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Based on document review and interview, it was determined that for 1 of 4 patient's (Pt. #2) clinical records reviewed for care planning, the Hospital failed to ensure that Pt. #2's representative participated in the development of the plan of care.

Findings include:

1. On 3/06/2023, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted on 2/27/2023 with a diagnosis of schizophrenia (mental disorder). The clinical record indicated that Pt. #2 had a state guardian/authorized representative. On 2/27/2023, the Hospital's interdisciplinary treatment team developed a plan of care without involving Pt. #2's state guardian.

2. On 3/06/2023, the Hospital's policy titled, "Patient Rights and Responsibilities" (effective 4/2022) was reviewed and included, "... III... A. Patient has the right to... 2. Designate an authorize representative... The patient's rights include... being involved in care planning..."

3. On 3/06/20223, findings were discussed with E #2 (Charge Nurse). E #2 stated that there was no documentation to indicate that Pt. #2's representative was involved in the development of Pt. #2's care plan.

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #3) clinical records reviewed for informed consent, it was determined that the Hospital failed to obtain consent for treatment from the patient's representative, to uphold the right to make informed decision.

Findings include:

1. On 3/06/2023, the clinical record for Pt. #3 was reviewed. Pt. #3 was admitted on 2/28/2023 due to aggression. The clinical record included a document, dated 2/28/2023, indicating that Pt. #3 has a state guardian. The document indicated, '... In the event that hospitalization... becomes necessary for (Pt. #3), you MUST obtain consent from (the) Public Guardian's representative before such hospital admission...." The consent for treatment was obtained and signed by Pt. #3 instead of the state guardian.

2. On 3/06/2023, the Hospital's policy titled, "Consent - Informed Consent" (effective 5/2022) was reviewed and included, "It is the policy... that the Hospital be responsible for obtaining the... patient's authorized representative's consent to medical treatment..."

3. On 3/06/2023, findings were discussed with E #2 (Charge Nurse). E #2 stated that the consent for treatment was signed by Pt. #3 instead of the state guardian.

Based on document review and interview, it was determined that the Hospital failed to provide an appropriate discharge planning services. As a result, the Condition of Participation, 42 CFR 482.43, Discharge Planning, was not in compliance.

Findings include:

1. The Hospital failed to ensure the discharge plan was updated with a re-evaluation to identify changes in discharge needs. See deficiency A-802.

2. The Hospital failed to demonstrate periodic assessment of the discharge planning process, including a review of patients admitted within 30 days of previous admission were conducted. See deficiency A-803.

3. The Hospital failed to ensure a discharge planning evaluation was made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge. See deficiency A-805.

Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) patients reviewed for discharge planning, the Hospital failed to ensure the discharge plan was updated with a re-evaluation to identify changes in discharge needs.

Findings include:

1. The Hospital's policy titled, "Discharge Planning (3/2022)" was reviewed on 3/6/2023 and required, "LSW [licensed social worker] ensures that all discharge plans discussed in the treatment planning meetings are documented in the multidisciplinary treatment plan."

2. The clinical record of Pt. #1 was reviewed on 3/6/2023. Pt. #1 was admitted from a nursing home on 1/5/2023 at 2:27 AM with a diagnosis of psychosis (mental disorder characterized by a disconnection from reality). Per the Social Worker's (E#1) note, dated 1/5/2023 at 7:48 AM, Pt. #1 was an involuntary discharge and could not return to the nursing home. The clinical record lacked any additional progress note from the LSW regarding changes in discharge plan.
- The Attending psychiatrist's (MD#1) discharge summary dated 01/13/2023 included that Pt.#1 was able to sustain himself in a structured living environment, where he can receive regular outpatient psychiatric medication management services. Discharge instructions stated that case management was engaged for transfer arrangements back to other nursing facility, where he will be followed by the nursing home physician & psychiatrist.
- Pt. #1 was discharged to a Shelter on 1/10/2023.

3. During an interview on 3/6/2023 at approximately 2:00 PM, the Social Worker (E#1) stated that the clinical record did not include any discharge planning documentation. E#1 stated, "Other nursing homes were looked into, but patient [Pt. #1] chose shelter placement instead of going to another nursing home. I can not explain why I did not document anything. I should have documented everything that was done regarding change of plans."

Based on document review and interview, it was determined that the Hospital failed to demonstrate periodic assessment of the discharge planning process, including a review of patients admitted within 30 days of previous admission were conducted. This potentially affect the discharge planning needs and outcomes for any patient in the Hospital.

Findings include:

1. The Hospital's policy titled, "Discharge Planning" (revised on 4/2022) was reviewed and included, "... CM (Case Management) Potential Functions... 3. Address and implement as needed to comply with governmental guidelines affecting hospital length of stay, readmissions, level of care and discharge follow-up calls..."

2. On 3/7/2023 at approximately 11:45 AM, any documentation, meeting minutes, or data collected to indicate that the Hospital conducted periodic review of the discharge planning program was requested. As of survey date 3/8/2023, no available information was provided.

3. On 3/7/2023 at approximately 1:00 PM, an interview was conducted with E #3 (Chief Nursing Officer). E #3 could not provide any documentation to indicate that the Hospital conducted periodic assessment of the discharge planning process. E #3 also stated that during discharge meetings, review of patient's discharge plans readmitted within 30 days was not discussed.

Based on documentation review and interview it was determined that for 5 of 5 (Pt. #1, Pt. #2, Pt. #3, Pt.#9 and Pt. #10) patients reviewed for discharge planning, the Hospital failed to ensure a discharge planning evaluation was made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge.

Findings include:

1. The Hospital's policy titled, "Discharge Planning (3/2022)" was reviewed on 3/6/2023 and included, "Licensed Social Worker completes an assessment, which addresses discharge needs within 72 hours of admission."

2. On 3/6/2023, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted from a nursing home on 1/5/2023 with a diagnosis of psychosis. The clinical record lacked a social worker psychosocial assessment for discharge planning to identify post hospital needs.

3. On 3/6/2023, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted on 2/27/2023 with a diagnosis of schizophrenia. The clinical record indicated that a psychosocial assessment, including discharge planning evaluation, was conducted on 3/6/2023 (five days, excluding weekends, after admission).

4. On 3/6/2023, the clinical record for Pt. #3 was reviewed. Pt. #3 was admitted on 2/28/2023 due to aggression. The clinical record indicated that a psychosocial assessment, including discharge planning evaluation, was conducted on 3/6/2023 (four days, excluding weekends, after admission).

5. On 3/7/2023, the clinical record for Pt. #9 was reviewed. Pt. #9 was admitted on 2/26/2023 with a diagnosis of schizoaffective disorder. The clinical record indicated that a psychosocial assessment including discharge planning was not completed.

6. On 3/7/2023, the clinical record for Pt. #10 was reviewed. Pt. #10 was admitted on 2/28/2023 due to aggression. The clinical record indicated that a psychosocial assessment was conducted on 3/6/2023 (four days, excluding weekends, after admission).

7. During an interview on 3/6/2023 at approximately 2:00 PM, the Social Worker (E#1) stated that a psychosocial assessment should be completed within 72 hours of admission for all patients. E#1 stated, "I should have documented my assessment, including discharge plan in the clinical record."

8. During an interview on 3/7/2023 at approximately 10:15 AM, the Chief Nursing Officer (E# 3) stated that all patients should have an assessment completed by the social worker within 72 hours, excluding weekends. E#2 stated, "These assessments are not completed or not completed on time."