HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 patients (Patient #2) in the sample, the hospital failed to develop and/or revise a nursing care plan that reflected the nursing care to be provided to meet the patient's needs. Findings included:

The hospital policy entitled "Patient Right" stated, "Each patient shall have an outcome-oriented, individualized, written treatment plan...revision of the plan consistent with treatment progress..."

The hospital policy entitled "Treatment Plan/Plan of Care" stated, "The treatment plan is an evolving document and will change based on the patient progress/lack of progress or change in condition..."

The hospital policy entitled "Levels of observation and Precaution Levels" stated, "The Multidisciplinary Treatment Plan will reflect 1:1 observation..."

1. Review of Patient #2's medical record revealed:
a. admitted on 2/25/20
b. "Plan of Care" initiated on day of admission
c. "Care Plan Notes" dated 4/14/2020 stated "Patient displaying inappropriate behavior with peers and problematic behavior has started to escalate"
c. on 4/16/20 physician ordered 1:1 continuous observation.
d. plan of care not updated to reflect change in observation level.

Interview with Director Performance Improvement and Risk Management on 12/3/20 at 1:50 PM confirmed this finding.

Based on medical record review, policy review and staff interview it was determined that for 2 of 6 patients in the sample (Patient #'s 4 and 5), the hospital failed to ensure medical records were accurately written or completed. Findings included:

The hospital policy entitled, "Patient Rights" stated, "...The hospital...shall maintain a clinical record for each patient...shall include all pertinent documents related to the patient. Copies of informed consent forms...shall be kept with each patient's...chart...ensure the completeness and accuracy of data..."

A. Patient #4

Medical record review revealed:
1. The "Patient Demographics" and "Aftercare Discharge Instructions" inaccurately documented Patient #4's home address as Group Home #1, rather than the LTC (long term care) Facility A where the patient actually resided.
This error contributed to the hospital's failure to discharge the patient appropriately to LTC Facility A, and instead the patient was discharged to Shelter A.

These findings were confirmed on 12/2/20 at 12:45 PM, by Director of Performance Improvement A.

B. Patient #5

Medical record review revealed:
1. "Interdisciplinary Notes Form: Discharge Safety Plan - DE" dated and signed 3/17/20 at 11:15 AM by Therapist C, inaccurately documented "Yes" to the question "Were family, friends or caregivers invited to participate".

2. "Patient Choice Information" dated 3/17/20 and signed by Patient #5, Discharge Planner B, and two registered nurses stated, "...Your physician has recommended continued services as you leave the hospital. You have the right to select who and where these services are provided. It is your choice...For releasing of this Aftercare Discharge patient Instructions and other discharge information you must complete and sign the Authorization to Release Information (ROI) in order for information to be sent to the next care Providers..."

- The medical record revealed no evidence of an ROI form or that the form was offered to, or refused by the patient.

These findings were confirmed on 12/3/20 at 2:07 PM by Director of Performance Improvement and Risk Management A who in addition confirmed no one was invited to paticipate.

Based on medical record review, policy and document review and staff interviews it was determined that the hospital failed to dishcarge 1 of 5 discharged patients in the sample (Patient # 4), to the approaite post acute care provider. Findings included:

The hospital policy entitled "Discharge Process" stated, "...All patients admitted...are assisted by the multi-disciplinary treatment team to create a plan for discharge..."

The hospital document entitled "Delaware Patient Rights" stated, "...Each patient shall have...support services that may be needed upon discharge..."

The hospital's Medical Staff Rules and Regulations stated, "...Discharge criteria should be specified as soon as possible after admission, and discharge planning should begin at that time. Updates and changes in discharge criteria and discharge planning should be recorded as appropriate..."

"Sun Behavioral Delaware" Adult Welcome Handbook" stated, "...Discharge planning...Family members may also be included in the discharge planning process to support continuity of care..."

Patient #4 (Admission 6/25 - 6/30/20)

A. Delaware State Division of Health Care Quality Investigator A's Report, received by the Delaware State Agency (SA) on 7/20/20, reported that:
- Patient #4 was discharged from the hospital on 6/30/20
- Transport Company A was to take Patient #4 to Homeless Shelter A
- while enroute to a Homeless Shelter A, Patient #4 requested that the driver drop him/her off near a public library (the driver dropped Patient #4 off as requested)
- On 7/1/20, LTC (long term care) Facility A, where Patient #4 was a resident, was notified Patient #4 was discharged from Sun Behavioral Hospital and notified the State Police that Patient #4 was missing
- On 7/1/20, Patient #4 was found, taken to an acute care hospital for medical evaluation and returned to LTC Facility A.

B. Medical record review revealed:

1. Documentation that identified Patient #4 as a resident of LTC Facility A included:
a. The transfer packet received by Sun Behavioral (Hospital) from the referring hospital
b. "Intake Assessment" completed 6/25/20
c. "Psychiatric Evaluation", completed 6/25/20 by Attending Physician A
d. "Psychosocial Assessment", completed 6/27/20 by Social Worker A

2. An "Interdisciplinay Note" dated, 6/25/20 at 9:45 AM stated, "...(patient name) disclosed he is currently homeless..."

3. "Physician Progress Note" dated 6/29/20 (day prior to discharge): Physician A documented, "...Pt (patient) again is confused...is at his baseline. Plan should be to...arrange for transition back to facility..."

4. The following medical record entries were dated 6/30/20:

a. 7:49 AM: "Aftercare Discharge Patient Instructions DE" completed by Discharge Planner A:
- inaccurately documented the patient's address, as Group Home #1, not LTC Facility A
- reported that the patient's discharge was "to home" via "personal vehicle" with Transport Company A.

b. 11:02 AM: Physician A completed/signed "Discharge Summary" which stated,
"...Patient known to me from prior treatment at a group where he reside (sic) for many years...Memory - Impaired. Unchanged from admission...functional condition at time of discharge: unchanged...Discharge...Group Home..."

c. 11:41 AM: "Interdisciplinay Note" stated, "...contacted 3 group homes...only for staff to reiterate...patient has been discharged from their facility...per insurance company the pt (patient) lives in a group home..."

d. At 1:28 PM, Social Worker (SW) B documented "...Pt will...be driven to...temporary shelter...Therapist completed dc (discharge) paperwork. Ensured pt has appointments for follow up care..."

During an interview on 12/2/20 at 12:45 PM with Director of Performance Improvement and Risk Management A, these findings were confirmed and the following was reported:
- that the patient's statement that he/she was homeless was not credible and should not have been relied upon.
- the hospital failed to coordinate an appropriate discharge for Patient #4