HospitalInspections.org

Based on a review of facility policies and procedures, the medical record and interviews, the facility failed to ensure that for one of one patients (Patient #1), a discharge plan was updated as needed to reflect a change after a re-evaluation of the patient's condition that identified changes that required modification of the discharge plan.

Findings included:

A review of facility policy entitled "Transition in Care Coordination & Discharge Planning, effective November 2010 and last reviewed April 2021 revealed but was not limited to the following:

"Discharge Planning is a partnership between the patient, his/her family, the facility treatment team and the next level of care provider (s). The discharge plan is reassessed and updated as changes in the patient's condition and needs occur. Newly identified aftercare providers are added to the discharge instructions/plan.

Review of a complaint from Patient #1's family member revealed but was not limited to the following. The family member alleged that Patient #1 was discharged to a boarding home and the family was not aware of this discharge. In addition, she alleged that Patient #1 ran away from the boarding home and was found wandering the streets of the city.

Review of Aftercare/Discharge Plan Part II (to be completed by social services) revealed the following: Patient #1 was admitted on 12/11/2022 and was discharged on 12/16/2022. He was to be discharged home to his mother. This form was signed by a facility social worker (Social Worker I) and dated 12/12/2022.

Review of an email, dated 12/13/2022 sent to Social Worker #1 from Patient #1's community mental health organization revealed that Patient #1's mother had moved in with her daughter and Patient #1 will have no home to return to. Patient #1's mother is in her late 70's and is unable to care for him. Patient #1 will need help being referred to a boarding home or group home as he will have no home to return to.

Interview on 02/07/2023 with Social Worker #1 revealed but was not limited to the following:
She stated that Patient #1 did go to a boarding home on the date of his discharge. She stated that his placement at the boarding home happened at the last minute. She further stated that once she knew he was going to a boarding home, she contacted Patient #1's mother by phone on the day of his discharge and informed her of his placement at the boarding home.

She confirmed that she did not document the phone contact with the mother or update his placement at the boarding home on his discharge plan.