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Based on interview, record and policy review, the facility failed to discuss the discharge planning process to the legal guardian acting on the behalf of 1 (SP#3) out of 7 sample patients (SP).

Findings include:

Review of SP#3 Case Management Notes dated 11/29/2018 at 11:36 AM documented case discussed in interdisciplinary team and a request for Guardianship will be filled out due to patient's mental condition and the fact that the family has not been in contact with the facility and patient is unable to provide any reliable information in reference to family.

Review of SP#3 Case Management Notes dated 12/06/2018 at 5:15PM documented patient started a process for guardianship.

Review of SP#3 Case Management Notes dated from 12/06/2018 to 06/26/2019 documented patient in the process for guardianship.

Review of SP#3 Petition to Determine Incapacity and seek Plenary Guardianship executed on 02/05/2019 by Director of Utilization Review/Case Management was electronically filed on 02/06/2019 at 3:34 PM.

Review of SP#3 Plenary Guardian was done and ordered on 04/01/2019 and electronically filed 04/01/2019 at 12:15PM.

Review of SP#3 Psychiatric Progress Notes dated 06/27/2019 at 7:19 PM documented patient indicates doing okay. States not hearing any voices. States does not want to harm self or anyone else. States does not know any family in the area. Patient appears to be competent at time of assessment. Patient has not been agitated or psychotic. Patient does not need inpatient psychiatric treatment.

Review of SP#3 Physician Order dated 06/28/2019 at 7:25AM documented order for Case Management Consultation. Reason for Consult: Discharge Planning. Comment: Homeless Patient. Please assist with shelter and clothing.

Review of SP#3 Physician Order dated 06/28/2019 at 7:25AM documented Discharge Order, Discharge to Home.

Review of SP#3 Discharge Instructions dated Discharge Date: 06/28/2019 at Discharge Time: 7:25AM documented Patient Unable to Sign on 06/28/2019 at 12:16PM.

Review of SP#3 Case Management Notes dated 06/28/2019 at 10:51AM for Discharge Planning documented patient was reevaluated by psychiatrist who said that patient look competent. Physician ordered discharge home. Patient was not accepted for the owner of the place previously living. Patient will be sent with a taxi to [named] Outreach to obtain a shelter. Patient will be evaluated by the task force outreach according to the staff who answered the phone when case management contacted to ask for the process.

Review of SP#3 Discharge Summary dated 07/08/2019 at 4:41PM documented patient was Baker-acted by police department for abnormal behavior and incoherent speech. Patient admitted to medicine for acute metabolic versus infectious encephalopathy and evaluation of abnormal lab values. Guardianship for placement initiated. Patient is now alert and awake times three, more coherent. Patient reevaluated by psychiatry and is now has capacity to be discharged to self-care. Case management consulted and followed the patient. Patient is stable to be discharged with outpatient follow up.

Interview with Chief Financial Officer on 09/09/2019 at 1:15PM revealed that if the patient has a guardian, the guardian is fully aware of the patient's care. The guardian participates in the discharge planning and works with the case management department. Prior to the patient's discharge, case management contacts the guardian to identify the location where the patient will be discharged.

Interview with Vice President of Quality Management on 09/11/2019 at 10:23AM revealed that there was no evidence of communication from the case management department to the guardian regarding the discharge plan for SP#3.

Review of Policy Title: Discharge Planning Process, last revised 01/19 documented Procedure, on page 2 of 5, G. Implement plan and communicate to patient /family. 2. Discuss Discharge Planning for patients 16 years of age or older with both the patient and their next of kin or legal guardian. Discharge, on page 4 of 5, b. Reassessment of vulnerable populations will be completed as needed prior to discharge such as homeless, victims of domestic violence and Behavioral Health.

Based on interview, record and policy review, the facility failed to reassess the patient's discharge plan for factors that may affect the appropriateness of the discharge plan for 1 (SP#3) out of 7 sample patients (SP).

Findings include:

Review of SP#3 Case Management Notes dated 11/29/2018 at 11:36 AM documented case discussed in interdisciplinary team and a request for Guardianship will be filled out due to patient's mental condition and the fact that the family has not been in contact with the facility and patient is unable to provide any reliable information in reference to family.

Review of SP#3 Case Management Notes dated 12/06/2018 at 5:15PM documented patient started a process for guardianship.

Review of SP#3 Case Management Notes dated from 12/06/2018 to 06/26/2019 documented patient in the process for guardianship.

Review of SP#3 Petition to Determine Incapacity and seek Plenary Guardianship executed on 02/05/2019 by Director of Utilization Review/Case Management was electronically filed on 02/06/2019 at 3:34 PM.

Review of SP#3 Plenary Guardian was done and ordered on 04/01/2019 and electronically filed 04/01/2019 at 12:15PM.

Review of SP#3 Psychiatric Progress Notes dated 06/27/2019 at 7:19 PM documented patient indicates doing okay. States not hearing any voices. States does not want to harm self or anyone else. States does not know any family in the area. Patient appears to be competent at time of assessment. Patient has not been agitated or psychotic. Patient does not need inpatient psychiatric treatment.

Review of SP#3 Physician Order dated 06/28/2019 at 7:25AM documented order for Case Management Consultation. Reason for Consult: Discharge Planning. Comment: Homeless Patient. Please assist with shelter and clothing.

Review of SP#3 Physician Order dated 06/28/2019 at 7:25AM documented Discharge Order, Discharge to Home.

Review of SP#3 Discharge Instructions dated Discharge Date: 06/28/2019 at Discharge Time: 7:25AM documented Patient Unable to Sign on 06/28/2019 at 12:16PM.

Review of SP#3 Case Management Notes dated 06/28/2019 at 10:51AM for Discharge Planning documented patient was reevaluated by psychiatrist who said that patient look competent. Physician ordered discharge home. Patient was not accepted for the owner of the place previously living. Patient will be sent with a taxi to [named] Outreach to obtain a shelter. Patient will be evaluated by the task force outreach according to the staff who answered the phone when case management contacted to ask for the process.

Review of SP#3 Discharge Summary dated 07/08/2019 at 4:41PM documented patient was Baker-acted by police department for abnormal behavior and incoherent speech. Patient admitted to medicine for acute metabolic versus infectious encephalopathy and evaluation of abnormal lab values. Guardianship for placement initiated. Patient is now alert and awake times three, more coherent. Patient reevaluated by psychiatry and is now has capacity to be discharged to self-care. Case management consulted and followed the patient. Patient is stable to be discharged with outpatient follow up.

Interview with Chief Financial Officer on 09/09/2019 at 1:15PM revealed that if the patient has a guardian, the guardian is fully aware of the patient's care. The guardian participates in the discharge planning and works with the case management department. Prior to the patient's discharge, case management contacts the guardian to identify the location where the patient will be discharged.

Interview with Vice President of Quality Management on 09/11/2019 at 10:23AM revealed that there was no evidence of communication from the case management department to the guardian regarding the discharge plan for SP#3.

Review of Policy Title: Discharge Planning Process, last revised 01/19 documented Procedure, on page 2 of 5, G. Implement plan and communicate to patient /family. 2. Discuss Discharge Planning for patients 16 years of age or older with both the patient and their next of kin or legal guardian. Discharge, on page 4 of 5, b. Reassessment of vulnerable populations will be completed as needed prior to discharge such as homeless, victims of domestic violence and Behavioral Health.