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Based on a review of medical records, documentation, and interview, the facility failed to ensure an effective discharge planning process and the discharge plan to be consistent with the patient's goals for care and his/her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions.


Findings:

1. Based on a review of medical records, documentation, and interview, the facility failed to ensure that discharge plans were updated, as needed, to reflect these changes, after re-evaluation of the patient's condition identified changes that require modification of the discharge plan. Please cross refer to A802.


2. Based on a review of medical records, documentation, and interview, the facility failed to provide an appropriate discharge including transfer or referal information and providing all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care. Please cross refer to A813.


3. The facility failed to ensure that Discharge Planning polices were followed and enforced consistently at the facility. See below findings:

Facility based policy PC-115 entitled, "Interdisciplinary Discharge Planning and Continuing Stay Criteria" stated in part,

"Purpose: To provide a process for determining patient readiness for discharge or transition to another level of care. To ensure that appropriate plans are made which will implement effective and adequate patient discharge ...

3. Responsibilities:
a. Attending Physician responsibilities:...
ii. Discontinues Suicide Precautions at least 24 hours prior to discharge...

v. Review the Discharge Suicide Risk Assessment and the Discharge Safety Plan with treatment team...

c. Social Worker Responsibilities:
i. Complete the Discharge Suicide Risk Assessment with patient..."

Facility policy PC-152 entitled, "Suicide Risk Assessment" stated in part,
"11. Upon discharge, pt must be assessed for suicidal ideation per the MD and documented in the MD progress notes."


Facility policy PC-150 entitled, "High Risk Behavior Precaution" stated in part,

"Prior to Discharge:

a. Suicide precautions will be discontinued at least 24 hours prior to discharge

b. A Crisis Safety Plan will be developed and completed with the patient's input

c. A discharge suicide risk assessment will be completed

d. Lethal means will be assessed and secured (when applicable)"


Review of medical records revealed 5 of 10 patients did not have suicide precautions discontinued 24 hours prior to discharge per policy and/or the Suicide Risk Assessment properly completed.

Patient #1

* The Discharge Suicide Risk Assessment was completed on 04/13/21 at 1058 by the LPC. This form had a check mark to indicate "yes" to question "7. Was the patient on suicidal precautions or heightened observations for suicidal ideation or self-injurious behavior in the past 24 hours?". The "Actions Taken" portion of this form was blank. This form was not updated or a new form completed to reflect the actual discharge date of 04/19/21.

* Review of Mental Health Tech Daily Notes which serve as the observation monitor sheet revealed the following dates had suicide precautions marked: 04/13/21 to 04/21/21.


Patient #2

* The Discharge Suicide Risk Assessment was completed on 03/29/21 at 1200 by a social worker. This form had a check mark to indicate "yes" to question "1. Thoughts: Since you were last asked, have you had thoughts about killing yourself?". The "Actions Taken" portion of this form was blank. The area on the form for "MD who reviewed and approved assessment and discharge decision:" was blank and not signed by the physician.


Patient #4

* The Discharge Suicide Risk Assessment was completed on 03/31/21 at 1100. This form had a check mark to indicate "yes" to question "1. Thoughts: Since you were last asked, have you had thoughts about killing yourself?". This form had a check mark to indicate "yes" to question "2. Suicidal Thoughts with method: Have you been thinking about how you might do this?" This form had a check mark to indicate "yes" to question "7. Was the patient on suicidal precautions or heightened observations for suicidal ideation or self-injurious behavior in the past 24 hours?". The "Actions Taken" portion of this form was blank. The area on the form for "MD who reviewed and approved assessment and discharge decision:" was blank and not signed by the physician.

* Review of Mental Health Tech Daily Notes which serve as the observation monitor sheet revealed the following dates had suicide precautions marked: 03/30/21 and 03/31/21.

* The physician discontinued suicide precautions on 03/31/21 at 0900 which was not 24 hours prior to discharge per policy.


Patient #8

* The Discharge Suicide Risk Assessment was completed on 03/22/21 at 1039. This form had a check mark to indicate "no" to question "7. Was the patient on suicidal precautions or heightened observations for suicidal ideation or self-injurious behavior in the past 24 hours?". The "Actions Taken" portion of this form was blank. The area on the form for "MD who reviewed and approved assessment and discharge decision:" was signed by the physician on 03/22/21 at 1100.

* Review of Mental Health Tech Daily Notes which serve as the observation monitor sheet revealed the following dates had suicide precautions marked: 03/22/21.

* The physician discontinued suicide precautions on 03/22/21 at 1100 which was not 24 hours prior to discharge per policy.


Patient #9

* The Discharge Suicide Risk Assessment was completed on 03/22/21 at 1330. This form had a check mark to indicate "yes" to question "7. Was the patient on suicidal precautions or heightened observations for suicidal ideation or self-injurious behavior in the past 24 hours?". The "Actions Taken" portion of this form was blank. The area on the form for "MD who reviewed and approved assessment and discharge decision:" was signed by the physician on 03/22/21 at 1300.

* Review of Mental Health Tech Daily Notes which serve as the observation monitor sheet revealed the following dates had suicide precautions marked: 03/21/21 and 03/22/21.

* The physician discontinued suicide precautions on 03/22/21 at 1100 which was not 24 hours prior to discharge per policy.


The facility policy requires discontinuing suicide precautions 24 hours prior to discharge. By failing to discontinue these orders 24 hours in advance, it cannot be establish that patients were safe for discharge. If a patient remains on suicide precautions at the time of discharge they could be at increased risk of suicide after discharge. By discontinuing suicide reactions 24 hours prior to discharge the facility is promoting safer discharge practices. The Suicide Risk Assessment needs to be completed appropriately, especially with the physician reviewing it prior to discharge, as this is important to ensure safe discharge practices at the facility.


Facility based policy PC-115 entitled, "Interdisciplinary Discharge Planning and Continuing Stay Criteria" stated in part,
"b. Nursing Staff Responsibilities:..

xiv. Nurse will document on discharge note the following:
1. Date/time of discharge
2. Activity instructions
3. Discharge treatments/teaching
4. Patient's disposition
5. Medications
6. Condition of patient including mental/emotional status
7. Ambulatory status. Indicate person/agency accepting responsibility for the patient..."


Review of medical records revealed 5 of 10 patients that did not have all elements documented in a nursing discharge note per facility policy.

Patient #1

* This patient discharged on 04/19/21.

* Nursing note on 04/19/21 at 1000 stated in part, "Robert is alert, disoriented, calm, and currently cooperative. Frequently agitated, pacing hallway/unit redirectable ...Scheduled for discharged today." Nursing note on 04/19/21 at 1120 stated, "Robert discharged at 11:10 via cab, all belongings secured."

* The above nursing noted did not indicate the "person/agency accepting responsibility for the patient" per policy.


Patient #2

* Discharged on 03/29/21 at approximately 1330. There was no discharge nursing note on 03/29/21 that noted the discharge or contained the elements required per policy.


Patient #3

* Discharged on 04/09/21. The nursing note on 04/09/21 at 1310 stated, "Discharge instructions reviewed with patient and all questions answered. Pt exited the facility with Rx, copy of forms, and all personal belongings[sic]."

* This discharge note did not contain all the elements required per policy.


Patient #5

* Discharged on 04/05/21. The nursing note on 04/09/21 at 1800 stated, "Discharge instructions given, all belongings obtained, patient went home at 1635."

* This discharge note did not contain all the elements required per policy.


Patient #8

* Discharged on 03/22/21 at approximately 1330. There was no discharge nursing note on 03/29/21 that noted the discharge or contained the elements required per policy


The above findings were verified with staff members #2, 11, and 12 on 04/22/21.

Based on a review of medical records, documentation, and interview, the facility failed to ensure that discharge plans were updated, as needed, to reflect these changes, after re-evaluation of the patient 's condition identified changes that require modification of the discharge plan.

Findings:

Facility based policy PC-115 titled, "Interdisciplinary Discharge Planning and Continuing Stay Criteria" stated in part,
"Purpose: To provide a process for determining patient readiness for discharge or transition to another level of care. To ensure that appropriate plans are made which will implement effective and adequate patient discharge ...

1. Discharge Criteria: Discharge planning begins upon admission and is the joint responsibility of the Attending Psychiatrist and members of the multidisciplinary treatment team. Discharge planning is documented in the Initial Assessments, Master Treatment Plan, Treatment Plan Review/Update, and the Continuing Care Discharge Plan.

2. Discharge Planning:

a. Multidisciplinary treatment team meets to review and discuss the Discharge Safety Plan and Discharge Suicide Risk Assessment on the day of expected discharge.

b. Patient discharges in all levels of care include communication with:

i. Patient/parent/guardian/significant other, as appropriate

ii. Previous treatment providers and After care providers ...

j. A Discharge Planning Assessment is completed....


3. Responsibilities:

a. Attending Physician responsibilities:

i. Conduct a face-to-face risk evaluation on the day of discharge and reviews risk factors/crisis that precipitated admission...

v. Review the Discharge Suicide Risk Assessment and the Discharge Safety Plan with treatment team.

vi. Write, sign and date the discharge order...

c. Social Worker Responsibilities:

i. Complete the Discharge Suicide Risk Assessment with patient

ii. Complete the Discharge Safety Plan with patient and, if possible, with family/support system input/feedback...

vi. Complete the Discharge Planning Assessment with the patient to ensure the patient's transportation plan is appropriate. If the transportation plan changes, complete a new Discharge Planning Assessment based on the new transportation plans...."


Facility based policy entitled, "MEDICAL RECORDS" stated in part,

"7.3.6 All entries to the medical record must be dated, timed and signed by the person making I the entry and must include his or her name and discipline at the time the entry is made. Only individuals authorized by Hospital's policies and procedures may make entries into medical records...

7.4.4 An order shall identify the author, shall be signed, timed, dated, written clearly and legibly, and shall be complete. In addition, all Hospital personnel shall record the time when the order has been transcribed...

7.7 Discharge Documentation:

7. 7.1 Patients shall be discharged only on a written order of the Attending Practitioner. Exceptions to this rule may only be made by the Medical Director who has the authority to discharge a patient for administrative reasons...

At the time of discharge, the Attending Practitioner shall complete the discharge according to the approved guidelines, shall state final diagnosis and shall sign the record

7. 7.3 The record of each discharged patient must have a discharge summary of the patient's hospitalization and recommendations concerning follow-up or aftercare as well as a brief summary of the patient's condition on discharge. The discharge summary must also include the reason for hospitalization, significant findings, procedures performed and treatments rendered, and any instructions to the patient and family. Additionally, the discharge summary shall identify and recommend to the patient appropriate facilities, agencies, or outpatient services for follow-up or ancillary care. The information included in such identification and recommendation shall include the patient's medical history, current medications, available social, psychological, and educational services to meet the needs of the patient; additionally, such information shall include the patient's nutritional needs, outpatient service needs, and follow-up care needs. Discharge planning shall utilize available community and Hospital resources to provide appropriate recommendations for the patient, or make available social, psychological, and educational services to meet the needs of the patient. The Hospital must develop and arrange for the initial implementation of a discharge plan for the continuing care of any patient whose discharge planning evaluation indicates the need for such a plan."


2 of 10 medical records had patients that had their discharges postponed and plans changed, however, the discharge order and discharge paperwork were not updated to reflect change in discharge date or change to where location/agency the patient was discharged to.


Review of the medical record for Patient #1 revealed the following:

* Patient #1 was originally scheduled to discharge on 04/13/21, this discharge was held by the physician "for better coordination with caseworkers on weekday for safety planning." Social services was having difficulty contacting the patient's outside case management to coordinate discharge planning. Patient #1's actual discharge date was 04/19/21.

* Patient #1 had Discharge Orders that were initially signed and dated by the physician on 04/13/21 at 1115, 04/13/21 had a line drawn through and 04/19/21 written above by the physician. The nurse signature on the order also reflected 04/13/21 at 1400. This order indicates the patient discharge date of 04/13/21 and "Discharged to: Salvation Army". This was the only order present in the medical record at the time the survey was initiated on 04/21/21. The there was no order written for the actual discharge date of 04/19/21. The discharge order also was not updated to reflect the patient being discharged to a different facility than the Salvation Army as indicated in this order. This patient actually discharged from the facility on 04/19/21 to Psychiatric Emergency Services (PES) not the Salvation Army, via taxi.

* The Transition Record Part I Physician Discharge Plan also initially signed and dated by the physician on 04/13/21 at 0900, 04/13/21 had a line drawn through and 04/19/21 written above by the physician.

* The Transition Record Part II Aftercare/Discharge was dated 04/13/21 at 1400. Discharge disposition was listed as Shelter "as available". Mode of transportation was listed as Taxi. This patient actually discharged from the facility on 04/19/21 to PES (not a "shelter" as indicated on this form) via cab. This form was not updated or a new form completed to reflect the actual discharge date of 04/19/21

* The Transition Record Part IIII Discharge Safety Plan was dated 04/13/21 at 1314. The patient refused to sign this form. This form was not updated or a new form completed to reflect the actual discharge date of 04/19/21.

* The Discharge Suicide Risk Assessment was completed on 04/13/21 at 1058 by the LPC. This form was not updated or a new form completed to reflect the actual discharge date of 04/19/21.


Review of the medical record for Patient #2 revealed the following:

* Patient #2 was originally scheduled to discharge on 03/27/21, this discharge was held by the physician after the patient expressed suicidal thoughts related discharge to the Salvation Army, and the possibility a bed not be available. Social work was able to secure placement for the patient at a respite care facility. Patient #2 was actually discharged on 03/29/21.

* Patient #2 had Discharge Orders that were signed and dated by the physician on 3/29/21 at 1000. The nurse signature on the order also reflected 03/27/21 at 1100. This order indicated a discharge date of 03/27/21 and "Discharged to: homeless shelter".

There was a physician order on 03/27/21 at 1215 to "hold discharge". The there was no new order written for the actual discharge date of 03/29/21. The discharge order also was not updated to reflect the patient being discharged to a different facility than a homeless shelter as indicated in this order. This patient actually discharged from the facility on 03/29/21 to 1st Street Respite via taxi.

* The Transition Record Part I Physician Discharge Plan also initially signed and dated by the physician on 03/27/19 at 1000, the physician had written 29 above this date to indicate the day of the month, there was no line drawn through 03/27/21.

The Transition Record Part II Aftercare/Discharge was dated 03/27/21 no discharge time was noted. Discharge disposition was listed as "1st Street Respite". Mode of transportation was listed as Taxi. The patient signed this form on 03/27/21 at 11:18 AM, this patient was actually discharged on 03/29/21. This form was not updated or a new form completed to reflect the actual discharge date of 03/29/21

* The Transition Record Part IIII Discharge Safety Plan form was dated by the physician 03/27/21 at 1117 (the patient refused to sign the form). The patient also refused to sign this form. This form was not updated or a new form completed to reflect the actual discharge date of 03/29/21.


In interview on 04/22/21 staff members #2, 11, and 12 verified that the discharge order and plans should have been updated to reflect changes to the discharge plan identified by re-evaluation of these patients' condition.

Based on a review of medical records, documentation, and interview, the facility failed to ensure that the hospital discharge the patient, and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care.

Findings:

Facility based policy PC-115 titled, "Interdisciplinary Discharge Planning and Continuing Stay Criteria" stated in part,

"2. Discharge Planning:

a. Multidisciplinary treatment team meets to review and discuss the Discharge Safety Plan and Discharge Suicide Risk Assessment on the day of expected discharge.

b. Patient discharges in all levels of care include communication with:

i. Patient/parent/guardian/significant other, as appropriate

ii. Previous treatment providers and After care providers ...

j. A Discharge Planning Assessment is completed.

k. Aftercare appointments are scheduled.

l. Discharge Planning materials are forwarded to the next provider.

m. Any patient refusals during the Discharge process are communicated to the physician/treatment team ...

c. Social Worker Responsibilities:..

x. Provide copies of discharge paperwork to patient and referral source/outpatient caregiver.

xi. Schedule aftercare appointments for planned, unscheduled, and AMA discharges as soon as possible after discharge (including medical follow up appointments)..."


Review of the medical record for Patient#1 revealed the following:

* A Social Services note completed by the Licensed Professional Counselor (LPC) on 04/11/21 at 1500 stated in part, "Pts CW [name and agency] is assisting with dc placement and requested a courtesy call prior to D/C. He is also wondering if he could d/c or transfer to state hospital ..."

* A Social Services note completed by the Licensed Professional Counselor (LPC) on 04/13/21 at 1310 stated in part, "TH [therapist] was trying to coordinate transfer to nursing home, however pt refused to consent to ROI [release of information]. Pt's insurance + [agency] CW stated pt cannot go back to group home ...Pt was observed responding to AVH [auditory visual hallucinations], and refused to answer TH questions or sign D/C paperwork. TH consulted with MD who said to continue with D/C as pt is at baseline. TH consulted with treatment team and felt pt should be released to PES [Psychiatric Emergency Services] in cab instead of to the streets. Pt has not made any significant improvement since court-ordered meds began on 04/07/21 ..."

* A Social Services note completed by the Licensed Professional Counselor (LPC) on 04/13/21 at 1415 stated in part, "MD pushed back DC so pt will not DC [discharge] today".

* A Social Services note completed by the Director of Clinical Services on 04/17/21 at 1050 stated, "DCS [Director of Clinical Services] attempted to contact [caseworker name at outside agency]. No answer and VM [voicemail] box is full. DCS attempted to contact APS [name], no answer. SW [social worker] left VM requesting her contact DCS back to discuss legal guardianship and safety planning. DCS met with pt. he was disorganized and irritable. Saying 'fuck you'. DCS notified MD of concerns and he reports okay to cancel d/c for better coordination with caseworkers on weekday for safety planning."

* A Social Services note completed by the Licensed Professional Counselor (LPC) on 04/19/21 at 1050 stated, "Pt was disorganized and refused to complete DC paperwork. Pt had moments yelling for no logical reason. TH [therapist] spoke with treatment team and we decided to send to send pt to PES . TH [therapist]attempted to contact PES to do pt handoff, but was no answer. TH called pt's CW [caseworker] [caseworker #1 name and agency]. TH gave PES contact phone # and address; [caseworker name] stated he will contact PES for continuance of care." This note indicated a mark beside "no change" regarding "Progress towards treatment plan goals". Living arrangement was listed as "shelter as available".


Discharge paperwork for the patient included:

* The Transition Record Part II Aftercare/Discharge was dated 04/13/21 at 1400. Discharge disposition was listed as Shelter "as available". Mode of transportation was listed as Taxi. Follow up Appointments were listed as "[outside case management agency name] with a note to "call to schedule". The family involvement portion stated that a family meeting was not held due to the patient "refusing ROIs". The patient refused to sign this form. This patient actually discharged from the facility on 04/19/21 to PES (not a "shelter" as indicated on this form) via cab. This form was not updated or a new form completed to reflect the actual discharge date of 04/19/21.

* The Transition Record Part IIII Discharge Safety Plan stated that "[case worker name from outside agency]" was invited to participate via phone. The only contact listed for emergencies related to this stay was "Crisis text line". This form was dated 04/13/21 at 1314. The patient also refused to sign this form. This form was not updated or a new form completed to reflect the actual discharge date of 04/19/21.

The Transition records including the "Discharge/Aftercare Plan" were faxed to the patient's outside case management on 04/19/21 at 12:09 PM according to a copy of the fax transmission sheet in the medical record. There was no evidence that the Transition records or discharge information had been faxed to PES where the patient was sent to prior to or after the discharge on 04/19/21. In interviews on 04/21 and 04/22, staff member #1 reported they faxed the information to the receiving facility (PES) prior to discharge but could not locate the fax transmittal report to prove this occurred.


Per interview with staff member #1 on 04/21/21, the patient discharged on the afternoon of 04/19/21 to PES via a taxi cab.


In an interview on 04/21/2021 at 11:28 AM staff member #1 was asked when they initially attempted to contact PES. Staff member #1 responded, "I called the first thing in the morning to figure out would need to be calling probably at 9:15 right after the meeting. Quite a bit later that I hadn't heard anything I had done the fax. I even tried again tried the intake admission (number) it rang and rang and rang and I hung up."

Staff member #1 was asked when they actually made contact with PES regarding the patient's discharged. Staff member #1 replied, "I can't remember. The nurses said, hey PES is calling. Nurse transferred (the call) it to me. I was like hey I tried to coordinate with you I faxed over clinicals. She said this is a big mess because he's refusing to come inside. I said I sent it over, he's on this med or that med. Unfortunately, I didn't get her name."

Staff member #1 was again asked if they had faxed discharged documents to PES. Staff member #1 replied, "I was certain I had sent those on my own prior to discharge, the packet and the facesheet". Staff member #1 also verified that they left follow up with PES up to the patient's outside caseworker. Staff member #1 "Yes mam he (outside agency caseworker) asked for PES address and phone number, said 'okay I'm gonna head over there and follow up there'. I believe he (outside agency caseworker) has worked with him (patient) for 2 years maybe".


In an interview on 04/22/21 at 1:30 PM, staff member #1 was again asked if they were able to locate the fax they stated they sent to PES prior to Patient #1's discharge on 04/19. Staff member #1 replied, "No I looked for it and under and the printer and behind it and where the discharge stuff goes. I'm hoping it didn't get loose."

Regarding the documented follow up appointments for the patient to call the outside case management agencies, staff member #1 was asked if Patient #1 had a cell phone. Staff member #1 looked at the property list for Patient #1 and replied, "Just seeing a belt, shirt, and pants." Staff member #1 was asked how, according to the discharge paperwork, was Pateint #1 expected to call their outside agency caseworker to arrange appointment with no phone? Staff member #1 replied, "I don't know how either. With [case management agency] he (patient) has [name's] number and was supposed to call [caseworker #1] from the shelter."

Staff member #1 was again asked how PES was expected to prepare for the patient's arrival with no notification. Staff member #1 stated, "I was told by the team that they had beds there and I was recently told...that is no longer true." Staff member #1 added later, "The number I called turned out to be the crisis line that didn't answer. There was an option for intake. It rang and rang and rang. I chose the social work option, left voicemail they didn't answer."


In a telephone interview on 04/20/2021 at 5:30 PM with a PES employee, they reported that Patient #1 was brought to the agency via taxi cab on 04/19/21 with no discharge communication from Austin Lakes prior to the patient's arrival. "The gentleman yesterday was in a mental health crisis currently in a state of psychosis from a hospital. He wouldn't engage in services or even come into the building. We had no information on him. He had dropped discharge paperwork on the ground that had discharge coordinator from another agency listed...The nurse went down to engage him, he declined. He was walking around the parking lot shirtless swinging a belt. He was very intrusive to personal space especially females. He was not violent but potential harm to him was great. ...We had no idea what was going on...Rather than call our discharge planner with a date of discharge, they put him in a cab and sent him over here."

Per the PES staff member, "We were waiting for APD... He [Patient #1] was outside for 2 hours... then wandered off before APD was to get on scene."


Based on the medical record and interview, patient did not have any scheduled after care appointments for follow up care. The Transition Record Part II Aftercare/Discharge for Patient #1 had Follow up Appointments listed as "[outside case management agency name] with a note to "call to schedule". In interview on 04/22/21 staff member #1 confirmed the patient did not have a phone, it is unknown how this patient was supposed to effectively secure their own appointment without access to a telephone.


Based on the above findings, Patient #1 was discharged to PES on 04/19/21 via taxi cab. Per interview on 04/20/21, staff at PES was unaware of this discharge plan. Staff member #1 verified they were unable to give report via telephone to PES unit the patient was already at PES. Staff member #1 had the incorrect number to contact a representative at PES to give discharge information for Patient #1. According to a note in the medical record and interview, staff member #1 left discharge communication with PES up to the patient's outside agency caseworker. Staff member #1 reported they had faxed discharge paperwork to PES on 04/19/21 prior to patient discharge but was unable to produce evidence to support this claim.


Patient #1 refused to participate in care at PES and wandered off, therefore the patient's whereabouts and safety post discharge are unknown. Clear and advanced communication with the PES by the facility prior to discharge would have encouraged continuity of care and possibly a safer and more effective discharge of this patient.


The above findings were verified with staff members #11 and 12 on 04/22/21.