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Based on interview with facility Behavioral Health Unit (BHU) staff and review of BHU discharge planning policy, staff failed to ensure patients who required a skilled nursing facility (SNF) on discharge were provided a list of SNFs to select from and staff failed to document the SNF selection/choice was included in the discharge planning. The facility census was 216 patients with 49 of those on the BHU.

Findings included:

1. Record review of the facility BHU policy titled, "Discharge Planning and Process", approved 06/27/11 showed the following direction:
-A discharge plan was developed with involvement from the client, the client's family or significant other (when appropriate) and from all members of the treatment team.
-The discharge planning process takes into consideration the client's need for post-hospital treatment, community resources, need for residential or institutional care, family support and other factors that impact a client's post hospital care.

2. During an interview on 08/02/11 at approximately 3:30 PM BHU Staff A, Licensed Professional Counselor (LPC) stated the following:
-He/she had discharged patients to a SNF (skilled nursing facility) in the past.
-If the patient needed a SNF, as the discharge planner, he/she would talk to the patient about placement.
-Then, he/she would start calling SNFs to see if they have beds available.

3. During an interview on 08/02/11 at 4:12 PM BHU Staff B, Social Worker stated if a patient required a SNF, he/she would start calling SNFs with a behavioral health unit or if the patient had a guardian, he/she would call the guardian for their recommendation/preference for a SNF.

4. During an interview on 08/03/11 at 9:15 AM through 10:30 AM BHU Staff C, Team leader who also served as Director of Social Services stated the following:
-Some patients were discharged from the BHU to a SNF in the community.
-Staff talked to the patients regarding their options for SNFs but did not give a list of facilities to select from.
-If the patient was a voluntary admission and required a SNF on discharge, no list of SNFs was provided to the patient to select from.
-If the patient had a guardian, guardians or families were not provided with a list of SNFs to select from.
-Staff social workers were not required to document a SNF selection/choice in any specific portion of the patient medical record.

5. During an interview on 08/03/11 at 10:30 AM BHU Staff D, Licensed Clinical Social Worker (LCSW) stated the following:
-If a patient required a SNF on discharge, Staff D selected the SNF.
-Patients were not aware of the SNFs in the area.
-Staff D had shown lists of SNFs to patients (depending upon their level of consciousness) however kept the list after showing it to the patient.

6. During an interview on 08/03/11 at 12:35 PM BHU Staff E, Qualified Mental Health Professional (QMHP) stated the following:
-If a patient required a SNF on discharge, Staff E called a SNF from his/her own list.
-Staff E sometimes took the list to the patient but did not give it to the patient.
-Staff E did not send a list of SNFs to any guardians of patients who required SNF placement on discharge.
-He/she does not document SNF selections/choices in the patient medical record.

Based on interview with facility Behavioral Health Unit (BHU) staff, review of BHU discharge planning policy and review of patient medical records staff failed to ensure patients discharged to other facilities were discharged with accurate, necessary information for one (Patient #1) of five patients transferred to other facilities. The facility census was 216 patients with 49 of those on the BHU.

Findings included:

1. Record review of the facility corporate (applicable to every unit in the facility) policy titled "Discharge Planning", approved 03/17/11 showed the following direction:
-The patient shall be referred at discharge to practitioners, settings, and organizations as needed to meet his or her continuing care needs.
-The hospital shall provide the information needed for others to meet the patient's continuing care needs in accordance with corporate policies on confidentiality and disclosure of protected health care information.

Record review of the BHU policy titled, "Discharge Planning and Process", approved 06/27/11 showed the direction including "the discharge planning process takes into consideration the client's need for post-hospital treatment, community resources, need for residential or institutional care, family support and other factors that impact a client's post hospital care".

2. Record review of Patient #1's admission history and physical dated 07/09/11 showed staff admitted the patient through the Behavioral Health Emergency Department (BHED) on a ninety six hour hold after the patient eloped from a group home.

Record review of the patient's Psychosocial Assessment dated 07/11/11 showed staff assessed the following:
-Reliability of Mental Health information was called "unreliable".
-The patient's ninety-six hour hold documentation showed the patient eloped from the group home on 07/07/11.
-The patient was returned to the group home by an adult sibling and the spouse of the sibling.
-The patient stated he/she would not stay and no one could stop him/her.
-The patient told facility staff to let him/her go.
-The staff assessed the patient's medical record included multiple hospitalizations, non-compliance with medications, diagnosis of paranoid schizophrenia (paranoid schizophrenia, a chronic mental illness where a person loses touch with reality, hears and sees hallucinations).
psychiatric disorder with symptoms emotional instability, detachment from reality, and withdrawal into the self) and was a flight risk.

Record review of the patient's social worker's notes showed the following:
-Dated 07/13/11 the social worker spoke with the patient's guardian who stated the administrator of the patient's group home refused to accept the patient back after discharge from the hospital.
-Dated 07/14/11 the social worker assessed the patient was concerned about return to the group home, informed the patient that the group home administrator and the guardian were discussing return to the group home.

Record review of the patient's Psychiatrist notes dated 07/15/11 and again on 07/17/11 showed the physician assessed the patient inquired about discharge to the group home or another group home and further documented the social worker was working with the group home and the guardian.

Record review of the patient's social worker's notes dated 07/18/11 showed the social worker attempted to contact the patient's guardian and the administrator of the group home to inform them the patient would be discharged the following day to the group home. Further review showed the administrator and the guardian were not available so messages were left for them and a staff person told the social worker the guardian would have to talk to the administrator before the patient could be accepted back to the group home.

Record review of the patient's Psychiatrist notes dated 07/18/11 showed the following:
-The psychiatrist assessed the patient's interview was only somewhat reliable due to mental illness.
-The patient had been followed by another psychiatrist who was currently on vacation.
-The current psychiatrist assessed the patient with only fair insight and only fair judgment.
-The current psychiatrist planned to change the patient's medication and planned to observe the patient for results of the change.
-Stated staff had continued to work on discharge plans.

Record review of the patient's social worker's notes dated 07/19/11 showed the social worker had contact with the administrator who asked for three conditions for the patient's return to the facility (no visitors for a week; no unescorted walks due to the patient being a flight risk; attendance at five day a week day care program). Further review showed the administrator requested the social worker to send the medication list, the psychiatry evaluation, nurse's notes and a copy of the discharge papers prior to discharge.

Record review of the patient's Discharge Checklist dated 07/19/11 (authenticated by the social worker) showed the social worker listed information sent to the receiving facility included a copy of "Depart", a copy of the physician Discharge Summary template and prescriptions.

Record review of the patient's Discharge Summary dated 07/20/11 showed the patient was discharged on 07/19/11. Further review of the Discharge Summary showed the psychiatrist assessed the interview with the patient appeared fairly reliable, the patient was discharged back to the original group home and one of the patient's medications was decreased over the next three days and finally discontinued completely.

3. Record review of Patient #1's admission history and physical dated 07/26/11 showed the physician assessed the patient was diagnosed with schizophrenia and was readmitted to the facility after eloping from a group home, was missing for three days and was without his/her psychotropic medications for that time.

4. During an interview on 08/03/11 at 9:20 AM Staff F, Medical Director and psychiatrist for the BHU stated the following:
-Patient #1 had improved during the last admission (07/09/11 through 07/19/11).
-The patient was currently admitted for the same reasons (eloped from the group home, found wandering, became combative with police and was here on ninety-six hour hold).
-The patient was discharged to a group home.
-The group home had called (Staff F) regarding the patient's medications (list received was not legible.
-Staff F offered to call the group homes pharmacist and directly discuss the medications ordered including the planned medication reduction over time.
-Staff F stated he and the pharmacist got the medications straightened out.

5. During an interview on 08/03/11 at 12:35 PM Staff E, the Social Worker/Qualified Mental Health Professional currently assigned to plan discharge for Patient #1 stated the following:
-The patient was readmitted as an inpatient for the third time for at least the third elopement.
-There may have been benefit from care addressing elopement on the second inpatient admission.