HospitalInspections.org

Based on interview and record review the hospital failed to ensure 2 of 5 patients (Patient #2 and Patient #11) discharge planning met patient needs as evidenced by,

1) Patient #2 was admitted inpatient to [Hospital A] with identified mobility needs. Patient #2 required the use of an assistive device during hospital stay. The patient was discharged 06/08/16 with no assistive device and taken by taxi to a local shelter. Patient #2 was left at the shelter with no assistive device where she fell and required EMS (emergency medical services) to intervene and transport her to [Hospital B].

2) Patient #11 was admitted to the the hospital 01/28/17 after threatening a family member who resided with him with a machete. Patient #11 was discharged 02/06/17 at which time the hospital failed to provide family/individual therapy to address the relationship between the patient and family member prior to discharge. The patient was discharged home with no intervention between the two family members.

Findings Included:

1) Patient #2's 06/03/16 Activities Therapy Assessment reflected, "Depressed, staggered unable to walk straight..."

The 06/03/16 Nursing Progress Note timed at 1640 reflected, "Sitting in wheelchair for unstable gait...says she uses walker at home..."

The 06/04/16 Psychiatric Progress note timed at 0755 reflected, "Physical exam...gait and station...wheelchair."

The 06/06/16 Nursing Progress Notes timed at 1900 reflected, "Patient remains in wheelchair..."

The 06/08/16 Progress Note/Social Services dated 06/08/16 timed 1630 reflected, "The doctor said I'm going home today...discussed with patient that she may have to go to a shelter..."

The 06/08/16 Nursing Progress Notes timed at 1430 reflected, "Discharged to shelter with instructions, letter, and prescriptions...picked up by taxi..."

The Aftercare Plan/Instructions dated 06/08/16 timed at 1230 reflected, "Shelter...patient will see PCP (primary care provider) as needed for medical issues..." No documentation was found which indicated the patient required the need of an assistive device such as a wheelchair and/or walker nor that one was provided.


Hospital B's Psychiatric Evaluation for Patient #2 dated 06/08/16 timed at 1639 reflected, "Abandoned at shelter after being discharged from [Hospital A]...was discharged from [Hospital A] psych today, and now here for evaluation...presents with altered mental status admit for further monitoring, as well as social placement (social work is following)...with mild elevated ammonia..."

The Social Work note dated 06/08/16 timed at 1846 reflected, "Met with patient...says she was diagnosed with mental retardation...according to EMS (emergency medical services), the patient was discharged from [Hospital A] and sent in a cab to...Night Shelter...the patient was dropped off by the cab and was unable to stand and fell to the ground and was left there...staff from Shelter contacted EMS who transported the patient to [Hospital B]...a letter by [Hospital A] that accompanied the discharge paperwork from [Hospital A]...will assist with safe discharge planning as needed."

The 06/09/16 Inpatient Psychiatric Consult timed at 1411 reflected, "She does admit to having seizures...depressed mood...acute exacerbation of altered mental status."

The 06/11/16 Social Work Note timed at 1154 reflected, "Contacted...Group Home in regards to possible placement...home able to provide 24 hour care and supervision...female group home and they are able to administer medications and provide meals daily...at 1445...group home will accept patient...requested patient be discharged 06/12/16 in order to set up the equipment in her home such as a hoyer lift and a hospital bed...will continue to assist with safe discharge planning as needed...at 1556...patient stated she has difficulty walking due to having degenerative arthritis in all of her joints including her back...informed that physical therapy requested a wheelchair at discharge..."

On 02/8/17 at 1516 Personnel #9 was interviewed. Personnel #9 was asked to review the medical record. Personnel #9 stated the patient could ambulate as far as she knew. Personnel #9 was asked why the hospital provided a wheelchair for the patient while she was inpatient. Personnel #9 stated she did not know. Personnel #9 was asked why the patient was discharged to a shelter by taxi with decreased mobility and the patient needing the use of an assistive device. Personnel #9 reported she did not know.


2) Patient #11's High Risk Notification Alert dated 01/28/17 timed at 1435 reflected, "Last Thursday tried to harm sister with knife and gun..."

The 01/28/17 Comprehensive Psychiatric Evaluation reflected, "Patient reports lives with his sister who does not like the fact he drinks...reports this is the second time sister has called the police on him...social history...sister lives with him...initial plan of care...family therapy to stabilize home environment, interrupt crisis..."

The Discharge Planning Worksheet dated 01/28/17 timed 1345 reflected, "Patient does not have a psychiatrist and needs assistance in locating one for follow-up...does not have an individual therapist and needs assistance in locating one for follow-up."

Access Release To/Obtain document dated 01/28/17 timed at 1345 revealed Patient consent signed and sister allowed access to patient.

The Integrated Intake and Psychosocial Assessment dated 01/30/17 timed at 0855 reflected, "Reports feelings of depression and aggression...[patient] came at sister with a machete and has come at her with a gun...does not feel safe with [patient]...interventions...group therapy, individual therapy, family therapy...discharge planning needs/community involvement...family therapy, individual therapy...initial discharge plan...return home..."

The 02/01/17 Physician Progress Note reflected, "Reports his sister is giving him the cold shoulder...notes willingness to work with sister."

The 02/06/17 Case Management Notes reflected, "Spoke with patients sister...told her patient was discharging and coming home...informed would send by cab..."

The Aftercare Plan/Instructions dated 02/06/17 timed at 0945 reflected, "Living arrangements...own home...taxi...individual/family therapy [blank]."

On 02/08/17 at 1532 Personnel #9 was interviewed by telephone. Personnel #9 was asked to review Patient #11's medical record. Personnel #9 was asked why Patient #11's relationship with family member was not addressed prior to the patient being discharged back to the same home situation which contributed to his admission to the hospital. Personnel #9 verified no family/individual therapy was provided and offered no explanation as to the reason. Personnel #9 verified the medical record documentation. Personnel #9 stated she thought she wrote a note but could not find it in the medical record.

The hospital policy and procedure entitled, "Discharge/Aftercare Planning" with a review date of 09/2016 reflected, "Address the patient's and family's need for instructions about continued treatment...how progress made in the current level of care will continue after discharge...physical and psychiatric needs, financial needs, housing needs and/or placement issues...accessibility to community resources...personal support systems...follow-up appointments based on the patient's clinical needs...home is secure and safe of potential self harm items for the patients return."