HospitalInspections.org

Based on record review and interview, the facility failed to reassess 1 (Patient #1) of 8 patients (Patient #1, #12, #13, #14, #15, #16, #17) for the appropriateness of the discharge plan as evidenced by Patient #1 being delivered home by taxi services without his father ' s knowledge. Patient #1 had made homicidal threats toward his father prior to his admission and perpetrated a violent assault to a staff member during his admission.

Findings included:

Record review of the Memorandum of Transfer by LPC #59 dated 12/18/2016 at 0720 revealed that Patient #1 was suicidal and attempted to burn himself with fire. He was admitted under an emergency apprehension warrant.

Record review of the High Risk Notification Alert by LPC #59 dated 12/18/2015 at 0800 and co-signed by RN #60 dated 12/18/2015 at 1210 revealed Patient #1 was homicidal - " Wants to kill father. "

Record review of the Psychosocial Assessment by LPC #61 dated 12/19/2015 [no time] revealed Patient #1 had a previous arrest in 1998 for an aggravated assault.

In an interview with Personnel #62 on 08/04/2016 at 1600, he stated Patient #1 violently assaulted RN #63, resulting in the RN being hospitalized with a broken jaw.

Record review of the Authorization to Release Information dated 12/24-27/2015 revealed authorization by Patient #1 for the hospital to release and/or obtain treatment information on himself with wife, mother and father.

Record review of Physician Order by MD #64 dated 01/06/2016 at 1300 revealed an order to discharge Patient #1 " today. "

Record review of the Discharge Summary Plan by LPC #65 dated 01/06/2016 at 1028 revealed Patient #1 was to follow up with a psychiatrist and therapist. He was discharged routinely to return home with wife.

In a phone interview with LPC #65 on 08/05/2016 at 0950, she stated she did not know why a taxi was called for Patient #1.

Record review of Patient #1 ' s medical record for treatment 12/18/2015 - 01/06/2016 revealed no documentation that Patient #1 ' s father was notified of Patient #1 ' s discharge or that Patient #1 had been transported home using a taxi service.

Record review of a Fare Receipt dated 01/06/16 [not timed] and the taxi service invoice for 12/31/2015 - 01/13/2016 revealed Patient #1 was picked up from Kingwood Pines Hospital and taken to his home address on 01/06/2016.

Record review of Policy PC 166, "Case Management and Discharge Planning" dated 09/2015 revealed: " The therapist shall be responsible for assuring completion of the following duties ... Communicates to the patient, family and staff regarding the patient ' s status, treatment progress, and discharge plan. "