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Based on record review and interview, the facility failed to ensure compliance with the Condition of Participation of Patient Rights as evidenced by:

1. Failing to ensure allegations of abuse and/or neglect were thoroughly investigated for 2 (#1, #10) of 2 grievances reviewed; and failing to ensure appropriate state agencies were notified of allegations of abuse and/or neglect. (See findings at A0145)

2. Failing to ensure the effective implementation of the grievance process for 2 (#1, #10) of 2 grievances reviewed as evidenced by the hospital's failure to address patient grievances in a timely manner and failing to inform patients of any resolution to their grievances. (See findings at A0119)

Based on record review and interview, the hospital failed to ensure the effective implementation of the grievance process for 2 (#1, #10) of 2 grievances reviewed. This was evidenced by the hospital's failure to address patient grievances in a timely manner and failing to inform patients of any resolution to their grievances. Findings:

Review of the policy titled Patient Grievance, Document Number RI-00-011, revised date 07/20/15 revealed in part: Procedure, 2. The Patient Advocate/designee: will record the concern/grievance on the designated tracking tool. -summarize the unresolved concern on the Grievance Process Tool. -immediately review and assess any reported abuse/neglect. 3. The Patient Advocate or CEO/designee will review the grievance and complete the following: -establish a date by which time a response is expected. If grievances are not resolved within (7) days the patient will be notified the Patient Advocate is still processing the grievance and provided the expected date of resolution. 4. The Director/Manager to whom follow-up assigned will: -investigate the grievance within (2) days ...record findings of the investigation on the Grievance Process Tool and return to patient Advocate. 5. The Patient Advocate will: -mail a written report (certified by mail) if the complainant is not the patient or the patient has been discharged.

1. Record review on 09/08/15 at 10:40 a.m. revealed patient #1 was admitted to the hospital on 08/21/15 with a diagnosis of Intermittent Explosive Disorder, Defiant Disorder, and ADHD.

Review of the Hospital Grievance Log for August 2015 on 09/08/15 at 10:10 a.m. revealed a grievance for patient #1 was received on 08/28/15. There was no date of resolution to this grievance.

Interview on 09/08/15 at 10:30 a.m. with S2DON and S3PI/RM stated that the hospital had first learned of the incident on 08/26/15 by a telephone conversation with the mother of patient #1. S3PI/RM reported that the investigation about the alleged grievance on 08/26/15 relating to patient #1 was still under investigation because the hospital has not received anything from Police Department "A". When asked where S3PI/RM was in the process of the investigation report regarding the incident involving patient #1, S3PI/RM replied that she had not received any documentation from Police Department "A" and had not completed the investigation.

2. Record review on 09/10/15 revealed patient #10 was admitted to the hospital on 04/09/15 with a diagnosis of Explosive Disorder and ADHD (Attention Deficit Hyperactivity Disorder). Patient #10 was discharged on 04/17/15.

Review of the Hospital Grievance Log for May 2015 revealed a grievance was received on 05/01/15 for patient #10. Documentation on the grievance log revealed the grievance was resolved on 06/10/15.

Interview on 09/09/15 at 2:45 p.m. with S3PI/RM revealed that the hospital had first been contacted by Children Family Services on 05/07/15 about the allegation of abuse involving patient #10. All of the documentation about the investigation had been recorded on a Witness Statement form; however, no resolution was identified in the documents presented relative to the investigation.

Interview on 09/10/15 at 1:30 p.m. with S2DON revealed that there had been no resolution letters sent to the family and/or patient after the investigation.

Based on record review and interview, the hospital failed to ensure the effective implementation of the grievance process for 2 (#1, #10) of 2 grievances reviewed. This was evidenced by the hospital's failure provide a written notice of its decision relative to the hospital's internal investigation that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
Findings:
Review of the policy titled Patient Grievance, Document Number RI-00-011, revised date 07/20/15 revealed in part: Procedure, 5. The Patient Advocate will: -Complete a written report on the Grievance Resolution Form. Report to the patient should contain the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, results of the grievance and date of completion. -mail a written report (certified by mail) if the complainant is not the patient or the patient has been discharged.

1. Review of the Hospital Grievance Log for August 2015 on 09/08/15 at 10:10 a.m. revealed a grievance for patient #1 was received on 08/28/15. There was no date of resolution to this grievance.

Interview on 09/08/15 at 10:30 a.m. with S3PI/RM revealed that she had not sent any letter to the patient because the investigation had not been completed.

2. Review of the Hospital Grievance Log for May 2015 on 09/08/15 at 10:10 a.m. revealed a grievance for patient #10 was received on 05/01/15 and marked resolved on 06/10/15.

Interview on 09/10/15 at 1:30 p.m. with S2DON revealed that no resolution letter was sent to the patient and/or patient representative after the grievance investigation was conducted on 06/10/15.

Based on observation and interview, the hospital failed to ensure that patients were provided privacy during personal bathing (shower) by having no shower curtains for the showers on the adult units. This deficient practice affected a total of 20 of 24 patients who were currently admitted to the Detoxify Unit (8) and Adult (male/female) Unit (16).
Findings:

Observation of the Hospital Adult Units on 09/08/15 at 10:30 a.m. revealed rooms are semiprivate (2) with one shower shared between each patient. No shower curtains were noted.

Detoxify Unit 4:
Room # 911 & #913

Adult (female & male) Unit:
Room #601, #602, #603, #604, #605, #606, #607, & #608.

In an interview on 09/08/15 at 10:30 a.m., S3PI/RM indicated that the shower curtains had been removed several weeks ago by the MHTs. S3PI/RM indicated that the curtains were removed from the rooms after patients were reporting pulling them down after showering. S3PI/RM indicated without shower curtains, the hospital failed to provide privacy during personal bathing (shower).

In an interview on 09/08/15 at 3:45 p.m., S2DON indicated she was aware that showers on the Adult Units were missing curtains and would have to be replaced.

Based on record review and interview, the hospital failed to ensure

1) allegations of abuse and/or neglect were thoroughly investigated for 2 (#1, #10) of 2 grievances reviewed; and

2) appropriate state agencies were notified regarding incidents of abuse and/or neglect. Findings:

1. Failing to ensure allegations of abuse and/or neglect were thoroughly investigated.
a) Review of Incident Report dated 08/23/15 that had been documented by S14LPN and revealed that patient #1 had gotten into a physical altercation with another patient and received multiple punches before MHT's broke them up. Further review had revealed under the nursing evaluation patient #1 had a small laceration to his upper nose, denied pain, offered Tylenol and ice pack, patient refused. Patient #1 was given an injection of Thorazine and Benadryl at that time.

Review of the Hospital Grievance Log for August 2015 on 09/08/15 at 10:10 a.m. revealed a grievance for patient #1 was received on 08/28/15. There was no date of resolution to this grievance.

Interview on 09/08/15 at 10:30 a.m. with S2DON and S3PI/RM stated that the hospital had first learned of the allegation of Abuse on 08/26/15 by a telephone conversation with the mother of patient #1.

Review of the policy titled Patient Grievance, Document Number RI-00-011, revised date 07/20/15 revealed in part: Procedure, 2. The Patient Advocate/designee: -will record the concern/grievance on the designated tracking tool. -summarize the unresolved concern on the Grievance Process Tool. -immediately review and assess any reported abuse/neglect. 3. The Patient Advocate or CEO/designee will review the grievance and complete the following: -establish a date by which time a response is expected. If grievances are not resolved within (7) days the patient will be notified the Patient Advocate is still processing the grievance and provided the expected date of resolution. 4. The Director/Manager to whom follow-up assigned will: -investigate the grievance within (2) days ...record findings of the investigation on the Grievance Process Tool and return to patient Advocate. 5. The Patient Advocate will: -mail a written report (certified by mail) if the complainant is not the patient or the patient has been discharged.

Interview on 09/08/15 at 10:30 a.m. with S3PI/RM confirmed that the hospital had not completed their investigation for patient #1. S3PI/RM indicated that the investigation was not complete because they had not received any documentation from Police Department "A " concerning the matter. S3PI/RM further confirmed that she had no documentation that included steps taken or the results of the investigation process.

b) Review of the Hospital Grievance Log for May 2015 on 09/08/15 at 10:10 a.m. revealed an allegation of Abuse from Children and Family Services for patient #10 that was received on 05/01/15 and marked resolved on 06/10/15.

Interview on 09/09/15 at 2:45 p.m. with S3PI/RM revealed that she was new to her position and was not aware of the hospital's grievance process. S3PI/RM confirmed there was no documentation that included the steps taken to investigate the allegation of Abuse, the investigation process, or the resolution for the allegation of abuse involving patient #10. S3PI/RM gave this surveyor a letter from Children and Family Services dated 06/10/15 stating the Offices of Community Services investigation had been completed and the findings for this investigation was invalid. S3PI/RM further stated that she was unaware since another agency was investigating a grievance that she had to also thoroughly investigate the grievance.


2. Failing to ensure appropriate agencies were notified regarding incidents of abuse and/or neglect.

a) Interview on 09/08/15 at 10:30 a.m. with S2DON and S3PI/RM revealed that the hospital first learned of the allegation of Abuse on 08/26/15 by a telephone conversation with the mother of patient #1. S3PI/RM confirmed that the investigation about the alleged Abuse on 08/26/15 was still under investigation because the hospital has not received any information from Police Department "A". Surveyor asked where S3PI/RM was in the process of the investigation report, and again replied that she had not received any documentation from Police Department "A". S3PI/RM led the surveyor to believe that it was the detective for Police Department "A ' s" fault that the investigation had not been completed for the hospital.

Review of Incident Report dated 08/23/15 that had been documented by S14LPN and revealed that patient #1 had gotten into a physical altercation with another patient and received multiple punches before MHT's broke them up. Further review revealed under the nursing evaluation patient #1 had a small laceration to his upper nose, denied pain, offered Tylenol and ice pack, patient refused. Patient #1 was given an injection of Thorazine and Benadryl at that time.

Interview on 09/08/15 at 10:30 a.m. with S2DON and S3PI/RM revealed that the hospital had not contacted DHH- HS concerning the abuse allegation by patient #1 on 08/23/15. S2DON and S3PI/RM indicated that they were not aware that the alleged abuse had to be reported to DHH-HS since Police Department "A" was already involved. S2DON reported that the mother of patient #1 had called Police Department "A" during her visit to the hospital on 08/27/15.

b) Interview on 09/09/15 at 2:45 p.m. with S3PI/RM revealed that the hospital had first been contacted by Children Family Services on 05/07/15 about the allegation of abuse involving patient #10. S3PI/RM reported that DHH-HS had not been notified of the alleged abuse involving patient #10.

Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to ensure nursing staff adequately assessed each patient each shift for changes in condition for 1 (#1) of 10 patient records reviewed for assessments. Findings:

Record review on 09/08/15 at 10:40 a.m. revealed patient #1 was admitted to the hospital on 08/21/15 with a diagnosis of Intermittent Explosive Disorder, Defiant Disorder, and ADHD. Further review revealed that this was the third admission to the hospital for Patient #1 with his last hospitalization being in May of 2015.

Review of the Integrated Assessment/Psychosocial note dated 08/21/15 revealed patient #1 was at risk of: Some danger of hurting self/others, and a history of fighting. Physicians Admit Orders dated 08/21/15 reveal line of sight observation.

Review of Nursing Reassessment Notes dated 08/23/15 revealed patient #1 was in a physical altercation with another patient. Patient #1 became physically aggressive with staff and was placed in a therapeutic hold for 2 minutes. S4MD was notified and ordered Thorazine and Benadryl IM STAT. During injection S14LPN documented small laceration to bridge of nose, cleaned and offered Tylenol and ice pack. S14LPN further documents attempted to notify family and there was no answer.

Review of Nursing Reassessment Note dated 08/24/15 revealed box checked skin pink and normal. There was no documentation relative to the small laceration to bridge of nose.

Review of Nursing Reassessment Note dated 08/25/15 at 8:35 a.m. revealed S13LPN documented eye, nose and finger hurt; unable to give any PRN due to no consent; will attempt to contact parent/guardian. Further review revealed 3:00 p.m. to 11:00 p.m. shift S26RN documented edema to nose and bruised left eye with no further assessment.

Review of Nursing Reassessment Note dated 08/26/15 revealed skin pink and normal. There was no documentation about the laceration or edema to the nose and/or bruising to left eye.

Interview on 09/09/15 at 1:05 p.m., S12LPN confirmed that she was working on the adolescent boys unit on 08/24/15 on the 3:00 p.m. to 11:00 p.m. shift and on 08/25/15 on the 7:00 a.m. to 3:00 p.m. S12LPN recalled patient #1 but was unable to recall his assessment. After reviewing her nurse's notes and documentation of the skin assessment this surveyor asked if she recalled Patient #1 having a laceration on his nose and/or bruises around his eyes. S12LPN was unable to recall if the patient had any issues with his nose or eye's. Surveyor asked if she had been given any report of patient #1's condition from the previous shift on 08/25/15 that documented the patient had edema to his nose and bruising to left eye. S12LPN was not able to recall any information about patient #1's assessment.

Interview on 09/09/15 at 1:30 p.m. with S13LPN confirmed that she was working on the adolescent boys unit on 08/25/15 on the 7:00 a.m. to 3:00 p.m. shift. S13LPN reviewed nurse's note dated 08/25/15 and the skin assessment documented pink and normal. S13LPN also documented that patient #1 complained of eye, nose and finger pain. Surveyor asked if S13LPN recalled any laceration or bruising to patient #1's face, S13LPN could not recall. Surveyor asked how the patients are assessed each shift. This surveyor asked if she noticed cuts and/or bruising would S13LPN be expected to document her findings. S13LPN stated that findings would be documented under the assessment note. S13LPN could not recall if patient #1 had any bruising or cuts to his face. Surveyor asked on 08/25/15 S13LPN had documented "will attempt to contact parent/guardian", S13LPN stated that she was going to notify about getting prn medication consent for pain. S13LPN stated that she did not contact the parent/guardian and could not recall why. Surveyor asked S13LPN what was the facility's policy for notifying the parent or legal guardian, and S13LPN stated that she was not sure.

Interview on 09/09/15 at 2:00 p.m. with S14LPN confirmed that when she gave patient #1 the injection ordered to help him calm down she noticed a small amount of blood from his nose. S14LPN cleaned the area and assessed a small laceration on patient #1's nose and offered him an ice pack and a band aid which the patient refused. S14LPN stated that the patient was not held down for the injection. S14LPN also stated that patient #1 had been in the hospital a number of times and was always getting into fights with other patients. S14LPN confirmed that she had called the patient's mother but there was no answer and because of the late hour did not attempt to call again. S14LPN further stated that she did not report that information to the other shifts.

After asking several times for a policy for Nursing Assessments surveyor was given a policy titled Plan for Provision of care, Document Number CTS-157, revised 01/15 revealed in part: 5.5.11 Nursing Services- are organized under the direction of the DON as defined in the hospital plan for nursing care. Additional responsibilities of nursing staff include, but are not limited to: -ongoing patient assessment and observation; -nursing staff maintains ongoing contact with the patient's family as appropriate.
Interview on 09/10/15 at 3:05 p.m. with S2DON confirmed that she would expect nurses to document any changes in condition and notify parents/guardians of changes.

Based on record review and interview, the facility failed to ensure compliance with the Condition of Participation of Discharge Planning as evidenced by:

1. Failing to reassess the discharge plan for appropriateness for patients with continuing care needs for 5 (#2, #6, #7, #8, #9) of 5 Patients who were discharged to a Homeless Shelter; (See findings at A0821)

2. Failing to ensure discharge planning evaluations were completed in a timely manner to allow for appropriate arrangements to be made for post-discharge care for 1 (#2) of 5 (#2, #6, #7, #8, #9) Patient records reviewed for discharge planning; (See findings at A0810)

3. Failing to ensure a list of all discharge medications, with clear indication of changes from the patients's pre-admission medications, was provided to each patient upon discharge for 4 (#2, #7, #8, #9) of 5 patient records reviewed for discharge planning. (See findings at A0820)

Based on record review and interviews, the hospital failed to ensure that discharge planning evaluations were completed in a timely manner to allow for appropriate arrangements to be made for post-discharge care for 1 (#2) of 5 (#2, #6, #7, #8, #9) Patient records reviewed for discharge planning from a total sample of 10.
Findings:

Review of the hospital's Policy & Procedure titled "Discharge Planning" presented by S2DON as being current (05/16/15) read in part: B. Therefore, all inpatients' post -discharge needs are identified and evaluated. All inpatients will have a discharge plan developed and implemented prior to discharge. 7. Include timely and direct communications with and transfer of information to other programs, agencies, or individuals that will be providing continuing care.

Patient #2
Review of the medical record for patient #2 revealed he had been admitted to the the hospital on 08/14/15 with diagnoses of: Axis I- Major Depression, Recurrent, with Psychosis Generalized Anxiety Disorder; Axis II: Mental Retardation, Mild; Axis III: DM II (without complication); Obesity NOS, Hyperlipidemia. Documentation revealed Patient #2 was discharged on 08/26/15 to a local shelter (homeless) pending acceptance to an out of town Nursing Home/Rehabilitation Center.
Review of the Progress notes written by S4Psychiatrist revealed the following:
08/21/15 at 9:30 a.m. S5LMSW working on placement in a Nursing Home/Rehabilitation Center
08/24/15 Plan: "Potential for discharge within the next 24 hours if initial improvement sustained. Note if placement in Nursing Home/Rehabilitation Center not available the patient may have to stay in a shelter or move in with his mother or other relatives temporarily."
08/25/15 8:40 a.m. - "He is considered safe for discharge."
08/25/15 Plan- "D/C (discharge) to placement on current medication with appropriate follow-up. For complete list of discharge instructions and aftercare (D/C forms). Note, the patient is aware that placement is temporary. He will be there until he is approved for placement at rehab (name of facility)."

Review of the Social Service notes written by S5LMSW revealed the following:
08/19/15 at 12:50 p.m. faxed referral to (Name of Nursing Home/Rehab).
08/20/15 at 10:30 a.m. Met with S24Admit Director (Nursing Home/Rehab).
08/24/15 at 3:10 p.m. " Pt. scheduled for D/C Tuesday (Name of facility) will transport to (Name of Shelter). "

Review of the Discharge aftercare plan revealed the following:
Name of Nursing & Rehabilitation Center (address & telephone #) pending.
Discharged Disposition:
Other type of facility: Local Homeless Shelter (until accepted to Nursing Home/Rehab. Address & telephone # listed).

In an interview on 09/09/15 at 12:30 p.m., S2DON indicated that the hospital will discharge patients to the local homeless shelter if they are ready for discharge and have no place to go due to all other avenues being exhausted. S2DON explained that there are times when patients will have no home and/or no family available upon discharge. S2DON indicated that the local shelter offers assistance with discharge (shelter) for these patients. S2DON indicated that staff members will call prior to discharge to ensure availability of space (bed) to accompany the patient. S2DON indicated that Patient #2 was discharged to the local shelter temporary pending admission to an out of town Nursing Home/Rehabilitation Center.

In an interview on 09/09/15 at 3:00 p.m., S5LMSW indicated she had been employed at the hospital for approximately 2 years. S5LMSW indicated that Patient #2 had been accepted into a Nursing Home/Rehabilitation Center (Inpatient Behavioral Health Unit) and was awaiting final approval which could take up to 14 days. S5LMSW indicated that Patient #2 had to be discharge to a local shelter pending approval for admission to the Nursing Home/Rehabilitation Center. S5LMSW indicated that there was a delay in discharge planning for Patient #2. S5LMSW indicated she was not familiar with all the paperwork and process for Patient #2 to be accepted into the Nursing Home/Rehabilitation Center. S5LMSW indicated that Patient #2 had to be discharged to a local shelter pending completion of the paperwork.

In a telephone interview on 09/09/15 at 3:30 p.m., S4Psychiatrist indicated that on 08/26/15 Patient #2 was suitable for discharge. S4Psychiatrist indicated that Patient # 2's discharge had been delayed for a few days pending placement into a suitable place upon discharge. S4Psychiatrist indicated that Patient #2 was temporarily discharged to a local shelter pending placement at the Nursing Home/Rehabilitation Center.

In an interview on 09/10/15 at 11:20 a.m., S5LMSW presented a document which she identified as a list agencies e-mailed to her by a state agency to assist with the placement of Patient #2 upon discharge from the hospital. S5LMSW was not able to recall the day that the list was made available to her. The list was noted to contain no dates of contact only the qualifications required. S5LMSW indicated she had no documented evidence of contacts made to agencies on the list.

Based on record reviews and interview, the hospital failed to ensure a list of all discharge medications, with clear indication of changes from the patients' pre-admission medications, was provided to each patient upon discharge for 4 (#2, #7, #8, #9) of 5 patient records.
Findings:

Review of the hospital policy titled "Discharge Planning", presented as a current (05/16/15) policy by S2DON, revealed that the hospital's discharge plan consisted of listing all medications that the patient is to continue taking after discharge and patients' methods for obtaining medications. There was no documented evidence that the policy addressed the need to include the changes in the discharge medications from the medications the patient was taking prior to admission.

Patient #2
Review of the medical record for patient #2 revealed he had been admitted to the the hospital on 08/14/15 with diagnoses of: Axis I- Major Depression, Recurrent, with Psychosis Generalized Anxiety Disorder; Axis II: Mental Retardation, Mild; Axis III: DM II (without complication); Obesity NOS, Hyperlipidemia.

Review of patient #2's discharge instructions and aftercare plan dated 08/25/15 revealed a list of current medications with no documented evidence of the changes in the current medications from the home medications being taken at the time of admission.

Patient #7
Review of the medical record for patient #7 revealed he had been admitted to the the hospital on 06/04/15 with the diagnoses of Alcohol Dependence, Benzodiazepine Dependence, Major Depressive Disorder recurrent without psychosis,Generalized anxiety disorder, Axis III- DJD (Degenerative Joint Disease, Chronic Pain syndrome, GERD (Gastroesophageal Reflux Disease) and Hypertension.

Review of patient #7's discharge instructions and aftercare plan dated 07/01/15 revealed a list of current medications with no documented evidence of the changes in the current medications from the medications being taken at the time of admission.

Patient #8
Review of the medical record for patient #8 revealed he had been admitted to the the hospital on 08/14/15 with the diagnoses of Axis I- Schizophrenia, Paranoid, Acute Exacerbation; R/O Schizoaffective Disorder Depressed Type.
Review of patient #8's discharge instructions and aftercare plan dated 08/26/15 revealed a list of current medications with no documented evidence of the changes in the current medications from the medications being taken at the time of admission.

Patient #9
Review of the medical record for patient #9 revealed he had been admitted to the the hospital on 07/10/15 with the diagnoses of Axis I- Impulsive Control Disorder, Bipolar Disorder, Depression; Axis II- Borderline Intellectual Deficit; Axis III- Obesity.

Review of patient #9's discharge instructions and aftercare plan dated 07/16/15 revealed a list of current medications with no documented evidence of the changes in the current medications from the medications being taken at the time of admission.


In an interview on 09/10/15 at 1:00 p.m., S7LMSW indicated that the hospital could provide no documentation that indicated patients was provided with a list of all discharge medications, with clear indication of changes from the patients's pre-admission medications upon discharge.

Based on record reviews and interviews, the hospital failed to reassess the discharge plan for appropriateness for patients with continuing care needs. This was noted for 5 (#2, #6, #7, #8, #9) of 5 Patients who were discharged to a Homeless Shelter out of a total sample of 10.
Findings:

Patient #2
Review of the medical record for patient #2 revealed he had been admitted to the the hospital on 08/14/15 with diagnoses of: Axis I- Major Depression, Recurrent, with Psychosis Generalized Anxiety Disorder; Axis II: Mental Retardation, Mild; Axis III: DM II (without complication); Obesity NOS, Hyperlipidemia. Documentation revealed Patient #2 was discharged on 08/26/15 to a local shelter (homeless) pending acceptance to an out of town Nursing Home/Rehabilitation Center.
Review of the Interdisciplinary Treatment Plan revealed the following:
Strength : Support System, Communication; Patient weakness: social/Medical Problems, Unable to live Independently.
Initial D/C Plan: Return to previous living arrangement, Outpatient therapy with psychiatrist or therapist.
Initial D/C Criteria: Adequate post-discharge living arrangements, Need for constant or close observation no longer required, Verbal commitment to aftercare and medication compliance.

Review of the Psychosocial Assessment dated 08/14/15 read in parts: Patient weakness, limitations, and/or Disabilities: " doesn ' t know when to take his own meds, "

Review of the Progress notes written by S4Psychiatrist revealed the following:
08/21/15 at 9:30 a.m. S5LMSW working on placement in a Nursing Home/Rehabilitation Center
08/24/15 Plan: "Potential for discharge within the next 24 hours if initial improvement sustained. Note if placement in Nursing Home/Rehabilitation Center not available the patient may have to stay in a shelter or move in with his mother or other relatives temporarily."
08/25/15 8:40 a.m. - "He is considered safe for discharge."
08/25/15 Plan- "D/C (discharge) to placement on current medication with appropriate follow-up. For complete list of discharge instructions and aftercare (D/C forms). Note, the patient is aware that placement is temporary. He will be there until he is approved for placement at rehab (name of facility)."

Review of the Social Service notes written by S5LMSW revealed the following:
08/19/15 at 12:50 p.m. faxed referral to (Name of Nursing Home/Rehab).
08/20/15 at 10:30 a.m. Met with S24Admit Director (Nursing Home/Rehab).
08/24/15 at 3:10 p.m. " Pt. scheduled for D/C Tuesday (Name of facility) will transport to (Name of Shelter). "

Review of the Discharge aftercare plan revealed the following:
Name of Nursing & Rehabilitation Center (address & telephone #) pending.
Discharged Disposition:
Other type of facility: Local Homeless Shelter (until accepted to Nursing Home/Rehab. Address & telephone # listed).

In an interview on 09/09/15 at 12:30 p.m., S2DON indicated that the hospital will discharge patients to the local homeless shelter if they are ready for discharge and have no place to go due to all other avenues being exhausted. S2DON explained that there are times when the patient will have no home and no family available to discharge to. S2DON indicated that the local shelter offers assistance with discharge for these patients. S2DON indicated that staff members will call prior to discharge to ensure there is a bed available. S2DON indicated that Patient #2 was discharged to the local shelter temporary pending admission to an out of town Nursing Home/Rehabilitation Center.

In an interview on 09/09/15 at 3:00 p.m., S5LMSW indicated she had been employed at the hospital for approximately 2 years. S5LMSW indicated that Patient #2 had been accepted into a Nursing Home/Rehabilitation Center (Inpatient Behavioral Health Unit) and was awaiting final approval which could take up to 14 days. S5LMSW indicated that Patient #2 had to be discharge to a local shelter pending approval for admission to the Nursing Home/Rehabilitation Center. S5LMSW indicated that there was a delay in discharge planning for Patient #2. S5LMSW indicated she was not familiar with all the paperwork and process for Patient #2 to be accepted into the Nursing Home/Rehabilitation Center. S5LMSW indicated that Patient #2 had to be discharged to a local shelter pending completion of the paperwork.

In a telephone interview on 09/09/15 at 3:30 p.m., S4Psychiatrist indicated that on 08/26/15 Patient #2 was suitable for discharge. S4Psychiatrist indicated that Patient # 2's discharge had been delayed for a few day pending placement into a suitable place upon discharge. S4Psychiatist indicated that Patient #2 was temporarily discharged to a local shelter pending placement at the Nursing Home/Rehabilitation Center.

In a telephone interview on 09/10/15 at 9:50 a.m., S23Program Director (Homeless Shelter) indicated that Patient #2 was transported to the homeless shelter on 08/25/15 by the hospital's transportation department. S23Program Director indicated that Patient #2 was not capable of providing ADL's independently, self-administration of medication, and decision making (f/u care) and for this reason was not appropriate for the homeless shelter.

In an interview on 09/10/15 at 11:20 a.m., S5LMSW presented a document which she identified as a list agencies e-mailed to her by a state agency to assist with the placement of Patient #2 upon discharge from the hospital. S5LMSW was not able to recall the day that the list was made available to her. The list was noted to contain no dates of contact only the qualifications required. S5LMSW indicated she had no documented evidence of contacts made to agencies on the list.

Patient #6
Review of the medical record for Patient #6 revealed he had been admitted to the hospital on 08/13/15 with the diagnoses of Axis I- Polysubstance Abuse Disorder, and Substance induced Mood Disorder. Review of the Master Treatment Plan revealed Potential Barriers/Problems for discharge: Issues around personal safety, Difficulty with housing, Relapse prevention, lack of support system, need for medical follow-up, and financial problems. Further review revealed Patient #6 was discharged to a local shelter for the homeless on 08/21/15. There was no documented evidence of an assessment for Patient #6's needs post-hospital discharge (housing, employment & income).

In an interview on 09/09/15 at 2:20 p.m., S9LMSW indicated that Patient #6 was homeless and he was returned to the local homeless shelter. S9LMSW indicated resources were limited, and barriers identified initially were difficult to achieve due to Patient #6's challenges: limited resources, family estranged, unemployed, no income, and insurance paid for limited days. S9LMSW indicated he was unable to provide the surveyor with any documented evidence that an assessment was made for Patient #6's needs post-hospital discharge (housing, employment & income).

In a telephone interview on 09/10/15 at 9:50 a.m., S23Program Director (Homeless Shelter) indicated that Patient #6 was transported to the facility 08/21/15 by the hospital's transportation department. S23Program Director indicated that Patient #6 was not able to lodge at the shelter for violation of shelter rules in the past. S23Program Director indicated that Patient #6 never checked into the shelter.

Patient #7
Review of the medical record for Patient #7 revealed he had been admitted to the hospital on 06/04/15 with the diagnoses of Alcohol Dependence, Benzodiazepine Dependence, Major Depressive Disorder recurrent without psychosis,Generalized anxiety disorder, Axis III- DJD (Degenerative Joint Disease, Chronic Pain syndrome, GERD (Gastroesophageal Reflux Disease) and Hypertension. Review of the Social Services notes written by S9LMSW on 06/15/15 at 8:00 a.m. read: "Patient reported that he is now homeless. "On 06/22/15 at 4:00 p.m., S9LMSW writes: "Social Worker discussed the Salvation Army for temporary resident for pt. (as written). Further review revealed Patient #7 was discharged to a local shelter for the homeless on 07/01/15. There was no documented evidence of an assessment for housing needs and/or available resources for community housing post-hospital discharge.

In an interview on 09/09/15 at 2:20 p.m., S9LMSW indicated that Patient #7 was homeless and he was returned to the local homeless shelter. S9LMSW indicated resources were limited and Patient #7's family wanted nothing to do with him. S9LMSW indicated he was unable to provide the surveyor with any documented evidence that an assessment was made for Patient #7's housing needs post-hospital discharge.

Patient #8
Review of the medical record for Patient #8 revealed he had been admitted to the hospital on 08/14/15 with the diagnoses of Axis I- Schizophrenia, Paranoid, Acute Exacerbation; R/O Schizoaffective Disorder Depressed Type. Review of the Master Treatment Plan revealed Potential Barriers/Problems for discharge: Difficulty with housing. Review of the Social Service notes on 08/17/15 written by S20SW read: "Pt. stated he has no place to live. Pt. stated he has no place to go once discharged." Further review revealed Patient #8 was discharged to a local shelter for the homeless on 08/26/15. There was no documented evidence of an assessment for housing needs and/or available resources for community housing post-hospital discharge.

In an interview on 09/09/15 at 5:15 p.m., S20SW indicated that Patient #8 informed her that he was "homeless" and had no place to live upon discharge. S20SW indicated a local agency had been contacted to assist Patient #8 with housing and at the time of discharge the process was incomplete. S20SW indicated that on 08/26/15, Patient #8 was discharged to a local shelter for the homeless. S20SW indicated she was unable to provide the surveyor with any documented evidence that an assessment was made for Patient #8's housing needs post-hospital discharge. S20SW indicated she made no contact with another community resources for housing, since a local agency was taking care of the housing issue.

In a telephone interview on 09/10/15 at 9: 50 a.m., S23Program Director (Homeless Shelter) indicated after checking his check in log indicated he had no documentation that Patient #8 checked into the Shelter.

Patient #9
Review of the medical record for Patient #9 revealed he had been admitted to the the hospital on 07/10/15 with the diagnoses of Axis I- Impulsive Control Disorder, Bipolar Disorder, Depression; Axis II- Borderline Intellectual Deficit; Axis III- Obesity. Review of the Master Treatment Plan revealed Potential Barriers/Problems for discharge: Issues around personal safety,Relapse prevention, and need for medical follow-up. Review of the Social Services notes written by S22LMSW on 07/13/15 at 4:00 p.m. read: " Pt. reports he is now homeless b/c his mom will not let him come home. A telephone family session note on 07/14/15 at 1:10 p.m. read: "Pt. mo. (as written) report pt. cannot come back to her home." Review of Patient #9's aftercare appointment revealed: Appointment: (name of agency) 07/16/15 at 1:00 p.m. Patient #9 follow-up appointment was noted to be on the day of discharge. Further review revealed Patient #9 was discharged to a local shelter for the homeless on 07/16/15 at 10:40 a.m. There was no documented evidence of an assessment for housing needs and/or available resources for community housing post-hospital discharge.

In a telephone interview on 09/10/15 at 9: 50 a.m., S23Program Director (Homeless Shelter) indicated Patient #9 checked into the shelter on 07/16/15 at 5:00 p.m. S23Program Director indicated that Patient #9 was Developmentally Disabled and was not capable of caring for himself independently. S23Program Director indicated Patient #9 was not able to self-administer his medications. S23Program Director indicated he was not certain if Patient #9 attended his scheduled appointment on 07/16/16 at 1:00 p.m. S23Program Director indicated it is the responsibility of the clients to make and keep their own doctor's appointment and transportation.

In an interview on 09/10/15 at 10:15 a.m., S22LMSW indicated that Patient #9 was homeless upon admission and was discharged to a local homeless shelter on 07/16/15. S22LMSW indicated she was not aware that Patient #9 was not capable of self-administration of medications and/or independently providing total care for himself. S22LMSW indicated that no reassessment of post-discharge needs for Patient #9 was made prior to his discharge to the local homeless shelter. S22LMSW indicated she was not aware that Patient #9's follow-up appointment was scheduled for the day of discharge.