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Based on medical record review, document review and staff interview, it was determined the facility failed to follow policy and procedure for providing discharge instructions to five (5) out of ten (10) patients, Patients 1, 2, 3, 7 and 8 (see Tag A 1104). This failure has the potential to negatively impact all patients receiving care at the facility. As a result of this failure, Immediate Jeopardy (IJ) was identified, and the facility was notified on October 4, 2023 at 3:00 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified onsite by the State Survey Agency. The IJ was removed on October 4, 2023 at 6:05 p.m. The facility remains out of long-term compliance.

The following interventions were implemented to resolve the IJ: Intake and Assessment staff will communicate plan of care directly to Emergency Room (ER) Provider (P); ERP will update medical record and create discharge instruction, including safety plan, as indicated by the clinical situation. New process to be implemented immediately, with ERP instructed by the ER Medical Director and Vice President of Medical Affairs. ER staff will be instructed on the new process starting October 4, 2023 by the Clinical Manager; Intake and Assessment staff will be instructed on the new process beginning October 4, 2023 by the Director of Behavioral Health Services. Auditing for correction will be a 100% review of psychiatric ER patients for provider discharge and safety plan, if indicated. Audits will be completed and reported weekly. Audit reports will be provided to the ER section and Senior Leadership to ensure correction.

Based on document review and medical record review, and interview, it was determined the facility failed to follow policy and procedure for providing discharge instructions to five (5) out of ten (10) patients, Patients 1, 2, 3, 7 and 8. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A review of policy, titled "Process for Admission, Transfer and Discharge", last revised May 2019, states, in pertinent part: Procedures For Discharge ED: Care Management, Behavioral Health staff, or nursing will contact the facilities/agencies of choice and give referral information for services needed. Nursing staff will be responsible for providing the interactive "hand off" communication regarding the patient's current condition, care, treatments, and services. Nursing staff will also be responsible for sending relevant copies of the medical record with the patient, as well as the Transfer Form and the Discharge/Order Instruction Sheet. Nursing staff will be responsible for assisting with appointment scheduling for follow up care for patients as needed."

A review of policy, titled "Discharge Procedure", last reviewed April 2021, states, in pertinent part: "Procedure: Patients who are to be discharged should have a discharge procedure and after-care instructions explained to them by a member of the nursing staff. Exit care or computerized after-care instructions will be given to each patient and a signature page regarding d/c [discharge] instructions will be placed on the patient's record."

A review of document, titled "Bylaws, Rules & Regulations St. Mary's Medical Center", approved January 26, 2021, states, in part: "Patients shall be discharged only on the order of a physician. The patient's medical records shall be made complete at the time of discharge and include history and physical, procedure notes, reports of any studies performed, progress notes, clinical visit notes, final diagnosis, and clinical summary."

A record review was conducted for Patient 1. The patient presented to the Emergency Department (ED) on September 18, 2023 at 9:02 p.m. The "Nurse Triage Note" completed by Employee (emp) #11 at 9:19 p.m., states, in part: "Sent here for medical clearance and psych consult." The patient was medically cleared and a psychiatric consult was ordered.
The "ER Nurse Free Text - Nurse Text Only" completed by emp #12 on September 19, 2023 at 8:36 p.m., states: "Spoke with [emp #13] from intake, was told mental hygiene was denied and patient can be discharged with outpatient follow up." The "ER Nurse Free Text - Nurse Text Only" completed by emp #12 on September 19, 2023 at 8:54 p.m., states: "Verbal discharge instructions given to patient and caregiver. Patient instructed to follow up with outpatient psych." The "Disposition - Nurse Disposition Note" completed by emp #12 on September 19, 2023 at 8:50 p.m., states, in part: "Pt discharged per psych, patient instructed to follow up outpatient with already established doctor."

There was no evidence of discharge instructions contained in the medical record.

A record review was conducted for Patient 2. The patient presented to the ED on August 1, 2023 at 1:07 a.m. via EMS. The "Psychiatric Symptom (Adult) - Provider Note; Emergency Department Orders" completed by emp #17 on August 1, 2023 at 2:28 a.m., states, in part: "Consult Intake and Assessment: STAT". The "Medical Decision Making and Diagnosis" states, in part: "Patient ultimately evaluated by behavioral health, dispose per psych." The "BEH (Behavioral Health) Intake Assessment" was completed by emp #18 on August 1, 2023 at 3:48 a.m. There was no evidence of discharge instructions contained in the medical record.

A record review was conducted for Patient 3. The patient presented to the ED on 8/1/23 at 5:41 a.m., ambulatory. The "Psychiatric Symptom (Adult) - Provider Note; Emergency Department Orders" completed by emp #8 on August 1, 2023 at 7:45 a.m., states, in part: "Consult Intake & Assessment: STAT". The "Psychiatry (Free Text Progress Note) - Inpatient SOAP; Plan" completed by emp #19 on August 1, 2023 at 4:01 p.m., states, in part: "Admit to [facility's] Behavioral Health Unit (BHU).
There was no evidence of discharge instructions contained in the medical record.

A record review was completed for Patient 7. The patient presented to the ED on September 17, 2023 at 8:44 p.m., ambulatory. The "Medical Decision Making and Diagnosis" completed by emp #24 on September 17, 2023 at 9:26 p.m., states, in part: "Patient presents for evaluation of needing a psych evaluation."
The "BEH Intake Assessment" completed by emp #25 on September 17, 2023 at 10:45 p.m., states, in part: "Patient was discharged home".
There was no evidence of discharge instructions contained in the medical record.

A record review was completed for Patient 8. The patient presented to the ED on September 17, 2023 at 8:46 p.m., ambulatory. The "General Medicine (Adult) - Provider Note; Emergency Department Orders" completed by emp #17 on September 17, 2023 at 9:28 p.m., states, in part: "Consult: Intake and Assessment: STAT." The "BEH Intake Assessment" completed by emp #25 on September 17, 2023 at 10:15 p.m. indicated the patient was discharged home.
There was no evidence of discharge instructions contained in the medical record.

An interview was conducted with emp #3 on October 2, 2023 at 1:00 p.m. Emp #3 was asked about the process of discharging patients from the ED that present with a psychiatric issue. Emp #3 stated, "Once they've been medically cleared, they are turned over to psych for disposition."

An interview was conducted with emp #7 on October 3, 2023 at 11:20 a.m. Emp #7 was asked about the triage process for patients presenting with a psychiatric issue. Emp #7 statedin part, "Once they are medically cleared, Intake Assessment evaluates, and the
disposition is at their discretion"

A telephone interview was conducted with emp #8 on October 3, 2023 at 2:30 p.m. Emp #8 was asked about the process of treating a patient that presents with a psychiatric issue. Emp #8 stated, "I don't know one hundred percent (100%) what happens with psych patients. Once they are medically cleared then psychiatry decides what to do. Disposition is up to psych; sometimes they say they can go, and they leave before I see them. We never get to talk to the psych team; we usually have to call if we have questions." Emp #8 was asked about discharging psych patients. Emp #8 stated, "They get discharge paperwork from me if I am here. If psych says they can go, then they go. I have said it was unsafe, if necessary. I didn't feel it was unsafe in the situation with [Patient 1]. I didn't feel like I should hold this patient or anything different than what psych had said. I had [Patient 1] for several hours and [Patient 1] was fine."

An interview was conducted with emp #29 and emp #30 on October 3, 2023 at 3:45 p.m. Emp #29 was asked about the process of treating a patient that presents with a psychiatric issue. Emp #29 stated, "From an Emergency Room (ER) perspective, we accept the patient, and they are provided with a regular medical clearance. An order is placed for Intake and Assessment (I&A) to see the patient; we add medication orders and a diet order, if needed. The incoming mid-level provider should see the patient after twelve (12) hours to re-evaluate them and patients are checked out to the next provider. Whatever communication is given to the ER provider by I&A staff, the ER physician still owns the patient. Clinical decision is for the ER provider."

A telephone interview was conducted with emp #11 on October 3, 2023 at 9:55 p.m. Emp #11 was asked about the process of discharging a patient with psychiatric concerns. Emp #11 stated, "Some docs give discharge papers, some do not. We give them (the patient) our recommendations; psych does not change medications if they are not admitted. We don't give a copy of meds given - the worker takes notes - if no worker, they call report to the group home."

A telephone interview was conducted with emp #12 on October 3, 2023 at 10:15 p.m. Emp #12 was asked about Patient 1's ED visit. Emp #12 stated, "I had [Patient 1] for about two (2) hours and reported to emp #8 that the mental hygiene had not been certified. Emp #8 said to go ahead and discharge [Patient 1]. I gave them a verbal discharge, no documentation. The caregiver said the patient was already connected with psychiatry. There was no outpatient follow up since [Patient 1] was already connected to a psych provider." Emp #12 was asked about discharge paperwork. Emp #12 stated, "If doc says the patient is not being admitted, then there is no discharge paperwork."

An interview was conducted with emp #9 on October 4, 2023 at 12:30 p.m. Regarding ED patients receiving discharge instructions, emp #9 states, "The expectation would be they would get the discharge paperwork. It was brought to the Medical Director of the ED's attention that the discharge paperwork was not completed on all ED patients, and a meeting is scheduled for next Tuesday to speak with the providers about the process." Regarding patients having a discharge disposition, emp #9 states, "After the patients are medically cleared, the patients are okay to leave pending the psychiatric evaluation, so there wouldn't be an official discharge order." Regarding a psychiatric intake consultation for a ED patient, emp #9 states, "The expectation would be that the intake and assessment nurse would come and assess the patient and discuss the patient with psychiatry. They would also complete any needed paperwork and send it to the proper location related to mental hygiene or detention orders. If we need mental hygiene, the mental hygiene commissioner would be in charge of the discharge disposition. We would be notified of the outcome and disposition the patient in the system and provide discharge instructions."