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Based on staff and complainant interviews and record review the hospital failed to ensure that prior to discharge of a patient from the Psychiatric Services Inpatient Unit (PSIU) adequate and effective discharge planning was initiated, validated and appropriate for 1 of 10 applicable patients. (Patient #1). Findings include:

Patient #1 was admitted to PSIU on 10/5/18 with a diagnosis of Bipolar, PTSD, Developmental Disabilities and a recent history of decompensation with suicidal ideation. During the course of Patient # 1's hospitalization s/he partially participated in programs offered on PSIU and exchanged discussions with the assigned social worker regarding discharge plans. Prior to admission, Patient #1 was followed by the United Counseling Services (UCS) of Bennington and remained a client of the Vermont Developmental Disabilities Services Division (DDSD) who have provided a court appointed Public Guardian for several years. On 10/8/18 the social worker had a telephone conversation with Patient #1's Public Guardian. It was confirmed that due to a holiday celebrated on 10/8/18 Patient #1's outpatient support team was unavailable to discuss and collaborate with the social worker regarding a safe discharge plan. Per interview on 12/3/18 at 1:00 PM, the social worker confirmed s/he had left a message on 10/8/18 with the answering service for UCS regarding Patient #1's potential plans to be discharged.

Without further review of discharge plans with community support and Public Guardian, the social worker created a discharge plan with Patient #1, an individual described by the attending psychiatrist as being "intellectually disabled" and whose insight was "limited" and judgement "poor". The social worker arranged to have Patient #1 transported via Medicaid transport van back to Bennington on the morning of 10/9/18 to an address listed by the patient. The social worker failed to validate Patient #1's living arrangements, assuming the patient was returning to his/her previous address. However, Patient #1 had no residence to return to once in Bennington. Patient #1 told the driver of the transport van to drop her/him off at an ice cream shop. The patient was in fact homeless, having lost a previous hotel room. With written resources provided at the time of discharge, Patient #1 did contact on 10/9/18, a case manager for UCS who was able to find a crisis bed for the patient.

Per interview on 12/4/18 at 11:55 AM, the attending psychiatrist did confirm s/he felt Patient #1 was indeed ready to be discharged, but confirmed s/he was unaware of the issues which presented with Patient 1's discharge plan. In addition, the Public Guardian stated via electronic communication, s/he did not consider the brief conversation with the social worker on 10/8/18 as sufficient to validate a discharge plan. It was acknowledged case workers for UCS would not be returning to work until 10/9/18 and at that time a more formal discussion with all interested parties would develop a safe discharge plan. The Public Guardian further stated s/he could not imagine the hospital would discharge Patient #1 via a van and dropping off the patient wherever s/he wanted to go, despite being developmentally disabled and homeless.

Based on staff interview and record review, there was a failure by the hospital to adequately identify and implement an appropriate discharge plan which met the needs of a patient and failed to include a collaborative process necessary in ensuring a safe discharge for 1 of 10 applicable patients. (Patient #1) Findings include:

Patient #1 receives services from UCS and for many years has received the support and assistance of a Public Guardian who provides general supervision regarding residence and medical treatment. Since July 2018, Patient #1 had decompensated and was finally admitted on 10/5/18 to PSIU for Bipolar, PTSD and recent suicidal ideation. During this hospitalization, Patient #1 listed her/his Public Guardian as the Emergency Contact and also signed authorization for disclosure of health care information for treatment planning and service coordination. On 10/8/18 the Public Guardian contacted Patient #1 to check on how hospitalization was progressing. The Guardian was informed by Patient #1 that s/he was due to be discharged the next day. The Guardian requested to speak with the patient's nurse but was transferred to the assigned social worker who confirmed a discharge was pending for Patient #1. Although Patient #1 requires community services and coordination was necessary to ensure a safe discharge, the social worker confirmed s/he had left a message for UCS despite the fact it was a holiday and knowing this agency was unavailable until 10/9/18. The Guardian had assumed there would be collaboration with UCS case management, the Guardian and the social worker prior to any discharge occurring. However, despite Patient #1's developmental disabilities and required oversight by community resources, the social worker failed to validate if Patient #1 had safe housing and was reliable and capable in handling his/her discharge. On the morning 10/9/18, without formulating a coordinated plan with those individuals/agency, Patient #1 was discharged to Bennington via a transport van. The social worker failed to confirm Patient #1 actually had safe housing and Patient #1's intellectual capacity prevented the patient from formalizing a safe discharge plan. Upon arrival in Bennington, Patient #1 requested to be dropped off at an ice cream stand, s/he was actually homeless. There was no residence available for the patient, although s/he had provided the social worker with an address of a previous location, this had not been verified. Information provided at the time of discharge did include a list of resources and later in the day Patient #1 did make contact with UCS and arrangements were made for a crisis bed.

Per review of policy Social Work Discharge Planning Process effective 3/1/17 specific for Behavioral Health/PSIU states: "g. Work with patient to determine most appropriate aftercare services at the first meeting. Ensure that all patients being discharged from PSIU have all the appropriate and available support that is available to them....". Although Patient #1 did have support systems within the community and through Guardianship, there was a failure to implement this hospital policy which would have enabled a successful collaboration of care and services upon discharge.