HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to ensure post-acute care plans were arranged and agreed upon by the patient and/or family members upon discharge for 1 of 3 (Patient #1) sampled discharged patients.

The findings included:

1. Review of the hospital's policy titled, "Discharges, PC-021" dated 3/2023 revealed, "... Planned Discharge... Practitioner's order will be written in the patient medical record... Nursing staff will assist the patient in... Understanding discharge instructions... The therapist will complete the aftercare plan and patient choice letter ensuring that appropriate aftercare appointments are scheduled to provide a continuum of care... The therapist will secure aftercare appointments and ensure hand off communication with aftercare providers..."

2. Medical record review for Patient #1 revealed an admission date of 4/26/2024 with diagnoses which included Major Depressive Disorder, Recurrent Severe with Psychotic Features and Unspecified Dementia with Behavioral Disturbances.

Review of the Intake assessment completed 4/26/2024 revealed Patient #1's daughter took her to the hospital because the patient was "... not presenting with normal behaviors. Rambling and confusion were some of the symptoms presenting with the patient during the assessment. When the pt. [patient] was questioned about her daughter the pt. began talking about other family members and a recent stroke event. Per collateral [patient's daughter] the pt. did not suffer from a stroke. Pt. seems to be oriented x [times] 3 (person, place, time)... Per collateral the pt cannot recall how to get home from church that she's been attending for years. The pt. reported the car knows where it's going... the pt. begins to cry when she thinks of events from the past... the pt. is frequently crying. Last week the pt. cried profusely over an individual [daughter] claims she didn't really know... Pt. drove 2 hrs [hours] away by herself when she knows she's not supposed to be driving per agreement between mother and daughter... pt. also reportedly spends impulsively... Due to the pt not complying with meds it's been reported that she is up all night calling her children... The pt. presented with rambling info [information] that didn't make sense..."

Review of the Admission Order dated 4/26/2024 revealed, "... Admit to Inpatient, inclusive of groups/programming... Legal Status... Involuntary..."

Review of the First Certificate of Need for Emergency Involuntary Admission dated 4/26/2024 at 8:15 PM revealed, "... Currently pt is a danger to self and others as evidenced by poor impulse, poor judgment [judgement] and poor insight... Patient is currently unable to contract for safety. Patient needs a safe and secure setting for adjusting to medications and treatment. Patient is at too high risk of danger to self to release into the community at this time..."

Review of the Second Certificate of Need for Emergency Involuntary Admission dated 4/27/2024 at 2:10 AM revealed, "... Risk to self + [and] others [symbol for secondary to] agitation... Risk to self + others [symbol for secondary to] noncompliance... unable to contract for safety..."

Review of the Psychiatric Evaluation dated 4/27/2024 at 10:00 AM revealed, "... presents for initial eval [evaluation] secondary to an increase in confusion and mood swings according to intake information provided by daughter. Reported as more confused, rambling and 'Just not herself.' Reported as not answering c [with] correct responses, forgetting how to get home, or where her church is in which she has gone for years. Mood is more depressed and explained an overly emotional/crying over minimal things, more delusional - Not supposed to be driving and forgetful and where she's going. Stated, 'The car knows where it's supposed to go.'... Hx [history of ] med [medication] noncompliance Multiple admissions to inpt [inpatient] psychiatry... Negative for any suicidal attempts... Estimated Length of Stay...7 - 10 days...J ustification for Hospitalization... Hallucinations, delusions, agitation, anxiety, depression resulting in significant loss of functioning... Inability to meet basic life and health needs..."

Patient #1's medications were adjusted, and she attended and participated in group therapy throughout her hospitalization.

A Psychiatric Progress Noted dated 5/2/2024 revealed Patient #1 was "Asking about a discharge date... her daughter lied...that's why she's here calm, cooperative... Medication Adjustment... [symbol for increase] Risperdal [a medication used to treat psychosis]...[symbol for increase] Lexapro [a medication used to treat depression]... Response to Treatment... Treatment goals achieved and patient stable for discharge or step down... Estimated Date of Discharge: 5/3/24..."

Review of the Discharge Order dated 5/2/2024 revealed, "... Date of Discharge: 5/3/24..." Further review of the order revealed the patient's home medications were listed, but there was no documentation of recommendations for follow up care noted.

Review of a Psychiatric Progress Note dated 5/3/2024 revealed, "... pt seen; she appears to be in a good mood; denies SI [suicidal ideations], HI [homicidal ideations] or psychosis; speech has slowed down; compliant c [with] meds, tolerating recent [symbol for increase] in Risperdal + Lexapro... Estimated Date of Discharge... scheduled today..."

Review of the Discharge Care Plan and Home Medications form dated 5/3/2024 and signed by facility staff member at 8:03 AM and by Patient #1 at 8:09 AM revealed the patient's home medications were listed, but there was no documentation of any after care plans or follow up appointments.

In a telephone interview on 5/13/2024 at 2:31 PM, Patient #1's daughter stated neither Patient #1 or a family member received any information regarding her post-hospitalization plans. The daughter further stated she called the hospital on 5/6/2024 regarding after care plans and was informed she could bring the patient to the hospital's Outpatient Center. Upon arrival to the Outpatient Center, the daughter stated she was informed by the Outpatient Therapist that there were no after care plans in Patient #1's medical record.

In an interview on 5/14/2024 at 1:12 PM, the Psychiatrist was asked why the discharge orders didn't have any after care instructions documented. The Psychiatrist stated the therapists make all the after care plans and appointments for the patients, so she didn't ever fill in that portion of the discharge order.

In an interview on 5/14/2024 at 1:13 PM, the Nurse Practitioner (NP) stated she didn't know why there were no after care plans documented in the patient's medical record.

In an interview on 5/14/2024 at 3:00 PM, the Outpatient Therapist verified Patient #1 presented to the hospital's Outpatient Center on Monday, May 6, 2024, but there were no after care plans documented in the patient's medical record, so she referred her back to Intake to be reassessed.

In an interview on 5/14/2024 at 3:22 PM, the Chief Executive Officer verified there were no after care plans documented for Patient #1.