patient was wholly disabled in managing both personal affairs and financial resources.

Review of the Nursing Admission Note, scribed by Registered Nurse (RN) #5 on 06/30/2020, revealed a contraband search revealed a rock with a pink and white residue on it and two (2) empty pen casings. The note further revealed the House Supervisor was contacted regarding the findings and the RN was instructed to throw them away.

Review of the Social Services Assessment, dated 06/30/2020, revealed that Patient #1 admitted to hearing voices and stated that he/she felt he/she might just need changes in medications.

Review of the Inpatient Master Treatment Plan for Patient #1, dated 06/30/2020, revealed an Admission diagnosis of Paranoid Schizophrenia. The plan also stated the patient had limited degree of insight, education/cognition, and motivation. The identified problems listed included the psychiatric diagnosis of Paranoid Schizophrenia and the medical issue of Substance Abuse Disorder.

Review of the Social Services Progress Note, dated 06/30/2020, revealed communication with the State Guardian and the agreement that Patient #1 could return to the PCH upon discharge from the BHU. Further review revealed a progress note, dated 07/07/2020, stating the patient would return to the PCH on this date (07/07/2020) and will receive therapy and medication management. The note also stated the State Guardian was notified of this information.

Review of the discharge instructions, dated 07/07/2020, revealed the resident had received medications and general instruction on dosage, route, scheduling, medication generic/brand names, purpose, medication precautions, side effects, food/drug interaction, smoking cessation, and when to call the care provider.

Review of the Emergency Department medical record, dated 07/08/2020, revealed Patient #1 was brought in by emergency medical services at 11:03 AM after responding to a call from the Personal Care Home. The patient was intubated and cardiopulmonary resuscitation (CPR) was in progress. The record also revealed two (2) oblong yellow pills were found in the front top pocket of the patient's bibs and a yellow sock was found in his/her left front pocket with the pills Lipitor and Wellbutrin, two (2) rocks, and a pipe inside. Further review of the record revealed the patient was pronounced dead at 11:14 AM and the diagnosis of cardiac arrest, cause unspecified-drug abuse was documented.

Interview with Registered Nurse (RN) #3 on 07/14/2020 at 10:55 AM, revealed she was the nurse in the Emergency Department of the local hospital where Patient #1 was transported on 07/08/2020. RN #3 stated the patient arrived in cardiac arrest with resuscitative measures being performed. Per the RN, they never got any cardiac activity and the patient was pronounced dead at 11:14 AM. She further stated the patient was noted to have pills in his/her pockets of clothing and a sock was found with two (2) rocks and some other pills. The hospital pharmacist identified two (2) of the pills as Lipitor and Wellbutrin. She stated there were multiple Wellbutrin pills, more than ten (10), found. RN #3 stated a drug screen (blood or urine) was not performed.

Interview with Patient #1's State Guardian/Complainant on 07/13/2020 at 2:35 PM, revealed she was the appointed guardian of Patient #1 since February 2020. She stated the patient resided at a PCH and had been admitted to the Behavior Health Unit related to suicidal/homicidal ideations. She stated she had spoken to the Discharge Planner/Social Worker, on 07/07/2020, and was informed the patient was being discharged back to the Personal Care Home on that day. The guardian then reported that later, on 07/07/2020, she received a call from Kentucky Medication Aide (KMA) #1 at the Personal Care Home that the patient had arrived at the home and had been sent with medications, but not all of the medications could be found. Per the State Guardian, she had not been informed by the Discharge Planner/Social Worker that Patient #1 would carry the medications from the hospital back to the PCH. She further stated she was sent a text message by the Personal Care Home on 07/08/2020 at 10:53 AM that the patient had been found unresponsive and was being transported to the Emergency Department at the local hospital. She stated she then contacted the hospital Emergency Department and was informed the patient expired at 11:14 AM; and RN #3 had told her it was due to a drug overdose.

A follow-up interview with the guardian on 07/15/2020 at 11:42 AM, revealed that she had spoken to the Discharge Planner/Social Worker on 07/07/2020 and was told Patient #1 was returning to the PCH, but she was not informed the patient was leaving with medications. The Guardian stated that had she been told (about the medications) it would have been of great concern to her, due to not only the patient's substance abuse but other residents' safety at the Personal Care Home as well.

Interview with the Kentucky Medication Aide (KMA) at the PCH on 07/13/2020 at 8:42 AM, revealed Patient #1 returned to the Personal Care Home between 1:00 PM and 1:30 PM on 07/07/2020. She stated the hospital had called and informed the PCH that the patient was returning. The KMA stated she had also spoken to the patient. Per the KMA, when the patient arrived at the PCH, the only thing he/she provided to her was a box of Nicotene patches. The KMA stated she asked the patient for the packet of information, which included the instructions and the written prescriptions. She revealed the patient stated he/she did not have anything else. Per the KMA, she then phoned the hospital's BHU and spoke with RN #1 who told her she had definitely sent the packet with Patient #1 as well as three (3) other medications. At this point, the KMA stated she immediately went to the patient and asked again about the packet and the medications. The patient denied having anything else. She then proceeded to search the patient's room and belongings. She stated she found prescription bottles of BuSpar and Lamictal in a coat pocket in the patient's closet. The KMA stated all of the Lamictal was present and four BuSpar pills were missing. She stated the Wellbutrin was not found.

Interview with the Social Worker/Discharge Planner on 07/13/2020 at 4:20 PM, revealed when she arranged for discharge, she communicated with the family, the facility where the patient resided, and any other entities needed for continued care of the patient. Per the Social Worker/Discharge Planner, she does not address medications as the nurse would address those issues. She further stated she was aware the patient left with medications and was aware the patient had a history of substance abuse.

A follow-up interview with the Social Worker on 07/15/2020 at 11:00 AM, revealed if a patient admitted to the BHU has a State Guardian, she initiated contact with the guardian as soon as possible. Per the Social Worker/Discharge Planner, upon discharge the guardian was notified of the patient leaving the BHU and how they were being transported. The Social Worker stated she does not inform the guardian that they are leaving with medications She stated she believed nurses were to notify the guardians regarding medications.

Interview with RN #1 on 07/14/2020 at 10:40 AM, revealed she was the nurse who discharged Patient #1 on 07/07/2020. She stated she sent the discharge information packet with the patient and he/she was discharged with the medications, BuSpar, Lamictal, and Wellbutrin. She also stated that typically they fax discharge information to the facility but she could not say for certain that was done when Patient #1 was discharged. Per RN #1, she received a call from the Personal Care Home on 07/07/2020 inquiring about Patient #1's discharge information. The RN stated she informed the PCH staff she had sent the discharge information and the medications with Patient #1 when discharged.

Follow-up interview on 07/16/2020 at 11:40 AM, revealed she did not speak to the State Guardian upon the discharge of this patient. She further stated that to her knowledge she had never been instructed to contact the State Guardian regarding medications.

Interview with RN #4 on 07/14/2020 at 11:17 AM, revealed on 07/07/2020 she transported Patient #1 to the hospital's pharmacy where the patient obtained the medications BuSpar, Lamictal, and Wellbutrin. She stated she assisted the patient to the transportation van and he/she had the discharge information and medications with him/her.

Interview with the Pharmacist on 07/14/2020 at 11:40 AM, revealed Patient #1 would have left the hospital on 07/07/2020 with four (4) bottles of medications, BuSpar 15 mg (milligrams), 30 pills, BuSpar 10 mg, 60 pills, Lamictal 25 mg, 60 pills, and Wellbutrin 100 mg, 90 pills, as well as a box of 28 Nicotene patches.

Interview with the Director of the Behavioral Health Unit on 07/14/2020 at 11:36 AM revealed Patient #1 had been admitted to another facility on 09/23/19 for snorting drugs and drinking, as well as paranoid thoughts. Further interview at 1:50 PM, revealed medications that would be considered for misuse would not be sent home with patients. Per the Director, some geriatric or intellectually disabled patients would not be discharged with medications on them.

Follow-up interview on 07/15/2020 at 2:50 PM, revealed that in lieu of Patient #1's history of substance abuse and admission with drug paraphernalia, the patient should not be discharged with medications without supervision.

Interview with the Nurse Practitioner on 07/14/2020 at 9:40 AM, revealed she was familiar with Patient #1 who had the diagnosis of Chronic Paranoid Schizophrenia and had multiple admissions for both suicidal and homicidal ideations. Per the Nurse Practitioner, she did not remember the patient having an overdose in 2019. The Nurse Practitioner stated she did not write the prescriptions for the patient at discharge so could not speak to what he/she left the hospital with; however, she stated that since she has been at the BHU patients were commonly sent home with medications. She further stated she felt the patient was safe discharging with medications as the patient was being transported directly to the Personal Care Home.

Interview with the Physician on 07/14/2020 at 1:20 PM, revealed he was familiar with Patient #1, but during this last admission the Nurse Practitioner had treated him/her. He stated everyone was discharged with medications so they would have medicine until they could get in for an appointment. The physician added that if there were any doubts related to the safety of this practice, then this would be addressed through the State Guardian. The physician also stated the patient had discharged with medications before and had not shown to abuse prescribed medications in the past.