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Based on facility policy review, North Carolina Rules, medical record review, and staff interview, the facility staff failed to determine a patient's representative/legal guardian prior to facility departure for 1 of 3 guardianship patients reviewed (Patient #6).

The findings included:

Review of "Patient Bill of Rights" last revised: 04/2018 revealed, "... A patient has the right to be informed of his rights at the earliest possible time in the course of his hospitalization... Attachment: ... The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment..."

Review of North Carolina Rules for Licensing Hospitals "10A NCAC 13B .3205 Discharge of Minor or Incompetent" readopted effective 04/01/2020 revealed, "Individuals who can not legally consent to his or her own care shall be discharged to the custody of parents, legal guardian... patient representative pursuant to 42 CFR 482.13(a)(1)... unless otherwise directed by the parent or guardian, or court of competent jurisdiction... If the parent or guardian directs that discharge be made otherwise, he or she shall so state in writing, and the statement shall become a part of the permanent medical record of the patient..."

Request for policy and/or procedure related to determination of a patient's representative or guardian/guardianship revealed the facility did not have any related policies or procedures.

Closed medical record review of Patient #6 revealed a 47-year-old female with Involuntary Commitment (IVC) orders who was admitted to the inpatient adult psychiatric treatment program at the facility on 10/14/2021 at 1515. Review of the Acknowledgement of Receipt of The Federal Patient Bill of Rights, undated, revealed Patient #6 refused to sign the form. Review of the History and Physical Examination dated 10/15/2021 at 0800 revealed, "History of Present Illness: ...here for paranoid and delusions. She refuses to answer any questions... Past Medical History: PTSD (Post Traumatic Stress Disorder), Schizophrenia, Schizoaffective D/O (disorder)... Physical Exam: ... Psychiatric: Paranoid; Poor Insight..." Review of Interdisciplinary Progress Note dated 10/18/2021 at 1430 revealed, "Writer spoke with pt's (patient's) mom.... She reports she went to the court this morning to apply for temporary guardianship - there is a hearing on 10/28/21 @ (at) 9 am. There is currently a guardianship hearing scheduled for November..." Review of Psychiatric progress note by MD #1 dated 10/22/2021 at 0730 revealed, "...Interval History: ... Served for guardianship hearing yesterday..." Review of Notice of Hearing on Incompetence and Order Appointing Guardian Ad Litem revealed, "... A petition has been filed alleging that the respondent (Patient #6) is incompetent and requesting that a guardian be appointed. If at the hearing, the Court finds by clear, cogent and convincing evidence that the respondent is incompetent, an adjudication of incompetence will be entered and a guardian of the person or a guardian of the estate or a general guardian or a limited guardian may be appointed. Date of hearing: 11/16/2021 Time: 9:00... Date of Hearing On Interim Guardian: 10/28/2021 Time: 0900... Order Appointing Guardian Ad Litem: It is ordered that the attorney named above be and hereby is appointed as Guardian Ad Litem to represent the respondent at all stages of this proceeding... Date: 10/18/2021 Time: 1212..." Review of Interdisciplinary Progress Note dated 11/15/2021 at 1650 revealed, "...1927: Lead Therapist called (named mother of Patient #6)... (named mother of Patient #6) stated she hopes that tx (treatment) team will wait until the court's decision on legal guardianship because pt will need someone to stay on top of her regarding tx, especially medication...She stated, 'Hopefully she (Patient #6) will come out with a good team and a guardian', so that she can receive consistent care upon discharge..." Review of Discharge Planning Progress Note dated 11/16/2021 at 1704 revealed, "...Safety concerns from the patient's family/support system: (named mother of Patient #6) stated guardianship was granted, but she believes the attorney they appointed at the time if (sic) for the 'financial piece.' She stated today in court... (named mother of Patient #6) stated she does not recommend for pt to discharge today... She stated, 'It's concerned (sic) that she's going home early. I will not be quiet about it.'..." Record review revealed Patient #6 refused to sign discharge paperwork. Medical record review revealed Patient #6 departed the facility at 11/16/2021 at 1937 via taxi. Medical record review failed to reveal documentation that the facility made attempts to determine or confirm the legal guardian of Patient #6 after notification of the findings at the Incompetence Hearing. Medical record review failed to reveal documentation that the facility notified the legal guardian prior to facility departure of Patient #6.

Interview on 01/19/2022 at 1015 with RN #6 revealed she was the discharge nurse for Patient #6. Interview revealed the patient had a "challenging personality" and refused discussing the discharge paperwork. Interview revealed Patient #6 was not cooperative with the discharge process and refused to sign paperwork. Interview revealed that no one from the treatment team informed RN #6 that Patient #6 had a guardian or guardianship concerns. Interview revealed RN #6 did not notify the guardian upon discharge of Patient #6.

Interview on 01/19/2022 at 1040 with Director #4 revealed she was made aware of Patient #6 during treatment team meetings and after discharge during a grievance phone call. Interview revealed the therapy staff were notified by the mother of Patient #6 that the county was pursuing guardianship of Patient #6. Interview revealed the core treatment team members were unaware of a guardian being appointed. Interview revealed that the therapist should notify the physician, if something changes with the discharge plan.

Interview on 01/19/2022 at 1205 with Therapist #3 revealed she was involved with the treatment team and discharge planning for Patient #6. Interview revealed she had a phone conversation with the mother of Patient #6 on the day of discharge (11/16/2021). Interview revealed Therapist #3 was notified that the incompetence hearing had taken place and guardianship was appointed. Interview revealed no paperwork was presented to the facility, so Therapist #3 proceeded with discharge as scheduled. Interview revealed Therapist #3 did not attempt to clarify the contact information for the DSS (Department of Social Services) guardian. Interview revealed Therapist #3 did not notify the rest of the treatment team that the hearing took place that day. Interview revealed Therapist #3 had not received training on the process of guardianship in courts, but was aware that guardians have to be notified for treatment plans and prior to discharge.

Interview on 01/19/2022 at 1325 with Director #4 revealed the facility did not have a policy or procedure that guided practice on verification of guardianship. Interview revealed the facility has no way of knowing if a patient has a guardian unless someone presents paperwork to the facility.

Interview on 01/20/2022 at 0915 with MD #1 revealed she recalled providing care for Patient #6. Interview revealed that MD #1 was aware that guardianship was being pursued for Patient #6. Interview revealed MD #1 did not recall being updated by the therapist that the incompetency hearing for Patient #6 had taken place and a guardian was granted. Interview revealed no guardian was notified prior to the discharge of Patient #6. Interview revealed if MD #1 had been notified, she would have notified the guardian prior to patient discharge.

Based on facility policy review, North Carolina Rules review, medical record review, and staff interview, the facility staff failed to reassess the appropriateness of a patient's discharge plan after significant changes in guardianship and support services were discovered for 1 of 3 guardianship patients reviewed (Patient # 6).

The findings included:

Review of "Determining Discharge Criteria and Medicare Discharge Appeal Rights" effective 10/2021, revealed, "...Discharge criteria are determined through Nursing Assessments, Psychosocial Assessments, and the Comprehensive Psychiatric Evaluation (CPE). These criteria will be discussed and agreed upon with the patient during treatment team meetings and any changes to expected length of stay or discharge criteria will be documented on the treatment planning update and signed by the patient and treatment team...The discharge plan will be incorporated into the Patient Treatment Plan and will address legal status (if indicated), housing, vocational, and financial needs, in addition to other concerns, to ensure optimal support of the patient after discharge..."

Review of North Carolina Rules for Licensing Hospitals "10A NCAC 13B .3205 Discharge of Minor or Incompetent" readopted effective 04/01/2020 revealed, "Individuals who can not legally consent to his or her own care shall be discharged to the custody of parents, legal guardian...patient representative pursuant to 42 CFR 482.13(a)(1)...unless otherwise directed by the parent or guardian, or court of competent jurisdiction...If the parent or guardian directs that discharge be made otherwise, he or she shall so state in writing, and the statement shall become a part of the permanent medical record of the patient..."

Closed medical record review of Patient #6 revealed a 47-year-old female with Involuntary Commitment (IVC) orders who was admitted to the inpatient adult psychiatric treatment program at the facility on 10/14/2021 at 1515. Review of the History and Physical Examination dated 10/15/2021 at 0800 revealed, "History of Present Illness:...here for paranoid and delusions. She refuses to answer any questions...Past Medical History: PTSD (Post Traumatic Stress Disorder), Schizophrenia, Schizoaffective D/O (disorder)...Physical Exam:... Psychiatric: Paranoid; Poor Insight..." Review of Comprehensive Psychiatric Evaluation Inpatient Note dated 10/15/2021 at 0900 revealed, "...PLAN: 1. Admit for crisis stabilization 2. Obtain collateral info (information)..." Review of Interdisciplinary Progress Note dated 10/18/2021 at 1430 revealed, "Writer spoke with pt's (patient's) mom....She reports she went to the court this morning to apply for temporary guardianship - there is a hearing on 10/28/21 @ (at) 9 am. There is currently a guardianship hearing scheduled for November..." Review of Psychiatric progress note by MD #1 dated 10/22/2021 at 0730 revealed, "...Interval History:... Served for guardianship hearing yesterday..." Review of Notice of Hearing on Incompetence and Order Appointing Guardian Ad Litem revealed, "... A petition has been filed alleging that the respondent (Patient #6) is incompetent and requesting that a guardian be appointed. If at the hearing, the Court finds by clear, cogent and convincing evidence that the respondent is incompetent, an adjudication of incompetence will be entered and a guardian of the person or a guardian of the estate or a general guardian or a limited guardian may be appointed. Date of hearing: 11/16/2021 Time: 9:00... Date of Hearing On Interim Guardian: 10/28/2021 Time: 0900...Order Appointing Guardian Ad Litem: It is ordered that the attorney named above be and hereby is appointed as Guardian Ad Litem to represent the respondent at all stages of this proceeding...Date: 10/18/2021 Time: 1212..." Review of Interdisciplinary Progress Note dated 11/15/2021 at 1650 revealed, "...1927: Lead Therapist called (named mother of Patient #6)...(named mother of Patient #6) stated she hopes that tx (treatment) team will wait until the court's decision on legal guardianship because pt will need someone to stay on top of her regarding tx, especially medication... She stated if pt is not able to have a legal guardian, 'I will not consent for any caregivers(sic). I don't want to be a caregiver...' She stated, 'Hopefully she (Patient #6) will come out with a good team and a guardian', so that she can receive consistent care upon discharge... (named mother of Patient #6) wants hospital transitions team to know that in pt's possesses (sic), pt should have keys to apartment, bank card, and EBT card, which she stated pt may need groceries before going home." Review of Discharge Planning Progress Note dated 11/16/2021 at 1704 revealed, "...Family support member contacted regarding discharge plan: (named mother of Patient #6), Date: 11/16/2021, Time: 1704 Safety concerns from the patient's family/support system: (named mother of Patient #6) stated guardianship was granted, but she believes the attorney they appointed at the time if (sic) for the 'financial piece.' She stated today in court... (named mother of Patient #6) stated she does not recommend for pt to discharge today, but to have someone from social services to make contact with her to follow up. She stated, 'It's concerned (sic) that she's going home early. I will not be quiet about it.'... She mentioned that pt will need to get groceries before she gets home...When asked if she would like to pick up pt, and/or provide her with groceries, (named mother of Patient #6) stated, 'Nope, I'm not going to do it.'...due to pt's mother not agreeing to pick up pt, or willing to provide additional food, Lead Therapist recommended for pt to stay until dinner, so that she could have a meal prior to discharging. Lead Therapist asked if there were any bagged meals, or items, that could be provided to pt for her to take at discharge, but due to nutritionist not being available at the time there was not..." Record review revealed Patient #6 refused to sign discharge paperwork. Medical record review revealed Patient #6 departed the facility at 11/16/2021 at 1937 via taxi. Medical record review failed to reveal documentation that the core treatment team was notified of the significant changes in guardianship or support services. Medical record review failed to reveal that the discharge plan was reevaluated by the treatment team after the facilty was notified of significant changes with the discharge plan and guardianship of Patient #6.

Interview on 01/19/2022 at 1015 with RN #6 revealed she was the discharge nurse for Patient #6. Interview revealed the patient had a "challenging personality" and refused discussing the discharge paperwork. Interview revealed Patient #6 was not cooperative with the discharge process and refused to sign paperwork at the time of discharge. Interview revealed that no one from the treatment team informed RN #6 that Patient #6 had a guardian or guardianship concerns, nor lack of supports at discharge. Interview revealed RN #6 was unaware of any significant changes in the discharge plan for Patient #6.

Interview on 01/19/2022 at 1040 with Director #4 revealed she was made aware of Patient #6 during treatment team meetings and after discharge during a grievance phone call. Interview revealed communication during the discharge process of Patient #6 was an area of opportunity and acknowledged discharge communication issues during the grievance phone call. Interview revealed that the expectation was for the therapist to notify the physician, if something changed with the discharge plan.

Interview on 01/19/2022 at 1205 with Therapist #3 revealed she was involved with the treatment team and discharge planning for Patient #6. Interview revealed she had a phone conversation with the mother of Patient #6 on the day of discharge (11/16/2021). Interview revealed Therapist #3 was notified that the incompetence hearing had taken place and guardianship was appointed. Interview revealed no paperwork was presented to the facility, so Therapist #3 proceeded with discharge as scheduled despite changes in Patient #6's legal status and post-discharge support. Interview revealed Therapist #3 did not attempt to clarify the contact information for the DSS (Department of Social Services) guardian. Interview revealed Therapist #3 did not notify the rest of the treatment team of the significant chages in guardianship of Patient #6. Interview revealed Therapist #3 had not received training on the process of guardianship in courts, but was aware that guardians have to be notified for treatment plans and discharges.

Interview on 01/20/2022 at 0915 with MD #1 revealed she recalled providing care for Patient #6. Interview revealed that MD #1 was aware that guardianship was being pursued for Patient #6. Interview revealed MD #1 did not recall being updated by the therapist that the incompetency hearing for Patient #6 had taken place and a guardian was granted, nor any additional discharge concerns. Interview revealed no guardian was notified prior to the discharge of Patient #6. Interview revealed if MD #1 had been notified, she would have notified the guardian prior to patient discharge. Interview revealed if anyone had brought forward new discharge concerns, then the team would have updated the discharge plan as needed.

NC00184154
NC00184752
NC00185037