HospitalInspections.org

Based on document review and interview, the facility failed to ensure staff supervision of development of a complete and accurate discharge evaluation in 10 (#1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) of 10 MR's reviewed:

Findings:

1. Policy/procedure, Policy Number: 12.4, Discharge Planning, revised/reviewed 1/23/19, indicated: "All patients of Valle Vista Health System will be discharged in a thorough and orderly manner to the setting/level of care deemed most appropriate by the treatment team".

2. Review of patient 1's MR lacked documentation that the patient was witnessed by a staff member leaving the facility per private vehicle with F1 on 8/10/19.

3. Review of patient 2 (discharged 8/12/19), 3 (discharged 8/12/19), 4 (discharged 8/6/19), 5 (discharged 8/7/19), 6 (discharged 8/7/19), 7 (discharged 8/9/19), 8 (discharged 8/9/19), 9 (discharged 8/9/19) and 10's (discharged 8/6/19) MR lacked documentation that the patients were witnessed by a staff member leaving the facility at time of discharge.

4. On 8/19/19 at approximately 1200 hours, staff N2 (Director of Risk Management) was interviewed and confirmed patient 1's MR lacked documentation that the patient was witnessed leaving the facility with F1 per private vehicle at time of discharge. Staff N2 confirmed staff members do not document confirmation that a discharging patient left the facility as indicated in the discharge plan. Staff N2 confirmed patient 2, 3, 4, 5, 6, 7, 8, 9 and 10's MR lack documentation confirming the patient left the facility at time of discharge as indicated in the discharge plan.

5. On 8/5/19 at approximately 1230 hours, staff N4 (Mental Health Technician [MHT]) was interviewed and confirmed he/she returned to the unit to continue working after escorting patient 1 to the lobby. Staff N4 confirmed he/she did not watch patient 1 leave the facility at time of discharge. Staff N4 confirmed staff members do not wait in the lobby with a discharging patient to witness the patient leaving the facility.