HospitalInspections.org

Based on policy review, medical record review and physician and staff interviews, the hospital failed to coordinate a safe discharge for 1 of 5 patient record reviewed. (Patient #3)

Review on 10/05/2023 of the policy Discharge/Transition Planning, last reviewed 07/14/2020 revealed "...I. POLICY... Each patient's needs for continuing care are assessed in an ongoing fashion by members of the healthcare team and coordinated by the Patient Care Manager (PCM) or Discharge Planner. The patient and their significant others are included in developing the discharge/transition plan, beginning at admission, and continuing during the hospital stay. The discharge planning function focuses on meeting the patient's continuing healthcare needs. The purpose is to identify a patient's unique needs for continuing physical, emotional, safety....and other needs and to facilitate resources to meet those needs...B. Evaluation...2. ...The Patient Care Manager or Discharge Planner will communicate with the anticipated care giver to assure that they are willing and able to meet the needs of the patient...4. The Patient Care Manager or Discharge Planner uses...patient/family/caregiver communication to identify patients with needs not identified in the initial assessment...C. Development...2. The Patient Care Manager or Discharge Planner will collaborate on developing a coordinated discharge plan using the evaluations and assessments of the interprofessional team along with the preferences and goals of the patient/family/caregiver...D. Initiation 1. The Patient Care Manager or Discharge Planner, Patient Care Coordinator, Nursing staff and /or Physician will communicate with patient/family/caregiver as early as possible regarding potential discharge date...E. Discharge Instructions include but are not limited to: ...1. ...including follow up care and signs and symptoms requiring immediate contact with a physician. 2. Medication instructions including instruction on potential food and drug interactions;7. Others as appropriate to reduce potential risks and/or improve patient safety outcomes..."

Closed medical record review on 10/05/2023 revealed Patient #3, a 36-year-old male who arrived direct admit from another hospital emergency department (ED) under involuntary commitment (IVC) orders to the hospital's acute Behavioral Health Unit (BHU) on 05/15/2023 at 2338. Past medical history included Schizophrenia, Autism Spectrum disorder, and borderline intellectual functioning. Record review revealed Patient #3 allegedly made homicidal threats toward staff and residents at the group home where he was residing that had required police intervention and was deemed a danger to himself and others. Review of the Psych Admission Note by Registered Nurse (RN) #2 revealed Patient #3's father was his legal guardian, "...it was reported that he requests that pt (patient) not be allowed to speak with other family members..." Review of the Admission Physician Note dated 05/16/2023 at 1235 by Medical Doctor, (MD) #1 revealed Patient #3 named his legal guardian as his father, there was no documentation MD #1 communicated with the father/guardian on admission for any data collection. On 05/25/2023 MD #1 met with guardian/father to discuss visitation with mother, and supervised visitation was approved. (first documented discussion between physician and guardian 10 days after admission). Patient #3's treatment team continued to look for placement options and did include his assigned Managed Care Designee (named) to ensure his appropriated funding (A waiver allowing $80,000/year for Patient #3's prescribed care) would not be jeopardized. Record review revealed no evidence of discharge planning communication between hospital staff and Patient #3's guardian/father from 05/26/2023 until 06/22/2023 (27 days). Physician Progress Note on 06/13/2023 (no time) indicated MD #1 communicated with guardian/father to confirm permission for Patient #3 to visit with his mother who was previously restricted. Review of the Psych DC/Continuing Care Plan Routine Note dated 06/22/2023 at 1043 revealed MD #1 revealed a Physician Order to "...DC (discontinue) Involuntary Commitment." On 06/22/2023, filed at 1049 Patient #1 had a court hearing regarding his involuntary commitment order, with "...Findings ...5. respondent was discharged before court date...Order...5. This matter to be dismissed..." and was signed by the District Court Judge. There was no evidence the guardian/father was present or participated with the reversal of the IVC order, or/with MD #1, or the Judge. Review revealed attempts to place Patient #3 in a group home setting had been declined. Review of the Case Management Note dated 06/22/2023 at 1150 by CM #3 revealed she had called Patient #3's guardian/father to discuss the Pt. being discharged and to arrange transportation. The guardian/father informed CM #3, Patient #3 could not live with him, and verbalized "...he was upset with Dr. (named MD #1) for discharging him..." On 06/22/2023 at 1215, CM #3 attempted to call Patient's #3's mother "...attempted to call (named) mother several times to arrange pick up. On 06/23/2023 at 0651 CM #3 called and reached Patient #3's mother to advise Patient #3 had been discharged and his guardian was refusing to pick him up. On 06/23/2023 at 0833 RN #5 documented "...Legal guardian, father was notified via phone that patient was being discharged in the care of patient's mother on 06/22/2023 [sic], Father declined to sign discharge instructions. Discharge instructions were reviewed with the patient and 2 nurses signed with him. Mother picked up patient today..." Record review revealed RN #5 gave discharge instructions to Patient #3, and not to the legal guardian/parent. Review of the Discharge Summary by MD #1 dated 06/23/2023 at 1027 revealed Patient #3 was discharged with a new prescription for "...risperidone (anti-psychotic medication) 2 mg (milligrams) tablet, to take 2 mg PO (orally) QHS (every night at hour of sleep) #30 tablets dispensed...06/22/2023...Home Medications prior to Hospitalization risperidone 4 mg tablet, 4 mg PO QHS...Referrals, Follow up Appointments for (named) Managed Care Agency on 06/29/2023 at 0830 am..." Patient #3 was discharged on 06/23/2023 at 0833 with his mother. Record review failed to reveal evidence of communication of discharge instructions, new medication prescription, or physician follow-up appointment information was given to the Patient #3's guardian/father from hospital staff prior discharge on 06/23/2023 at 0833.

Review of the record after Patient #3's discharge date of 06/23/2023 revealed a CM Note added on 06/29/2023 at 1610 (6 days later) by CM #3, she had received a call from (named) Managed Care Designee requesting MD to send the discharge prescription for risperidone 2mg for Patient #1 electronically. Review of the record revealed an electronic prescription was sent and verified to Walmart on 06/30/2023 at 1022 am by MD #1. Review revealed Patient #3 had went without his medication prescription of risperidone 2mg for 6 days after discharge.

Interview on 10/04/2023 at 1458 with CM #3 revealed that all discharge planning for Patient #3 from 05/23/2023 through 06/22/2023 [27 days] had been communicated to the Managed Care Designee and not the legal guardian. The interview revealed after Patient #3's follow up appointment on 6/29/2023 she was asked to refax the discharge instructions with medication prescription to the Managed Care Designee on 06/29/2023, as the patient had been without his medication since discharge (6 days). The interview revealed hospital policy was not followed for Patient #3.

Interview on 10/06/2023 at 1241 with the Supervisor for Case Management, revealed "...It was the expectation for Behavioral Health Unit staff to include the legal guardian in the discharge plan of care, and to review the discharge instructions for the plan of care with the legal guardian prior to discharge..." Interview revealed Case Management staff had received education, up to disciplinary action was on-going related to Patient #3's discharge. Interview revealed hospital policy was not followed for Patient #3.

Interview on 10/06/2023 at 0852 with the Discharge Nurse, RN #5 revealed she remembered Patient #3. Interview revealed "...I did not give discharge instructions to the father; he wouldn't come and sign the papers. I gave a copy to the patient. I gave the patient his discharge instructions, next outpatient appointment, and medication prescription..." Interview revealed RN #5 did not give discharge instructions to Patient #3's mother at discharge. Interview revealed RN #5 gave discharge instructions, including medication instructions to a patient with a court appointed guardian. Interview revealed hospital policy was not followed for Patient #3.

Interview on 10/04/2024 at 0921 with the BHU Nurse Manager, RN #7 revealed the expectation for the BHU RN was to give discharge instructions to the legal guardian. The interview revealed a discharge prescription would not be given to a patient with a guardian without guardian approval. Interview revealed hospital policy for discharge planning was not followed for Patient #3.

NC00204317 NC00202147 NC00202630