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Based on interview and record review the facility failed to protect and promote Patient #1 and Patient #2's rights when the hospital discharged patients without proper transfer arrangements and 2 patients on civil commitment accessed and used chemical substances while en route to the receiving entity. The potential impact of these failures places the Condition of Participation of Patient Rights out of compliance. See documentation at A144.

Based on interview and document review the hospital failed to provide care in a safe setting when they failed to implement safe procedures for transferring 2 of 11 patients reviewed, Patient #1/P1 and Patient #2/P2, when the patients were transferred by volunteer drivers or family members and were allowed access to their medications or alcohol resulting in ingestion of medications or alcohol during the transfer. Both patients were being held under civil commitment and required readmissions to the original hospital. Findings include:

Medical record review revealed that P1 was admitted to the hospital in early 2012 with diagnoses that included Schizoaffective disorder and drug abuse. Patient #1 had a history of medication seeking while at the hospital. Patient #1 was being held under a civil commitment.

Patient #1's Nursing notes dated 4/9/2012 were reviewed and revealed that he was discharged on 4/9/12, but took an overdose of 5 tablets of 5 mg. Artane (alters nerve impulses), one tablet of 2 mg. Lorazepam (antianxiety medication), 2 tablets of 150 mg. Welbutrin and 1 tablet of 300 mg. Welbutrin (antidepressant medication) in the transport car. The note further indicated that P1 was sent to the emergency room, then transferred back to the hospital.

Human Services Technician(D)/HST(D), was interviewed on 6/22/2012 at 9:00 a.m. and stated that he was asked to bring P1 down to the volunteer driver to be transferred to another facility. HST(D) stated that he did not assemble P1's belongings, but was aware there were probably medications in with his belongings. HST(D) stated that he asked the volunteer driver to open the trunk to place the patient's belongings in the trunk. HST(D) stated that the driver said no, just place them in the back seat, which he did. HST(D) stated that he was not aware of any set system or facility policy to secure patient belongings during transfer and was under the impression that when a patient is discharged, the volunteer driver is responsible for the patient safety while being transported.

Director of Nursing(B)/DON(B) was interviewed on 6/19/2012 at 10:20 a.m. and stated that she was aware that P1 was transported to another facility by a volunteer driver on 4/9/2012 and that he accessed his medications and took some of them. DON(B) stated that the hospital did not have a policy or system in place to secure patient belongings and/or medications during transfer. DON(B) stated that they usually put the medications in a sealed envelope, but not necessarily in the trunk during transport. DON(B) stated that P1 did not have any negative physical effects as a result of the overdose.

Individual(F)/I(F) staff from the receiving facility was interviewed on 6/22/2012 at 11:15 a.m. and stated that P1 came to their facility accompanied by a volunteer driver on 4/9/2012. I(F) stated that when P1 arrived he was disoriented and confused and attempted to urinate in the corner of the room. I(F) stated that they knew immediately something was wrong and called 911. I(F) stated that as they were attempting to admit P1 they realized that medications were missing and P1 opened his mouth and revealed several medications in his mouth as well as in his pockets.

Medical record review revealed that P2 was admitted to that hospital in April 2012. P2 had diagnoses that included organic brain syndrome and alcohol dependence. P2 was being held on a civil commitment.

P2's discharge summary dated 5/8/2012 was reviewed and revealed that P2 was originally discharged on 3/26/2012 on a provisional discharge to another facility. At that time arrangements were made by hospital staff to have a family member transfer P2 to the receiving facility. During the transfer P2 stopped at a liquor store and ingested alcohol. Staff at the receiving facility noted the smell of alcohol and tested his blood alcohol which was found to be at 0.035.

Policies related to the secure transfer of patients and securing patient medications and belongings were requested, but hospital staff were unable to access any relevant policies.