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Based on document review and interview, the facility failed to ensure a patients discharge plan was re-evaluated as needed in one (1) instance. (P#10)

See Tag 0802

The cumulative effect of this deficient practice resulted in the facility's inability to provide safe discharges.

Based on document review and interview, the facility failed to ensure a patients discharge plan was re-evaluated as needed in one (1) instance. (Patient # 10)

Findings include:

1. The facility policy titled, "TRANSFERS TO ANOTHER FACILITY PROCEDURE", Daily Procedures/ Nursing 4.10.1, indicated when an order is written for the discharge of a patient, and he/she will be transferred to another facility, the nurse will complete a transfer form. This policy was last revised in 11/2015.

2. The facility policy titled, "PATIENT SENT TO AN EMERGENCY ROOM", Nursing 4.11, indicated the unit nurse will contact the hospital the patient will be arriving at to provide a Registered Nurse (RN) to RN report and document on the Emergency Services Report. This policy was last revised in 12/2022.

3. Review of Patient # 10's medical record (MR) indicated the patient was a 36 y/o (year/old) admitted to H # 2 (Psychiatric Hospital) on 02/08/2023 with a diagnosis of unspecified schizophrenia spectrum and other psychotic disorder. The Discharge Summary dated 2/16/2023, indicated the patient had tried to elope from the unit, jumped out of a moving vehicle, had poor insight, and was paranoid and delusional. The patient was accepted to H#3 (Acute Care Hospital) and would be transported via ambulance. Physician's Order dated 2/16/2023 at 11:08 am indicated to discharge patient today. Discharge Nursing Note dated 2/17/2023, indicated patient was given discharge and medication instructions. The medical record lacked a transfer form, documentation from H#2 RN (Registered Nurse) to H#3 RN transfer report, and physician order indicating it was ok for patient to travel by car.

4. In interview dated 03/07/2023 at approximately 12:40 PM with administrative staff member A#1 (Director of Nursing), confirmed P#10 was treated as a discharge not a transfer.

5. In interview dated 03/07/2023 at approximately 1:43 PM with administrative staff member A #3 (Regional Vice President), confirmed the facility initiated a Root Cause Analysis (RCA). A meeting was conducted on 03/01/2023 related to patient # 10's discharge. "We were not happy", the patient transferring late at night in a Toyota Corolla.

6. In interview dated 03/07/2023 at approximately 1:59 PM with medical staff member MS#1 (Medical Doctor/Psychiatrist), confirmed he/she wanted P#10 to be transferred via ambulance to H#3. MS#1 confirmed that he/she was not informed until the day after discharging that Pt#10 was transferred by car not ambulance.

7. In interview dated 03/07/2023 at approximately 2:05 PM with administrative staff member A#4 (Director of Social Services), confirmed he/she could not recall who made the decision to transport P#10 by car instead of ambulance.