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Based on medical record review and staff interviews, it was determined the facility staff failed to notify Patient #1's (P1's) guardian of their discharge.

The findings included:

P1's medical record evidenced guardianship paperwork that designated a guardian for all medical decision making.

The surveyor reviewed P1's Order of Appointment of Guardian and/or Conservator on 1/24/24 at 12:30 p.m. This document was kept in P1's hard chart within the ICU. This document confirmed that P1 was under guardianship with the West Virginia Department of Health and Human Resources Adult Protective Services. This document dated 4/8/22, evidenced, in part, "(P1), the individual alleges to be a protected person, is a "protected person" and meets the definition of a "protected person" under West Virginia Code 44A-1-4 because of mental impairment due to other concerns...The current address of the Protected Person is believed to be: Unknown...The guardian/limited guardian/co-guardian/limited co-guardian is hereby granted the following specific areas of protection and assistance: All areas of the Protected Person's daily life to include medical and mental health decision making..."

In interviews with six (6) staff members (SM), SM5, 3, 6, 13, 14 and 15, conducted on 1/24/24 between the hours of 11:30 a.m. and 2:00 p.m., all staff confirmed that the guardian for P1 was not notified prior to discharge to the homeless shelter on 1/9/24.