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Based on review of medical records, interviews, and policy and procedures, it was determined that the facility failed to ensure a safe discharge for one (Patient #1) out of five sampled patients reviewed when the facility failed to secure timely and direct communication with the receiving facility that resulted in P#1 being discharged to the wrong location.

A review of the medical record revealed Patient #1 (P #1) was transferred to the facility from a local hospital on 10/11/23 at 12:52 p.m. P #1 was on a 1013 (involuntary) status. A review of the Intake Assessment completed on 10/11/23 at 1:27 p.m. revealed that P #1 had a chief complaint of Auditory and Visual Hallucinations (hearing and seeing things that did not exist in reality) and psychosis (a severe mental condition that resulting in loss of contact with external reality). P #1's appearance was described as disheveled and thought process as disorganized.
Program Therapist BB completed the Psychosocial Assessment on 10/12/23 at 11:33 a.m. the current living situation indicated P #1 had lived in a group home for three months and financial hardship was an identified stressor. Community Support and resources were identified as P #1 indicated she was at risk for food insecurity. The assessment indicated P #1 was able to return to the group home after discharge. P #1 stated that her goal was to get back to work and be stable on her medication.

Review of "Collateral Notes" from P #1's medical record indicated the following communication:

On 10/23/23 at 4:18 p.m. Therapist (BB) called and spoke with P #1's group home 1's coordinator. The group home stated P #1 was okay to return. The coordinator was available to receive P #1 between 12:00 p.m. and 1:00 p.m.

On 10/23/23 at 4:25 p.m., Therapist BB called P #1's parent (was also the guardian) to inform her of upcoming discharge to the group home where she had been living. Therapist BB notes indicated P #1's guardian stated No; she did not want P #1 to go back to the group home.

On 10/24/23 at 11:25 a.m., Therapist BB called and spoke with a community Group Home Placement Coordinator (telephone number on file) to inquire about group home placement for P #1. Placement Coordinator said they may have a placement available in the next few days. Therapist BB was to follow up with placement options.

On 10/24/23 at 4:19 p.m., Therapist BB and Director of Clinical Services AA called and spoke with P #1's parent to inform the parent that P #1 was medically cleared for discharge. P #1's parent stated P #1 could not return to the previous group home. Staff AA and Therapist BB informed parent that P #1 was medically cleared for discharge and there was no placement available at this time. Staff AA and Therapist BB gave different placement options to P #1's parent including picking her up while they continued to work on placement. P #1's parent declined.

On 10/24/23, the facility had communication for P #1 to be discharged to a group home with address and phone number.

Nursing progress notes dated 10/26/23 at 1:32 a.m. indicated P #1 was stable and medication compliant. Progress notes stated P #1 was cooperative with staff.
A Nursing Discharge Note dated 10/26/23 at 8:53 a.m. revealed that P #1 was alert, cooperative, denied suicide ideation, homicidal ideation, auditory and visual hallucinations. Nursing notes revealed that P #1 was discharged with instructions on medications, follow-up care appointment, and P #1 received all her belongings.

On 10/26/23 at 8:55 a.m. RN HH completed the Columbia -Suicide Severity rating Scale (C-SSRS) and P #1 was not a suicide risk.

On 10/26/23 at 9:44 a.m. Discharge Planner CC requested transportation for P #1 and trip report showed driver dropped P #1 off at address indicated for group home #2 at 11:08 a.m. Communication between group home #2 and the facility indicated P #1 never made it to group home #2 but ended up returning to the previous group home where she resided at the time of admission.

During an interview with Program Therapist (BB) on 11/14/23 at 3:20 p.m. in the conference room, Therapist BB explained her role in discharge planning process. Therapist BB said she worked with all patients while they were admitted to inpatient; she established contact with family to get information pertaining to Psychosocial for continuation of care after discharge. Therapist BB said she and her team were mainly involved in post discharge placement. Therapist BB said she saw patients within 24 hours of admission to complete their Psychosocial Assessment and she gathered information that helped determine resources patients in general were going to need once they became stable to leave the facility. Therapist BB said she was the discharge facilitator for P #1. Therapist BB said P #1 came from a group home. Therapist BB said she was in contact with P #1's father at the beginning of the process because it was difficult to get in touch with P #1's mother. Therapist BB said that P #1's mother did not want her to go back to the group home where she came from and once, she was aware of it, she started working on finding placement for P #1. Therapist BB said on 10/25/23 she was able to find a group home that accepted P #1. Therapist BB stated she gave the group home contact person to P #1's mother for vetting. Therapist BB said she then finalized the transfer with the group home, and it was fine for P #1 to go to the new group home on 10/26/23 (the next day). Therapist BB explained unless P #1's mother had made payment arrangements, the group home would not have allocated a bed to P #1; therefore P #1's mother could not say she was not aware of transfer. Therapist BB said P #1 was discharged the next day via Uber Health services (taxi). Therapist BB said the transport service was safe, they had been using them to transport patients for over two years. Therapist BB said she called the group home sometime after P #1 left the facility as a follow-up; that was when the group home administrator told her P #1 had not made it to the group home. Therapist BB said she had ordered staff CC to call the county and file a missing person report. Therapist BB said before that was done, P #1's mother called the facility to report they had found P #1 near the former group home.



During an interview with Discharge Planner (DC) CC on 11/14/23 at 4:00 p.m. in the conference room, he explained that his role in discharge planning process was to start getting patients ready once they were admitted. DC CC explained that the therapists did the Psychosocial Assessment that focused on finding resources for patients such as housing placements. DC CC explained that if placement was difficult, the team started working on placement early in the admission. DC CC said the case of P #1 became complicated when the patient's mother did not want P #1 to return to the most recent group home although the group home welcomed her to come back. DC CC recalled that the facility learned of this just as the physician wrote the discharge order.

DC CC said Therapist BB was able to find a new group home that would take P #1. DC CC stated that Therapist BB informed P #1's mother because she was the guardian and was responsible to make payment arrangement. DC CC recalled that he arranged for the ride once he received order from Therapist BB. DC CC said one of the techs took P #1 to the vehicle with her belongings. DC CC explained that the facility arranged transportation for patients with no family to pick them up. DC CC said the facility used Uber Health for safety and he had the capacity to monitor the vehicle from the time the driver left the facility until the patient arrived to the final destination. DC CC said he was able to track the vehicle for P #1 and he kept it on record. DC CC said the driver dropped P #1 off at the new group home and P #1 recognized the neighborhood and walked to the former group home located about a mile away. DC CC said when Therapist BB called the group home to check on P #1, they told her that P #1 never made it. DC CC said Therapist BB asked him to call the county police to report P #1 as missing, but P #1 was found minutes later near the former group home.

During a second interview with DC CC on 11/16/23 at 11:35 a.m. in the conference room. DC CC confirmed that the morning that P #1 was discharged, Therapist BB asked him to call the group home where P #1 was going to make sure someone was waiting to receive P #1. DC CC said he called the group home after P #1 got in the Uber and nobody answered the phone. DC CC said he left a voice message for the group home administrator. DC CC confirmed that he never had direct communication with the group home administrator. DC CC confirmed the group home administrator never returned his call.

During a second interview with Program Therapist BB on 11/16/23 at 11:50 a.m. in the conference room, Therapist BB confirmed she spoke with the group home administrator the morning P #1 was getting discharged, but she could not remember the time. Program Therapist BB said she communicated with the group home administrator that morning via text messages, but she had deleted the messages. Program therapist BB said she was not aware that DC CC did not communicate directly with the group home coordinator; she knew about the lack of direct communication after the facts. Program Therapist BB stated that DC CC did not tell her that he did not speak with the group home administrator although she had asked him to call the group home to let them know P #1 was on her way. Program Therapist BB said she learned about the breakdown in communication after she placed a call to the group home to check on P #1's arrival status.

A review of Policy Number: NR #46, title: "DISCHARGE PLANNING" effective 1/2017, last reviewed 1/2023 revealed the development of a Discharge Plan began on admission.
The policy delineated that the Discharge Plan should:
a. Prepare the patient and family for the transition to the next level of care.
b. Address the patient's and family's need for instructions about continued treatment.
c. Delineate how progress made in the current level of care was to continue after discharge.
d. Identify problems to be addressed in the next level of care.
e. Identify the responsibility for ensuring that the prescribed follow-up was accomplished.
f. Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care.

Review of Policy Number: SS #17, title: "DISCHARGE" effective 1/2017, last reviewed 1/2023 revealed Discharge Planning began the day of admission and continued through-out the treatment.
II: PROCEDURE
1. During the initial assessment the client's discharge plans were discussed.
2. In the development of the Initial Treatment Plan the therapist and client/guardian developed a specific discharge plan.
3. Discharge plans were updated as changes occurred.
4. The discharge plan included but was not limited to:
a. Appropriate referrals.
b. Activities needed to be conducted to facilitate accessibility to services.
c. Assistance needed to resolve obstacles to effective transition back into the community; and
d. Involvement with referral sources in discharge planning with consent from the client/ guardian.
5. The client's family was involved in the discharge planning process, with the client's consent.
6. The completed discharge plan was signed by the therapist, client/guardian.
7. Upon discharge a copy of the discharge plan was given to the client/guardian.
8. The signed discharge plan was placed in the client's chart.
9. A discharge order from the physician was obtained.