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Based on interviews and document review, the hospital failed to ensure that 1 of 11 patients (Patient #1) received adequate discharge planning when the hospital failed to correctly identify patient #1's legal status and guardian status, failed to provide adequate discharge planning and discharged patient #1 without notification and consent of patient #1's guardian, and without appropriate post hospital services in place.

Findings include:

The hospital did not meet the Condition of Discharge Planning at 42 CFR 482.43.

See A 806

Based on interviews and document review, the hospital failed to ensure that 1 of 11 patients (Patient #1) received adequate discharge planning when the hospital failed to correctly identify patient #1's legal status and guardian status, failed to provide adequate discharge planning and discharged patient #1 without notification and consent of patient #1's guardian, and without appropriate post hospital services in place.

Findings include:
Review of patient #1's 11/15/16 medical record and admission documentation indicated patient #1 arrived at the the hospital's Adult Psychiatric Emergency Department (ED) on a 72 hour hold order at approximately 5:43 p.m. The hold order indicated patient #1 was delusional, paranoid and combative. The documentation further indicated patient #1 has a history of prior psychiatric hospitalizations and commitment and a diagnosis of Bipolar 1 Disorder with psychotic features and autism.

An 11/15/16 ED admission progress note indicated patient #1 was very manic, had flight of ideas exhibited flight of ideas, was very difficult to redirect and would be admitted to inpatient psychiatry. The note indicated patient #1 was voluntary by proxy of his guardian and said patient #1's guardian was contacted and informed of patient #1's admission to the hospital.

Patient #1's 11/16/16 history and physical indicated patient #1 had been living independently in an apartment with services prior to his admission to the hospital. The history and physical indicated the patient was to admitted by guardian consent, and further instructed viewer to see EPIC (computer program) for full details of patient #1's plan. The patient's outpatient medications for anxiety, agitation and psychosis were restarted upon admission to the hospital.

During review of 11/15/16-11/19/16 progress notes in patient #1's medical record, it was mentioned several times that patient #1 was admitted per permission of his guardian. However, there were several references to patient #1's legal status being voluntary.

Patient #1's 11/19/16 discharge summary, completed by psychiatrist-D was reviewed. It indicated patient #1 was encouraged to stay for a few more days for further stabilization. However, patient #1 signed a 12 Hour Notice for Voluntary Patients, requesting to be discharged. Psychiatrist-D reviewed the patient's medical record and determined the patient could not be held and would be discharged. The discharge summary did not indicate that guardian-G was contacted related to patient #1's request to leave or that post hospital services were arranged related to his return to his apartment. The discharge summary indicated patient #1 told psychiatrist-D that he would continue taking his medications and follow up with the recommendations of psychiatrist-D.

The voluntary discharge request, completed by patient #1 on 11/19/16 at 11:40 a.m., was reviewed. The Notice for Voluntary Patients indicated patient #1 was discharged from Inpatient Psychiatry on 11/19/16.

Review of patient #1's 11/28/16-12/12/16 medical record and admission documentation indicated patient was brought from his apartment to the ED via ambulance and police escort. The 11/30/16 initial assessment, completed by social worker-E, stated guardian-G told ED staff that patient #1 barricaded himself in his apartment and had been aggressive towards staff at his apartment building. In addition, guardian-G told staff that patient #1 had not been taking his medications, had been using marijuana and should not have been discharged from the hospital on 11/19/16. The assessment indicated patient #1's legal status is voluntary by guardian consent.

Social worker-E was interviewed in person on 1/20/17, and she stated she developed patient #1's discharge plan and knew that patient #1 was a voluntary admission by guardian consent. She stated psychiatrist-G discharged patient #1 in error on 11/19/16. She stated patient #1 was discharged on a weekend and social workers and discharge staff do not work on weekends. Social worker-E stated she spoke with guardian-G on 11/21/16. She recalled that guardian-G was upset about patient #1 signing a discharge request, and that patient #1 was discharged without her knowledge.

Psychiatrist-D was interviewed in person on 1/20/17, and he stated he treated and discharged patient #1 on 11/19/16. Patient #1 had requested to leave the hospital, and patient #1 signed a voluntary discharge request. Psychiatrist-D stated he should not have allowed patient #1 to sign the voluntary discharge request. The patient's EPIC medical record and discharge plan did not advise him that patient #1 had a guardian and that patient #1 was voluntary and admitted per guardian consent. Patient #1 should not have been discharged without the consent of his guardian. Psychiatrist-D did not feel that patient #1 was a danger to himself on 11/19/16. Patient #1 was not provided medications or medication orders because it was a weekend. Patient #1's apartment building and home care providers were not notified about his discharge. Physician-D spoke to medical director/psychiatrist-F about his error after it occurred. Psychiatrist-D stated he is not aware of any corrective action being implemented by the hospital following the error.

Medical director/psychiatrist-F was interviewed in person on 1/20/17, and he stated patient #1 was a voluntary admission per guardian consent. The patient's EPIC medical record did not contain a legal tab that said "guardian" and "consent of guardian." The legal status section of EPIC needs to be reviewed and corrections need to be made to the section so that medical records will contain the correct information. Psychiatrist-D thought patient #1 was voluntary. Patient #1's condition declined due to being discharged in error on 11/19/16. Medical director/psychiatrist-F stated he has talked with guardian-G about the incident.

Guardian (G) was interviewed by phone on 1/24/17, and she stated she was not notified that patient #1 requested to be discharged and was discharged from the hospital on 11/19/16. Patient #1's apartment building and home care provider were not notified about patient #1's discharge. Patient #1 was not provided medications or medication orders when he was discharged. Patient #1 returned to his apartment and his mental condition worsened. The police were called, and patient #1 returned to the hospital for further care on 11/28/16 related to his worsened mental health problems.