HospitalInspections.org

Based on observation, interview and record review, the hospital failed to meet safety requirements for 1 of 1 patient (Patient #2) discharged from the facility on 06/19/13. (Patient #2) was allowed to walk outside during increased afternoon temperature without assuring a safe transport after discharge.

Findings included:

The Physician Discharge Summary dated 06/19/13 at 09:18 AM reflected (Patient #2's) admission diagnoses included Bipolar Disorder Mixed With Psychotic Features, Methamphetamine Abuse, and previous Alcohol Abuse, Borderline and Histrionic Personality Disorder. The patient was "quite adamant that she was involuntarily injected with methamphetamines against her will." The document noted "high risk behavior." (Patient #2) was prescribed Lithium (a mood stabilizer) and Seroquel (an antipsychotic medication)..."
Discharge Planning dated 06/18/13 at 11:07 AM reflected Hospital Personnel #20's disposition arrangement included (Patient #2's) intention to "walk to shelter, refused ride."
The Precaution Sheet dated 06/19/13 reflected Patient #2 was "actively psychotic" and was discharged 06/19/13 at 15:45 PM.
The Daily Inpatient Discharge Sign Out log dated 06/19/13 at 15:57 PM reflected (Patient #2's) name and Hospital Personnel #20's signature.
On 06/19/13 at 16:15 PM surveyors observed (Patient #2) walking outside from the hospital parking lot toward the front entrance. (Patient #2) asked the surveyors for a ride. The outside temperature was 93 degrees.
Hospital Personnel #29 was interviewed on 06/20/13 at 17:20 PM and stated she witnessed Hospital Personnel #20 and Patient #2 in the lobby. (Patient #2) was overheard stating that her "cousin ran out of gas at...[name of a store]" and she wanted to get a ride there. Hospital Personnel #20 stated that a ride had been set up for (Patient #2) but was no longer available. Hospital Personnel #20 stated she would provide a walking map for (Patient #2). The patient also asked Hospital #29 for walking directions to the store. Hospital Personnel #29 stated a male person came into the hospital to drop off cigarettes for an unrelated inpatient. Hospital Personnel #29 observed that the male person and (Patient #2) left the hospital lobby together "and the man had a...look on his face." Hospital Personnel #29 stated, "I never saw the cousin."
The Hospital entrance surveillance videos dated 06/19/13 were reviewed with Hospital Personnel #3 on 06/20/13 at 14:15 PM. (Patient #2) was observed leaving and re-entering the hospital front entrance three times between 15:56 PM and 16:19 PM. The patient was observed leaving the hospital again at 16:26 PM and returned with a male person at 16:27 PM. Both (Patient #2) and the unknown male person left one minute later.
The hospital Discharge Planning/Policy II.10 dated 04/2013 reflected the purpose "to ensure that a patient is safe to discharge..."