HospitalInspections.org

Based on medical record review, document review and interview the facility did not ensure a safe discharge to an assisted living center for Patient #1 following an evaluation in the CPEP (Comprehensive Psychiatric Emergency Program).

Findings include:

Review of Patient #1 CPEP evaluation dated 12/15/2020 revealed the patient was sent to the CPEP for evaluation of suicidal ideation. The patient was noted to have dementia, depression and neurocognitive dysfunction. Following the evaluation, a decision was made to discharge the patient back to the assisted living facility.

Review of social work note dated 12/16/21 at 3:29 PM revealed the assisted living center agreed that the patient could be discharged via cab, but that someone would need to stay with the patient until the cab arrived. The patient was discharged from the CPEP on 12/16/20 at 5:00pm.

Review of the facility's investigation dated 1/5/21 revealed that the patient was taken to the lobby to wait for the cab. The tech assigned to remain with the patient was called back to the CPEP and the patient was left unattended. The patient wandered away prior to the arrival of the cab. The police were notified and the patient was found several miles away on 12/17/20 at 12:52am.

Review of facility policy 2.6 - Ambulatory Discharge Policy last revised 10/22/20 revealed that when the discharge plan is created it should consider and address functional independence. The policy does not specifically address the discharge of a patient to a supervised living situation.

Interview on 3/30/21 with Staff (B), Assistant Quality Officer verified Patient #1 was left unattended in the lobby and that the standard of care for a safe discharge was not met.