HospitalInspections.org

Based on record review and interview, the facility failed to provide a complete discharge planning evaluation per the facilities policy and procedures in 4 of 10 patients discharged (Patient #1, Patient #2, Patient #3, and Patient #5) in a total of 10 medical records reviewed.

Findings include:

Review of policy "203.04 Discharge Planning" #4436466, last revised 12/2018 revealed "Planning for discharge shall begin upon admission... shall be ongoing and documented in the medical record... documentation shall include an assessment of the availability of services to meet the patient's identified needs after hospitalization" with a "collaborative effort involving the patient/family... B. The social worker shall be responsible for communicating with the patient... and the family...5. Documentation of final discharge plan to include...h. Family/support system/involvement. i.... transportation issues, funding, patient's functional ability."

Review of policy "Documentation Guidelines" #5489897, last reviewed 1/2019, page 15 under Social Service initial assessment revealed "must be completed on every patient and placed in the medical record within 72 hours of admission." Transfer progress notes revealed "The sending social worker will complete a Progress Note within 24 hours of transfer... shall include at least the following information: Whether the contacts have been notified of the transfer *Current status of discharge planning." Page 16 under Social service discharge progress note revealed "Documentation of the final discharge plan shall be completed within one workday following discharge. The Social Service Discharge Progress Note shall include the following:... Family/Support System/Involvement... transportation issues... patient's functional ability... Risk Reduction: Documentation that a discussion was held with the patient and family."

Patient #1's medical record was reviewed and revealed Patient #1 was a 70-year-old. Patient #1 was admitted 7/08/2019 on a 14 day detention following medical stabilization for trying to commit suicide. Initial Social Service Assessment revealed "Discharge To: Home independently." Discharge Social Services Assessment dated 7/12/19 at 12:03 PM (two days prior to discharge) revealed "she did demonstrate some confusion while on the unit and often was observed attempting to open doors asking to find a way off the unit. This was not an attempt to elope... She will return to her final hearing...will be placed under a commitment order based on the recommendations from the independent evaluators... following the hearing she will be transferred home where she lives independently... written prescriptions were provided." Patient #1 was discharged 7/15/2019. There was no documentation on how she is to be transferred home from the hearing, how she will fill the prescriptions, how the recommendations of the independent evaluators will be implemented, or any documentation of discussion with family to discuss barriers and establish aftercare.

Patient #2's medical record was reviewed and revealed Patient #2 was a 15-year-old admitted 6/27/2019 after trying to hang herself. "Initial Assessment Social Services" dated 7/11/2019 revealed "Barriers to Treatment and Aftercare: Family conflict... Unstable living situation." Under "Discharge Needs" revealed Advanced Practice Nurse Practitioner L estimated Patient #2 "would likely require... inpatient stay for medication and mood stabilization and to ensure proper aftercare and supervision upon discharge." Patient #2 was started on fluoxetine (an antidepressant) which was continued on discharge. "Discharge Social Services Assessment "Entered On: 07/12/19" (10 days after Patient #2 was discharged) under "Barriers to Discharge Identified" revealed "Follow-Up appointments needed." "Discharge Documentation" included "What to do next" with list of schedule of outpatient appointments for crisis planning signed by Patient #2. Care management notes documented no follow-up with family "to ensure proper aftercare and supervision" or ability to ensure follow-up of crisis planning appointments or obtain medications to continue medication regimen after discharge.

Patient #3's medical record was reviewed and revealed Patient #3 was a 13-year old admitted 6/29/2019 on a 72 hour detention due to suicidality. Initial Assessment Social Services was dated 7/09/2019 (10 days after admission) under "Discharge Needs" revealed "The treating psychiatrist recommended... discharge home with services in the community once deemed no longer a risk to herself or others." Last nursing note dated 7/13/2019 at 8:30 PM revealed "Pt presented writer with a note that she had ridden (sig). The note stated that she did not like herself, and that she felt like harming herself...On-coming staff and tx (treatment) team will be made aware." Patient #3 was discharged 7/15/19. Discharge Summary written 7/16/2019 at 9:28 AM revealed "Final Assessment I was not with pt (patient) on day of discharge, pls (please) see nurses note. To my knowledge, she had no active suicidal ideations at time of discharge, she was not in psychosis." Discharge Instructions dated 7/15/19 at 9:02 AM revealed five "New medications and ... Printed Prescriptions" and instructions on "What to do next You Need to Schedule the Following Appointments Follow Up with" outpatient services name and number listed, signed by Patient #3. There was no care management documentation on discharge, no updated care management notes, no documentation of follow-up with family to ensure patient's ability to receive medications or recommended outpatient follow-up.

Patient #5's medical record was reviewed and revealed patient #5 was a 37-year-old admitted 11/02/2019 at 7:14 AM on a Chapter 51 hold endorsing suicidal ideation to her roommate. Social Services Progress Note dated 11/04/2019 at 5 PM revealed "Pt (patient) approached writer for alternative treatment... stated she was eager to return to the community." Patient #5 was discharged 11/05/2019 at 10:05 PM, greater than 72 hours after admission. There was no initial assessment by Social Services.

On 11/12/2019 at 11:25 AM during an interview with Director of Social Services I, Director I stated the social workers are responsible for documentation of discussion of the patient's identified needs with the family at discharge. Director I confirmed there was no follow-up with the family at discharge documented by Social Services in the medical records of Patient #1, #2 or #3 and no initial assessment documented by Social Services in Patient #5's medical record.

On 11/12/2019 at 12 PM during interview with Clinical Social Worker (CSW) N, CSW N stated she discussed discharge needs with County Crisis Worker O, but CSW N confirmed "I do not remember" discussing Patient #1's discharge needs or the independent evaluation recommendations with the family during Patient #1's hospitalization on 7/8/2019 to 7/15/2019.