HospitalInspections.org

Based on record review and interview, the facility failed to reassess the discharge plan of 1 of 1 patients who refused to leave at the time of discharge (patient #7), increasing the risk discharge without current assessments and discharge plans for all patients. Findings include:
Policy Review:
On 4/17/14 at approximately 1200 facility discharge policies were reviewed, revealing:
Interdisciplinary Treatment Team and Treatment Planning, HBS: PC105, dated 04/2010 states:
F. "After formulation of the treatment plan, the psychiatrist or case manager/therapist will review and obtain consent to the following with the patient and significant other of the patient's choice...." 5. "The discharge plan"
The policy does not provide a procedure to be followed if the patient withdraws consent for discharge.
Record Review:
On 4/17/14 from 0830-1300 review of patient #7's closed clinical record revealed:
1. Patient #7 was admitted to the inpatient psychiatric unit on 3/18/14.
2. On 3/19/14 a Progress Note by physician N, describes patient #7's mood and cognitive processes as: "possibly delusional ...judgment and insight are poor ...impaired memory and concentration."
3. On 3/20/14 at 1230 "An Important Message from Medicare" was signed by staff G but not by patient #7. On the "patient's signature" line, staff G noted: "I don't want to sign" on behalf of the patient. There was no documentation of a reason for the patient's refusal to sign.
4. On 3/20/14 at 1248 a Progress Note by staff G states that patient #7: "wants to go home ...We will plan for her to discharge today."
5. Patient #7's "Patient Discharge Instruction Signature Page" was unsigned by patient #7. The "Patient Signature" line was blank. Nurse K signed the "Clinician Signature" line on the form on 3/20/14 at 1518.
6. The "Special Precautions Monitoring Record" indicates that patient #7 was discharged at 1541 on 3/20/14.
7. Patient #7's multidisciplinary Treatment Plan was requested but not provided for this admission (3/18/14-3/20/14).
8. Patient #7 was readmitted for psychiatric inpatient treatment on 3/21/14.
On 4/17/14 from 0900-1300 review of facility incident reports and discharge notes revealed:
1. A "Discharge/Depart Form" for patient #7 states: "Patient was not compliant with discharge. She had stated that she was fine with it earlier in the shift, but when it was time to be discharged she would not get out of bed. It took a show of support to get the patient into a wheelchair and into the cab to go home. Patient did not sign discharge paperwork and would not engage with staff for discharge instructions."
2. A 3/20/14 Security Department note by staff M states that Security staff I was called to the Adult North Unit due to an incident involving: "a female patient (#7) who was being discharged and who was now declining to leave..."
Interviews:
1. On 4/17/14 at 0955 nurse K confirmed that patient #7's "Patient Discharge Instruction Signature Page" was unsigned by patient #7. Nurse K stated that patient #7: "wouldn't sign discharge paperwork." Nurse K confirmed that there was no documentation of a reason for patient #7's refusal to sign discharge forms. Nurse K stated that she was not aware of efforts to reassess the discharge plan when patient #7 refused to sign discharge documents.
2. On 4/17/14 at approximately 1030 staff M stated that patient #7 was unwilling to leave her room for discharge on 3/20/14 and was "placed in a wheelchair and wheeled to the exit by several staff."
3. On 4/17/14 at 1045 patient #7's Social Worker (staff G) stated that there was no documentation stating a reason for patient #7's refusal to sign "An Important Message from Medicare." Staff G stated that he was not informed of patient #7's refusal to leave on 3/20/14. Staff G confirmed that there was no documentation of patient #7's discharge plan being reviewed when the patient refused discharge on 3/20/14.