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Based on medical record review and interview, the hospital did not ensure that Patient #1 had an appropriate post-hospital discharge destination. Specifically, the hospital discharged the patient back to the nursing home despite the nursing home's refusal to accept the patient. This has the potential to place the patient's safety at risk.

Findings Include:

Review of the Mental Health assessment dated 08/27/16 at 07:08 AM revealed the patient was brought to the Comprehensive Psychiatric Emergency Program (CPEP) for evaluation after severely assaulting a female patient at the nursing home where the patient resides. It was noted that the patient had a past medical history of dementia and had remained calm and cooperative throughout a 19 hour stay in CPEP. The patient was cleared medically and psychiatric evaluation revealed that the patient was not appropriate for an for acute psychiatric hospitalization as his condition cannot be expected to change. It was noted that now that the nursing home is aware of his propensity for unpredictable, aggressive behavior, they can factor this into his treatment plan and the patient will be released to the nursing home.

Review of the physician order dated 08/27/16 at 07:31 AM revealed an order to discharge the patient to a long term care dementia unit.

Review of the nursing note dated 08/27/16 at 09:25 AM revealed the social worker reported that the nursing home is refusing to accept the patient back. After speaking with psychiatry, medical clearance was obtained, followng which the nursing home was contacted and informed that the patient was medically and psychiatrically cleared for discharge and that the hospital would be transferring the patient back to the nursing home via wheelchair van.

Review of the nursing note dated 08/27/16 at 10:44 AM revealed the patient was waiting for wheelchair transportation and remained on safety checks.

Review of Emergency Department (ED) Triage assessment dated 08/27/16 at 12:00 PM revealed the wheelchair van driver returned to the ED with the patient after the nursing home refused to take the patient back.

Interview on 09/07/16 at 09:35 AM with Staff # 5 revealed that although the nursing home had informed the social worker they would not take the patient back, the physician indicated the patient had been discharged and "has to go". Staff #5 called the nursing home back to inform them the patient was medically and psychiatrically cleared. Again the nursing home refused the patient and stated they would send the patient back to the hospital if he was brought to the nursing home. The patient was discharged via wheelchair van. A short while later, the wheelchair van driver returned with the patient stating that someone from the nursing home met them in the parking lot and sent them back to the hospital. The patient was taken to the medical ED for a social admit. Staff #5 stated in the past they have discharged a patient back to a nursing home even when they have refused that patient.

Interview on 09/08/16 at 09:00 AM with Staff # 9 revealed that although a nursing home may refuse to accept a patient back, the patient may be sent back to the nursing home regardless of the nursing home refusal. On occasion, the nursing home will send the patient back to the hospital.

Interview on 09/08/16 at 09:30 AM with Staff #12 revealed that when facilities refuse to take patients back, she informs them that the hospital is not an acceptable final discharge location and she reads them the transfer and discharge letter from the Department of Health stating this. If facility still refuses to take the patient back and the patient/family wants to go back, then the Department of Health is contacted. There have been instances where it has been taken to an Administrative Law Judge.