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Based on review of medical records, review of policy and procedures and interviews it was determined that the facility failed to discharge Patient #3 who was a ward of the state in a safe manner.

Findings:

Medical Record Review
A review of the Patient's #3's medical record revealed that the patient was admitted to the facility on 6/22/2020 at 2:25 a.m. for increased psychosis (a disorder in which thought, and emotions are so impaired that contact is lost with external reality) and combative behavior. Patient #3 had a past medical history of traumatic brain injury, schizoaffective disorder bipolar type (a mental disorder in which a person experienced acute psychotic symptom along with disturbed mood) and nicotine (active constituent of tobacco) use disorder. Further review of the medical record revealed that the patient had a previous craniotomy (surgical removal of part of the bone from the skull to expose the brain) and his current medications included: Keppra ( medicine used to treat seizures), Tegretol (medicine used to prevent and control seizures), Abilify ( medicine used to treat the symptoms of psychotic conditions) and Zoloft (used to treat depression).
A review of the initial nursing assessment revealed that Patient #3 had been admitted to the hospital with bipolar disorder. The patient was alert and oriented to self and the situation. Patient #3's previous medical history included asthma, seizure disorder, and traumatic brain injury. The nursing assessment revealed that he had a moderate risk of suicide.
A psychosocial assessment was conducted on 06/26/2020 at 06:46 p.m. An alcohol use screening indicated that Patient #3 had harmful drinking behavior. He was receptive to and acknowledged the harmful effects of alcohol on his mental health. Further review of the psychosocial assessment revealed that Patient #3 required placement after discharge which was difficult due to his aggressive behavior. Patient #3 lacked an active support system and it was difficult for him to obtain and take medications as ordered and he did not have the capacity to follow discharge planning instructions without help of his legal guardian. It was anticipated that Patient #3 would go to a personal care home (PCH) when discharged. Transportation needed to be arranged to transport him to the PCH at discharge.
A review of progress notes revealed that on 6/26/2020, a therapist made an unsuccessful attempt to contact Patient's legal representative. Therapist documented that during a previous conversation, Patient #3's legal representative reported that the patient was a ward of the State and had had problems at the PCH due to aggressive behavior.
On 06/26/2020 at 06:43 p.m. A voice mail message was left with Patient #3's legal guardian informing her that Patient #3 had had an interview with a personal care home (PCH).
A review of the Social Service Discharge Summary revealed that an address for a Personal Care Home was listed as discharge address. A checklist on the Summary included 'Family contact made at Discharge' that listed legal representative and phone number and checked 'yes'. The Summary was signed by DCP CC on 6/29/2020 at 2:15 p.m.
A review of the nursing progress notes dated 06/29/2020 at 3:00 p.m. revealed that Patient #3 was discharged after seeing his physician. At the time of discharge, he was alert, oriented and denied suicidal ideations. Patient #3 was given discharged instructions and he verbalized understanding.
A review of the physician discharge note on 6/29/2020 at 09:40 a.m. revealed that Patient #3 had a final diagnosis of schizoaffective disorder bipolar type, was alert, oriented, denied suicidal ideations and presented no acute danger to self and others at discharge. Patient #3 was discharged to a group home.
A review of the facility's "Discharge Care Plan and Home Medications Sheet" dated 6/29/2020 at 2:15 p.m. revealed that DCP CC documented that Patient #3 was discharged to a personal care home (PCH). The address and telephone number of the PCH was included on this form. A review of the record failed to reveal any communication or attempted communication with the PCH prior to discharge portion of the sheet titled "Discharge Transportation" failed to reveal a means of transportation to the PCH. Patient #3 was scheduled for an aftercare appointment.
Interviews:
An interview was conducted with Discharge Planner (DCP) CC on 10/20/2020 at 3:22 p.m. DCP CC had been with the facility for 4 years and her responsibilities regarding discharge planning only included finding accommodation for the patients that were homeless. The patient's discharge care plan and home medications sheet dated 6/29/2020 was reviewed with DCP CC, and she verified signing off the sheet and stated she remembered the patient. DCP CC explained that it was not her role to contact and notify the patient's legal guardian about the discharge process and that she was only filling in for the therapist. DCP CC explained that it was the therapist responsibility to confirm patient placement after discharge with the legal guardian or State case worker. After definitive discharge plans were made, the therapist contacted the home or facility that would be caring for the patient, confirmed the address and provided the anticipated discharge date and time. DCP CC explained that she discharged the patient based on the paperwork and did not know who listed the patient's contact information. DCP CC explained that it was the duty of the therapist to communicate with the legal representative at the time of discharge.
An interview with Adult Therapist (Therapist) II took place on 10/20/2020 at 3:50 p.m. in the conference room. AT II explained that she had been with the facility for 3 years and her responsibilities included facilitating process groups, family sessions, and safety plans for the patients. She also obtained additional information and coordinated discharge planning. AT II explained that patients were asked about their plans when discharged during initial assessments. If the patient needed a place to go after discharge, they would find a place for them. Therapist II explained that patients without means of transportation were transported through the facility's contracted non- emergency transport provider. Therapist II explained that when an adult patient in the custody of the State was being prepared for discharge, she confirmed placement with the legal representative (State Case Worker). When definitive discharge plans were made, she contacted the home or facility that the patient was being discharged to, confirmed the address and provided a discharge date and time. Therapist II recalled that she documented communication and communication attempts with Patient #3's legal representative/case worker in the Progress Notes. Therapist II explained that she did not discharge Patient #3 and was not involved in the final discharge process. Therapist II further explained that it was the responsibility of the staff that signed the discharge summary to contact the home that Patient #3 was going to, confirm the address, and provide the discharge date and time. She further explained that in the event a patient was transported to a discharge destination and no one was available, the driver would bring the patient back to the facility.
An interview was conducted with Adult Therapist (Therapist) HH on 10/20/2020 at 11:47 a.m. in the conference room. Therapist HH explained that her job responsibilities included organizing group therapy, discharge planning, finding a home for the patient, and communicating with a patient representative. Therapist HH explained that she wasn't on the same unit with Patient #3 the first time he was admitted to the facility. Therapist HH explained that she recalled Patient #3 being on her assigned unit during his second admission. Therapist HH recalled that during the second admission, the patient was assigned a personal care home by the State Case Worker and was eventually discharged there. Therapist HH further explained that before patients were discharged, the facility called the PCH with a discharge date and time interval.
An interview with the Director of Clinical Services (DCS) JJ and the Director of Risk Management (RM) KK took place on 10/21/20 at 10:30 a.m. in the conference room. At the time of Patient # 3's hospitalization, DCS JJ had just started at the facility and was being trained by RM KK. DCS JJ explained that he had been at the facility since May and job duties included treatment team facilitation, program scheduling, supervision of recreational therapy, oversee clinical processes, and assist with difficult cases. The treatment team meeting took place every day on all patients.
DCS JJ explained that discharge processes for adult patients who were wards of the State were done like those of minors. When an adult patient in the custody of the State was being prepared for discharge, the therapist confirmed with the legal representative or State case worker the placement of the patient. After definitive discharge plans were made, the therapist contacted the home or facility that was going to be caring for the patient and confirm the address and provide the discharge date and time. If a legal guardian or a caregiver such as a personal care home or group home could not be reached, the therapist notified Adult Protective Services (APS) of the abandonment.
DCS JJ and RM KK explained that the facility became aware of the problems with Patient #3 discharge on 7/1/20 when the patient was brought back to the facility by the personal care home. DCS JJ immediately met with the therapists involved and provided re-training on the definition of 'Ward of the State' and what that entailed. DCS JJ recalled that Therapist II and another therapist were involved in that meeting. DCS JJ explained that formal documentation of the re-training was not done. DCS JJ explained that he prepared a more formal in-service to present to the entire clinical staff that took place approximately two weeks later. DCS JJ explained that Patient #3's legal representative (State case worker) was very involved with the patient's discharge planning during the second admission (7/1/20) and the discharge process went smoothly on 7/9/2020. DCS JJ explained that the clinical staff conducted 'Flash Meetings' daily to provide handoff communication. As a result of the problems with Patient #3 discharge, any adult patient under the custody of the State or with a legal warrant was discussed at 'Flash'.
RM KK explained that monitoring of the discharge process was done using a corporate audit tool. The data was now being collected and aggregated to trend and track improvements or areas of needed improvement. This tool was started on 10/1/20; therefore, there is not enough data to aggregate yet. A discussion of the audit tool occurred at the September Quality Council meeting.
Regarding Patient #3, RM KK explained that he was discharged on 6/29/20 and was transported via the contracted transportation company to a personal care home. The van driver phoned DCP CC and informed her that there was no one at home at the address provided. DCP CC instructed the van driver to bring the patient back to the facility. Patient #3 was returned to the facility. DCP CC contacted the staff of the PCH, and they came to pick up the patient at the facility. Patient #3 waited in the lobby during this time and was not formally admitted and there was no documentation made of the incident. On 7/1/20 the legal representative (State case worker) instructed the PCH to take Patient #3 to the facility as it had been decided that another placement would be located for Patient #3. Patient #3 was readmitted to the facility on 7/1/20.
An interview with Chief Executive Officer (CEO) LL and Chief Operating Officer (COO) MM took place on 10/21/20 at 1:30 p.m. in the conference room. COO MM explained that after further investigation, it was determined that the facility wrote the incorrect address for the personal care home on the discharge paperwork; however, the transportation company had the correct address as provided by the discharge planner and that was where Patient #3 was taken on discharge 6/29/20. COO MM stated that she had contacted the transportation company and requested a copy of the trip report or other documentation regarding the discharge on 6/29/20. COO MM explained that the company informed her that they (company) were in the process of a software change and were unable to print or send the documentation.
CEO clarified that per their investigation, Patient #3 was brought back to the facility on 7/1/20 for aggressive behavior.
An interview with Patient Advocate (Advocate) DD took place on 10/20/20 at 4:15 p.m. in the conference room. Advocate DD explained that she had been in this role for about a year and previously was a discharge planner. Advocate DD explained that she had no information to provide and was not aware of Patient #3.
Policies and Procedures reviewed included but was not limited to:
A review of the facility policy number CTS-101, titled "Discharge Planning", original date of issue: 03/2013, date of approval: 03/2013, revised: 09/2020 revealed that discharge planning commenced upon admission to any program. Tentative discharge plans are established and reviewed and modified or preformed throughout treatment. The condition for discharge is when the optimal functioning level for the patient has been reached and the patient is able to function at a lower level of care or if the patient is in need of services to reach optimal functioning level that are not provided within the facility, a transfer to a facility or a provider that provides that service may be initiated by agreement of the patient's care team.
Procedures included:
Risks for discharge were identified on admission.
Treatment Team updates post discharge plans as assessments were completed and treatment progresses.
The physician wrote an order to discharge from facility, recommended after-care, wrote prescriptions and specified if previous medications were continued.
The therapist/case manager:
-Reviewed the precipitating events and stressors that led to current treatment and the resources that the patient will need after discharge.
- arranged for need/recommendations for after-care to included but was not limited to:
Medical appointments/referrals, home health appointments, psychiatric appointments, substance abuse prevention
-arranged for resources for any daily living changes that patient may need to prevent relapse.
-arranged for community resources,
-contacted post-discharge referent to ascertain suitability of placement, schedule appointments, and facilitate transfer.
-obtained a signed release of information from the patient or guardian for the purpose of contacting post-discharge referent (state mental facility, nursing home, therapist) and sharing patient information
-reviewed with the treatment team the family needs post-discharge and decided for those needs
-validated safety plan
-made transportation arrangements with patient/family prior to discharge
-notified patient and family of the date that transfer will occur
-completed the discharge care form with the summary of discharge plan review with patient/family. Had patient sign DC instructions.
The Registered Nurse:
-implemented discharge orders by communication with the therapist/case manager of discharge orders any medical/psychological referrals, transfers etc.
-completed the DC Care Plan form including medications and appointments
-provided discharge instructions in a manner understandable by patient.
Therapist/Case Manager/RN
-if a transfer, exchanged or communicated necessary information to other providers with the patient's consent including reason for transfer/discharge, summary of care, medications, community resources or referrals.
A review of the facility's policy number RI-032 originated on 03/2013, last reviewed 11/2019, titled " Patient/Family Involvement in Treatment " revealed that it was the policy of the facility to acknowledge the importance of patient and family involvement in the plan of care. When appropriate and possible, the involvement of the patient and family was sought and encouraged during treatment. Patients were involved in at least the following:
1. Giving informed consent
2. Making Care decisions, management of pain.
3. Resolving dilemmas about care decisions.
4. Formulating Advanced Directives
5. Withholding resuscitative services.
Procedures included:
1. Clinical staff elicited the expectations of the patient and/or family for treatment and involvement in treatment during the psychosocial assessment.
2. Staff encouraged family to be involved in the admission process. Regardless of age, family members were encouraged to review patient rights information prior to admission.
3. Family members of patients of adult patients were invited to be a part of the admission process with the patient's permission.
4. Following admission, patients and families were encouraged to participate in the formulation of the treatment plan and discharge plan.
5. Once treatment had begun, family members were encouraged to take part in the treatment process by providing information to the clinical treatment team, attending family meetings and/or participating in family therapy.
6. Discharge/aftercare plans were developed on each patient; family members were frequently asked to attend discharge planning meetings.
7. The patient and family were encouraged to participate in decisions regarding care.
8. Families could participate in a variety of programs designed to educate them in mental illness and the recovery process.
Review of the facility's policy number CTS-166, titled " Discharge Process " , originated 03/17, last reviewed 9/20, revealed that the procedure for planned discharges was as follows:
1. A physician's order was written in the patients record and noted by licensed nursing staff.
2. Nursing staff assisted patient in:
a. Gathering personal belongings
b. Claiming valuables
c. Understanding the discharge process
d. Obtaining any medications stored in the pharmacy
e. Understanding discharge instructions
3. The nursing staff documented the discharge on the discharge note. Documentation included:
a. Progress or lack of progress toward goal attainment as prescribed in the patient's treatment plan.
b. The patient's behavior and attitude at discharge
c. The patient's destination and mode of transportation at discharge.
d. The current medications
e. The patient's method for obtaining the current medications
f. Informing patient and patients awareness of any follow up appointments
4. Regular planned discharges took place generally bet