HospitalInspections.org

Based on review of facility policy, grievance log and interviews the facility failed to properly investigate and document grievances/complaints for each month in 6 (August, September, October, November, December, January) of six months reviewed.

Review of the facility policy, Complaints and Grievances, last reviewed 07/2023, revealed when grievances are received, the Patient Advocate and/or Risk Manager will review, investigate, and resolve grievances and determine the appropriate response to the complainant. The Risk Manager/designee will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance. If a written response cannot be made within seven calendar days, the Risk Manager or Patient Advocate will inform the patient or his/her representative that the hospital is still working to resolve the grievance and a written response will be made within thirty (30) calendar days of receipt of the grievance.

Review of grievance log from 08/05/2023 to 02/14/2024 reveals 95 entries in the log. No letter or written response was documented to the complainant for 91 out of 94 entries. There were no complaints/grievances listed on the log after 01/18/2024.

During an interview with Staff G, Division President, on 2/13/24 between the hours of 12:00PM and 2:00PM, the grievance log was reviewed, and she stated that it is highly unlikely that no grievances or complaints were received [in that time period].

In an interview on 02/14/2024 at 2:00 PM, regarding Patient #5, Staff D, Risk Manager (RM) stated Staff C, Discharge Planner (DCP) had let her know that Department of Childrens and Families (Florida State Agency that investigates adult and child abuse and neglect) was in the building and was asking for information about Patient #5's discharge that occurred 01/11/2024. Then she notified Staff A, Director of Clinical services (DCS) of the situation; Staff A, DCS made calls and investigated when the breakdown occurred. There was no RCA (Root Cause Analysis) performed, we only met for meetings at the round table. There was a grievance filed with the ethics committee; I will get the information for you on it.
No information was provided.

Based on facility policy review, record review, and interviews, the facility failed to have an effective discharge plan for 3 (Patient #3, #4, #5) out of 7 patients reviewed for discharge planning, resulting in 1 patient (#5) being discharged without guardian notification and is currently listed as a missing person. Refer to A0808.

The facility provided an Immediate Jeopardy removal plan on 02/14/2024 which was accepted. This included Clinical staff, including Inpatient Clinicians, Therapists, Outpatient Clinicians, and Discharge Planners, to complete training on discharge planning and transitions of care. They will sign an attestation of understanding related to Clinical Expectation and Discharge Planning. All staff mentioned to complete this training prior to their next assigned shift unless working 02/14/2024 with expectation to complete prior to leaving current shift or be removed from their shifts until completion. This was verified by review of educational material and interviews of current staff working on site (4 Registered Nurses, 1 Licensed Practical nurse, 2 Therapists, 2 Discharge Planners, 2 Behavioral Health Technicians, and 1 Utilization Manager). The staff was able to explain the training received and the transition of care expectations for patients to discharge. Immediate Jeopardy was removed on 02/14/2024.

Based on facility policy review, medical record review, interviews, and review of Florida Department of Law Enforcement Missing and Endangered Persons Information Clearinghouse, the facility failed to establish appropriate discharge plans to ensure patient and patient representatives' involvement and provided appropriate follow up care in 3 (#3, #4, #5) out of 7 patients reviewed.

Findings included:

Review of facility policy, Discharge Planning, last reviewed 12/2023, revealed: The facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, to discharged to include: reason for transfer, referral or discharge, patients physical and psychosocial status, summary of care provided and progress toward goals, and community resources and referrals provided to the patient. Aftercare plans are communicated to the patient/family/legal representative or receiving facility/agency, as appropriate and documented in the medical record. A copy of the aftercare/discharge form is given to the patient/family/ legal representative or sent to the receiving facility/agency with the patient. In developing discharge aftercare plans, the following is assessed: Physical and psychiatric needs, housing and/or placement issues, social and recreational needs, accessibility to community resources, transportation problems related to after care treatment ...The discharge/aftercare plan is a multidisciplinary form and defines the following: Where the patient will live following discharge based on patient/family needs or wants. The level of care which the patient will be to (i.e., partial hospitalization, ...etc.) . . . All professionals who will follow-up with the patient, including medical follow-up, to monitor medications. State all appropriate recommendations and specific plans to include ...psychiatric, medical, case management, housing, ...and community resources available to meet these needs. The treatment team will develop a discharge plan with active participation from patient/family/legal representative. This post discharge plan shall be reviewed and signed by the patient/family/legal representative and by each member of the clinical treatment team responsible for reviewing the plan with the patient. A patients' inability or refusal to sign or participation in discharge planning and the patient's reason for such shall be documented on the plan.

A review of Patient #3's medical record showed he was admitted to the hospital on 12/22/2023 on a BA52 (a Baker Act is the Florida Mental Health Act, commonly referred to as the Baker Act, focuses on crisis services for individuals with mental illness.) Patient #3 was admitted to the hospital from an acute medical hospital in another county. Patient #3 was homeless and used a wheelchair for mobility. He was alert and oriented and capable of making his own decisions. A review of nursing progress notes reflected Patient #3 was discharged on 01/10/2024. The note reflected that he was refusing to engage in a conversation, yelling, cussing, and attempting to delay discharge. The note stated he received assistance from a staff member to escort him to the front where his ride was waiting. Review of Staff E, Therapist/ Discharge Planner's (T/DP) note dated 01/09/2024, showed she called a homeless shelter in another county, and no one answered. Patient #3 was supposed to be transported by a facility van, but the driver said he doesn't transport patients in wheelchairs. Attempts were made to contact his family, with no answer. The CFO (Chief Financial Officer) approved a [Ride Share Company] (a non-medical transportation company with an app that allows passengers to hail a ride and drivers to charge fares and get paid) transport. The CEO (Chief Executive Officer) said the best option was to send the patient to a shelter. Patient #3 was discharged to the homeless shelter via [Ride share Company]. A review of the discharge care plan provided to Patient #3 reflected Patient #3 needed after care appointments for medication management and for therapy/mental health. A note on the form indicated the patient refused to engage in the discharge instructions. He also had 4 prescriptions for medication and needed a follow up with a primary care physician and cardiologist.

In an interview conducted with the Director of Quality on 02/12/2024 at 03:47 PM, the Director of Quality said there was a video on social media. The video showed Patient #3 being dropped off at the homeless shelter. The driver from the [Ride share Company] was interviewed and said the patient didn't want to be there. The Director of Quality admitted there was no documentation in his record that another facility would not take him. The discharge planners are supposed to arrange placement and services. There are facility vans to take the patients where they want to go. If not, we send them in a [Ride share Company vehicle].

At 1:27 PM on 02/12/2024 an interview was conducted with Staff A, Director of Clinical Services (DCS). Staff A said there should at least have been some arrangements for Patient #3's follow up appointments. An assessment of his community resources should have been the least that was done. Staff A confirmed there was no documentation the homeless shelter was notified and agreed to take the patient.

On 02/12/23 at 4:14 PM an interview was conducted with Staff E, Therapist. She stated Patient # 3 was in a wheelchair. She was having difficulty finding placement for him. He had a lot of medical issues. She tried to get him into an Assisted Living Facility (ALF). The ALF denied him. There is only one ALF company that the facility uses. It has several different ALFs. Patient #3 discharged to a homeless shelter. The discharge planners make the follow-up appointments. Prescriptions are the nurses and providers responsibility. It was difficult. Staff E said she didn't know what to do. Staff E asked administration what to do. Staff E stated she was not provided case management or discharge planning orientation.

On 02/13/2024 at 9:25 AM an interview was conducted with the Division President (DP). The DP stated the CEO was terminated because of Patient #3 and #5. "We do not send a man who is in a wheelchair to a homeless shelter in a [Ride Share Company]." Staff E, Therapist wrote an inappropriate note in the patient's chart, but she wasn't equipped to address that circumstance and reached out for help, and they failed her.

On 02/14/2024 at 10:15 AM an interview was conducted with the Risk Manager (RM). The RM said the facility sent Patient #3 in a [Ride Share Company] versus the facility vehicle. The van cannot take wheelchairs. The patient arrived in a wheelchair, and he was going to discharge in a wheelchair. His wheelchair was an assistive device due to his neuropathy and pain. The outside records did not indicate he was wheelchair bound. There was not much documentation on the patient's involvement in the discharge process. "We don't send patients to a shelter that doesn't accept patients in wheelchairs. There was no proof they would accept a patient in a wheelchair." The risk manager said she was not aware there was a problem with discharging patients to shelters. She was under the assumption the shelter was a place where they would have a bed versus a street corner.


A review of the record for Patient #4 revealed he was admitted to the facility on 01/23/2024 under a BA52 (Baker Act), with multiple medical diagnoses including type 2 diabetes mellitus, right below the knee amputation (RBKA) with use of a wheelchair. Patient #4 was homeless. A review of the 01/25/2024 psychosocial assessment reflected Patient #4 wants to go to an ALF. A physician's note dated 01/30/2024 reflected the ALF can't take the patient until 01/31/2024, cancel discharge. The discharge care plan dated 01/30/2024 had no documentation reflecting where Patient #4 discharged to. The instructions reflected to follow up with his PCP (primary care physician) within 1 week. There were copies of prescriptions he was discharged with in the record. There was no documentation of any arrangements to obtain his medications or arrangement for his follow-up appointments. Further review of the record revealed an untitled, undated form indicating a planned discharge to a shelter in another county, with approval for a [Ride share Company] to transport. The initial discharge planning assessment dated 01/25/2024 reflected Patient #4 would like placement in ALF.

On 02/12/24 at 1:51 PM an interview was conducted with Staff E, Therapist. Staff E said she participates in discharge planning. Patient #4 was in a wheelchair. He said he wanted an ALF. He was living with his sister. They had an argument and he left. He did not want to go back there. Staff E said she called an ALF company they use to help with referrals to one of their ALFs. The owner came and met the patient. He noticed Patient #4 had an ulcer on his stump. The next day Staff E called the ALF and he said he would not take the patient because the patient wanted [narcotic pain medication] and they couldn't give that at the Alf. Patient #4 did not have access to his income, because he was from another state, and he didn't have any resources so that's why he was discharged to a shelter. Shelters are first come first serve. They don't hold beds. If they have a wheelchair a phone call is made to the shelter to see if they can take them. Staff E said she did call, and they didn't answer the phone at the shelter. It is a last resort after talking to the director about not being able to place him. It appeared he may have had medical issues. He had an amputated leg. Staff E said she had not heard the facility is responsible to assist with getting medications or appointments. She has worked in this role since July of 2023. She does not recall any requirement to know what the discharge policy says. She was trained by someone and had orientation from them and was provided an orientation packet.


Review of Patient #5's medical record showed Patient #5 was admitted on 01/05/2024 for Disorganized Schizophrenia after eloping from her ALF (Assisted Living Facility). Staff B /Social Worker/Therapist (SW/T) documented that she placed a call to Patient #5's ALF and learned Patient #5 cannot return there. Patient #5 was given a 45- day notice and the last day was believed to be 01/24/2024. Patient #5 has a guardian who is aware and reportedly working on finding her a placement. The guardian's name and phone number were noted in the chart. Staff B placed a call to the guardian, but he stated he needed to call Staff B back; facility number provided. Staff B placed legal guardian paperwork in the chart and informed the interdisciplinary team during huddle (meeting) the paperwork is on the chart. Staff C/ Discharge Planner (DCP) discharged patient on 01/11/2024 to a homeless shelter in another county.

In an interview with Staff A, DCS on 02/12/2024 at 1:09 PM, Staff A, DCS stated [the guardian agency] filed a complaint/grievance and he called to speak to the guardian. The guardian told him that he needed to see the chart and the records were sent to him. Staff A stated he investigated the chart. He then went to Staff B, Social Worker/Therapist (SW/T), and she said she was made aware Patient #5 had a guardian and she told him she needed the paperwork. The paperwork was sent in, and Staff B, SW/T said she put it in the chart. Staff B, SW/T informed the discharge planner. Staff C, DCP did not see the paperwork in the chart, so he set up discharge to the homeless shelter in another county. Staff B, SW/T did document the guardian paperwork was placed in chart, but Staff C, DCP did not see the note from Staff B, SW/T. Staff C, DCP did not read the social workers notes prior to setting up location and transportation for discharge. "The guardian, told me that he was going to file a formal complaint with the state, and I knew AHCA (Agency for Healthcare Administration) was going to be coming in again soon."

In an interview with Staff B, SW/T on 02/12/2024 at 2:55 PM, Staff B, SW/T stated Patient #5 was being discharged. I made contact with the ALF she came from and was told she couldn't come back, and that she had a legal guardian. Even though they said 01/24/2024 is the last day she can stay there, they still would not accept her back. I contacted the guardian again when she was being discharged but he did not have a place for her to go to yet. The patient expressed wanting to go to [another County], so I told the guardian. He said he did not want her discharged there and not to discharge her because he is working on placement. I told the team that in the morning huddle. The guardian sent over the paperwork for the legal guardianship. I printed the paperwork and put it in the chart.

In an interview with Staff C, DCP (Discharge Planner) on 02/12/2024 at 3:15 PM, Staff C, DCP stated Patient #5 was on Unit A and there was talk about discharge. I was getting ready to set Patient #5 up to go back to her ALF but got notice she could not go back. I let the patient know she can't go back but she stated she is willing to go to a shelter in [another County] because she knows people in [another County]. So, I set up transport for her and she left. I didn't see anything in her chart regarding a guardian. Sometimes I look through the chart, but I do rely on the information communicated in the huddles.

In an interview with Staff D, Risk Manager (RM) on 02/14/2024 at 2:00 PM, Staff D stated Staff C, DCP called and said DCF (Department of Children and Families - State Agency that investigates abuse) was in the building and was asking for information about Patient #5's discharge. He confirmed it was ok to give the information, then notified Staff A, DCS of the situation. Staff A, DCS made all the calls and investigated when the breakdown occurred. "I did not perform an RCA (Root Cause Analysis); I only met for meetings at the round table. I did not feel it was necessary. I do know the patient is a missing person but did not feel the situation needed to be investigated. There was a grievance filed with the ethics committee; I will get the information for you on it."
No information was provided.

A review of FDLE (Florida Department of Law Enforcement) missing and endangered persons information clearing house, Patient #5 is listed as a purple alert missing person as of 02/15/2024. The Florida Purple Alert is used to assist in the location of missing adults suffering from a mental or cognitive disability that is not Alzheimer's disease or a dementia-related disorder; an intellectual disability or a developmental disability; a brain injury; other physical, mental or emotional disabilities that are not related to substance abuse; or a combination of any of these and whose disappearance poses a credible threat of immediate danger or seriously bodily harm.

Based on facility policy review, record review, interviews and review of job description, the facility failed to ensure social services were involved in discharge planning to arrange appropriate follow up care and exchange of information with sources outside the hospital in 3 (#3, #4, #5) out of 7 patients reviewed for discharge planning.

Findings included:

Review of facility policy, Discharge Planning reviewed 12/2023, stated the facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, to discharged to include: reason for transfer, referral or discharge, patients physical and psychosocial status, summary of care provided and progress toward goals, and community resources and referrals provided to the patient. The physician, therapist, and discharge planner with the support of nursing, coordinate the discharge arrangements with the patient and family. Certain dispositions/discharge needs may be considered for the patient, including a return to the home, placement in an ALF or SNF, partial hospitalization, outpatient therapy ...transportation, medical follow up ... Aftercare plans are communicated to the patient/family/legal representative or receiving facility/agency, as appropriate and documented in the medical record. A copy of the aftercare/discharge form is given to the patient/family/ legal representative or sent to the receiving facility/agency with the patient. The treatment team will develop a discharge plan with active participation from patient/family/legal representative. This post discharge plan shall be reviewed and signed by the patient/family/legal representative and by each member of the clinical treatment team responsible for reviewing the plan with the patient. A patients' inability or refusal to sign or participation in discharge planning and the patient reason for such, shall be documented on the plan.


A review of Patient #3's medical record showed he was admitted to the hospital on 12/22/2023 on BA52 (Baker Act- The Florida Mental Health Act, commonly referred to as the Baker Act, focuses on crisis services for individuals with mental illness.) Patient #3 was admitted to the hospital from an acute medical hospital in another county. Patient #3 was homeless and used a wheelchair for mobility. He was alert and oriented and capable of making his own decisions. A review of nursing progress notes reflected Patient #3 was discharged on 1/10/2024. The note reflected he was refusing to engage in a conversation, yelling, cussing, and attempting to delay discharge. Received assistance from staff member to escort him to the front where his ride was waiting. Review of the discharge planner's (Staff E, Therapist) note dated 1/9/2024, showed she called a homeless shelter in another county, and no one answered. Patient #3 was supposed to be transported by a facility van, but the driver said he doesn't transport patients in wheelchairs. Attempts made to contact his family, no answer. CFO (Chief Financial Officer) approved a [Ride Share Company] transport. CEO (Chief Executive Officer) said the best option was to send the patient to a shelter. The patient was discharged to a homeless shelter via [Ride share Company], (a non-medical transportation company with an app that allows passengers to hail a ride and drivers to charge fares and get paid). A review of the discharge care plan provided to Patient #3, reflected Patient #3 needed after care appointments for medication management and for therapy/mental health. A note on the form indicated the patient refused to engage in the discharge instructions. He had 4 prescriptions for medication and needed a follow up with a primary care physician and cardiologist.

An interview was conducted with the Director of Quality on 02/12/2024 at 3:47 PM. The Director of Quality said there was a video on social media. The video showed Patient #3 being dropped off at a homeless shelter. The driver from the [Ride share Company] was interviewed and said the patient didn't want to be there. The Director of Quality admitted here was no documentation in his record that another facility would not take him. The discharge planners are supposed to arrange placement and services. There are facility vans to take the patients where they want to go. If not, we send them in a [Ride share Company vehicle].

At 1:27 PM on 02/12/2024 an interview was conducted with Staff A, Director of Clinical Services. Staff A said there should at least have been some arrangements for Patient #3's follow up appointments. An assessment of his community resources should have been the least that was done. Staff A confirmed there was no documentation the homeless shelter was notified and agreed to take the patient.

On 02/12/23 at 4:14 PM an interview was conducted with Staff E, Therapist. Patient # 3 was in a wheelchair. Staff A said she was having difficulty finding placement for him. He had a lot of medical issues. She tried to get him into an ALF (Assisted Living Facility). The ALF denied him. There is only one ALF company that the facility uses. It has several different ALFs. Patient #3 discharged to a homeless shelter. The discharge planners make the follow up appointments. Prescriptions are the nurses and providers responsibility. It was difficult. Staff E said she didn't know what to do. Staff A asked administration what to do. Staff A stated she was not provided case management or discharge planning orientation.

On 02/13/2024 at 9:25 AM an interview was conducted with the Division President (DP). The DP stated the CEO (Chief Executive Officer) was terminated because of Patient #3 and 5. "We do not send a man who is in a wheelchair to a homeless shelter in a [Ride Share Company vehicle]." Staff E, Therapist wrote an inappropriate note in the patient's chart, but she wasn't equipped to address that circumstance and reached out for help, and they failed her. Every discharge is reviewed every morning in [morning meeting].

On 02/14/2024 at 10:15 AM an interview was conducted with the Risk Manager (RM). The RM said the facility sent Patient #3 in a [Ride Share Company] versus the facility vehicle. The van cannot take wheelchairs. The patient arrived in a wheelchair, and he was going to discharge in a wheelchair. His wheelchair was an assistive device due to his neuropathy and pain. There was not much documentation on the patient's involvement in the discharge process. "We don't send patients to a shelter that doesn't accept patients in wheelchairs. There was no proof they would accept a patient in a wheelchair." The risk manager said she was not aware there was a problem with discharging patients to shelters. She was under the assumption the shelter was a place where they would have a bed versus a street corner.

A review of the record for Patient #4 revealed he was admitted to the facility on 01/23/2024 under a BA52 (Baker Act), with multiple medical diagnoses including type 2 diabetes mellitus, right below the knee amputation (RBKA) with use of a wheelchair. Patient #4 was also homeless. A review of the 01/25/2024 psychosocial assessment reflected Patient #4 wants to go to an ALF. A physician's note dated 01/30/2024 reflected the ALF can't take patient until 01/31/2024, cancel discharge. The discharge care plan dated 01/30/2024 had no documentation reflecting where Patient #4 discharged to. The instructions reflected to follow up with his Primary Care Physician within 1 week. There were copies of prescriptions he was discharged with in the record. There was no documentation of any arrangements to obtain his medications or arrangement for his follow up appointments. Further review of the record revealed an untitled, undated form indicating a planned discharge to a shelter in another county, with approval for a [Ride share Company] to transport. The initial discharge planning assessment dated 1/25/2024 reflected Patient #4 would like placement in ALF.

On 2/12/24 at 1:51 PM an interview was conducted with Staff E, Therapist. Staff E said she participates in discharge planning. Patient #4 was in a wheelchair. He said he wanted an ALF. He was living with his sister. They had an argument and he left. He did not want to go back there. Staff E said she called an ALF company they use to help with referrals to one of their ALFs. The owner came and met the patient. He noticed Patient #4 had an ulcer on his stump. The next day Staff E called the ALF and he said he wouldn't take the patient because the patient wanted [a narcotic pain medication] and they couldn't give that at the ALF. Patient #4 did not have access to his income, because he was from another state, and he didn't have any resources so that's why he was discharged to a shelter. Shelters are first come first serve. They don't hold beds. If they have a wheelchair a phone call is made to the shelter to see if they can take them. Staff E said she did call and they didn't answer the phone at the shelter. It is a last resort after talking to the director about not being able to place him. It appeared he may have had medical issues. He had an amputated leg. Staff E said she had not heard the facility is responsible to assist with getting medications or appointments. She has worked in this role since July of 2023. She does not recall any requirement to know what the discharge policy says. She was trained by someone and had orientation from them and was provided an orientation packet.

Review of Patient #5's medical record, Patient #5 was admitted on 01/05/2024 for Disorganized Schizophrenia after eloping from her ALF (Assisted Living Facility). Staff B /Social Worker/Therapist (SW/T) documented she placed a call to Patient #5's ALF and learned Patient #5 cannot return there. Patient #5 was given a 45- day notice and the last day was believed to be 01/24/2024. Patient #5 has a guardian who is aware and reportedly working on finding her a placement. The guardian's name and phone number was noted in the chart. Staff B placed a call to the guardian, but he stated he needed to call Staff B back; facility number provided. Staff B placed legal guardian paperwork in chart and informed the interdisciplinary team during huddle (meeting) the paperwork is on the chart. Staff C/ Discharge Planner (DCP) discharged patient on 01/11/2024 to a homeless shelter in another county.

In an interview with Staff B, SW/T on 02/12/2024 at 2:55 PM, Staff B/SW/T stated Patient #5 was being discharged. I made contact with the ALF she came from and was told she couldn't come back, and that she had a legal guardian. Even though they said January 24th is the last day she can stay there, they still would not accept her back. I contacted the guardian again when she was being discharged but he did not have a place for her to go to yet. The patient expressed wanting to go to [another county], so I told the guardian. He said he did not want her discharged there and not to discharge her because he is working on placement. I told the team that in the morning huddle. The guardian sent over the paperwork for the legal guardianship. I printed the paperwork and put it in the chart.

In an interview with Staff C, DCP on 02/12/2024 at 3:15 PM, Staff C/DCP stated Patient #5 was on Unit A and there was talk about discharge. I was getting ready to set Patient #5 up to go back to her ALF but got notice she could not go back. I let the patient know she can't go back but she stated she is willing to go to [a homeless shelter] in [another County] because she knows people there. So, I set up transport for her and she left. I didn't see anything in her chart regarding a guardian. Sometimes I look through the chart, but I do rely on the information communicated in the huddles.

A review of the job description for Staff E, therapist revealed: Essential functions: May perform case management, discharge or after care planning as needed.