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Based on interview and documentation review, the hospital was found to be out of compliance with the Condition of Participation for Discharge Planning at CFR 482.43. The hospital failed to ensure the discharge plan provided for the safety and medication needs for 1 of 10 patients reviewed for discharge planning (P1) who was on a commitment status and required monitoring of medications. Refer to deficiency issued at A-0820.

Based on documentation review and interviews the hospital failed to ensure the discharge planning standards required for 1 of 10 patients (P1) reviewed were implemented as appropriate, safe, and met the patient's needs. P1 was on a commitment status and required medication administration monitoring by her group home staff. The hospital discharged her to a shelter and failed to ensure she would be accepted at the homeless shelter and monitored according to her needs. Findings include:
Review of P1 ' s medical record revealed P1 presented to the hospital from a group home on the evening of September 29, 2013. P1 ' s diagnoses included mild intellectual impairment, major depression, non-insulin dependent diabetes mellitus and a maladaptive interpersonal style. P1 was accompanied to the hospital by law enforcement due to exhibiting aggressive behaviors and endorsing suicide ideation with a plan. P1 was seen in the emergency department. P1 declined to give any contact information at that time. Documents provided by law enforcement indicated P1 resided at a group home. P1 could not contract for safety. P1 was admitted to a psychiatric unit for safety and further evaluation of suicidal ideation with a plan. Her admitting diagnoses were depression and suicidal ideation. The hospital form titled Emergency Department Visit Note dated September 29, 2013 at 9:31 p.m. indicated that P1 ' s group home monitors her medication administration. The hospital form titled Regions Hospital Inpatient Psychiatric History, Physical, and Same Day Discharge, dated September 30, 2013 at 6:43 a.m. indicated the psychiatrist evaluated P1 and determined she did not require inpatient hospitalization. The psychiatrist gave P1 the options of participating in group to learn better coping skills, return to her group home, or discharge to a homeless shelter. She chose the third option to discharge to a shelter. P1 told the psychiatrist she did not want to go back to the group home. This documentation note also indicated P1 had a current commitment status. The psychiatrist ordered P1 to discharge to a shelter. The social worker began discharge planning.

The hospital form titled BH Social Work Initial Assessment, dated September 30, 2013 at 7:55 a.m. indicated the social worker spoke with P1's case manager who said P1 was under a commitment and cannot go to a shelter. The case manager also told the social worker it would be counter therapeutic for P1 to discharge to a shelter. Discharge nursing note dated September 30, 2013 revealed P1 discharged to a shelter at 2:00 p.m. P1 was on the psychiatric unit for 15 hours before she was discharged from the hospital to the homeless shelter.

An interview was conducted with P1's guardian-W on December 4, 2013, who stated she called the hospital back after she received a message from the hospital on September 30, 2013. The message said that P1 was being discharged from the hospital to another facility. Guardian-W said she told the hospital staff P1 was not to be released to another facility besides the group home. She asked to speak with the psychiatrist but was unable to do so. Guardian -W stated she told the hospital staff P1 was a vulnerable adult and was under commitment, had a risk management plan, and was not to be in the community alone. The hospital staff told guardian- W that P1 was already going to the taxi to be transported to the shelter. Guardian-W stated she contacted the shelter and was told the shelter would not accept P1. The shelter only accepted families. Guardian-W stated she was aware that case manager-V had spoken with the hospital staff but the hospital still released P1 even even though P1 was a vulnerable adult who lived in a group home. An interview was conducted on November 26, 2013 at 9:16 a.m. with P1's case manager-V who stated she told the hospital staff who contacted her that shelter placement was totally inappropriate. P1 should not be sent to a shelter given the nature of her diagnoses and vulnerability. P1 has mild intellectual disability and borderline personality diagnoses, is under commitment as a danger to self and or others. Case manager-V said she told hospital staff P1 was under a commitment. The hospital staff did not ask for the commitment documentation. Case manager-V stated P1 has a long history of wanting to be at a hospital and will say anything to stay at a hospital. Case manager-V also stated P1 presents herself as high functioning and is very good at creating how to get what she thinks she needs. P1 became out of control at some point after she went to a second shelter. P1 was then transported to a second hospital. The group home staff transported P1 back to her prior residence, the group home, from a second hospital the day after discharge from Regions Hospital. An interview was conducted on November 4, 2013 at 9:52 a.m. with group home manager-U. Group home manager-U stated that on September 30, 2013, P1 went to the shelter the hospital discharged her to but that shelter did not accept her. P1 walked to a second shelter which did not accept her. At the second shelter P1 decompressed and this shelter called for emergency medical assistance. Emergency medical transport took P1 to a second hospital. P1 had no food or medications after being discharged from the hospital until she was evaluated at the second hospital. Group home manager-U also said the group home wanted to take P1 back but needed a day or two to get adequate staff to meet P1 ' s behavior needs. P1 has a history of wanting to be hospitalized and attention seeking. P1 had a mentally ill/developmental disability commitment to a group home. The next day group home staff transported P1 back to the group home from the second hospital.

An interview was conducted with hospital social worker (SW)-J on November 13, 2013 at 1:53 p.m. SW-J stated P1 declined to go back to the group home where she previously resided. Discharge plan was to discharge P1 to a shelter on September 30, 2013. P1 was given a choice of a shelter and she chose Mary' s Place from a list of shelters. SW-J spoke with P1's case manager and left a message about the discharge plan for P1's guardian. P1 was voluntary at the hospital, although SW-J stated she was told P1 was on a commitment status at the group home where she resided. SW-J did not contact the shelter. SW-J was not aware if the shelter had any beds available or what type of clientele the shelter served. SW-J also stated she was not aware of the services provided by the shelter P1 chose.Documentation from the second hospital established P1 presented to the emergency department with abdominal pain, nausea and vomiting on September 30, 2013 at 1831. After evaluation and treatment with pain medications, the hospital determined P1 was on a commitment and would be admitted until the group home staff were able to meet her needs. The group home staff transported P1 back to the group home the next day .The Criteria Based Job Description for the Hospital Social Worker, dated 4/5/2011, " 1.b.ii. Established and implements care plans to ensure safety, continuity of care, and appropriate treatment after discharge from hospital, working with community providers and resources as needed. " The hospital staff did not follow the case manager's recommendations and did not ensure the shelter chosen provided the needed services for P1, including accepting P1 and monitoring P1 ' s medications. This failure was a lack of implementation of P1 ' s discharge plan and led to a second hospitalization in one day.