HospitalInspections.org

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Based on medical record review, and staff interview, in one (1) of three (3) medical records reviewed, the hospital did not afford the patient the right to participate in the development of her treatment care plan (Patient #7).

Findings include:

Review of medical record identified a 50-year-old woman with history of bipolar I with psychotic features and multiple psychiatric admissions, was brought to the facility's Emergency Department (ED) on 11/7/17, for a psychiatric evaluation, due to agitation and starting a fire in her apartment. She was agitated, screaming, and threatening to burn down the hospital. The patient was admitted to an inpatient psychiatric unit for management and treatment of her psychiatric symptoms.

The Acute Psychiatric Care Services Interdisciplinary Treatment Plan forms dated 11/9/17 and 11/16/17 indicated that the treatment plans must be reviewed and signed by the patient.

The two treatment plans were not signed by the patient and there was no documented evidence in the medical record that the patient participated in the development of these treatment plans.

During interview with Staff H, Medical Doctor on 11/30/17 at approximately 3:10 PM, he stated that the patient's Interdisciplinary Treatment Plan is a team discussion and plan, and that the patient was not involved.

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Based on medical record review and interview, in one (1) of three (3) medical records reviewed, the facility did not afford the patient the right to have her physician informed of her admission to the hospital (Patient #7).

Findings include:

Review of medical record for Patient #7 noted a 50-year-old woman with history of bipolar I with psychotic features and multiple psychiatric admissions. The patient was evaluated in the Emergency Department on 11/7/17 for agitation and starting a fire in her apartment. The patient was involuntary admitted to an inpatient psychiatric unit on 11/7/2017.

On 11/8/2107, the patient gave a consent for the treating staff to speak to her doctors.

There was no documentation in the medical record that the patient's psychiatrist was informed of her admission to the facility.

During interview with Staff H, Medical Doctor on 11/30/17 at approximately 3:15 PM, he acknowledged that he had not spoken to the patient's psychiatrist regarding her admission or her discharge back into the community.

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Based on medical record review, document review and staff interview, in one (1) of three (3) medical records reviewed, the facility did not ensure that a psychiatric patient with a preoccupation for setting fire was afforded a safe discharge (Patient #7).

Following discharge, the patient set fire to her apartment, injuring herself and others.

Findings include:

Review of medical record for Patient #7 identified a 50-year-old woman with history of bipolar I with psychotic features and multiple psychiatric admissions. She was brought to facility's Emergency Department by Emergency Medical Services and New York Police Department officers in handcuffs on 11/7/2107 at 8:39 AM for a psych evaluation due to agitation and starting a fire in her apartment. The patient was involuntary admitted to an inpatient psychiatric unit on 11/7/2017 and was discharged home on 11/21/2017.

There was no documented evidence of a safety plan to address the patient's preoccupation with fire setting and her capacity for self care in her home environment.
The patient's discharge planning evaluation did not include an assessment of the patient's ongoing refusal of services and staff implementation of identified discharge needs.

See Tag A-0806.

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Based on medical record review, document review and staff interview, in one (1) of three (3) medical records reviewed, the discharge evaluation did not address the patient's post hospital needs. Specifically, the facility did not ensure that:
1) discharge planning evaluation included an assessment of the patient's ongoing refusal of services and the implementation of identified discharge needs;
2) a safety plan was developed to address the patient's preoccupation with fire setting and her capacity for self care in her home environment (Patient #7).

Following discharge, the patient set fire to her apartment, injuring herself and others.

Findings include:

1. Review of medical record for Patient #7 identified a 50-year-old woman with history of bipolar I with psychotic features and multiple psychiatric admissions. She was brought to facility's Emergency Department by EMS/NYPD (Emergency Medical Services and New York Police Department officers) in handcuffs, on 11/7/2107 8:39 am, for a psych evaluation due to agitation and starting a fire in her apartment. The patient was involuntary admitted to an inpatient psychiatric unit on 11/7/2017 and was discharged home on 11/21/2017.

Social Work initial assessment dated 11/8/2017 5:13 PM indicated that the patient had case management services in the past. The social worker (SW) called and spoke with the case manager who stated the patient had requested the case be closed in September 2017. The SW noted that the patient disconnected from Health Home Services and it was unclear whether patient had any social support. The patient makes medical, legal and financial decisions independently. The SW recommended that the patient would benefit from reconnection with ICM (Individual Case Management). The initial Disposition/Anticipated Discharge Plan: Connect patient with case management.

On 11/14/2017 at 3:54 PM, the SW notes " ... patient has previously been referred for ACT (Assertive Community Treatment) in December of 2016 but patient appeared never related to an ACT team. This may be because patient self-terminated with her care coordination in September 2017."

Social work Discharge Summary dated 11/21/2017 at 4:51 PM indicated that the patient met criteria for assisted outpatient treatment but an application was not submitted due to a clinical decision not to submit an Assisted Outpatient Treatment application.

There was no documentation of the patient's refusal of intensive case management services as initially recommended by hospital staff on 11/8/17. The clinical rationale for a change in the initial plan for case management services and the intervention provided for the patient refusal of services were not documented.

During interview with Staff I, Social Worker on 11/30/2017 on 3:45 PM, she stated that the patient was identified as needing case management services; however, this is a voluntary service that requires the patient to accept the services. The discharge plan was discussed in interdisciplinary team meeting and it was determined that the patient was not a suitable candidate due to her history of noncompliance with case management services.


2. On 11/14/17 3: 54 PM, SW noted that she spoke with the patient's building manager at The New York City Housing Authority who stated that the patient could return to her apartment. The building manager expressed concern for the patient, he stated that patient usually 'decompensates frighteningly' after discharge and she wished that patient could be provided with further supports in the community.

The Acute Psychiatric Care Services Interdisciplinary Treatment Plan forms dated 11/9/17 and 11/16/17 noted there was no documented safety plan to address the patient's preoccupation with fire setting. The capacity of the patient to function in her home environment was not adequately evaluated and documented.

During interview with Staff B, Chief of Psychiatry on 12/4/2017 at approximately 3:00 PM, he stated that a fire safety plan was not documented in the treatment plan but the patient was offered a safety plan on the day of discharge, which she declined.