HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that patients had the right to participate in the implementation of his or her plan of care. This was evidenced by the hospital failing to involve the patient in discharge planning for 3 of 3 sampled patients (Patient #1, 2, 3).
Findings:

Patient #1
Review of the medical record revealed an 17 year old female with admission date of 09/30/2024 with a diagnosis of major depression.

Review of the patient's treatment plan, signed off by S6MD on 11/25/2024, revealed that the patient improved with treatment and appointments were made with the patient's primary physician and for the local behavioral health center. The treatment plan revealed that the patient was discharged and accompanied by her guardian. There was no indication where the patient was discharged to.

Review of the nursing discharge summary dated 11/26/2024 at 2:20PM revealed the patient was being transferred to Hospital A (another behavioral health hospital).

There was no documentation in the record that the patient was involved in the discharge planning.

Patient #2
Review of the medical record revealed an 11 year old female who was admitted to the hospital on 10/02/2024 with admitting diagnosis of persistent mood (affective) disorders.

Review of S6MD's progress note dated 11/26/2024 revealed the patient was deemed stable for discharge and was discharging to Hospital A and all follow-up appointments to be managed by guardian.

Review of the nursing discharge summary dated 11/26/2024 revealed the patient was discharged to DCFS worker. Under "facility type", group home was indicated.

There was no documentation in the record that the patient was involved in the discharge planning.

Patient #3
Review of the medical record revealed an admission date of 08/31/2024 with diagnoses including major depression and suicidal ideations.

Review of the patient's discharge summary completed by S6MD, dated 11/26/2024 at 7:20AM, revealed that the patient's short term goals were met and the patient was discharging to Hospital A.

Review of the form titled, Discharge Continuing Care Plan, revealed that this plan was signed off by the nurse and physician on 11/26/2024 at 11:59AM, and stated that the patient was discharged home accompanied by guarantor.

There was no documentation in the record that the patient was involved in the discharge planning.


On 12/30/2024 at 3:00PM, interview with S2Transportation revealed that he drove the van that transported Patients #1, 2 and 3 to Hospital A on 11/26/2024. S2Transportation stated that he was told by the staff at the hospital not to tell the patients where they were being transferred to and stated that the patients thought they were going home. Further interview with S2Transportation revealed that after pulling up to Hospital A's campus, the patients saw the sign and became upset and eventually jumped out of the van and attempted to elope.

On 01/02/2025 at 9:30AM, interview with S4Discharge Planner revealed that Patients #1, 2 and 3 did jump from the transportation van when they arrived at Hospital A because they stated they did not want to go there. She also stated there was contradictory information in the above records regarding discharge plans. S4Discharge Planner confirmed that there was no evidence that Patients #1, 2, and 3 were involved in their discharge planning.


40957

Based on record review and interview, the hospital failed to ensure the QAPI program took actions aimed at performance improvement as evidenced by failing to implement a performance improvement plan for discharges after three patients eloped from the transport van while being transferred to another hospital (Patients #1, 2, 3).
Findings:

Review of the hospital policy titled, Case Management-Discharge Planning (Dec. 2023) revealed in part that this organization monitors the effectiveness and compliance of the proactive comprehensive discharge planning process by conducting record of care audits daily and/or per admission. The organization also conducts quality monitoring of completeness of the Discharge Continuing Care Plan daily and/or per discharge occurrence.


Patient #1
Review of the medical record revealed an 17 year old female with admission date of 09/30/2024 with a diagnosis of major depression.

Review of the nursing discharge summary dated 11/26/2024 at 2:20PM revealed the patient was being transferred to Hospital A (another behavioral health hospital).

Patient #2
Review of the medical record revealed an 11 year old female who was admitted to the hospital on 10/02/2024 with admitting diagnosis of persistent mood (affective) disorders.

Review of S6MD's progress note dated 11/26/2024 revealed the patient was deemed stable for discharge and was discharging to Hospital A.

Patient #3
Review of the medical record revealed an admission date of 08/31/2024 with diagnoses including major depression and suicidal ideations.

Review of the patient's discharge summary completed by S6MD, dated 11/26/2024 at 7:20AM, revealed that the patient's short term goals were met and the patient was discharging to Hospital A.

On 12/30/2024 at 3:00PM, interview with S2Transportation revealed that he drove the van that transported Patients #1, 2 and 3 to Hospital A on 11/26/2024. S2Transportation stated that he was told by the staff at the hospital not to tell the patients where they were being transferred to and stated that the patients thought they were going home. Further interview with S2Transportation revealed that after pulling up to Hospital A's campus, the patients saw the sign and became upset and eventually jumped out of the van and attempted to elope.

On 01/02/2025 at 9:30AM, interview with S4Discharge Planner revealed that Patients #1, 2, and 3 did jump from the transportation van when they arrived at Hospital A because they stated they did not want to go there. When asked if a quality improvement plan was implemented after the incident with the above patients to prevent future occurrences, she stated no. When asked if there was a current quality improvement plan that addressed discharges/discharge planning, she stated no.

Based on record review and interview, the hospital failed to ensure medical records for each patient are complete and accurately written for 3 of 3 records reviewed (Patient #1, 2, 3).
Findings:

Patient #1
Review of the medical record revealed a 17 year old female with admission date of 09/30/2024 and a discharge date of 11/26/2024.

Review of the patient's treatment plan, signed off by S6MD on 11/25/2024, revealed that the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented. There was no indication where the patient was discharged to.

Review of a form titled, Discharge Continuing Care Plan, dated 11/26/2024 at 2:13PM and completed by the RN revealed the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented.

Review of the nursing discharge summary dated 11/26/2024 at 2:20PM revealed the patient was being transferred to Hospital A (another behavioral health hospital).

On 12/30/2024 at 11:30AM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital's van) on 11/26/2024. She further confirmed that the patient was not accompanied by her guardian, as noted on the above Discharge Continuing Care Plan. S4Discharge Planner further confirmed that the above records were incomplete and/or inaccurate.

Patient #2
Review of the medical record revealed a 11 year old female with admission date of 10/02/2024 with a diagnosis of persistent mood (affective) disorders.

Review of the patient's discharge nursing summary dated 11/26/2024 revealed the patient was discharged to Group Home B with DCFS worker.

On 12/30/2024 at 2:15PM, interview with S4Discharge Planner revealed that the patient was not accepted to the group home but was transferred to Hospital A (per this hospital's van) on 11/26/2024. She further confirmed that the patient's discharge nursing summary was inaccurate.

Patient #3
Review of the medical record revealed a 10 year old female with admission date of 08/31/2024 with diagnoses including major depression and suicidal ideations.

Review of the patient's discharge summary completed by S6MD, dated 11/26/2024 at 7:20AM, revealed that the patient's short term goals were met and the patient was discharging to Hospital A.

Review of the form titled, Discharge Continuing Care Plan, revealed that this plan was signed off by the nurse and physician on 11/26/2024 at 11:59AM, and stated that the patient was discharged home accompanied by guarantor.

Review of the Close Observation form dated 11/26/2024 revealed the patient monitoring stopped at 3:00PM, with "discharged" written at that time. Review of the medical record revealed a group therapy note dated 11/26/2024 from 8:00PM - 8:11PM, stating the patient had fair participation. However, the patient had already been discharged from the hospital prior to that time.

On 12/30/2024 at 11:30AM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital's van) on 11/26/2024 and was not accompanied by her guarantor. She further stated that the group therapy note on 11/26/2024 at 8:00PM was inaccurate because the patient was not a patient at the hospital at that time. S4Discharge Planner further confirmed that the above records were contradictory and inaccurate.

Based on record review and interview, the hospital failed to ensure the discharge plan was updated and reflected any changes for 3 of 3 discharged patients reviewed (Patient #1, 2, 3).
Findings:

Review of the hospital policy titled, Case Management-Discharge Planning (Dec. 2023) revealed in part that reassessment of the discharge planning process is performed on an ongoing basis to determine the needs of each patient at the hospital.

Patient #1
Review of the medical record revealed a 17 year old female with admission date of 09/30/2024 with a diagnosis of major depression.

Review of the patient's treatment plan, signed off by S6MD on 11/25/2024, revealed that the patient improved with treatment and appointments were made with the patient's primary physician and for the local behavioral health center. The treatment plan revealed that the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented. There was no indication where the patient was discharged to.

Review of a form titled, Discharge Continuing Care Plan, dated 11/26/2024 at 2:13PM and completed by the RN revealed the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented.

Review of the nursing discharge summary dated 11/26/2024 at 2:20PM revealed the patient was being transferred to Hospital A (another behavioral health hospital).

There was no documentation in the record that Hospital A accepted Patient #1.

There was no documentation in the record of when the patient left the hospital or who the patient was accompanied by. There was also no documentation regarding who the patient was released to at Hospital A.

On 12/30/2024 at 11:30AM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital's van) on 11/26/2024 because this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. S4Discharge Planner confirmed that there was no documented evidence in the record of whom from Hospital A accepted Patient #1. She further stated that the patient had multiple notes regarding discharge plans but they were not updated and did not reflect changes that were made.

Patient #2
Review of the medical record revealed a 11 year old female with admission date of 10/02/2024 with a diagnosis of persistent mood (affective) disorders.

Review of the patient's discharge nursing summary dated 11/26/2024 revealed the patient was discharged to Group Home B with DCFS worker.

On 12/30/2024 at 2:15PM, interview with S4Discharge Planner revealed that the patient was not accepted to the group home but was transferred to Hospital A (per this hospital's van) on 11/26/2024. She stated that this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. S4Discharge Planner confirmed that there was no documented evidence in the record of whom from Hospital A accepted Patient #2. She further confirmed the patient's discharge plan was not updated or accurate.

Patient #3
Review of the medical record revealed a 10 year old female with admission date of 08/31/2024 with diagnoses including major depression and suicidal ideations.

Review of the patient's discharge summary completed by S6MD, dated 11/26/2024 at 7:20AM, revealed that the patient's short term goals were met and the patient was discharging to Hospital A.

Review of the form titled, Discharge Continuing Care Plan, revealed that this plan was signed off by the nurse and physician on 11/26/2024 at 11:59AM, and stated that the patient was discharged home accompanied by guarantor.

There was no documentation in the record that Hospital A accepted Patient #3.

There was no documentation in the record of when the patient left the hospital or who the patient was accompanied by. There was also no documentation regarding who the patient was released to at Hospital A.

Review of nurses notes dated 11/26/2024 at 1:57PM revealed "see discharge summary". The nurse did not document the time the patient left the hospital.

On 12/30/2024 at 11:30AM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital's van) on 11/26/2024 because this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. S4Discharge Planner confirmed that there was no documented evidence in the record of whom from Hospital A accepted Patient #3. She further stated that the patient had discharge planning notes regarding discharge plans for home and for Hospital A. S4Discharge Planner confirmed that the patient's discharge plans were not updated with changes.


40957

Based on record review and interview, the hospital failed to ensure an appropriate discharge plan was developed and implemented for 3 of 3 discharged patients reviewed (Patient #1, 2, 3).
Findings:

Patient #1
Review of the medical record revealed a 17 year old female with admission date of 09/30/2024 with a diagnosis of major depression.

Review of the contact log revealed the last contact note was dated 11/19/2024 when a voicemail message was left with the patient's DCFS worker. Contact note dated 11/15/2024 at 3:02PM revealed voicmail left with DCFS worker to get update on placement with updated discharge date of 11/16/2024.

Review of the patient's treatment plan, signed off by S6MD on 11/25/2024, revealed that the patient improved with treatment and appointments were made with the patient's primary physician and for the local behavioral health center. The treatment plan revealed that the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented. There was no indication where the patient was discharged to.

Review of a form titled, Discharge Continuting Care Plan, dated 11/26/2024 at 2:13PM and completed by the RN revealed the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented.

Review of the nursing discharge summary dated 11/26/2024 at 2:20PM revealed the patient was being transferred to Hospital A (another behavioral health hospital).

There was no documentation in the record that Hospital A accepted Patient #1 or that Hospital A was notified that the patient was clinically discharged and was only waiting for DCFS placement.

There was no documentation in the record of when the patient left the hospital or who the patient was accompanied by. There was also no documention regarding who the patient was released to at Hospital A.

On 12/30/2024 at 11:30AM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital's van) on 11/26/2024 because this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. She further confirmed that Patient #1 had been clinically discharged for a while and was only waiting for another DCFS placement. When asked if there was any documented evidence in the record that Hospital A was informed that the patient was clinically discharged and only waiting for DCFS placement, S4Discharge Planner stated no. She stated that she emailed all of the patient's records to Hospital A but none mentioned that patient was only awaiting DCFS placement.

S4Discharge Planner further confirmed that a "Transportation Sheet" was supposed to be completed on all transfers which included driver assigned to transport, name of facility, person releasing patient, person receiving patient and date/time and signatures of each person. She stated this form was not completed for Patient #1 and she was unsure exactly when the patient was transported or what staff at Hospital A received her.


Patient #2
Review of the medical record revealed a 11 year old female with admission date of 10/02/2024 with diagnoses including persistent mood (affective) disorders.

Review of the patient's discharge summary completed by S6MD, dated 11/26/2024 at 6:55AM, revealed that the patient's short term goals were met and the patient was stable for discharge. The patient was discharging to Hospital A and all follow-up appointments to be managed per guardian.

Review of the form titled, Discharge Continuing Care Plan, revaled that this plan was signed off by S4 Discharge Planner. S4 Disharge Planner signed off on 11/26/2024 at 5:48PM. The plan stated that Patient #2 was transferred to another facility. The physician signed off on 11/26/2024 at 12:03PM. Discharge, other, long term.

On 12/30/2024 at 2:30PM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital's van) on 11/26/2024 because this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. She further confirmed that Patient #2 had been clinically discharged and was only waiting for another DCFS placement. When asked if there was any documented evidence in the record that Hospital A was informed that the patient was clinically discharged and only waiting for DCFS placement, S4Discharge Planner stated no. She stated that she emailed all of the patient's records to Hospital A but none mentioned that patient was only awaiting DCFS placement.

S4Discharge Planner further confirmed that a "Transportation Sheet" was supposed to be completed on all transfers which included driver assigned to transport, name of facility, person releasing patient, person receiving patient and date/time and signatures of each person. She stated this form was not completed for Patient #2 and she was unsure exactly when the patient was transported or what staff at Hospital A received her.


Patient #3
Review of the medical record revealed a 10 year old female with admission date of 08/31/2024 with diagnoses including major depression and suicidal ideations.

Review of the contact log revealed the last contact note (by the therapist) was dated 11/21/2024 when the patient's DCFS worker was contacted to discuss placement with at discharge date of 11/16/2024. The therapist informed case worker that this hospital would no longer be able to house the patient after next week.

Review of the patient's discharge summary completed by S6MD, dated 11/26/2024 at 7:20AM, revealed that the patient's short term goals were met and the patient was discharging to Hospital A.

Review of the form titled, Discharge Continuing Care Plan, revaled that this plan was signed off by the nurse and physician on 11/26/2024 at 11:59AM, and stated that the patient was discharged home accompanied by guarantor.

Review of nurses notes dated 11/26/2024 at 1:57PM revealed "see discharge summary". The nurse did not document the time the patient left the hospital or who accompanied the patient.

On 12/30/2024 at 2:30PM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital's van) on 11/26/2024 because this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. She further confirmed that Patient #3 had been clinically discharged and was only waiting for another DCFS placement. When asked if there was any documented evidence in the record that Hospital A was informed that the patient was clinically discharged and only waiting for DCFS placement, S4Discharge Planner stated no. She stated that she emailed all of the patient's records to Hospital A but none mentioned that patient was only awaiting DCFS placement.

S4Discharge Planner further confirmed that a "Transportation Sheet" was supposed to be completed on all transfers which included driver assigned to transport, name of facility, person releasing patient, person receiving patient and date/time and signatures of each person. She stated this form was not completed for Patient #3 and she was unsure exactly when the patient was transported or what staff at Hospital A received her.





40957