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Based on interviews, medical record reviews and facility record review, the facility failed to ensure the condition of the client was documented at the time of discharge for 1 of 3 medical records reviewed. (Client #1)

The findings include:

A medical record review was conducted for client #1. The medical record revealed that the client had been admitted to the facility on 2/22/15 and had refused to sign his admission consent and had refused to participate in group treatment while residing in the facility. Further review indicated that client #1 had been seen by the physician on 2/23/15 at 3:15pm and that the client had been screaming and had demonstrated agitated behavior at that time. A subsequent order had been written and signed by the physician for the client to be discharged from the facility. There were no further notations made in the client's medical record until 2/23/15 at 7:25pm when a nurse documented "client discharged and escorted out by the Leon County Sheriff's Office. Client was supplied a phone umber to make an appointment and supplied with a prescription. Client was given all of his personal medications and belongings." There was no other documentation in the record to indicate what had occurred from the time the discharge order was written, until the time the client was escorted out by law enforcement. There was no documentation indicating the condition of the client at the time of discharge.

On 03/16/15 at approximately 11:15am, the client's record was reviewed with the program director regarding discharge information. She was not able to locate in the record what occurred from the time the physician wrote the discharge order, until the time the leon County Sherrif's Office arrived to escort the client out of the building. She stated that usually when law enforcement is called an incident report is written, but the risk manager indicated there was not an incident report for this particular event.

On 03/16/15 at approximately 12:40pm an interview was conducted with Client #1, who had been readmitted to the facility. Client #1 stated that the last time he was admitted, he had not been ready to discharge and stated that no one even told him he was being discharged until the police showed up. He stated that he had been taking a nap and that when he woke up he thought it was later than it was. He stated that he had gotten up to go get his medication, and the next thing he knew the cops were there. He stated that the cops talked to him and told him to calm down or they would have to taser him. He stated that he complied with the officers and left the building. He stated that he was given bus passes and did catch the bus. He confirmed that all of his belonging had been returned to him including his medications.

A review of the facility's policy and procedure for discharge planning indicated that progress towards development and implementation of the discharge plan must be documented on an ongoing basis in the progress notes along with the family's involvement, and their understanding and approval of the final discharge plan. Discharge prerequisites included all arrangements for aftercare such as appointments, transportation, notification of family/significant others and informing the client must have been completed and verified prior to the client's departure from the unit, and documented in the progress notes.

A review of the facility's policy and procedure for discharges indicated that its purpose was to outline the necessary steps to be completed by inpatient staff during the discharge process. It stated that the nurse, in conjunction with the admissions/discharge coordinator would complete the discharge instruction summary sheet and that the sheet must be reviewed with, and explained to the client by the nurse. The nurse should then sign the form and obtain the client's signature. The nurse would then give the client his or her copy, and the admission/discharge coordinator would notify the client's case manager of the discharge. Family, guardian and/or significant others would be notified as appropriate. The client would be notified that he or she would be required to remain on the unit until his or her designated ride arrived, an the nurse and admission/discharge coordinator would enter discharge notes in the client record.