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Based on review of policy and procedure, clinical records and interview, it was determined the facility failed to:

1. Provide re-evaluation and modification to the discharge plan for two (#1 and #6) of eleven (#1-#11) patients reviewed.
2. Provide re-evaluation and/or modification to discharge plan for one (#1) of eleven (#1-#11) patients in that the facility administered new medication prior to documented discharge time and did not document patient response or condition at discharge.
3. Ensure appropriate arrangements had been made prior to discharge for two (#1 and #6) of eleven (#1-#11) patients in that no scheduled follow-up care or referral was made to address ongoing physical and mental health needs, nor was discharge prescriptions provided or information on how to obtain them.
4. Provide necessary medical information on discharge to representatives accepting care of the discharged patient in two (#1 and #6) of eleven (#1-#11) patients reviewed in that the facility failed to re-evaluate and update patient goals, treatment preferences or provide post-discharge referral or schedule appointments.

The failed practice did not allow for modification of discharge planning that met the patients needs. The failed practice had the likelihood of affecting all patients discharging from facility. See A-0802, A-0805 and A-0813 for details.

Based on review of policy and procedure, clinical records and interview, it was determined the facility failed to provide re-evaluation and modification to the discharge plan for two (#1 and #6) of eleven (#1-#11) patients reviewed. The failed practice did not allow for modifications to meet the patient's needs. The failed practice had the likelihood to affect all patients discharging from facility. Findings follow:

A. Policy titled "Discharge Planning," approved 4/2020, last reviewed 2/2024, stated that all patients are included in the discharge plan and that discharge planning includes evaluating the needs for professional follow-up, medication needs, family relationships, physical and psychiatric needs, housing needs and placement issues as part discharge planning. The policy further stated that "discharge plans are to be reviewed by and signed by the patient/legal representative."

B. Document titled "Patient Rights/Patient Advocate," no effective or review date, stated that patients have the right to reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of persons providing care; be informed of continuing health care requirements following discharge from the hospital; have all patient's rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient.

C. A Review of patient #1's clinical record on 7/31/2024 showed the following:
1) The patient was admitted on 4/19/2024 and administratively discharged on 7/11/2024.
2) The discharge plan implemented on 7/11/2024 at 1:30pm, showed the guardian would pick up the patient later that same afternoon on 7/11/2024. The guardian telephoned the facility and stated she would be unable to pick up the patient due to transportation issues. The patient was transported to a local Department of Human Services office (DHS) on the same afternoon of 7/11/2024. There was no evidence which showed the facility re-evaluated the discharge plan or included the patient, guardian and/or DHS.
3) A review of the discharge form showed the patient was "administratively discharged" and "DHS will make arrangements for this child's care when placed". The form did not contain a signature and there was no evidence as to whom the patient was discharged to.

D. A Review of patient #6's clinical record on 8/1/2024 showed the following:
1) The patient was admitted on 4/18/2024, a discharge plan was developed on admission.
2) A progress note dated 5/21/2024 stated that the patient had an involuntary order for court "tomorrow".
3) A discharge summary dictated on 6/6/2024 by Physician Assistant and countersigned by the Physician on 6/7/2024 stated the patient was administratively discharged on 5/22/2024 to local police for "aggression".
4) There was no evidence the patient's discharge plan was re-evaluated or updated to show the patient was to be discharged to the police department. There was no evidence of physician order for discharge. There was no evidence discharge information (medication needs, treatment follow-up, etc..) was provided on discharge to police department or patient representative. There was no evidence to whom the patient was discharged.

E. Findings were confirmed for A-D during interview with the Interim Chief Executive Officer (CEO) and Director of Clinical Services on 7/31/2024 at 11:30 am, and again with Interim CEO on 8/1/2024 at 11:52 am.




Based on review of policy and procedure, clinical records and interview, it was determined the facility failed to re-evaluate and modify discharge plans in one (#1) of eleven (#1-#11) patients in that the facility administered new medication prior to documented discharge time and did not document patient response or condition prior to discharge. The failed practice had the likelihood to affect all patients receiving new medications prior to discharging from facility. Findings follow:

A. Review of patient #1's clinical record on 7/31/2024 showed the following:
1) On 7/11/2024, at 1:30 pm, Patient #1's guardian gave verbal consent for long-acting antipsychotic medication, Invega Sustenna during a discharge planning meeting call.
2) Medication Administration Record showed that Patient #1, was given the oral antipsychotic medication, Zyprexa, at 3:48 pm on 7/11/2024 and was injected with first dose of Invega Sustenna at 3:50 pm.
3) The discharge form showed patient #1 was discharged on 7/11/2024 at 3:55pm.
4) There was no evidence the patient had been re-evaluated following medication administration or that Department of Human Services was provided information on what to monitor for or who to call if adverse reactions occurred.

B. A Request was made on 7/31/2024 for a policy on medication administration and/or medication follow-up. There was no policy provided by facility.

C. Findings were confirmed for A-B during interview with the Interim CEO and Director of Clinical Services on 7/31/2024 at 11:30 am, and again with Interim CEO on 8/1/2024 at 11:52 am.

Based on review of policy and procedure, clinical records and interview it was determined the facility failed to ensure appropriate arrangements had been made prior to discharge for two (#1 and #6) of eleven (#1-#11) patients in that no scheduled follow-up care or referral was made to address ongoing physical and mental health needs, nor was discharge prescriptions provided or information on how to obtain them. The failed practice did not allow for continuity of care or allow for mitigation of potential risk of adverse health consequences due to unidentified post-discharge needs and follow-up. The failed practice had the likelihood of affecting all patients discharging from facility. Findings follow:

A. Policy titled, "Discharge Planning," last reviewed 2/2024, showed that the Discharge Care Plan and Home Medications form serves as the post-discharge continuing care plan. It includes discharge medications ordered at discharge, next level of care recommendations, discharge diagnosis, scheduled appointments as well as other important discharge information.

B. Review of Patient #1's clinical record on 7/31/2024 showed the following:
1) A review of the Discharge Care Plan and Home Medications form, for patient #1 showed no evidence of follow-up appointments or referral and four discharge medications were to be continued. A second injection of the medication Invega Sustenna, was ordered to be injected in "one week".
2) No evidence was provided which showed a discharge plan had been provided or medications prescriptions had been provided to the guardian or Department of Human Services (DHS).
3) No evidence was provided which showed how the guardian or DHS should obtain discharge medications or with whom the patient should follow up with to meet ongoing physical or mental health needs.

C. A Review of Patient #6's clinical record on 8/1/2024 showed the following:
1) No evidence was provided of physician discharge order or that a Discharge Care Plan and Home Medications form had been completed.
2) No evidence was provided that showed communication of post-discharge physical and mental health needs, or continuing medication needs to the patient or representative at discharge.
3) No evidence was provided to whom the patient was discharged as there was no patient or representative signature.

D. Findings were confirmed for A-C during interview with the Interim Chief Executive Officer (CEO) and Director of Clinical Services on 7/31/2024 at 11:30 am, and again with Interim CEO on 8/1/2024 at 11:52 am.

Based on review of policy and procedure, clinical records and interview, it was determined the facility failed to provide necessary medical information on discharge to representatives accepting care of the discharged patient in two (#1 and #6) of eleven (#1-#11) patients reviewed in that the facility failed to re-evaluate and update patient goals, treatment preferences and/or provide post-discharge referral or scheduled appointments. The failed practice had the likelihood of affecting all patients discharging from facility. Findings follow:

A. Policy titled, "Discharge Planning," last reviewed 2/2024, showed the Discharge Care Plan and Home Medications form serves as the post-discharge continuing care plan which communicates key components such as discharge medications or no medications if none are ordered at discharge, next level of care recommendations and referral, discharge diagnosis, scheduled appointments as well as other important discharge information.

B. Document titled "Patient Rights/Patient Advocate," no effective or review date, stated that patients have the right to reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of persons providing care; be informed of continuing health care requirements following discharge from the hospital; have all patient's rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient.

C. Review of patient #1's clinical record on 7/31/2024 showed the Discharge Care Plan and Home Medications form dated 7/11/2024 timed 3:55pm, showed no evidence that form which communicated necessary information was provided at discharge or to whom Patient #1 was discharged, as the signature line has "administrative discharge" written in place of patient/representative signature.
D. A review of patient #6's clinical record on 8/1/2024 showed no evidence was provided that necessary medical information was provided on 5/22/2024, to the patient or a representative at discharge.

E. Findings were confirmed for A-D during interview with the Interim Chief Executive Officer (CEO) and Director of Clinical Services on 7/31/2024 at 11:30 am, and again with Interim CEO on 8/1/2024 at 11:52 am.