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Based on medical facility policy, record review, observation, and staff interview, it was determined that the hospital failed to ensure the patient's privacy and basic right for respect, dignity, and comfort for 1 of 2 patients (Patient #2) sampled, by not providing clothing for the patient, keeping the patient in paper scrubs for most of her hospital stay, and discharging her in paper scrubs with no resources (money, cell phone, clothing) somewhere other than her home or a hospital. Failure to ensure that the patient had adequate clothing to maintain her dignity places her at risk in the community. Findings include:

I. The hospital policy titled, "Guidelines for the Use of Restraints and Seclusion" stated, "...Prior to the application of restraints and/or seclusion, attempts will be made to use less-restrictive measures...".
- Interview with Employee #7, Care Manager, on 8/25/2023 at 12:55 PM stated one of the reasons patients are put in paper scrubs is if their clothing poses a ligature risk or if the patient is at risk for elopement. This is considered a less restrictive measure, an alternative to chemically or physically restraining a patient.
-Patient #2 was not an elopement risk.
-Patient #2 did not have anything considered a ligature risk.


II. Record review:
- Physician's order sheet dated 8/17/2023 "D/C (discharged) via taxi off of Rockford campus. Pt. (patient) had no belongings".
- Patient #2 was provided transportation to the Sunday Breakfast Mission, a homeless shelter, by the facility.

III. Interviews with staff revealed:
- Interview with Employee #6, MSW (Masters in Social Work), on 8/25/2023 at 12:45 PM: "If a patient is admitted with no clothing, a family or church member is contacted to see if they can bring in clothes."
- "If no one can bring in clothes we have gone out and purchased clothes for patients".
- When asked is it a usual occurrence for patients to be discharged in paper scrubs, Employee #6 stated, "It is not the usual way things are done. It is not the norm for patients to be discharged in paper scrubs and most agencies will not accept a patient in paper scrubs or a hospital gown." When asked if this is unusual for a patient to be discharged in paper scrubs, Employee #6 stated, "It would be very unusual. Paper scrubs rip or tear easily so they are not a ligature risk and will tear if they get wet or sweaty".
- Interview with Employee #7, Care Manager, on 8/25/2023 at 12:55 PM: When asked if a patient does not have any clothing or belongings, what would they wear at discharge? Employee #7 responded, "We have actually bought clothes for patients. We did that today for a patient who is morbidly obese, and nothing fits him. We usually don't discharge a patient in paper scrubs. The patient would have no dignity and be at risk in the community".
- Interview with Employee #8, MSW, on 8/28/2023 at 3:02 PM: stated that Patient #2 had a bag of clothes that her church friends brought in, so she doesn't know why the patient left in paper scrubs.

IV. Video Surveillance dated: 08/17/2023 at 4:18 PM - 4:20 PM revealed:
- Patient #2 left the facility in paper scrubs.
- Patient #2 was carrying a bag in her hands, contents unknown.


- Interview on 8/29/2023 at 09:18 AM with APS Nurse Employee #1 who met Patient #2 at the homeless shelter, confirmed that Patient #2 exited the transportation with no belongings, and the back of the paper scrubs were soiled, torn, and exposed her buttocks.

The finding of Patient #2 discharged in paper scrubs was confirmed by video surveillance on 8/17/2023 at 4:18 PM - 4:20 PM. The facility failed to ensure that the patient had adequate clothing to maintain her dignity and dropping her off in a public place with no resources which placed her at risk in the community. This was corroborated by APS Nurse #1.

Based on medical record review, observation, policy review and staff interview, it was determined that the hospital failed to provide a safe discharge plan, according to their policy, for 1 of 2 discharged patients in the sample (Patient #2). This failure places the patient at risk in the community because she was dropped off at the homeless shelter without prior notice, the mission was full and could not accept her, and the patient arrived in a paper scrub suit, with no clothing, belongings, money, or cell phone.

Findings include:

I. Policies revealed:
-The facility policy titled "Discharge/Aftercare Planning" stated, " The Discharge Plan should...identify problems to be addressed in the next level of care...include timely and direct communication with and transfer of information to individuals that will be providing continuing care...".
-The facility document titled "Job description- Social Worker" states..." the social worker's responsibility is to develop and coordinate an individualized discharge plan for the patient... identify and assess family or community resources... to meet the patient's aftercare needs...".

II. Record review revealed:
Per record review, the discharge plan for Patient #2 stated:
- "[He/She] was going to the Sunday Breakfast Mission for housing."
- "[He/She] would stay at the Mission for a week and the Bridge Program would supply aftercare services".
- Patient was not homeless, and owned a home in New Castle but utilities had been turned off for non-payment.
- Homeless Shelter was in Wilmington and did not dispense medication.
- Medications were called to Walmart in New Castle, not Walgreen's inWilmington.
- Patient #2 had no resources to get medication.
- Patient #2 needed prompting to take medication.
- Patient #2 was diagnosed as delusional, schizophrenic, severe cognitive dysfunction, unspecified dementia, diabetes insulin dependent.


III. Interviews revealed:
A. Interview with Sunday Breakfast Mission Employee #1(Administrative Assistant), on 08/29/2023 at 12:00 PM, revealed:
- "They (Sunday Breakfast Mission) have no agreement with any Behavioral Centers. The process is a psych eval needs to be faxed and reviewed by their Director". No psych eval was faxed on [Patient #2]".
- There was no communication or transfer of information to the Sunday Breakfast Mission regarding Patient #2.
- "The client must be interviewed to be accepted into the Life Changing Program, (an 18-month program where participants live, take classes, and learn life skills)".
- Patient #2 was never interviewed or accepted into any program by the Sunday Breakfast mission.
- "The overnight shelter - people must come in between 6:00 PM and 6:30 PM, first come/first served, attend Chapel, shower, eat, and spend the night. They must leave by 7:00 AM.

B. Interview with hospital Employee #8, MSW, on 8/28/2023 at 3:02 PM stated: "The Sunday Breakfast Mission is an open shelter. We have a good relationship with them and send many people there".

C. Interview with Employee #2, Sunday Breakfast Mission Director, on 8/30/2023 at 12:30 PM revealed:
- "I don't recognize [Patient #2's] name".
- "Because the program has a lot of children living there, I am very strict on who is accepted". Patient #2 was never accepted.
- "If someone was dropped off, they cannot just be accepted, so whoever drops them off is essentially dropping them off to the street."

D. Interview with APS (Adult Protective Services) Employee #1 on 8/30/2023 at 9:18 AM revealed that:
- APS Employee #1 arrived before Patient #2.
- APS Employee #1 was told "[Patient #2] was not there yet, and they were already full, so [he/she] would not have a place to stay".
- Patient #2 was dropped off in a paper scrub suit that was soiled and ripped at the back exposing Patient #2's buttocks. APS Employee #1 stated "I took off my own scrub jacket to tie around [Patient #2's] waist to maintain [his/her] dignity".

The facility failed to meet this requirement for safe discharge as the Sunday Breakfast Mission was unaware that Patient #2 was coming, there was no room when the patient arrived, and the psychiatric consult was never faxed for review for admission into their program.

The finding of Patient #2 dropped off at the Sunday Breakfast Mission without prior arrangement to a program, at a time when the facility was full and could not receive the patient was confirmed by APS Nurse Employee #1 on 8/30/23 at 09:18 AM and corroborated by Sunday Breakfast Mission Director Employee #2, on 08/29/2023 at 12:00 PM.

IV. Video Surveillance dated: 08/17/2023 at 4:18 - 4:20 PM revealed:
- Patient #2 left the facility in paper scrubs.
- Patient #2 was carrying a bag in her hands, contents unknown.
- Patient #2 was provided transportation to the Sunday Breakfast Mission.

Interview 8/30/23 at 09:18 AM with APS Nurse Employee #1 who confirmed that Patient #2 exited transportation with no belongings, and the back of the paper scrubs were torn, soiled and exposed her buttocks.