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Based on interview and record review the hospital failed to ensure that appropriate nursing plans of care included legal guardian as evidenced by guardian not being notified of discharge placement of ward in 1 out of 10 patients.

Findings:

Record review of Patient #1's medical chart (Treatment Plan) Discharge planning needs dated 07/15/19, 07/10/19 did not include the Guardian of Patient #1.

Record review of Patient #1's medical chart Psychiatric progress Note (Section Plan) dated 07/14/19 at 12:35 PM showed that the Psychiatrist Employee #5 wrote nursing to contact guardian. Plan discharge with social work.

Interview on 07/19/19 at 10:30 AM with Employee #4. Employee #4 said that the discharge instructions should have included the guardian before the patient was going to be discharged not on the day of discharge.

Interview on 7/22/19 at 09:30 AM with the Chief Nursing Officer (CNO) Employee #3. The CNO said that they realized after the mother made a complaint on the day she was being discharged. We have instituted a new discharge policy when a patient has guardian and that guardianship is a full guardianship.