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Based on medical record review and interview, it was determined facility staff failed to document in the patients' plan of care (POC) the use of restraints for three (3) out of four (4) patients sampled (Patients #1, 3, 11).

The findings include:

Patient #1 was admitted to the facility on 2/22/19 with diagnosis including, but not limited to, vomiting clots of bright red blood, diarrhea, and abdominal pain. A review of the medical record revealed an order dated 2/22/19 at 3:28 p.m. for soft BUE (bilateral upper extremity) non-violent restraints, with a time limit of 24 hours. It was discovered restraint use was not documented as part of Patient #1's plan of care.

Nursing restraint documentation revealed that restraints were discontinued at 11:20 a.m. on 2/23/19, after Patient #1 met criteria for restraint release.

An interview was conducted on 2/26/19 at 9:45 a.m. with Staff Member (SM) #9, chart navigator, who stated "there is not documentation in the care plan that restraints were on".

Patient #3 was admitted to the facility on 2/16/19 as a transfer from another facility with medical history including, but not limited to, congestive heart failure, diabetes, chronic kidney disease, and dementia. A review of the medical record revealed that Patient #3 was placed in soft BUE restraints on 2/17/19 at 6:00 a.m. by SM #19, a Registered Nurse (RN), in the intensive care unit (ICU). SM #20, a nursing supervisor, signed off as the second tier reviewer.

The record included documentation that Patient #3 was restrained on 2/17/19, 2/18/19, 2/19/19, 2/20/19, 2/22/19, 2/23/19, and through 2/24/19 at 6:00 a.m.

There was no order for or documentation of when restraints were discontinued. In an interview with SM #9, chart navigator, he/she stated "Based on the orders, I don't see when restraints were removed. The 24th would have been when (he/she) was moved to hospice".

The use of restraints were not included in Patient#3's plan of care.

Patient #11 was admitted to the facility on 1/15/19 with diagnosis including, but not limited to, diabetic ketoacidosis, sepsis, hypotension, hyponatremia, and hyperkalemia. A review of Patient #11's medical record revealed an order for violent restraint written 1/5/19 at 10:47 p.m. for bedrails and soft BUE for a time frame of four (4) hours due to attempt to self harm and attempts to remove device. The order was renewed on 1/6/19 at 2:00 a.m.. On 1/6/19 at 7:11 a.m., the restraint order was modified and changed to non-violent BUE with a 24 hour time limit due to unsafe mobile attempts. The restraints were discontinued on 1/7/19 at 2:00 a.m. Patient #11 was discharged from the facility on 1/9/19.

The plan of care for Patient #11 did not contain documentation of the use of restraints. On 2/25/19 at 1:35 p.m. during an interview, SM #10, a chart navigator, stated "there is no care plan for restraints".

Concerns were discussed as noted above, and again with members of administration on 2/28/19 at 10:30 a.m.

The facility's policy and procedure (P&P) entitled "Patient Restraint/Seclusion" was reviewed, and included the following under the heading "...10. Care of the Patient/Plan of care: a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications. b. Patients and/or families should be involved in care planning to the extent possible and made aware of changes to the plan of care...". Under the heading "...12. Documentation Requirements: The medical record contains documentation of: ...l. Modifications of the plan of care...".

Based on medical record review and interview, it was determined that facility staff failed to ensure that the restraint order for two (2) of five (5) patients sampled matched restraint documentation for that patient (Patients #9 and 10), and that initial restraint orders were issued for one (1) our of five (5) patients sampled (Patient #3).
(Patient #3).

Findings included:

Patient #9 was admitted to the facility on 2/20/19 with diagnosis including, but not limited to seizures. The medical record was reviewed, which included documentation that Patient #9 was combative in the rescue squad prior to arrival, and that the EMT (emergency medical technician) advised that the patient was given Versed prior to arrival.

The record included an order dated 2/20/19 at 12:40 p.m. for a physical hold/violent restraint, time limit 15 minutes for combativeness.

At 12:56 p.m. on 2/20/19 a second restraint order was noted for violent restraints, including bedrails, physical holding, and quick release synthetic BUE (bilateral upper extremity) restraints, time limit four (4) hours. Unfortunately, Nursing documentation at 3:18 p.m. on 2/20/19 was that Patient #9 was in 4 point restraints. Additionally, restraint documentation dated 2/20/19 at 2:50 p.m. for discontinuation of violent restraint was for "violent restraint device soft, all extremities".

Patient #10 entered the facility ED via ambulance on 2/25/19 due to drug overdose. A review of Patient #10's medical record revealed the following documentation when the nurse attempted to start a new IV( intravenous) line on 2/25/19 at 11:46 a.m.; patient "became combative requiring 6 staff to hold (him/her) while placing new IV. Pt was continuously combative and required restraints for pt and staff safety. Dr. ordered restraint order {sic} and Nursing supp aware. Pt medicated and resting comfortably currently. Pt safe and restraints properly applied...".

The physician order for restraints was reviewed and the surveyor noted the following initial order:
"Clinical justification: Combative; Level of restraint: Violent/self destructive; Violent restraint device: Bedrails, Quick release synth all ext; Violent restraint time limit 4 hours.

Both the initial nurse restraint assessment on 2/25/19 at 11:37 a.m. and the second tier assessment on 2/25/19 at 11:40 a.m. document that Patient #10 had "soft BUE" restraints.

The two (2) hour nursing restraint assessment at 1:46 p.m. on 2/25/19 that the patient was in "soft BUE", "drowsy/sleeping", and that "the least restrictive restraint" was in use.

BUE restraints were documented as discontinued on 2/25/19 at 3:30 p.m., after Patient #10 met criteria for restraint release.

Patient #3 was admitted to the facility on 2/16/19 as a transfer from another facility, with medical history including, but not limited to congestive heart failure, diabetes, chronic kidney disease, and dementia.

A review of the medical record revealed that Patient #3 was placed in soft BUE restraints on 2/17/19 at 6:00 a.m. by SM #19, a Registered Nurse (RN) in the intensive care unit (ICU). SM #20, a nursing supervisor, signed off as the second tier reviewer.

The surveyor was unable to find evidence in the record of a physician order for the restraint which documented as placed by SM #19 on 2/17/19 at 6:00 a.m. A discussion was held with SM #9, the chart navigator, between 10:00 a.m. and 10:30 a.m. on 2/26/19 while reviewing restraint documentation for Patient #3. At 10:05 a.m., SM #9 stated "You are correct, nursing documentation shows restraints were started at 6:00 a.m. on 2/17/19". At 10:30 a.m., SM #9 stated "There was no restraint order until 2/18/19 at 9:47 a.m.; that order was written as a renewal, not an initial restraint order".

Concerns were discussed as noted above, and again with members of administration on 2/28/19 at 10:30 a.m.

The facility's restraint P&P was reviewed, and included the following under "...Procedure: ...4. Second Tier of Review: A member of nursing administration/management (e.g., nursing supervisor/manager, charge nurse, manager/director, CNO, etc.) will review the need for restraint or seclusion with the RN who has determined that the patient requires restraint or seclusion. Renewals of restraint or seclusion orders do not require a second tier of review...".

Based on medical record review and interview, it was determined that patient medical records failed to include documentation of safety check for restrained patients for two (2) of five (5) records sampled (Patient #1 and 3).

The findings include:

The medical record for Patient #1, who was admitted on 1/15/19, was reviewed and revealed a physician order for violent restraint written 1/5/19 at 10:47 p.m. and renewed on 1/6/19 at 2:00 a.m. On 1/6/19 at 7:11 a.m., the restraint order was modified, and changed to non-violent restraint.

Patient #1's medical record lacked documentation, either on paper or in the EHR, that he/she was monitored during the period between 10:47 p.m. and 7:00 a.m. while in violent restraints, except for the initial assessment at
10:47 p.m., and at the time of the order renewal.

The medical record for Patient #3, who was admitted 2/16/19, was reviewed and revealed that he/she was restrained with soft bilateral upper extremity restraints (BUE) between 2/17/19 at 6:00 a.m. and sometime on 2/24/19 at or after 6:15 p.m.

The medical record lacked restraint documentation from 12:00 a.m. on 2/19/18 until 8:00 a.m. on 2/19/19.
The record lacked restraint documentation on 2/19/19 after the 6:00 p.m. entry until 11:50 p.m. on 2/19/19.
There was no restraint documentation on 2/21/19 at 6:00 p.m. The last documented restraint documentation was on 2/24/19 at 6:15 p.m. There was no nursing note or other documentation which indicated when restraints were discontinued. On 2/26/19 at 11:15 a.m., Staff Member #9, the chart navigator, stated "Based on orders, I don't see when the restraints were removed. The 24th would have been when (he/she) was moved to hospice".

Concerns were discussed as noted above, and again with members of administration on 2/28/19 at 10:30 a.m.

The facility's Policy and Procedure (P&P) entitled "Patient Restraint/Seclusion" was reviewed. Under the heading "...7. Monitoring the Patient in Restraints or Seclusion" the following information was present: "...d. A trained staff member monitors each patient in restraint or seclusion at least three (3) times an hour for safety, and to confirm that the patient's rights and dignity are maintained. This check will be documented in either electronic record or on paper. If a paper checklist is used as a summary, recording time and observation from each of the three (3) times an hour check, may be recorded at the end of the shift and the checklist scanned into the EHR/HPF patient record...".

Based on a review of employee records and interview, it was determined that five (5) of five (5) physicians lacked documentation of acknowledgement of the facility's restraint policy after the update/revision dated 11/2018.

Findings included:

The facility's policy and procedure (P&P) entitled "Patient Restraint/Seclusion CSG.CSG.001" was reviewed, and evidenced a "last revised" date of 11/2018.

Five of five physician staff records reviewed lacked physical evidence that the policy had been reviewed after the date of revision (11/2018).

An interview was held with Staff Member (SM) #18, responsible for physician credentialing, at 2:30 p.m. on 2/27/19; he/she was asked how physicians received training related to updated policies, and stated "An email goes out with P&P updates, but there is no confirmation".

SM #11, the Director of Clinical Services, who was also present for the interview, added that policy updates were discussed during medical staff meetings; however, the surveyors were not given documentation of an agenda or physician sign in sheet for the meeting when the restraint policy update was discussed.

Concerns were discussed with SM's #11 and 18 as noted above, and again with members of administration on 2/28/19 at 10:30 a.m.

Based on medical record review and interview, it was determined that facility staff failed to ensure a discharge planning evaluation was completed for one (1) of five (5) patients sampled (Patient #2).

The findings included:

Patient #2 was admitted to the facility Behavioral Health Unit on 12/30/18 in transfer from another acute care Emergency Department (ED) after a TDO (Temporary Detaining Order) was obtained. Admitting diagnoses included, but were not limited to: Schizoaffective Disorder-Bipolar Subtype, PTSD (Post Traumatic Stress Disorder), hypertension and diabetes mellitus (by history).

The clinical record was reviewed and evidenced the following, in part:

Further review of the clinical record revealed a "BH (Behavioral Health) Psychosocial Assessment" dated 12/31/18 as 1202 (12:02 p.m.) which also included family support, Living situation, safety concerns, and a "Preliminary Discharge Plan" which was "Patient will dc (discharge) to sisters home and follow-up with (initials of Behavioral Health Authority) PACT".

A BH (Behavioral Health) Recovery Plan/Review was contained in the clinical record dated 1/5/19 and another on 1/12/19. These "Behavioral Health Plans" documented the patients "Problems/alterations" and target dates and progress toward meeting the goals. Patient #2's "plan" had documented on 1/5/19: "Problem #1 Thought Processes- Related to: Characterized by impairment or disruption in cognitive operations and activities- As Evidenced By: Altered attention span, impaired judgement, non-reality thinking, periods of confusion with disturbed sensory perception....Problem #2 Mood- Characterized by unstable sustained abnormal emotional tone and symptoms wither depressive or bipolar- as evidenced by: altered attention span, impaired judgement or ability to think, reason and problem solve. Problem #3 Home Maintenance- related to discharge planning and follow up treatment- as evidenced by patient has an appropriate discharge plan that is understood by both the patient and family." Each of the three problems had a "target date" of 1/17/19 for the short term goals and 1/19/19 for the long term goals. Under the area for "Progress toward goal, for each problem, there was no documentation indicating how the patient had been progressing toward meeting any of the goals. The "Behavioral Health Plan" dated 1/12/19 had the same three problems documented, with the same target dates and under "Progress toward goals" there was no indication on this plan as to the progress of the patient in meeting the set goals.

The surveyor requested the discharge assessment and any documentation related to the discharge planning for Patient #2 and was told in an interview with Staff Member #13 on 2/26/19 at 12:15 p.m., that "All the information should be included in the patient's clinical record. I don't have any additional information". The surveyor was unable to locate a document which evidenced a complete "Discharge Planning Assessment" or and revisions to an assessment for Patient#2. There was no evidence of any contact made with the patient's family where the patient had been living prior to admission.

The survey team discussed the concerns regarding the discharge with the facility Administration on 2/27/19 at 3:40 p.m.

Review of the facility policy and procedure "Case Management Discharge Planning and the Continuum of Care" was reviewed and evidenced, in part: "Discharge Planning provides for continuing care based upon the patient's assessed needs...Important factors such as functional status, cognitive ability of the patient and family support will be considered...the discharge plan must be thorough, clear, comprehensive and understood... A. 1. RN Case Manager/Social Worker- completes the pintail assessment and identifies continuum of care and discharge planning needs...c, Case Management: The Case Manager/Social Worker completes a discharge planning assessment, initiates the plan and obtains approval for services...B. 1. Evaluation of a Discharge Plan- The case manager will conduct an ongoing assessment and reassessment of the patient's condition every 3-5 days or as necessary to determine if modifications to the plan are necessary. The plan will be revised as necessary...The case manger/social worker will assess the patient's readiness for discharge by assessing the patient's understanding of their health related condition as it pertains to their post discharge treatment plan, medical regime and follow-up services..."

Based on medical review and interview, it was determined the facility staff failed to ensure a patients' discharge plan was reassessed when the patient continued to demonstrate behavioral health issues which were present throughout the hospital stay and effected the appropriateness of the discharge plan for one (1) of five (5) patients sampled (Patient #2).


The findings included:

Patient #2 was admitted to the facility Behavioral Health Unit on 12/30/18 in transfer from another acute care Emergency Department (ED) after a TDO (Temporary Detaining Order) was obtained. Admitting diagnoses included, but were not limited to: Schizoaffective Disorder-Bipolar Subtype, PTSD (Post Traumatic Stress Disorder), hypertension and diabetes mellitus (by history).

Patient #2 was admitted to the Behavioral Health Unit with significant psychiatric concerns and behaviors which continued throughout the more than two (2) week hospital stay. The patient was discharged on 01/15/19 to PACT and had to be immediately taken to another facility for an ECO (Emergency Custody Order) and subsequent TDO (Temporary Detaining Order) due to aggressive, paranoid, and delusional behaviors.

The clinical record was reviewed and evidenced the following, in part:

"Behavioral Health Initial Assessment - Date of Service: 12/30/2018...admitted to Spotsylvania Regional Medical Center's Behavioral Health Unit on a temporary detaining order...(Name of Patient # 2) apparently has a fairly long-standing psychiatric history. (He/She) has been ascribed a diagnosis of schizoaffective disorder, although (his/her) records also indicate schizophrenia....(He/She) is an open case with (name of service)...(he/she) has fallen out of adherence with (his/her) psychotropic medication. (He/She) apparently does quite well from a symptomatic standpoint when (he/she) is medication adherent. However, with medication nonadherence, (he/she) has developed acute symptoms including paranoid ideations, mood liability, disorganized through processing and persecutory delusions. (He/She) was taken to (Name of Hospital ED). Subsequent to medical clearance, (he/she) was evaluated by local Community Mental Health Center. (He/She) was placed on a detention order and then transferred to this facility for further evaluation and treatment. Mental Status Exam: The patient was hyper alert, pressured, irritable demeanor. Thought processing loose and tangential. Paranoid themes were prominent....no current thoughts of harm to self or others, although acute agitation with the emergency medications noteworthy within the past 24 hours. Judgement and insight are grossly impaired...Initial Treatment Plan: The patient's safety will be closely monitored. (His/Her) psychosocial supports will be assessed. Psychotropic medication will be instituted and modified as warranted...The importance of medication adherence will be emphasized to the patient. (He/She) will be encouraged to actively participate in group and milieu therapy. Assets and Strengths: (He/She) has a history of improved functionality when on medication. Family is concerned about (his/her) condition..."

An "Initial Nurse Assessment" dated 12/30/18 at 1844 (6:44 p.m.) documented, in part: "Pt (patient) arrived on the unit by transport and police officer and was in a wheelchair. Pt initially refused to get out of the wheelchair and to let staff take (his/her) vital signs, after a few minutes pt allowed staff to get vitals and moved out of the wheelchair...pt refused to complete safety search with staff...security came to room to assist and patient was still uncooperative. Pt was escorted by several staff members to the quiet room to do the safety search. Pt had no clothing under (his/her) hospital gown and had (blood) between (his/her) legs. Pt appeared unkempt with poor hygiene...posturing with staff and making fists as well as cracking (his/her) knuckles....when escorted to (his/her) room (he/she) willingly took injections to help (him/her) calm down. Pt then layed (sic) down on the bed and has been in (his/her) room for the past several hours. Pt refused assessment question. Prescreen stated that pt was found wondering (sic) in the middle of the road and refusing to speak with anyone...at the hospital pt reports a delusion that (he/she) was raped, is pregnant and was having a miscarriage. A pregnancy test was done which was negative, along with the fact the pt has a birth control implant. Pt is exhibiting paranoia, delusions and is very guarded..."

1/15/19 0851 (8:51 a.m.) Social Worker's Notes: "...1140 (11:40 a.m.) Patient discharged today in care of (Behavioral Health Authority) PACT team. Patient was eager to discharge and treatment team agreed patient was at baseline and ready for today's discharge. Met PACT team outside the unit as they were transporting patient to Crisis Stab (Stabilization)...PACT team noted that patient was not at 100% (one-hundred percent) baseline..."

On 2/26/19 at 11:30 a.m., the surveyor interviewed Other Interviewee A (OI-A) who stated, "The patient was unstable at the time of discharge. If you speak with the PACT team they will tell you that they had to immediately seek help for inpatient hospitalization. The hospital had contacted us prior to the patient's discharge to see if we would emergently admit (him/her) but they were told we do not do emergent admissions. We can only admit under a TDO (temporary detaining order) and the patient was already hospitalized at that time. After the PACT team picked the patient up at the hospital, they saw (he/she- Patient #2) was unstable and tried to get them to reconsider the discharge but they refused. We ended up getting the patient after (he/she) was again TDO'd to our facility....this is the information I was given regarding the patient on admission to our facility...it is my understanding, from the records, that the patient expressed homicidal ideations, was in an angry mood and had soiled (him/herself) twice when they picked (him/her) up at the hospital when discharged. The hospital refused to reconsider the discharge. According to the pre-screening, the patient was manic, expressed suicidal and homicidal ideations , was agitated, paranoid and delusional..."

On 2/26/19 at 11:40 a.m., the surveyor interviewed Other Interviewee "B" (OI-B). OI-B was a Licensed Clinical Social Worker (LCSW) for the Behavioral Health Authority in the City to which the patient was transported after being discharged from the hospital. OI-B stated, " My only interaction was as the pre-screener. When I saw the patient, (he/she) was not in a situation that (he/she) should have been discharged. (He/She) was not stable... The patient after being transported here, was immediately ECO'd (Emergency Custody Order) and transported to the Emergency Room (ER) of (name of hospital). The patient had soiled (him/herself) prior to being discharged and was incoherent. The patient stated that (he/she) wanted to kill someone and had suicidal ideation, but no plan. (He/She) was manic and with the history of assault on police officers, and the inability to protect (him/herself) from harm and meet basic needs. (He/She) was oriented X3 (times three) but was manic, paranoid, restless, agitated and requested not to talk to anymore and then refused to continue to speak to me. When (he/she) was discharged as an inpatient they (discharging hospital) had said the patient was at (his/her) baseline. When the PACT team arrived, they found the patient not at baseline, had soiled (him/herself) and the hospital refused to reconsider the discharge. Upon return to the community, the patient was immediately ECO'd. The PACT team shared progress notes that I will share with you: 'Client presented soiled, aggressive and irate with staff. When asked about changing clothing the patient stated "I'll be fine". When the writer reported this to the hospital staff they stated its "all behavioral" and the hospital continued to push for the discharge." OI-B continued, "The patient presented as bizarre and delusional and had no ability to consent. We have provided services to this client in the past and (he/she) was clearly not at (his/her) baseline. I personally would have not been comfortable transporting the patient..."

On 2/26/19 at 3:18 p.m., the surveyor interviewed OI-C (PACT Team Supervisor). OI-C stated, "The hospital called us the week prior on Friday. At that time they reported (the patient) was stabbing (him/herself) with needles and throwing chairs on the unit, and they wanted us to come and get (him/her). We explained to them (he/she) was not at (his/her) baseline and that we could not take (him/her) on the CSU (Crisis Stabilization Unit) due to the aggressive behaviors as that unit is not designed to handle those behaviors. I told them to call the police because we cannot take the patient with behaviors like that. They continued to push the discharge and on 1/15 when we got there to assess (him/her) (he/she) had soiled him/herself) was aggressive and irate. My team attempted to advocate for the patient, for them to reconsider the discharge as clearly the patient was not in a good space, but they told the team that all this was "behavioral". We tried to explain that the patient was not at baseline and was delusional. We took (the patient) because they refused to reconsider the discharge and they said (he/she) was ready and to take (him/her). We had to call for an ECO immediately when we got back to (city). (He/She) was uncooperative, aggressive, and trying to elope. It was clear the patient did not have capacity. When this patient is at (his/her) baseline, (he/she) is extremely independent, takes (his/her) medications, is not paranoid, can transport (him/herself) to appointments and treatment, and coordinate all (his/her)own ADLs (activities of daily living). I was present during the ECO and I witnessed the behaviors. The pre-screener saw (the patient) at (name of hospital). (He/She - Patient #2) had soiled pants, and didn't respond to (his/her) name. The patient was clearly below (his/her) baseline. The discharging hospital had told the PCT team that "all this was behavioral and we are proceeding forward with the discharge." I called the supervisor of the (discharging hospital) Behavioral Health Unit with my concern and I never received a return phone call. I also called (Name) (Region 4) and never received a return phone call....this is not the first time this has happened when we have had a client from this facility that had to be TDO's the same day they were discharged...This patient (Patient #2) had not been hospitalized in over a year..."

A BH (Behavioral Health) Recovery Plan/Review was contained in the clinical record dated 1/5/19 and another on 1/12/19. These "Behavioral Health Plans" documented the patients "Problems/alterations" and target dates and progress toward meeting the goals. Patient #2's "plan" had documented on 1/5/19: "Problem #1 Thought Processes- Related to: Characterized by impairment or disruption in cognitive operations and activities- As Evidenced By: Altered attention span, impaired judgement, non-reality thinking, periods of confusion with disturbed sensory perception....Problem #2 Mood- Characterized by unstable sustained abnormal emotional tone and symptoms wither depressive or bipolar- as evidenced by: altered attention span, impaired judgement or ability to think, reason and problem solve. Problem #3 Home Maintenance- related to discharge planning and follow up treatment- as evidenced by patient has an appropriate discharge plan that is understood by both the patient and family." Each of the three problems had a "target date" of 1/17/19 for the short term goals and 1/19/19 for the long term goals. Under the area for "Progress toward goal, for each problem, there was no documentation indicating how the patient had been progressing toward meeting any of the goals. The "Behavioral Health Plan" dated 1/12/19 had the same three problems documented, with the same target dates and under "Progress toward goals" there was no indication on this plan as to the progress of the patient in meeting the set goals.

The surveyor requested the discharge assessment and any documentation related to the discharge planning for Patient #2 and was told in an interview with Staff Member #13 on 2/26/19 at 12:15 p.m., that "All the information should be included in the patient's clinical record. I don't have any additional information". The surveyor was unable to locate a document which evidenced a complete "Discharge Planning Assessment" or/and revisions to an assessment for Patient#2. There was no evidence of any contact made with the patient's family where the patient had been living prior to admission.

The surveyor reviewed the clinical record for Patient #2 from the second facility to which the patient was sent for evaluation after discharge on 1/15/19. The clinical record evidenced the following:

"History and Physical" dated 1/15/19 at 1433 (2:33 p.m.) "(age) (gender) h/o (history of bipolar disorder presents to the ED (Emergency Department) with RPD (Police Department) for medical clearance/ECO (Emergency Custody Order). (He/She) is uncooperative and will not answer questions. Reviewed old records, recently here and admitted to psych and dc'd (discharged) this morning...1603 (4:03 p.m.) No medical problems identified which would require immediate intervention or which would preclude psychiatric evaluation..pt medicated with 10mg Geodon prior tome assuming care of patient (provider handoff 2035 -8:35 p.m.), (he/she) was throwing things at nursing staff thus an additional 10mg of Geodon ordered. Pt was calmer for a few hours. However, now (he/she) is yelling at the police and nursing staff, (he/she) will not stay in (his/her) room and is becoming an issue for other patients thus haldol and benadryl have been ordered at this time...Disposition request time 1800 1/15/19 - receiving Hospital- Central State- Transfer accepted- Yes- Acceptance time 0200- date 1/16/19...

According to the triage record Patient #2 was brought to the ED at 1427 (2:27 p.m.) under a ECO. Nurses notes revealed the patient, while in the ED was "Pacing, yelling", "Screaming, throwing blankets", "Yelling (he/she) about to deliver a baby".

Medication Administration Records revealed the patient received the following:
Geodon 10mg IM at 1935 (7:35 p.m.)
Geodon 10mg IM at 2033 (8:33 p.m.)
Haldol 5mg IM at 0106 (1:06 a.m.) and
Bendaryl 25mg IM at 0113 (1:13 a.m.)

The clinical record documentation evidences Patient #2's aggressive behaviors and paranoia persisted throughout (his/her) hospitalization requiring multiple doses of PRN (as needed) antipsychotic and antianxiety medications. Behaviors on 1/13/19 (2 days prior to discharge) were documented as "extremely liable...calm pleasant one moment then screaming and threatening the next". On 1/14/19, the day prior to discharge, the staff continued to document the patient was "labile and irritable and still needing PRN medications". Behaviors were described as "intrusive and aggressive, and continuing to curse at staff". It was documented the patient "was engaged in treatment" however, the clinical record evidences the patient did not participate in any group therapies while hospitalized, had refused medications and staff were "concerned" the patient was "cheeking" medications. According to interviews with Staff Member #13 the patient's "baseline" was "mood stabilized, less agitated and thoughts were clearer", however upon discharge and according to the prescreening information at the facility to which the patient was immediately transferred (after an ECO was obtained), the patient was expressing "suicidal and homicidal ideations, was manic, restless, and agitated". While in that ED, the patient was "uncooperative, will not answer questions, throwing things at nursing staff, yelling" and required emergency medications for management of the behaviors.

In interviews with the receiving agency, and upon further review of the clinical record from the receiving facility, the patient was still experiencing aggressive, paranoid and manic behaviors. It was documented in interviews and supporting evidence the patient was incontinent at discharge, which was not a behavior that had been documented during the patient's hospitalization. According to further evidence, the patient was discharged at 11:25 a.m., on 1/15/19 and arrived at the other facility under an ECO at 2:33 p.m. on the same day. The patient required a TDO be obtained and was admitted to another facility for further treatment.

The survey team discussed the concerns regarding the discharge with the facility Administration on 2/27/19 at 3:40 p.m..

Review of the facility policy and procedure "Case Management Discharge Planning and the Continuum of Care" was reviewed and evidenced, in part: "Discharge Planning provides for continuing care based upon the patient's assessed needs...Important factors such as functional status, cognitive ability of the patient and family support will be considered...the discharge plan must be thorough, clear, comprehensive and understood...1. Evaluation of a Discharge Plan- The case manager will conduct an ongoing assessment and reassessment of the patient's condition every 3-5 days or as necessary to determine if modifications to the plan are necessary. The plan will be revised as necessary...The case manager/social worker will assess the patient's readiness for discharge by assessing the patient's understanding of their health related condition as it pertains to their post discharge treatment plan, medical regime and follow-up services..."