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Based on policy and procedure review, medical record review, and staff and physician interviews, facility staff failed to notify a guardian of the plan of care for 1 of 2 patient's with guardians(Patient #3).

The findings included:

Review on 09/11/2018 of the facility's policy "Patient Rights" last reviewed/revised 01/2015 revealed, "...3. The patient has the right to participate in the development and implementation of his/her plan of care and to obtain relevant, understandable and current information regarding diagnosis, treatment and prognosis...4. The patient or his/her representative has the right to make informed decisions regarding care. This includes being informed of his/her health status, a description of a procedure or treatment, alternatives to the choice of treatment and risk involved in the course of treatment or non-treatment..."

Request on 09/12/2018 at 1415 for a policy related to patient's with guardians and when to notify guardians revealed there was no policy.

Closed medical record review on 09/12/2018 of Patient #3's face sheet revealed "Emergency Contact(s)...(Patient #3's family member) Guardian..." Review of a scanned form titled "LETTERS OF APPOINTMENT GUARDIAN OF THE PERSON" revealed Patient #3 had two family members as his guardian since 03/31/2017. Review revealed Patient #3 arrived to the emergency department (ED) on 07/08/2018 at 1029 with a chief complaint of "Mental Eval (evaluation)." Review revealed MD #1 saw Patient #3 at 1049. Review of the "ED Provider Note" revealed "...36 year old male arrives voluntarily from group home. Review of past medical recordds (sic) indicates he has a hx (history) of schizoaffective disorder/multiple psych (psychiatric) admissions. He states he does not feel safe in his group home as there are some other residents there who have been aggressive and are 'sick.' He denies SI (suicidal ideations)/ HI (homicidal ideations)/ hallucinations/drug or etoh (alcohol) use. Has been compliant with all psych meds..." Review revealed at 1049 MD #1 ordered a social work consult. Review of Counselor #2's note at 1141 revealed "...HE IS WELL KNOWN TO THE HOSPITAL FROM PREVIOUS VISITS. PT (patient) PRESENTS TODAY STATING HE DOES NOT FEEL SAFE AT THE HOME WHERE HE IS LIVING. HE STATES 'SOMETIMES THEY LOOK AT ME FUNNY.' HE DENIES ANY CRISIS TODAY...PT HAS A HX OF FEELING PARANOID ABOUT THE HOME WHERE HE LIVES. PT HAS A LONG HX OF SCHIZOAFFECTIVE DISORDER. HE WAS RECENTLY HOSPITALIZED AT A PSYCHIATRIC FACILITY...X 2 WEEKS...HE IS LINKED WITH THE (Outpatient Provider). HE IS TAKING PRESCRIBED MEDICATION...PT DENIES CURRENT SUICIDAL OR HOMICIDAL IDEATION. HE DENIES THOUGHTS TO HARM ANYONE IN THE HOME WHERE HE LIVES. HE DENIES FEELING LIKE ANYONE MIGHT HURT HIM THERE. PHONE CALL TO (Outpatient Provider)...SHE STATES AT BASELINE PT HAS PARANOID THOUGHTS..." Review of the "ED Provider Note" at 1156 revealed "...Seen by (Counselor #2) w (with) psych team/patient is at his baseline no indication for admit. Fu (follow up) w pcp(primary care physician)/(Outpatient Provider). Return if worse..." Review of an additional note by Counselor #2 at 1158 revealed "PHONE CALL TO (MD #3). ASSESSMENT INFORMATION PROVIDED. SHE RECOMMENDS DISCHARGE BACK TO GROUP HOME, F/U WITH (Outpatient Provider). (Outpatient Provider) INFORMED. WILL MEET WITH PT TODAY AT 1400." Review revealed Patient #3 was discharged at 1225. Review of the discharge documentation revealed "...Mobility at Departure: Ambulatory Departure Mode: By self..." Review failed to reveal Patient #3's guardian or group home was notified of his discharge from the ED.

Closed medical record review on 09/11/2018 of Patient #3's face sheet revealed "Emergency Contact(s)...(Patient #3's family member) Guardian..." Review of a scanned form titled "LETTERS OF APPOINTMENT GUARDIAN OF THE PERSON" revealed Patient #3 had two family members as his guardians since 03/31/2017. Review revealed Patient #3 arrived to the ED on 07/13/2018 at 0608 for a chief complaint of "MENTAL EVALUATION." Review revealed MD #4 saw Patient #3 at 0628. Review of the "ED Provider Notes" revealed "...This is a 36-year-old man who was sent from his group from home (sic) for disorganized thinking and medication noncompliance...He states that he thinks he has been poisoned with his medications at his group home. He reports that he has 'every symptom.' He denies any suicidal or homicidal ideation, although he states that he 'should be suicidal' because of his life experiences. History is limited by altered mentation..." Review revealed MD #4 placed an order for "Inpatient consult to Social Work" at 0639. Review of Counselor #2's note at 0717 revealed "...HE IS VERY WELL KNOWN TO PSYCHIATRIC SERVICES FROM PREVIOUS VISITS...PT HAS A LONG HX OF SCHIZOAFFECTIVE DISORDER. HE HAS A HX OF MULTIPLE PRIOR INPATIENT PSYCHIATRIC ADMISSIONS. HE RECENTLY HAD AN ADMISSION...HE IS SEEN BY (Outpatient Provider). THEY MADE CONTACT WITH HIM EARLIER THIS WEEK FOLLOWING AN EMERGENCY DEPARTMENT VISIT...PT REPORTS TAKING HIS MEDICATION AS PRESCRIBED..AWAITING MEDICAL CLEARANCE..." Further review revealed Patient #3 was having auditory hallucinations. Review of Counselor #2's note at 0859 revealed Counselor #2 spoke to Patient #3's guardian and verified medication. Review of Counselor #2's note at 0932 revealed "PHONE CALL TO (MD #6). ASSESSMENT INFORMATION PROVIDED. HE ORDERS ADMISSION TO (Psychiatric Unit). ED PROVIDER AWARE OF PLAN TO ADMIT." Review revealed no inpatient psychiatric beds were available at the facility and calls were made to other psychiatric facilities to get Patient #3 an inpatient psychiatric bed. Review of a note by Counselor #2 at 1615 revealed "GUARDIAN...UPDATED ON PLAN OF CARE." Review of a nursing note at 0015 on 07/14/2018 revealed Patient #3 was in the ED psychiatric holding unit when he was violent with staff and assaulted three staff members. Further review revealed the police were called and Patient #3 was taken to jail. Review failed to reveal Patient #3's guardian being notified of the event or Patient #3's discharge. Review revealed Patient #3 was discharged with law enforcement at 0135 on 07/14/2018.

Interview on 09/12/2018 at 1405 with RN #7 (Registered Nurse) revealed she discharged Patient #3 on 07/08/2018. Interview revealed RN #7 did not recall Patient #3. Interview revealed when patients come from a group home they are usually discharged back to their group home. If a patient was to go back to a group home RN #7 would call the group home to arrange transportation. Interview revealed if the group home did not answer their phone then RN #7 would notify the guardian of a patient's discharge. RN #7 stated she would usually write a note when she spoke to the group home.

Interview on 09/12/2018 with MD #3 revealed she was called by Counselor #2 on 07/08/2018 about Patient #3. Interview revealed MD #3 did not recall that specific encounter with Patient #3, but was familiar with Patient #3. Interview revealed MD #3 recommended Patient #3 go back to his group home and follow up with his outpatient provider. Interview revealed MD #3 did not speak with Patient #3's guardian during his 07/08/2018 visit to the ED she would have expected the ED staff to call Patient #3's guardian and update her on the plan of care. Interview revealed MD #3 would know if a patient had a guardian by looking at the paperwork a group home or facility sent with the patient, calling the group home or facility or asking the patient if they had a guardian. Interview revealed facilities or group homes don't always send paperwork with a patient and sometimes it takes a couple days to figure out if a patient had a guardian. MD #3 stated "That piece of communication falls short sometimes."

Interview on 09/14/2018 at 1250 with MD #1 revealed he was the physician for Patient #3 during his 07/08/2018 ED visit. Interview while looking at the medical record confirmed that Patient #3 was discharged without notification to his group home or guardian. Interview revealed normally the nurse would notify the group home of a patient's discharge to set-up transportation to the group home.

Interview on 09/12/2018 at 1045 with Counselor #2 revealed she was involved with Patient #3's care on 07/08/2018 and 07/13/2018. Interview revealed Counselor #2 knew Patient #3 had a guardian because she was familiar with him. Interview revealed when a patient was discharged and had a guardian, the guardian should be notified of the discharge. Interview revealed the primary ED RN or Counselor #2 would notify the patient's guardian of the discharge. Interview revealed she did not recall notifying Patient #3's guardian of his discharge on 07/08/2018. Interview revealed Counselor #2 updated Patient #3's guardian of the plan of care on 07/13/2018 and then her shift was over prior to his violent incident.

Interview on 09/12/2018 at 1230 with the ED Director revealed if patients come from group homes or have guardians the expectation was that the group home or guardian would be called upon discharge. Interview revealed the ED Director while looking at Patient #3's 07/08/2018 ED visit confirmed there was no documentation the group home or guardian was called upon discharge. Interview revealed the ED Director was called into the ED on 07/13/2018 from the ED charge nurse because Patient #3 had assaulted 3 staff members. Interview revealed when the ED Director arrived Patient #3 was with law enforcement and going to be discharged to their custody. Interview revealed the ED Director was ensuring the staff members who had been assaulted were doing okay. Interview revealed usually the primary nurse would notify the guardian via phone if a patient was being discharged to jail. Interview revealed in this case the primary nurse was injured and did not notify the guardian. Interview revealed Patient #3's guardian or group home were not notified that Patient #3 was discharged to jail.

NC00141214