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Based upon record review and interviews, the hospital failed to ensure 1 of 7 (#1) discharge plans were reassessed. This was evidenced by the discharge of patient #1, who was not oriented to time or place, to refuse his orginal discharge plans by refusing to go to a nursing home for further mental health care, and instead was taken to the bus station in order to return to California. Findings:

Review of patient #1's medical record revealed the patient was admitted to the hospital on 03/01/17 with the diagnoses of rhadomyolysis and delirium. On 03/02/17, the patient was transferred to the psychiatric unit for further care. Review of the psychiatric evaluation dated 03/02/17 revealed the patient was oriented to name only. Review of the discharge plans completed by S7LCSW, revealed the plans were for the patient to be discharged to a nursing home for further care.

Interview with S10MHT on 05/04/17 at 3:10 p.m. revealed the nursing home personnel came to the unit to retreive patient #1. According S10MHT when the patient and herself left the unit, the nursing home staff went in another direction and she and the patient went to the University Police office in order for the patient to collect his personal items which included $20,000.00 in cash. It was during this time the patient told her he was not going to the nursing home but to the bus station so he could go home to California. S10MHT further stated she called the unit and told the charge nurse that the patient was refusing to go to the nursing home. S10 MHT further stated administrative staff then became involved and told her since the patient had been discharged, the hospital could not hold the patient against his will.

Interview with S4Psychiatrist on 05/04/17 at 10:20 a.m. revealed a Petition for Judicial Committment had been started but was dropped when the patient agreed to go to the nursing home. S4Psychiatrist further stated no one from the Psychiatric Unit or administration contacted her that the patient was refusing to go to the nursing home. S4Psychatrist further stated if she had been aware of the patient's refusal to go to the nursing home, she would have done a PEC (Physician Emergency Certificate) and had the patient brought back to the unit since he was still confused as to time and place.