HospitalInspections.org

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the §482.43 Condition of Participation: Discharge Planning was out of compliance.

A-0802- The hospital's discharge planning process must require regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. Based on document review and interviews, the facility failed to provide evidence a re-evaluation for safety to discharge occurred following a change in condition in one of one records reviewed in which the patient had a change of condition prior to discharge (Patient #2).

Based on document review and interviews, the facility failed to provide evidence a re-evaluation for safety to discharge occurred following a change in condition in one of one records reviewed in which the patient had a change of condition prior to discharge (Patient #2).

Findings include:

Reference:

The Case Management/Discharge Planning Protocol read, specific discharge criteria included: a patient was not a danger to themselves or others; there was no legal detainment or commitment for treatment; the patient no longer had a need for continuous skilled observation and treatment; the patient no longer had an indication of impaired mental status or physical functioning or mood alteration sufficient to interfere with capacity to meet demands of family, education/occupational, or social environments; the patient had achieved maximum benefit as an inpatient and care could be on an outpatient basis; the patient completed an aftercare and safety plan with provision for continued contact/support.

1. The facility failed to ensure Patient #2 was reassessed to determine if the patient met discharge criteria in accordance with facility policy after experiencing a change of condition to determine if the patient was safe to discharge.

a. Patient #2's medical record was reviewed which revealed Patient #2 was admitted to the facility on 7/6/22 with a diagnosis of schizoaffective disorder, bipolar type (combination of psychiatric symptoms including delusions, hallucinations, depressed and manic episodes). On 7/11/22, documentation in the medical record revealed Patient #2 reported suicidal ideation (thoughts of killing oneself) with a plan to walk into traffic.

According to the discharge Columbia-Suicide Severity Rating Scale (CSSRS) completed on 7/11/22 at 12:00 p.m., Patient #2 scored in the high risk category indicating he was at high risk for self-harm.

In addition, on 7/11/22 from 11:01 a.m. through 11:21 a.m., the medical record revealed Patient #2 required physical restraint for agitation and aggression.

On 7/9/22 at 11:20 a.m., Provider #1 documented a Psychiatric Progress Note which read, Patient #2 was agitated and threatened suicide if he was to leave the facility.

On 7/11/22 at 11:25 a.m., the Discharge Safety Plan revealed Patient #2 reported suicidal ideation with a plan to walk into traffic. The Discharge Safety Plan revealed Patient #2 declined to participate in creating a safety plan and refused to sign the plan. There was no evidence in the medical record in which Patient #2 was able to contract for safety after discharge.

On 7/11/22 at 11:30 a.m., Provider #1 documented a Psychiatric Progress Note which read, Patient #2 was safe to discharge and did not pose an imminent threat. Provider #1 documented Patient #2 posed imminent danger to others on the unit compromising others treatment and the risk outweighed the benefit of Patient #2 to remain hospitalized at the facility.

Patient #2 was then discharged at 12:18 p.m. to a homeless shelter clinic, which was 56 minutes after being physically restrained for 20 minutes.

Provider #1's discharge note did not reveal how Patient #2 was determined to be safe for discharge within an hour of being restrained at the facility, reported suicidal ideation with a plan to walk into traffic, and being unable to contract for safety.

This was in contrast to The Case Management/Discharge Planning Protocol which read patient discharge criteria included the patient was no longer a danger to themselves or others.

b. On 7/19/22 at 8:11a.m., an interview with Provider #1 was conducted, who provided care to Patient #2 upon discharge. Provider #1 stated a patient should no longer be suicidal or homicidal to meet discharge criteria. Provider #1 stated a patient who scored high on the CSSRS at discharge was reassessed and discharge would not occur. Provider #1 stated when a patient was high risk on the CSSRS there would be an update to the discharge plan.

Provider #1 stated Patient #2 needed to continue treatment as an outpatient and go to a suboxone (medication used to treat narcotic dependence) clinic. Provider #1 stated even though the facility did not discharge the patient to a suboxone clinic, Patient #2 had information on where to go for treatment of substance abuse. Provider #1 stated she evaluated Patient #2's affect and there were no red flags. Provider #1 reported Patient #2 stated, "I'm fine" and reported feeling well on the day of discharge. Provider #1 stated when Patient #2 was informed he would be discharged, Patient #2 endorsed suicidal ideation. Provider #1 stated Patient #2's goals were to use illegal substances again, and the goal was not able to be controlled despite the facility offering resources. She stated Patient #2 was medication seeking throughout his hospitalization and it appeared being at the hospital provided no therapeutic gain.

c. On 7/19/22 at 11:05 a.m., an interview with registered nurse (RN) #2 was conducted, who provided care to Patient #2 on the day of discharge. RN #2 stated a patient who scored high on the CSSRS at discharge was at risk of self harm if discharged. RN #2 reviewed Patient #2's medical record and stated on the day of discharge, Patient #2 did not voice being suicidal until after he was told he was going to be discharged and would not receive medications he requested.