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Based on record review and interview, the hospital failed to ensure the patient's discharge plan included an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital. This deficient practice was evidenced by failure of the Social Worker to verify a patient's (#2) requested change in discharge location was an environment to which the patient could be returned to at discharge, as set forth in hospital policy, for 1 (#2) of 3 (#1, #2, #3) discharged patient records reviewed from a total patient sample of 5 (#1- #5).

Findings:

Review of the hospital policy titled,"Care, Treatment, and Services", policy number: CTS-086, revealed in part: Purpose: To establish guidelines for assisting patients in appropriate level of care for post-treatment placement/continued follow-up care. Policy: Discharge Planning commences upon admission to any program. Tentative discharge plans are established and reviewed and modified or performed throughout treatment. Procedure: 3. Therapist/Discharge Planner: Discharge planning should encompass the following areas: * Review of any daily living changes (need for nursing home, group home, home health, etc.) patient may need to decrease relapse potential. * Facilitates post discharge planning by: Ensuring safe home environment. * Finalize living arrangements and post treatment care plans.

Review of Patient #2's medical record revealed an admission date of 5/15/18 and a discharge date of 5/30/18. Further review revealed Patient #2 had been transported to an area hospital emergency department, on 5/15/18, on an OPC (order for protective custody) for violent behavior and suicidal/homicidal thoughts. Additional review revealed the patient had been PEC'd due to being violent, dangerous to others, gravely disabled, and unable to seek voluntary commitment on 5/15/18. The patient had been CEC'd on 5/16/18 due to being delusional and dangerous to self and others. Patient #2 had a history of Bipolar Disorder and Schizophrenia.

Review of Patient #2's Psychosocial Assessment, dated 5/16/18, revealed the patient's current living arrangements, prior to hospitalization, had been listed as "my own apartment". Further review revealed the patient's desire had been to return to the same placement. Additional review revealed Patient #2's address had been listed as discharge address "a".

Review of Patient #2's discharge paperwork, dated 5/30/18, revealed discharge address "a" had a line drawn through it and discharge address "b" was written in the space next to a checked box indicating the patient had been discharged to home.

Review of Patient #2's Medicaid transportation request record revealed the patient had been discharged to discharge address "b".

Review of Patient #2's entire medical record revealed no documented evidence that discharge address "b" had been verified, by the hospital social worker, as an environment to which the patient could be returned to at discharge.

In an interview on 7/3/18 at 12:16 p.m. with S3SW, she reported she remembered Patient #2. S3SW further reported Patient #2 had been discharged with a plan that differed from the discharge plan she came in with. S3SW indicated Patient #2 had changed her discharge plan on the day of discharge. S3SW further indicated the patient had been living in an apartment prior to her admission, but could not return to the apartment.

In an interview on 7/3/18 at 12:35 p.m. with S5RN, she reported she remembered Patient #2 and confirmed she had discharged the patient. S5RN also confirmed, after review of Patient #2's discharge paperwork, that the patient had been documented as discharge to home. S5RN also confirmed discharge address "a" had a line drawn through it and discharge address "b" had been written in as the patient's discharge address.

In an interview on 7/3/18 at 12:53 p.m. with S6SW, she reported she had performed Patient #2's Psychosocial Assessment. S6SW further reported part of the discharge process was to verify patient housing prior to patient discharge to ensure the patient could be discharged to that location.

In an interview on 7/5/18 at 10:45 a.m. with S2Quality, he confirmed it was the hospital's policy to verify the discharge address/verify patient housing information provided by the patient prior to the patient's discharge. S2Quality verified, after reviewing Patient #2's entire medical record, that the discharge address had been changed from discharge address "a" to discharge address "b". He confirmed there was no entry in the patient's record regarding verification of discharge address "b" as an appropriate discharge location prior to the patient's discharge. S2Quality confirmed there should have been an entry in the patient's medical record indicating the patient's change of address had been verified as an appropriate discharge location prior to the patient being brought to discharge address "b".