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Based on interview and record review, the facility failed to reassess the discharge plan for 1 of 10 patients (#1) reviewed for discharge planning needs to account for significant changes in available support resulting in the potential for poor outcomes related to diabetic management and continuing care needs. Findings include:

During an interview with the Director of Nursing (RN D) on 03/22/18 at 1140, RN D said Pt #1 was discharged from the facility with a family member on 02/01/18 per schedule. RN D said Pt #1's discharge medication orders, including insulin orders, were provided to Pt #1's family member at discharge with the intent that the family member would take the orders to be filled by a community pharmacy, as that was the standard practice at the facility, however, Pt #1's family member refused to take Pt #1 home unless the facility provided Pt #1 with the insulin prior to departure from the hospital. RN D said Pt #1's family member requested such because Pt #1 had not lived at home in quite some time and claimed there was no insulin in the home. RN D said Pt #1's family member also reporting having financial challenges that would prohibit them from obtaining the insulin in a timely manner. RN D said Pt #1's discharge plan indicated that aftercare follow-up with the community support coordinator would not occur until "days later" (02/05/18) and RN D was not comfortable allowing Pt #1 to depart the facility without the needed insulin. RN D's concern was that Pt #1 would most likely go several days without insulin unless it was provided by the hospital. RN D said they obtained Pt #1's specific insulin vials via floor stock, as well as several sterile insulin syringes and supplies and provided them to Pt #1's family member upon departure from the facility. RN D said they did not reassess or update Pt #1's discharge plan to reflect the change in diabetic management needs or consult with the physician or attending psychiatrist prior to discharging the patient.

During an interview with the Medical Director (MD L) on 03/22/18 at 1025, MD L said medicine was a "balancing act" and one had to weigh the risk and benefits of their decisions. MD L said insulin was an important medication to receive timely. MD L said it was hospital practice that the patient or responsible party was responsible to obtain discharge medications in the community, however, if the hospital knew a family would have challenges obtaining needed medications, the hospital would make every effort to ensure the delivery of such. MD L indicated the discharge plan assessment process was ongoing and delegated to various members of the treatment team.

Review of Patient (Pt) #1's medical record on 03/22/17 at 1315 revealed the following information:

The Inpatient Psychiatric Discharge Summary dated 02/20/18 indicated Pt #1 was a 19-year old male admitted to the hospital on 11/16/17 and discharged 02/01/18 with a history of pouring medications down the sink drain, destruction of property, and hostility and aggression towards others. This summary indicated Pt #1 had a prolonged hospitalization due to difficulty finding placement in the community, as the patient had destroyed multiple adult foster care homes in the past and all homes were refusing him back. This summary indicated Pt #1 was eventually discharged to a family members home after a Social Security application was completed as the patient had no income. The psychiatric discharge diagnoses included Intermittent Explosive Disorder, Unspecified Intellectual Disabilities, Fetal Alcohol Syndrome, and Attention Deficit Hyperactivity Disorder.

The History and Physical dated 11/17/17 indicated Pt #1 was a Type I diabetic who self-reported taking sliding scale coverage only. A hemoglobin A1C diagnostic test, completed on 12/20/17, indicated a finding of 11.4 (normal range is 4.0-6.0) which was consistent with a person with diabetes.

Review of the most recent Medication Administration Record (MAR) prior to discharge, dated 02/01/18 indicated Pt #1 was prescribed Humalog insulin injected subcutaneously per specific sliding scale orders based on glucose levels, as well as other psychiatric and co-morbid medications.

The Discharge and Care Plan and Home Medications form dated 02/01/18 indicated, under section labeled "Current Medications- Discharge Medications with Dosage Changes", indicated Pt #1 was prescribed a specific dose of Humalog insulin for injections, as well as other psychiatric and co-morbid medications.

The Individual Contact notes, specific to discharge planning, dated 01/31/18 at 1022, indicated Pt #1 was scheduled to be discharged to a family member on 02/01/18 at 1100 and would be going back to the family home address. These notes indicated Pt #1's initial aftercare contact with the support coordinator was scheduled for 02/05/18 at 1000. Note this initial community contact would not be until approximately 4 days after actual discharge from the facility.

The Interdisciplinary Team Progress Note dated 02/01/18 at 1230 indicated Pt #1 discharged from the facility with family at 1230.

Additional review of Pt #1's medical record did not contain any additional documentation showing evidence that Pt #1's discharge care plan was reassessed or updated to reflect Pt #1's diabetic management needs or to address the challenges verbalized by Pt #1's family member at the point of discharge, including the need for continuity of insulin during the time frame from discharge to initial community contact (02/01/18 to 02/05/18).

On 03/22/17 at 1345 the facility policy titled, "Discharge Planning", last revised August 2015, was reviewed. This policy indicated, under policy section, "...Social work staff, in conjunction with nursing and activity therapy staff will identify initial discharge plans and address barriers to discharge at the earliest opportunity. Aftercare treatment and residential needs will be incorporated into the discharge planning process...". This policy also indicated, under Inpatient Discharge section, "ALL STAFF: If at time of discharge the patient or significant other communicates to any staff member a change of status that would place the patient or others at risk of harm if discharged, they must communicate this information immediately to the charge nurse. The charge nurse must then speak with the patient and notify the attending psychiatrist before discharging the patient.".