HospitalInspections.org

Based on interview, review of documentation in 1 of 1 medical record of a patient who was discharged from the hospital (Patient 1), and review of hospital policies and procedures, it was determined the hospital failed to develop and implement its discharge planning policies and procedures in the following areas:
* The patient's discharge plan was unclear, incomplete, and was not evaluated on an ongoing basis, including arrangements for and appropriateness of post discharge services and settings identified by the hospital, including those that were located 275 miles from the hospital.
* The patient's discharge planning evaluation did not include an evaluation of the patient's capacity for self-care with respect to his/her health conditions.

Findings include:

1. The policy and procedure titled "Routine Discharge Process, IP," dated last revised "3/6/2017" was reviewed. It stipulated:
* "...Discharge planning begins during the admission process. An Assessment Counselor completes...the 'Discharge Needs Assessment', where information regarding existing providers is documented...The Assessment counselor completes the 'Release of Information (ROI)' with the patient, adding existing providers and any family members participating in the patient's treatment."
* "...Within 48 hours of admission, the assigned Therapist initiates the 'Discharge Checklist', completes...the 'Discharge Needs Assessment'...and introduces the patient to the 'My Crisis/Safety Plan' form."
* "Within 72 hours of admission, the Therapist completes the Master Treatment Plan, which includes adding the findings/patient discharge needs to the plan."
* "The social services team documents on-going discharge planning efforts in the patient record. Discharge efforts that should be documented include collaboration with previous and existing providers, family members, as well as aftercare appointment scheduling."
* "On the day prior to the scheduled date of discharge, the Primary Therapist meets with the patient and completes the discharge 'Risk Assessment' form.' The patient is given education on suicide and relapse prevention and the completed 'My Safety/Crisis Plan' is reviewed...all relevant documents are placed in the medical record...The Therapist signs off on all items completed on the 'Discharge Checklist' form."
* "On the day of discharge...provider completes their section of the 'Discharge Checklist' form."
* "On the day of discharge, the Provider writes a prescription for medications...Education is provided to the patient..."
* "At the time of discharge...discharging Nurse will complete the nursing section for the 'Discharge Checklist' form."
* "Medical Records staff will complete their portion of the 'Discharge Checklist' form and forward the checklist to the PI Department for process analysis."

2. The medical record of Patient 1 was reviewed on 09/28/2018 at 1545 with the CPI, DCS, CNO and QMHP E. The record reflected the following:

The patient was admitted to the hospital from ARRMC on 04/14/2018 at 2213.

The "Psychiatric Evaluation Assessment" dated 04/15/2018 reflected the patient's chief complaint was "...[He/she] was suicidal for 4 days. [He/she] was thinking of running into traffic or cut (sic) himself with a knife." The mental status examination reflected "Thought Content...reports suicidal ideation with a plan..." The initial diagnoses reflected "Unspecified depression. Late-onset bipolar disorder and cognitive impairment, by history. Hypertension, Diabetes...Chronic obstructive pulmonary disease."

The physician "Progress Note" dated 04/16/2018 reflected "...Notable for vague suicidal ideation in the context of having no support or structure in [his/her] life...Mood...appears to be generally depressed...[he/she] may be reaching a point that [he/she] is unable to function and cope effectively in a sustained homeless situation and has not been able to organize resources around being able to move past this predicament."

The 23 page "Clinical Assessment" form signed by a LPC Intern on 04/18/2018 at 1600 reflected:
On page 3:
* The "Psychosocial Assessment" reflected "Who will be involved in treatment and services: Name: [name] Senior Services." There was no further information or follow up related to the plan to involve the case worker in treatment and services post discharge.
On page 4:
* "Current Housing...Shelter/Homeless"
* "Living Conditions...Housing dangerous/deteriorating"
* "Housing Plans Upon Discharge...Residential Care." There was no further information or follow up related to the plan for "Residential Care."
On page 7:
* The "Community Supports" section reflected "Case Manager." There was no further information or follow up related to a case manager for community support.
On page 21:
* The "Preliminary Discharge Plan" reflected "Step-Down to Outpatient Providers." There was no further information or follow up related to the plan for "Step-Down to Outpatient Providers."
* The "Current Providers" section was not completed and was blank.
* The "Discharge Planning Needs" section reflected the "Patient has a Psychiatrist/Clinic (verify above)...Existing appt date/time:" There was no "Psychiatrist/Clinic" identified "above" and "Existing appt date/time:" was followed by a blank line.

The "Master Treatment Plan, Part 1" reflected the "Problem/Short-term Goals" included "Medication Non-compliance...Sleep Apnea...COPD..." and the interventions included "Assess barriers to learning and readiness for medication teaching...Reinforce benefits of compliance to the following medication: Risperidone...Assure patient can competently use CPAP/BIPAP..." Although the treatment plan reflected the patient was non-compliant with medications, there was no documentation that the patient was assessed regarding his/her ability to appropriately and safely self medicate after discharge. There was no documentation that reflected the patient was assessed and able to use CPAP/BIPAP. There was no documentation that reflected if CPAP/BIPAP equipment was needed and/or available after discharge.

The "Multidisciplinary Master Treatment Plan, Part 2" reflected:
* "Patient Vulnerabilities...Unstable Living Environment." There was no further information related to the unstable living environment.
* "Initial Discharge Disposition...Alternative living arrangements...Medication Management...Individual Therapy...Mental Health Center...Medical &/or Psychiatric Referral." The information was preprinted and generic. There was no further information that reflected what the "Alternative living arrangements" were, nor the other aspects of the discharge disposition.
* The "Patient Participation" section reflected the following options that were each preceded by a box: "Contributed to goals/plan," "Aware of plan content," "Unable to participate due to clinical reasons," "Refused to participate," "Refused to sign," and "Unable to sign." None of the boxes were checked.
* The bottom of the treatment plan reflected "This treatment plan has been presented and reviewed with me in language that I understand. I had the opportunity to ask questions." This was followed by a blank patient signature line.

The physician discharge orders signed by the physician and dated 04/19/2018 at 1100 reflected "Discharge Patient to: Home...Routine [Discharge]..."

The "Physician Discharge Medication Orders" form signed by the physician and dated 04/19/2018 at 1100 reflected "List the Medications the Patient will be taking at home..." followed by the names of 12 medications. The record contained a prescription for 2 of the medications, Risperidone and Trazadone. There was no documentation that reflected a plan for how the patient would obtain the other 10 medications on the list.

The "Social Services" notes documented by QMHP E dated 04/19/2018 at 1500 reflected "[QMHP E] spoke with [Patient 1], [he/she] will be discharged to the Portland rescue mission..." There was no prior documentation that reflected the patient was informed and involved in this discharge plan, nor the patient's response to the plan.

The "Discharge/Aftercare Plan" signed by a "Social Service Staff" on 04/19/2018 but not timed reflected:
* "Destination...Portland Rescue Mission"
* "Accompanied By...Self"
* "Transportation...Cab"
* "[checked box] I have received a list of all recommended medications (Medication Reconciliation Form)...Patients should see their Primary Care Provider concerning issues regarding medications post-discharge."
* The form reflected a referral to "Individual/Family Therapist Columbia Care Connect...wrap around services." This was followed by [Patient 1] will follow-up [QMHP E] has reached out...[phone number]."
* The form reflected a referral/follow up to Asante Physicians Associates, White City followed by "Reason For Follow up...Follow-up to inpatient, medication management."
* The form reflected "Reason for Hospitalization...Safety Risk: Harm to Self" and "[Discharge] Type...Patient Request/Tx Incomplete." This was contradictory to the physician order above that reflected "Routine [Discharge]."
* The form was signed by the patient but not dated or timed.

The physician "Discharge Summary" dated 04/19/2018 reflected "Discharge Instructions...the patient discharged with aftercare including a followup (sic) appointment through Columbia Care Connect. [He/she] is also referred to Old Town Clinic...The patient has an appointment on Tuesday, April 24, 2018, at 1120 hours with...Asante Physician's Associates...White City, Oregon...Concerns related to discharge include continued use of [his/her] medications as prescribed and followup (sic) in the community with [his/her] aftercare providers...Discharge Suicide Risk Assessment...patient has a history of limited coping skills and significant social stressors...long-term prognosis is contingent upon [his/her] adherence to [his/her] treatment plan, followup (sic) care in the community with [his/her] aftercare providers...and continued use of [his/her] medications as prescribed...Psychosocial and Contextual Factors: Moderate to severe."

The record reflected the patient was discharged in a cab by him/herself to Portland Rescue Mission on 04/19/2018 at 1545.

Although the record reflected the patient's long-term prognosis was contingent upon adherence to the treatment plan, follow up care in the community with aftercare providers, and continued use of medications as prescribed, there was no documentation that reflected appropriate initial and ongoing discharge evaluation and planning as follows:
* An evaluation or plan for how and when the patient would get from Portland Rescue Mission to White City for follow up care and services, including medication management post discharge.
* An evaluation or plan for how Columbia Care Connect and "wrap around services" would be involved in the discharge plan.
* An evaluation or follow up to the discrepancy between "Routine [Discharge]" on the physician order versus "[Discharge] Type...Patient Request/Tx Incomplete" on the "Discharge/Aftercare Plan" with respect to the patient's readiness for discharge and post discharge plan.
* That the patient was appropriately and timely involved in the discharge evaluation and plan prior to discharge.
* The patient's response to the discharge plan.

In addition, there was no documentation that reflected:
* That the patient was introduced to the "My Crisis/Safety Plan" form and a "Discharge Checklist" form was completed in accordance with the hospital policy in finding 1.

3. During an interview with QMHP E on 09/28/2018 at the time of the medical record review, the following information was provided:
* The patient's discharge plan was to return to White City or Eagle Point where he/she had established care providers and "resources who could coordinate housing, meds, case management and follow up appointments." He/she stated the patient was supposed to go to the Portland Rescue Mission as a "layover" until he/she could "get to White City or Eagle Point." However, he/she confirmed there was no documentation that reflected how long the patient was to "layover" at the Portland Rescue Mission or arrangements for how the patient would get from the Portland Rescue Mission to White City or Eagle Point.
* He/she confirmed the discharge evaluation and plan were unclear and incomplete.

4. During an interview with CPI on 09/28/2018 at the time of the medical record review, he/she stated:
* The discharge 'Risk Assessment' form' reflected in the hospital policy in finding 1 was no longer completed by a therapist. The CPI stated the current process was that the physician was responsible for completing the discharge risk assessment form. The CPI acknowledged the hospital policy did not reflect the current process.
* Regarding the "Discharge Checklist" form, the CPI confirmed there was no documentation that reflected the "Discharge Checklist" form was initiated or completed.

5. During an interview with DCS on 09/28/2018 at the time of the medical record review, the following information was provided:
* He/she confirmed the hospital policy in finding 1 required a discharge needs assessment be completed within 48 hours of admission by the patient's primary therapist. However, he/she confirmed that was not done.
* Regarding the "My Crisis/Safety Plan" form, the DCS stated "It's not done."
* He/she confirmed the Master Treatment Plan included no plan for where the patient would be discharged to.
* He/she confirmed the Master Treatment Plan reflected the patient would be provided medication teaching and there was no documentation that was done. He/she confirmed there was no documentation that reflected the patient was assessed for his/her ability to safely self administer medications after discharge.
* He/she confirmed there was no documentation that reflected the patient was assessed and determined capable of making arrangements to get from Rescue Mission Portland to White City where he/she had support services.
* He/she confirmed there was no documentation that reflected the patient was included in the post discharge plan prior to discharge, including informing him/her how and when he/she would get from Portland Rescue Mission to White City.

6. During an interview with the CNO on 09/28/2018 at the time of the medical record review, he/she stated the usual process would be to help get the patient transportation back to his/her usual community where post discharge services were available. He/she confirmed that was not done.

7. Online driving instructions reflect White City, Oregon is 275 miles and 4 hours and 11 minutes driving time from Portland, Oregon.

8. Online driving instructions reflect Eagle Point, Oregon is 288 miles and 4 hours and 43 minutes driving time from Portland, Oregon.

Based on interview, review of documentation in 1 of 1 medical record of a patient who was discharged from the hospital (Patient 1), and review of hospital policies, procedures and other documentation, it was determined the hospital failed to develop and implement its discharge planning policies and procedures in the following areas:
* The patient's discharge plan was unclear, incomplete, and was not evaluated timely and on an ongoing basis, including arrangements for and appropriateness of post-discharge services and settings identified by the hospital, including those that were located 275 miles from the hospital.

Findings include:

Refer to the findings identified at Tag A806 that reflected the hospital failed to ensure a timely evaluation and appropriate post discharge arrangements were made for Patient 1.

Based on interview, review of documentation in 1 of 1 medical record of a patient who was discharged from the hospital (Patient 1), and review of hospital policies, procedures and other documentation, it was determined the hospital failed to develop and implement its discharge planning policies and procedures in the following areas:
* The patient was not appropriately informed and involved on an on-going basis in the discharge evaluation and discharge plan including arrangements for post discharge services identified by the hospital that were located 275 miles from the hospital.

Findings include:

Refer to the findings identified at Tag A806 that reflected the hospital failed to ensure Patient 1 was appropriately involved and informed of the results of the discharge evaluation and discharge plan.

Based on interview, review of documentation in 1 of 1 medical record of a patient who was discharged from the hospital (Patient 1), and review of hospital policies, procedures and other documentation, it was determined the hospital failed to develop and implement its discharge planning policies and procedures in the following areas:
* A clear and complete discharge planning evaluation was not documented and was not used to develop an appropriate and timely discharge plan, including arrangements for post discharge services and settings identified by the hospital that were located 275 miles from the hospital.

Findings include:

Refer to the findings identified at Tag A806 that reflected the hospital failed to ensure a clear and complete discharge planning evaluation was completed and documented in Patient 1's medical record and was used to establish an appropriate discharge plan.

Based on interview, review of documentation in 1 of 1 medical record of a patient who was discharged from the hospital (Patient 1), and review of hospital policies, procedures and other documentation, it was determined the hospital failed to develop and implement its discharge planning policies and procedures in the following areas:
* The hospital failed to ensure it arranged, and appropriately involved and prepared the patient and other support persons regarding the plan for post hospital care, including arrangements for follow-up services and potential medical equipment and medication teaching.

Findings include:

Refer to the findings identified at Tag A806 that reflected the hospital failed to ensure it arranged, and appropriately involved and prepared the patient regarding the plan for post hospital care.