HospitalInspections.org

Based on a review of docuemntation and interview, the facility failed to ensure their discharge planning process was effectively applied to all patients.

Findings included:

1. The facility failed to create a discharge evaluation in a timely manner so that appropriate arrangements for post-hospital care could be made before discharge, due to the dismissal of Patient#1's commitment status. Appropriate arrangements for post-hospital care were not arranged, as evidence by discharging the patient via cab directly to the guardian office with only one follow up appointment scheduled for 02/14/17. This did not properly address the patient's aftercare issues. Cross refer to A0810.

2. The facility failed to ensure the discussion of the results of the discharge evaluation with the patient or individual acting on his or her behalf were effectively documented. Cross refer to A0812.

3. The facility failed to reassess the patient's discharge plan after factors occurred that that affected the continuing care needs or the appropriateness of the discharge plan. The initial discharge plan for the patient was placement in a nursing home, all nursing homes contacted by the facility denied admission for the the patient. Due to the dismissal of Patient#1's commitment status the facility discharged the patient without securing appropriate placement (nursing home or other placement option) , as evidence by discharging the patient via cab directly to the guardian office with only one follow up appointment scheduled for 02/14/17. Per interview on 07/19/17, the facility was not sure anyone would be present at the office when the patient was dropped off, jeopardizing the safety of this patient. The patient needed placement to address their continuing care needs, discharging them via cab to an office did not address placement or continued care. Cross refer to A0821.

Based on a review of documentation and interview, the facility failed to ensure that hospital personnel completed the discharge evaluation in a timely manner so that appropriate arrangements for post-hospital care were made before discharge.

Findings included:

Facility policy entitled, "Discharge Planning" stated in part,

"The Discharge Plan addresses the needs of the patient identified in the Discharge Planning
Evaluation. The Discharge Planning Evaluation shall be completed early in the admission process by qualified personnel, i.e., Social Workers, Registered Nurses or other individuals with appropriate assessment skills and previous experience in discharge planning to address clinical, social, insurance/financial, physical factors, and knowledge of community resources that must be considered when evaluating how the patient post-discharge care needs can be met. The Discharge Planning Evaluation begins within one day of patient admission...

4) At the discretion of the medical staff, a final discharge planning consultation may be held with their representative members of the Multidisciplinary Treatment Team prior to the patient's hospital discharge to complete the Discharge Plan for follow up to address the needs identified in the Discharge Planning Evaluation, assign specific responsibility, make specific arrangements for services, and educate the patient and/or significant others regarding the service delivery system.

5) The patient, family, service coordinator and/or Rehab Provider participate in discharge planning by providing input at the Multidisciplinary Treatment. Team meetings and through individual contact with the Social Worker and other members of the Multidisciplinary Treatment Team..."

* The review of the medical record for patient #1 revealed this adult patient had a legally appointed guardian.
* Discharge planning was initiated for this patient appropriately. A discharge evaluation was completed after their admission identifying that the patient was anticipated to return to the nursing home they were a resident at prior to admission. The nursing home refused to accept the patient back at the facility due to their aggression. Due to this refusal the facility identified that another nursing home facility would be an appropriate placement option for this patient.
* The facility attempted to find placement for this patient at multiple nursing homes, per recommendations provided by the guardian. The patient was denied admission to all nursing homes the guardian recommended. The facility struggled to finding discharge placement for this patient due to their history of aggression. Continued attempts to contact the guardian for placement options were documented in the medical record.
* The facility pursued an extension of the patient's commitment status on 02/01/17. The application for Emergency Detention and Temporary Mental Health stated in part, "pt continues to experiencing auditory hallucinations and paranoid delusions. Pt does not have appropriate housing and if discharged with [sic] be homeless. Pt has guardian and cannot be at SRCH voluntarily."
* On 02/08/17 the judge issued a "Dismissal of Commitment" which stated in part, "Based upon evidence, the court finds that the state had not presented clear and convincing evidence that the proposed patient presents a substantial risk of serious harm to himself or others. It is therefore the order of the court, his involuntary hospitalization is hereby terminated."
* Due to this dismissal of commitment the patient was not involuntarily committed to the facility and could not be placed in the facility on voluntary status, due to having a guardian.
* A social worker note on 02/08/17 at 3:30 PM stated in part, "This time was spent in pt's court hearing for a 1 year extension. The judge ruled that pt did not meet criteria for a 1 year extension on the Order of Protective Custody. Therefore SRCH must discharge pt from hospital today. After the court hearing, I attempted to visit with [guardian] about what service package I had obtained for pt in the community. However, [guardian] was on the phone and refused to speak to [another social worker] or myself... also stated on her phone call that she was upset she was not allowed to testify by the court. [Guardian] stated to the individual on the phone the she guessed pt would be sleeping in someone's car because she could not go to the Salvation Army due to be on psychiatric medications [sic], could not go to Paul's place (Grace campus) due to no space, and could not got to a motel because she did not have any funds. Due to [guardian] not terminating her call in order to speak to [social worker] or I. [Social worker] and I went onto the unit in order to work on pt.'s discharge....
* Another social work note on 02/09/17 at 4:30 PM stated, "This time was spent attempting to make contact with the pt's guardian to discuss discharge planning. I have made several attempts today to get ahold of both [guardian name] and [guardian name]. I have left several messages with both parties informing them that Sunrise Canyon will have to discharge [Patient #1] by 5:00 PM today to court orders for her dismissal yesterday. I informed [guardian] over message that we will be sending her to [address for guardian office] at 5 PM today. I will provide {Patient #1] with 4 all day bus passes should she not be retrieved at the [guardian office]. I will provide [Patient #1] with all known contact information for [company name] Guardians. Social Worker spoke with [facility administrative employee] and [facility administration employee] who instructed me to send [Patient #1] by taxi to [address for guardian office] along with several bus passes and contact information for [company name] guardian. [Guardian] did not return my call but did however send an e-mail reporting that I left a message then states that [address] is not the correct address for [guardian] Offices. I responded as requested that [guardian] provide me with a better address but got no response. The only other office address we have is [another address]. We will now be sending [Patient #1] to [second address]. With bus passes and contact information for [company names] guardians."
* Patient #1 was subsequently discharged on 02/09/17 at 5:30 PM via cab to the guardian offices. The guardians did not pick up the patient or sign discharge paperwork.
* The facility failed create a discharge evaluation in a timely manner so that appropriate arrangements for post-hospital care could be made before discharge, due to the dismissal of Patient#1's commitment status. Appropriate arrangements for post-hospital care were not arranged, as evidence by discharging the patient via cab directly to the guardian office with only one follow up appointment scheduled for 02/14/17. This did not properly address the patient's aftercare issues.

The above findings were confirmed in an interview on 07/19/17 with staff member #2.

Based on a review of documentation and interview, the facility failed to effectively document discussion of the results of the discharge evaluation with the patient or individual acting on his or her behalf.

Findings included:

Facility policy entitled, "Discharge Planning" stated in part,

"4) At the discretion of the medical staff, a final discharge planning consultation may be held with their representative members of the Multidisciplinary Treatment Team prior to the patient's hospital discharge to complete the Discharge Plan for follow up to address the needs identified in the Discharge Planning Evaluation, assign specific responsibility, make specific arrangements for services, and educate the patient and/or significant others regarding the service delivery system.

5) The patient, family, service coordinator and/or Rehab Provider participate in discharge planning by providing input at the Multidisciplinary Treatment. Team meetings and through individual contact with the Social Worker and .other members of the Multidisciplinary Treatment Team..."

* The review of the medical record for patient #1 revealed this adult patient had a legally appointed guardian.
* A "Discharge Planning Evaluation" was initiated on 09/13/16 indicating that the patient's need for housing was a nursing home.
* The Discharge Plan on 02/08/17 stated, "SRCH went to court for a 1 year extension which was denied by judge. Pt is to discharge to guardian today. An ANSA was completed for ACT service. Pt has an ACT a pt on 2/14 @ 9 am. Pt will discharge with 10 days of medication. Pt does not have housing. Pt. has been denied @ multiple nursing homes.
* There was no documentation in the medical record that the patient's legal guardian was informed of or invited to participate in the treatment planning, including weekly treatment plan meetings.
* Both the "Discharge Planning Evaluation" and "Discharge Plan" were on the same form, both had portions which stated,
"Evaluation of Patient's Discharge Planning Needs
Unless otherwise documented in the comments section, the patient and/or Legally Authorized Representative (LAR) was actively involved in this process and is in agreement with evaluation".
For "Discharge Planning" this area had a "yes" or "no" to mark, neither were indicated.
* Without "yes" or "no" not being indicated, it cannot be established the evaluation was discussed with the individual acting on the behalf of the patient.
* There was also no documentation in the medical record that the patient's legal guardian was informed of or invited to participate in the treatment planning, including weekly treatment plan meetings.


In an interview on 07/19/17, staff member #2 stated the guardian of Patient #1 was notified of treatment planning and opportunities to attend meetings (as reflected by facility e-mail correspondence), however this was not documented in the medical record. Staff member #2 also stated the patient's guardians did not attend a single treatment plan meeting in person or via telephone, this also was not documented in the medical record.

The above findings indicate that the discussion of the results of the discharge evaluation with the patient or individual acting on his or her behalf were not effectively documented.

Based on a review of documentation and interview, the facility failed to reassess the patient's discharge plan when there were factors that may affect continuing care needs or the appropriateness of the discharge plan.

Findings included:

Facility policy entitled, "Discharge Planning" stated in part,

"4) At the discretion of the medical staff, a final discharge planning consultation may be held with their representative members of the Multidisciplinary Treatment Team prior to the patient's hospital discharge to complete the Discharge Plan for follow up to address the needs identified in the Discharge Planning Evaluation, assign specific responsibility, make specific arrangements for services, and educate the patient and/or significant others regarding the service delivery system."

* The review of the medical record for patient #1 revealed this adult patient had a legally appointed guardian.
* Discharge planning was initiated for this patient appropriately. A discharge evaluation was completed after their admission identifying that the patient was anticipated to return to the nursing home they were a resident at prior to admission. The nursing home refused to accept the patient back at the facility due to their aggression. Due to this refusal the facility identified that another nursing home facility would be an appropriate placement option for this patient.
* The facility attempted to find placement for this patient at multiple nursing homes, per recommendations provided by the guardian. The patient was denied admission to all nursing homes the guardian recommended. The facility struggled to finding discharge placement for this patient due to their history of aggression. Continued attempts to contact the guardian for placement options were documented in the medical record.
* The facility pursued an extension of the patient's commitment status on 02/01/17. The application for Emergency Detention and Temporary Mental Health stated in part, "pt continues to experiencing auditory hallucinations and paranoid delusions. Pt does not have appropriate housing and if discharged with [sic] be homeless. Pt has guardian and cannot be at SRCH voluntarily."
* On 02/08/17 the judge issued a "Dismissal of Commitment" which stated in part, "Based upon evidence, the court finds that the state had not presented clear and convincing evidence that the proposed patient presents a substantial risk of serious harm to himself or others. It is therefore the order of the court, his involuntary hospitalization is hereby terminated."
* Due to this dismissal of commitment the patient was not involuntarily committed to the facility and could not be placed in the facility on voluntary status, due to having a guardian.
* A social worker note on 02/08/17 at 3:30 PM stated in part, "This time was spent in pt's court hearing for a 1 year extension. The judge ruled that pt did not meet criteria for a 1 year extension on the Order of Protective Custody. Therefore SRCH must discharge pt from hospital today. After the court hearing, I attempted to visit with [guardian] about what service package I had obtained for pt in the community. However, [guardian] was on the phone and refused to speak to [another social worker] or myself... also stated on her phone call that she was upset she was not allowed to testify by the court. [Guardian] stated to the individual on the phone the she guessed pt would be sleeping in someone's car because she could not go to the Salvation Army due to be on psychiatric medications [sic], could not go to Paul's place (Grace campus) due to no space, and could not got to a motel because she did not have any funds. Due to [guardian] not terminating her call in order to speak to [social worker] or I. [Social worker] and I went onto the unit in order to work on pt.'s discharge....
* Another social work note on 02/09/17 at 4:30 PM stated, "This time was spent attempting to make contact with the pt's guardian to discuss discharge planning. I have made several attempts today to get ahold of both [guardian name] and [guardian name]. I have left several messages with both parties informing them that Sunrise Canyon will have to discharge [Patient #1] by 5:00 PM today to court orders for her dismissal yesterday. I informed [guardian] over message that we will be sending her to [address for guardian office] at 5 PM today. I will provide {Patient #1] with 4 all day bus passes should she not be retrieved at the [guardian office]. I will provide [Patient #1] with all known contact information for [company name] Guardians. Social Worker spoke with [facility administrative employee] and [facility administration employee] who instructed me to send [Patient #1] by taxi to [address for guardian office] along with several bus passes and contact information for [company name] guardian. [Guardian] did not return my call but did however send an e-mail reporting that I left a message then states that [address] is not the correct address for [guardian] Offices. I responded as requested that [guardian] provide me with a better address but got no response. The only other office address we have is [another address]. We will now be sending [Patient #1] to [second address]. With bus passes and contact information for [company names] guardians."
* Patient # 1 was subsequently discharged on 02/09/17 at 5:30 PM via cab to the guardian offices. The guardians did not pick up the patient or sign discharge paperwork.


The facility failed to reassess the patient's discharge plan after factors occurred that that affected the continuing care needs or the appropriateness of the discharge plan. The initial discharge plan for the patient was placement in a nursing home, all nursing homes contacted by the facility denied admission for the the patient. Due to the dismissal of Patient#1's commitment status the facility discharged the patient without securing appropriate placement (nursing home or other placement option) , as evidence by discharging the patient via cab directly to the guardian office with only one follow up appointment scheduled for 02/14/17. Per interview on 07/19/17, the facility was not sure anyone would be present at the office when the patient was dropped off, jeopardizing the safety of this patient. The patient needed placement to address their continuing care needs, discharging them via cab to an office did not address placement or continued care.

Based on a review of documentation and interview the facility failed to ensure the record of each patient who has been discharged must have recommendations from appropriate services concerning follow-up or after care.

Findings included:

Facility policy entitled, "Discharge Planning" stated in part,

"The Discharge Plan addresses the needs of the patient identified in the Discharge Planning
Evaluation. The Discharge Planning Evaluation shall be completed early in the admission process by qualified personnel, i.e., Social Workers, Registered Nurses or other individuals with appropriate assessment skills and previous experience in discharge planning to address clinical, social, insurance/financial, physical factors, and knowledge of community resources that must be considered when evaluating how the patient post-discharge care needs can be met. The Discharge Planning Evaluation begins within one day of patient admission...

4) At the discretion of the medical staff, a final discharge planning consultation may be held with their representative members of the Multidisciplinary Treatment Team prior to the patient's hospital discharge to complete the Discharge Plan for follow up to address the needs identified in the Discharge Planning Evaluation, assign specific responsibility, make specific arrangements for services, and educate the patient and/or significant others regarding the service delivery system.

5) The patient, family, service coordinator and/or Rehab Provider participate in discharge planning by providing input at the Multidisciplinary Treatment. Team meetings and through individual contact with the Social Worker and other members of the Multidisciplinary Treatment Team..."

* The review of the medical record for patient #1 revealed this adult patient had a legally appointed guardian.
* Discharge planning was initiated for this patient appropriately. A discharge evaluation was completed after their admission identifying that the patient was anticipated to return to the nursing home they were a resident at prior to admission. The nursing home refused to accept the patient back at the facility due to their aggression. Due to this refusal the facility identified that another nursing home facility would be an appropriate placement option for this patient.
* The facility attempted to find placement for this patient at multiple nursing homes, per recommendations provided by the guardian. The patient was denied admission to all nursing homes the guardian recommended. The facility struggled to finding discharge placement for this patient due to their history of aggression. Continued attempts to contact the guardian for placement options were documented in the medical record.
* The facility pursued an extension of the patient's commitment status on 02/01/17. The application for Emergency Detention and Temporary Mental Health stated in part, "pt continues to experiencing auditory hallucinations and paranoid delusions. Pt does not have appropriate housing and if discharged with [sic] be homeless. Pt has guardian and cannot be at SRCH voluntarily."
* On 02/08/17 the judge issued a "Dismissal of Commitment" which stated in part, "Based upon evidence, the court finds that the state had not presented clear and convincing evidence that the proposed patient presents a substantial risk of serious harm to himself or others. It is therefore the order of the court, his involuntary hospitalization is hereby terminated."
* Due to this dismissal of commitment the patient was not involuntarily committed to the facility and could not be placed in the facility on voluntary status, due to having a guardian.
* A social worker note on 02/08/17 at 3:30 PM stated in part, "This time was spent in pt's court hearing for a 1 year extension. The judge ruled that pt did not meet criteria for a 1 year extension on the Order of Protective Custody. Therefore SRCH must discharge pt from hospital today. After the court hearing, I attempted to visit with [guardian] about what service package I had obtained for pt in the community. However, [guardian] was on the phone and refused to speak to [another social worker] or myself... also stated on her phone call that she was upset she was not allowed to testify by the court. [Guardian] stated to the individual on the phone the she guessed pt would be sleeping in someone's car because she could not go to the Salvation Army due to be on psychiatric medications [sic], could not go to Paul's place (Grace campus) due to no space, and could not got to a motel because she did not have any funds. Due to [guardian] not terminating her call in order to speak to [social worker] or I. [Social worker] and I went onto the unit in order to work on pt.'s discharge....
* Another social work note on 02/09/17 at 4:30 PM stated, "This time was spent attempting to make contact with the pt's guardian to discuss discharge planning. I have made several attempts today to get ahold of both [guardian name] and [guardian name]. I have left several messages with both parties informing them that Sunrise Canyon will have to discharge [Patient #1] by 5:00 PM today to court orders for her dismissal yesterday. I informed [guardian] over message that we will be sending her to [address for guardian office] at 5 PM today. I will provide {Patient #1] with 4 all day bus passes should she not be retrieved at the [guardian office]. I will provide [Patient #1] with all known contact information for [company name] Guardians. Social Worker spoke with [facility administrative employee] and [facility administration employee] who instructed me to send [Patient #1] by taxi to [address for guardian office] along with several bus passes and contact information for [company name] guardian. [Guardian] did not return my call but did however send an e-mail reporting that I left a message then states that [address] is not the correct address for [guardian] Offices. I responded as requested that [guardian] provide me with a better address but got no response. The only other office address we have is [another address]. We will now be sending [Patient #1] to [second address]. With bus passes and contact information for [company names] guardians."
* Patient #1 was subsequently discharged on 02/09/17 at 5:30 PM via cab to the guardian offices. The guardians did not pick up the patient or sign discharge paperwork.

The facility failed to reassess the patient's discharge plan after factors occurred that that affected the continuing care needs or the appropriateness of the discharge plan. The initial discharge plan for the patient was placement in a nursing home, all nursing homes contacted by the facility denied admission for the the patient. Due to the dismissal of Patient#1's commitment status the facility discharged the patient without securing appropriate placement (nursing home or other placement option) , as evidence by discharging the patient via cab directly to the guardian office with only one follow up appointment scheduled for 02/14/17. Per interview on 07/19/17, the facility was not sure anyone would be present at the office when the patient was dropped off, jeopardizing the safety of this patient. The patient needed placement to address their continuing care needs, discharging them via cab to an office did not address placement or continued care. This patient's discharge did not contain recommendations from appropriate services concerning follow-up or after care.