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Based on record review and interview, the facility failed to adequately prepare 1 of 6 sampled patients for post-hospital care. (#4)

The findings:

The discharge instruction sheet provided to Patient #4 was reviewed.
Under the section for 'Discharge Instructions' staff documented "Waterfront Mission in Pensacola".
Under the Follow-up section staff documented, "follow-up Lakeview Center. Patient will make appointment."
Under the section for 'Discharge Instructions Given to' staff wrote "Pensacola"
Under the section for 'patient accompanied by', staff wrote, "bus".
Under the section for Discharge Orders, staff wrote "follow-up with Lakeview Mental Health in Pensacola."
No contact numbers were provided. There was no contact number for the hospital, none for any physician, or any resource. There was no phone number or address for either the Waterfront Mission or the Lakeview Center.

The notes from the discharge planner were reviewed. On 12/14/09 at 1:08p.m., the discharge planner wrote: telephone call to administrator (facility in Pensacola) regarding placement (address and phone number documented). Administrator stated that he would have to interview the patient in person before accepting him/her. Telephone call to Greyhound bus station and the bus leaves at 8:50a.m. Then when Patient #4 gets to Pensacola, they will be able to ride a city bus for $2.50. The bus will run until 5:30p.m. There was no indication that this detailed information was provided to Patient #4 upon discharge.

An interview was conducted with the Discharge Planner on 01/13/09 at approximately 9:51a.m. The Discharge Planner stated that Patient #1 had requested to go to Lakeview Lodges in Pensacola. The facility would not accept the patient unless they were residing in the Pensacola area. The patient asked to go to the Waterfront rescue mission in Pensacola. A bus ticket to Pensacola was provided along with money for the second bus fare and instructions. The patient was stable when they were discharged.

A further record review was conducted. On the day of discharge, 12/15/09 at 8:35a.m. a nurse documented, "restless - actively responding to internal stimuli." The nurse also documented "discharge instructions discussed" and that the patient was discharged to the bus station. There was no documentation of specifically what instructions were provided on the patients discharge.

On 1/13/10 at approximately 8:38a.m., an interview was conducted with a mental health advocate. The advocate stated that Patient #4 became delusional on the bus and the police were contacted. The advocate stated that the patient was unable to tell them where they were supposed to go once they arrived in Pensacola. Patient #1 was admitted to an acute care mental health facility in Pensacola due to being delusional.

There was no documentation in the medical record that a list of available facilities was provided to the patients on discharge who required post-hospital extended care services for 4 of 6 sampled patients (#2, 3, 4, and 6).

The findings:

Record reviews for discharge planning were conducted.

Patient #2 was re-admitted to the facility for the third time in December on 12/21/09. Patient #2 had diagnosis which included a "housing problem." Patient #2 was admitted from a homeless shelter. The discharge planner and treatment team assessed that an Assisted Living Facility (ALF) would be an appropriate placement for Patient #2. The Discharge planner documented that she contacted an ALF regarding placement. There was no documentation that Patient #2 was provided a list of available facilities from which to choose.

Patient #3 was assessed by the treatment team as unable to live independently on 12/7/09. The team discussed a group home or ALF. On 12/8/09, the discharge planner documented that she spoke with a specific group home about admitting the patient. There was no documentation that Patient #3 was provided a list of available facilities from which to choose.

Patient #4 was assessed by the treatment team as unable to live independently on admission 12/3/09. The patient was living in an ALF, but was unhappy with the facility. The team discussed placement in a different ALF. The discharge planner documented that she contacted several different ALFs. The discharge planner failed to document that Patient #4 was provided a list of available facilities from which to choose.

Patient #6 was admitted to the facility from the mission. The patient did not want to return there. The treatment team determined that Patient #6 should not live independently, and that a group home or ALF was appropriate for the patient. The discharge planner documented that she contacted a group home and an ALF about placement. The discharge planner failed to document that Patient #6 was provided a list of available facilities from which to choose.

On 01/13/10 at approximately 2:30p.m., an interview was conducted with the Risk Manager. The Risk Manager stated that the facility does have lists of available after-care facilities, and that these lists are provided to patients as indicated.