HospitalInspections.org

Based on findings at A2405, A2406 and A2407, the facility failed to ensure compliance with C.F.R. (Code of Federal Regulations) 489.24.

Based on document review and interview, the facility failed to ensure the Psychiatric Observation Unit (POU) maintained a central log which identified individuals who presented to the POU and whether the individuals refused treatment, denied treatment, were treated, admitted, stabilized, transferred or discharged from the unit.

Findings include:

A review of the POU admission/discharge logs from April 2012 through April 2013 revealed the logs did not include required criteria and/or were not consistently completed.

The POU daily logs for the months of April, May, June, July, August, September, October, November and December 2012 identified the following:

- There were columns listed with the following information: ER (Emergency Room) From; Client's Name; Social Security #; Time In & Out; Clinician; Type of Insurance; I, PR, DA, N/O; A,D, A&D; Trans by; and Disposition.
- There were many areas on the log left blank.
- The log was inconsistent with documenting the disposition of the patients. Many had just room numbers indicated or discharge with no further information on where the individual was discharged to.
- The log was handwritten, with the exception of the client's name, which was a sticker. Many of the handwritten entries were illegible.


The POU daily log for January 2013 identified the following:

- There were columns listed with the following information: Hospital; Client; Time; Clinician; Disposition.
- There were many areas of the log left blank.
- The log was inconsistent with documenting the disposition of the patients. Many had just room numbers indicated or discharge with no further information on where the individual was discharged to.

The POU log for March 2013 identified the following:

- There were 3 columns with the following information: Time; Admission; and Discharge/Transfers (IP) (inpatient admission)
- The log lacked consistent documentation related to if the patient was discharged, transferred or admitted to the facility.

The POU log for April 2013 identified the following:

- There were 3 columns with the following information: Time; Admission; and Discharge/Transfers (IP) (inpatient admission)
- The log lacked consistent documentation related to if the patient was discharged, transferred or admitted to the facility.

On 5/2/13 at 10:55 AM, a Registered Nurse Manager indicated the POU log book had been changed three times. It was identified the previous log book had unnecessary information. The new version dated November 2012, removed the social security number, insurance, PR, DAm, no alcohol and drugs. The new log showed pertinent data.

On 5/2/13 at 11:05 AM, a Charge Nurse on the POU indicated the meaning of the following abbreviations on the POU log. PR meant the patient was previously here, the abbreviation DA was not used, and I indicated an initial admit.

Based on interview, clinical record review and document review, the facility failed to ensure each patient was provided with an appropriate medical screening examination for one of 37 sampled patients (Patient #3).

Findings include:

The facility's policy entitled, Outpatient Direct Admits to POU (Psychiatric Observation Unit) dated revised 8/30/11, documented in part... E. "POU psychiatrists will evaluate the client for medical clearance and appropriate disposition. In the event the client presents with medical issues which requires further evaluation and treatment which is unavailable at the POU, POU staff will arrange for transportation to the nearest hospital emergency room".

Patient #3 was a direct admission to the Psychiatric Observation Unit(outpatient department) on 2/1/13 on a legal 2000 hold. The clinical record revealed the patient was hearing voices causing the patient significant emotional distress with episodes of suicidal ideation. The patient revealed thoughts of wanting to harm another person.

On 2/1/13 at 3:30 PM, a physician's order was received for a complete blood count, comprehensive metabolic panel, urine toxicology, chest x-ray and electrocardiogram.

The clinical record lacked documented evidence the complete blood count and comprehensive metabolic panel had been completed in accordance with the physician's order. The clinical record lacked documented evidence Patient #3 had been cleared medically while at the facility. The clinical record lacked documented evidence of a contact number for this patient.

Documentation entitled Medical Clearance dated 2/1/13, revealed medical clearance was pending based on results of a complete blood count, comprehensive metabolic panel, chest x-ray and electrocardiogram.

A Progress Note dated 2/2/13 revealed Patient #3 was discharged at 7:00 AM, per the physician's order.

During an interview on 5/3/13 at 1:45 PM, a Registered Nurse (RN) revealed the documentation on the Legal 2000 form did not indicate the patient had been cleared medically. The RN verbalized the documentation on the Medical Clearance form dated 2/1/13, did not indicate the patient had been medically cleared. The RN confirmed there was no documentation in the clinical record or the computer system to validate the laboratory/diagnostic tests had been completed.

During an interview on 5/6/13 at 4:20 PM, two Licensed Nurses verbalized any patient on a Legal 2000 were to received medical and psychiatric clearance per the facility's policy.

During an interview on 5/6/13 at 12:30 PM, the Medical Director verbalized the facility's policy indicated if a patient was on a Legal 2000 hold or a direct admission, the patient must be medically cleared. The Medical Director verbalized the area on Legal 2000 form was to be completed.

Based on clinical record review, document review and interview, the facility failed to ensure 16 out of 41 sampled patients received the necessary discharge instructions to secure aftercare services identified by the treatment team to prevent worsening of the psychiatric condition. (Patients #13, #18, #24, #31, #35, #38, #46, #45, #3, #37, #23, #17, #4, #28, #34, #12).

Findings include:

Posted on the Nevada Department of Health and Human Services, Division of Mental Health and Developmental Services website (mhds.nv.gov), validated psychiatric emergency services are offered at Rawson Neal Hospital. The posting included "Psychiatric Crisis Services...If the consumer is acutely and severely ill enough, they may be referred to .... POU (Psychiatric Observation Unit). The POU offers rapid screening and stabilization for consumers in an acute psychiatric crisis..."

Patient #13

Patient #13 presented to the Psychiatric Observation Unit (POU) on 12/06/12, on a legal hold for suicidal ideation with a plan. The diagnoses included mood disorder and amphetamine abuse. Patient #13 was discharged on 12/09/12 to Daytona, Florida.

The nursing note dated 12/07/12, indicated Patient #13 was admitted from another psychiatric hospital on a legal hold for "suicidal ideation and has a plan of walking into traffic." The patient was calm and cooperative with good eye contact noted. The patient denied suicidal ideation and homicidal ideation.

The psychiatric note, dated 12/08/12, described the patient's status as "...patient continues to endorse having suicidal ideas. He appears to be exaggerating his symptoms and secondary gain may be housing...willing to return to Florida to live with his parents, though he does not have their phone number, he is aware of the street they live on. Mood was depressed, affect was anxious....continues to report having suicidal ideation and denied having homicidal ideation...He feels hopeless. Insight and judgment are poor....would be discharged to Florida tomorrow. Consider psychological testing to rule out malingering if patient continued to report suicidal ideas."

The psychiatric resident note, dated 12/09/12, indicated "Patient states he feels somewhat better today, denies current suicidal ideation. States he is willing to go to Florida to live closer to his family including his parents, as he lacks any current support system.... Patient denied current suicidal ideation, mood was "ok", affect somewhat restricted. No evidence of psychosis. Insight and judgment fair. Patient would be discharged today to Daytona Beach, Florida via Greyhound bus pass. Patient stated he would follow up with outpatient care in Florida. The patient would reside to a shelter with information provided, while he attempts to locate his parents in Daytona, Florida." Discharge medications included Cymbalta (an antidepressant) 30 milligram (mg) daily.

The social work note, dated 12/09/12, included "Patient reports he is homeless, unemployed in Las Vegas with no support system; he is motivated to return to Florida where his parents and sibling live....history of polysubstance abuse which patient reports has exacerbated since he moved to Las Vegas community....Patient is appropriate for discharge to a least restrictive environment....denies suicidal/homicidal ideation, intent or plan. Denied auditory hallucinations and visual hallucinations with no acute psychosis demonstrated or reported. Patient will be discharged Daytona, Florida rescue mission; he will be transported via taxi to Las Vegas Greyhound bus station; patient provided with discharge medication and liquid meal replacements for 2+ day trip. Outpatient mental health aftercare for medication management and referral to substance abuse counseling will be arranged with the Volusia County Mental Health Services; Medical follow up with the Daytona Beach medical center; patient provided with handouts for mental health and medical contact. Volusia County Crisis line information provided."

The medical record lacked documentation as to the location or addresses of rescue missions or homeless shelters in Daytona Beach, Florida. There was no documentation indicating services had been arranged with the Volusia County Mental Health Services. There was no documentation regarding how the patient would get to the rescue mission from the bus station. There was no documentation of any attempt made to contact or locate the patient's family to coordinate the patient's aftercare in Florida.

Patient #18

Patient #18 was admitted to the POU on 02/09/13 on a legal hold for suicidal ideation and auditory hallucinations.The diagnoses included psychotic disorder, rule out mild MR (mental retardation), and rule out schizoaffective disorder. Patient #18 was discharged from POU on 02/11/13 to Sacramento, California.

The psychiatric evaluation, dated 02/10/13, indicated Patient #18 "appears to have some degree of MR (mental retardation) (mild). Some conflicting information being given between myself and social worker....patient indicated he was having trouble caring for himself and did not know what to do.... patient reported having trouble with his memory recently.... patient was unable to state exactly why he was here and seemed to perseverate on recently being discharged from a local psychiatric hospital. Patient currently endorses auditory hallucinations in the form of voices in his head. They are currently telling him to 'try to be good' but admits that yesterday they were telling him to hurt people. Also endorses visual hallucinations in the form of 'colors and shadows'. Patient also reports feeling sad and depressed....has failed multiple trials of antidepressants. The patient currently endorsed depressive symptoms. Denied suicidal ideation at this time, but endorsed recent thoughts of suicide. Denied mania and homicidal ideation....Patient has no reasonable plan for self care besides wanting to find a group home to live in."

Patient #18 was recently discharged from a local psychiatric facility "with a plan to go to California." Psychiatric medications included Cymbalta (an antidepressant), Thorazine (an antipsychotic) and Valium (an antianxiety). Patient #18 had been out of medications for about one week. Patient #18 had lived in a local assisted living housing facility but was currently homeless. The urine drug screen was positive for benzoids.

The facility initial treatment plan included: "Observe and re-evaluate in the morning. Evaluate for any concerning psychosis or mood symptoms, suicidal ideation/homicidal ideation and response to medication; Social Worker to assist with dispositional needs. Patient could benefit from group home placement. Perhaps (name) assisted living. Will also need a case worker; Will start Thorazine (antipsychotic) 10 mg three times a day, Cymbalta (antidepressant) 30 mg daily, Klonopin (anticonvulsant) 1 mg times one for now for anxiety and Klonopin 1 mg twice a day as needed for anxiety; medical consult; consider IP (inpatient) admission for psychological testing and for more dispotional needs that cannot be provided in the POU setting."

The psychosocial assessment dated 02/10/13 indicated the patient had a "self reported history of mental illness," urine drug screen was positive for benzodiazapines. The patient was placed on a legal hold due to psychosis, hearing voices and thinking of suicide. "Patient states he wants to go to a group home because he forgets where he is or how to get home. Patient states he is homeless, living at hospitals or on the streets. Previously stayed at (name) assisted living and would like to go back. Reportedly had SSI (supplemental security income) and Medicaid. Patient stated he had no collateral contacts. Patient indicated he did not have contact with his children." The current plan did not include the patient being sent out of state. The patient was requesting a referral to (name) assisted living. "Social Worker to assist patient with possible discharge to (name) assisted living and follow up for aftercare at an outpatient clinic."

The nursing note dated 02/11/13 at 12:41 PM, validated the psychiatrist had seen the patient and signed the discharge order. The patient's diagnoses included rule out malingering, psychotic disorder, opiod abuse and rule out polysubstance abuse. "Patient remained cooperative, no observed inappropriate behavior, independent activities of daily living, speech was clear, thoughts were coherent with no reports of auditory or visual hallucinations, denied suicidal or homicidal ideation, no medical problems identified. Discharge procedure continued today to Greyhound bus station, with 3 day supply of medications via taxi. Discharge instructions explained to client especially on medications and follow ups. Client verbalized an understanding of discharge instructions explained, client signed and a copy was provided on discharge, personal belongings returned."

The psychiatrist note dated 02/11/13 at 9:56 AM, documented the patient reported he lost his identification card (ID) and Medicare card. The patient reported "when he was stressed out he hears voices." The patient had "been off his medications for 6 days prior to admission as he had been given prescriptions; however could not fill it as he lost his ID." The patient reported he could function if he had a "safety net." The patient "felt that the voices are getting better and they told him to smash one of the computers." The patient denied any delusions or referential ideas. Insight and judgement were poor. The patient "wants to go to California to find a group home." Per (name) assisted living, the patient was not welcomed back at the home and had to be given an eviction notice. "Discharge the patient with one week supply of medication."

The social work note dated 02/11/13 at 10:12 AM, confirmed "discharge to California via Greyhound, affect mood within normal limits, denied suicidal ideation and homicidal ideation".


The physician discharge summary dated 02/11/13, included the presenting problem of hearing voices. Diagnoses included rule out malingering, rule out psychotic disorder, opioid abuse, and rule out polysubstance abuse. Medications included Thorazine (antipsychotic) 10 mg three times a day, Klonopin (anticonvulsant) 1 mg three times a day and Cymbalta (antidepressant) 30 mg daily. The discharge plan included follow up counseling in California and to a homeless shelter. The patient's condition was written as stable and there was no family involvement.

The medication reconciliation report dated 2/11/13, revealed the follow up care instructions. The patient would be "discharged to the Greyhound bus station by taxi with a three day supply of medication." The facility purchased a one way ticket to Sacramento, California. Paint #18 was to "follow up with mental health, Narcotic Anonymous (NA) meetings in California, follow up with medical doctor in California for any medical concerns." Ensure (liquid feeding supplement) and snacks provided. Medications provided at discharge were Klonopin, Thorazine and Cymbalta.

The clinical record lacked documentation of the after care planning process, and how the facility determined to discharge the patient to Sacramento. There was no address/location of the discharge location documented in the record. There was no evidence in the record as to how the patient would travel from the bus station to a homeless shelter. There was no evidence of the names and addresses of homeless shelters in California. There was no documentation regarding the names, addresses, and phone numbers of mental health services, hours of operation, services available or how to access the services.

On 05/09/13 at 4:15 PM, Patient #18 was interviewed by telephone. Patient #18 indicated he was in the facility for 2-3 days when the Psychiatrist asked him where he wanted to go. The patient indicated the Psychiatrist asked "What State?" Patient #18 indicated he wanted to stay in Nevada. He was told he had to go and would have a bus ticket. The patient was told California had better mental health services. After speaking with the psychiatrist, the patient changed clothes, was provided 4-6 packages of cheese crackers, 6 bottles of 4 ounces each of ensure, walked out to a cab to be taken to the Greyhound bus station and given a ticket to Sacramento, California. The patient indicated he did not want to go to California. The patient did not speak with staff about going to California. The patient confirmed that he was not provided with any names, address or maps to shelters in Sacramento. The patient was not provided with any information regarding mental health services in Sacramento. The patient was not offered services in Nevada, it was made clear the patient had to go out of state. The patient was told to call 911 and to go to the nearest hospital and he could get his medications.

The patient revealed he did not know anyone in Sacramento. The patient indicated the facility did not provide him with any discharge paperwork. The patient was only provided with a piece of paper to call when he arrived in Sacramento. The patient indicated when he left the facility, he was hearing voices, he was unsure what was waiting down the line, he was scared and having panic attacks.

Patient #18 was discharged with a 3 day supply of Cymbalta, Thorazine and Klonopin. The patient indicated he had taken all of his medications during the 15 hour trip to Sacramento. The patient indicated he took the last pills when he arrived in Sacramento. The patient indicated he did not know when to take the medications.

Patient #18 indicated the cheese crackers and ensure did not keep him full during the 15 hour trip to Sacramento. The patient described there were approximately 9 stops and other bus passengers were able to buy food. The patient was hungry and thirsty, but he did not have any water.

The patient was not provided with any money for the trip. The patient did not get back his food stamps, Medicaid/Medicare card or driver's license.

The patient revealed he was hearing voices when he go off the bus. One telling "good", one to do something to get arrested, one to go to the police station and one to jump off the bridge over the river. The patient indicated when he got off the bus, he asked the bus station manager if he could use the phone to call 911. The manager said no, the patient could see the police station and went there.

The patient was taken to a shelter in Sacramento, who provided a bus ticket to the hospital. The patient showed the hospital a letter from the shelter and the patient was evaluated by a psychiatrist and started on medication. The patient stayed at a board and care for mental health patients for 2 weeks.

During an interview on 05/09/13 at 3:15 PM, Social Worker #1, the social worker (SW) who evaluated the patient with Psychiatrist #2 on the day Patient #18 was discharged, indicated the social service notes in the chart were not complete. The SW indicated the patient had expressed a desire to go to either Northern Nevada or Sacramento. The SW indicated the patient was unable to return to a sober living environment and really wanted to leave Las Vegas. The SW indicated the patient revealed Sacramento had good group homes, good services, good shelters, and he liked the mental health services. The facility offered to get a hold of family, but the patient indicated the daughter did not want to speak with him and lived in either North Carolina or South Carolina. The patient was offered to go to Utopia (temporary housing) and refused to go to a shelter. The patient did not qualify for a group home or case manager. The SW indicated Patient #18 was capable of caring for self. The patient's long term goal was to get to Northern California. No one at the facility told the patient that when he got to Sacramento to call 911. The patient said he would go to a shelter until he gets his check. The patient had researched the shelters near the bus station. The patient received an internal discharge form to Greyhound bus station and not the discharge form for patients. The SW indicated the facility would not offer bus tickets until a patient asked about going someplace else or wanted a bus ticket. If patient did not have a picture ID, the facility would give them a picture taken when they first came into the POU with their name on it to show proof if ID.

On 05/10/13, the surveyor attempted to contact Psychiatrist #1. The psychiatrist no longer works for the facility and the number was no longer in service. An internet search for the psychiatrist revealed the same phone number that was no longer in service.

On 05/10/13 and 05/16/13, contacted Psychiatrist #2, the psychiatrist no longer works for the facility and declined to be interviewed.

Patient #24

Patient #24 presented to the POU on a legal hold due to suicidal ideations with no plan. Patient's diagnoses included mood disorder.

The psychiatric evaluation dated 03/21/13, documented the patient was recently discharged from the POU on 03/16/13. The following day, the patient took 50 Roxicets (Opiate analgesic) (5 mg) and crack (street drug) in order to "pop my heart" and then went to the emergency department. On interview, the patient could only give a vague description of his symptoms and his affect did not match content. The patient indicated ongoing suicidal ideation without a plan. No visual or auditory hallucinations, the urine drug screen was positive for cocaine.

The patient was identified as a moderate risk for suicide. Impulse control/judgement/insight were poor. Diagnosis included mood disorder, the "patient's report does not match clinical symptoms and inconsistency of data suggested some degree of symptom fabrication".

The initial treatment plan included continue POU observation for ongoing severe psychiatric symptoms; re-evaluate tomorrow for follow up regarding need for admission or discharge; consider psych testing to rule out malingering and for further diagnostic clarification; patient care notes from transferring medical facility reviewed; continue outpatient psychotropic medications; and observe for medication compliance, efficacy and side effects.

The psychosocial assessment dated 03/21/13 indicated Patient #24 was a rapid readmit, as the patient was discharged from the POU on 03/16/13. The legal hold indicated the patient was suicidal with no plan and reported a depressed mood. The patient reported hearing a voice whispering his name sometimes; he reported that 2 days prior to most recent admission he took an overdose of cocaine and other medications to "blow his heart out" then passed out and was taken to the emergency department. Urine drug screen was positive for cocaine. The "patient is having thoughts of provoking the police and having them shoot him." Patient denied any suicidal or homicidal ideation. Patient was unemployed and resides at a rescue mission. Support system was limited. No emergency contact information was provided. Clinical impression was depression.

The social work after care instructions included referrals for outpatient services including medication management and therapy and a homeless shelter as the living arrangement. The patient would return to the rescue mission and would participate in rescue mission programs. "Outpatient mental health aftercare at outpatient clinic, refer to chemical dependence program, refer to Alcoholic Anonymous (AA), Narcotics Anonymous (NA) and Gamblers Anonymous (GA) support groups."

The social work discharge note dated 03/23/13, documented no collateral contact information or consent was provided by patient. Patient resides at a homeless shelter and would return there after discharge. Patient participated in substance abuse treatment program at the shelter. Patient was stable for discharge to a lower level of care. Denied suicidal or homicidal ideation, denied auditory or visual hallucinations, no psychosis noted or reported. Patient reported good response to medication with improved mood. Patient was future oriented as evidenced by plans to return to substance abuse program at the rescue mission. Patient would be discharged to the rescue mission shelter with discharge medication and 24 hour bus pass for transportation. Outpatient mental heath aftercare would be provided by outpatient clinic with patient to walk in next Wednesday. Refer to the chemical dependence outpatient program, refer to AA/NA/GA support groups, continue to participate in gambling addiction program. A copy of community resource guide with crisis numbers provided.

The patient had previously presented to the POU on 03/14/13 on a legal hold for suicide and was discharged on 03/16/13. The patient's clinical impression was major depressive disorder. On 03/15/13, the social worker noted the patient would be transferred to inpatient for further treatment as patient was still expressing suicidal ideation. On 03/16/13, the social worker noted the patient was feeling well and ready for discharge. No collateral contacts were made as the patient did not consent to any. The patient denied suicidal or homicidal ideation, and denied auditory or visual hallucinations. Patient was discharged to rescue mission and to follow up with outpatient clinic within 14 days of discharge. Patient was provided a list of AA/NA support groups in the community and a referral for Bridge counseling. The patient was given a bus pass to get home at time of discharge.

The clinical record lacked documentation of other aftercare resources assessed as the patient was a rapid readmit to the facility for suicidal ideation and depression. The patient was discharged with the same aftercare plan on 03/23/13 as when he was discharged on 03/16/13.

Patient #31

Patient #31 presented to the POU on a legal hold due to being depressed with suicidal ideation and non-compliant with medication. The diagnoses included bipolar disorder, polysubstance dependence and borderline personality disorder.

The psychiatric evaluation dated 02/11/13, documented the patient presented to the POU with a history of previous diagnosis of bipolar disorder, previous polysubstance use, history of overdose attempt, now increasingly depressed, occasional passive suicidal ideation. The patient presented with linear, depressed thoughts, wanted to get help back to Oklahoma.

The facility initial treatment plan included "patient was seen and evaluated, for discharge to Greyhound to Tulsa, Oklahoma, going to a rehab facility in Oklahoma - "The Haven."

The psychosocial assessment dated 02/11/13, documented the patient presented on a legal hold due to being "depressed with suicidal ideation and non-compliant with medication, attempted suicide by overdose." The patient denied any suicidal or homicidal ideation. The patient stated "I was tired the way I always living...my life just sucks." The patient tested positive for benzodiazepines. The patient was unemployed, received SSI, and the support system was poor. The patient presented as agitated and irritable. The clinical impression was bipolar disorder. The patient demonstrated poor insight, judgment, credibility and impulse control pertaining to her mental health symptom management. The patient denied symptoms of psychosis now. Patient had received previous treatment in Oklahoma. Patient was currently living in a shelter.

The social worker discharge note dated 02/11/13 at 4:45 PM, documented the patient reported feeling well and ready for discharge. No collateral contacts were made as the patient did not consent for any. Patient appeared stable and related appropriate safety plan and future oriented goals. Patient denied suicidal ideation, homicidal ideation, auditory hallucinations and visual hallucinations. "The patient was discharged this date to Heaven Treatment Center in Oklahoma. The patient's primary support is unidentified." The patient requested to be discharged to the Heaven Treatment Center Staff in Tulsa, Oklahoma.

The discharge order dated 02/11/13 at 2:50 PM, documented the patient was "for discharge today; Greyhound to Oklahoma at 8:20 PM tonight; taxi to Greyhound at 6:00 PM; Ensure for 2 day trip."

The discharge summary dated 02/11/13 at 2:50 PM, documented the diagnosis was polysubstance dependence, bipolar disorder and borderline personality disorder. The patient was discharged to Tulsa, Oklahoma rehab.

The medication reconciliation report dated 2/11/13, documented the patient to be discharged "to Greyhound bus station via taxi, no medications, with Ensure."

There was no documentation regarding if the facility had contacted the Heaven/Haven treatment center as to the hours of operation, services provided, and process for accessing services. There was no documentation regarding where the patient would go once the patient had arrived in Tulsa, Oklahoma.

Patient #35

Patient #35 presented to the POU on 12/12/12, on a legal hold for wanting to kill himself. The diagnoses included mood disorder and alcohol abuse.

The psychiatric evaluation dated 12/12/12, indicated the patient had a reported history of bipolar disorder and alcohol abuse. The patient presented for suicidal ideation and depression. The patient had called paramedics from his hotel room expressing suicidal ideation and under the influence of alcohol. On interview, the patient denied suicidal ideation, stated he had time to think about it and stated he wanted to live to "make money." The patient did state he had been thinking about suicide for the past 45 days. Patient was identified as a moderate risk for suicide. The patient had been living in California for the last several years. Judgment, insight, and impulse control were poor. The patient indicated he had a wealthy father who provided him with money.

The psychosocial assessment dated 12/13/12, documented no emergency contact information was provided. Patient indicated his "family was all busy". It took the patient 10 hours to get to his hotel because he was disoriented. Patient lived with his parents and was currently unemployed receiving SSI for 72 months. The after care instructions included discharging the patient by bus pass to Los Angeles, California, recommended follow up with outpatient chemical dependence treatment program and Alcohol Anonymous.

The psychiatric note dated 12/13/12, documented the patient stated "he threatened suicide only because he was drunk." The patient reported being in "Alcohol Anonymous in the past and did not like it." Patient to be discharged today. The patient "did not want referrals for substance abuse treatment."

The discharge summary dated 12/13/12, documented the diagnosis as mood disorder, patient was given a bus ticket to Los Angeles, referred to Alcohol Anonymous and substance abuse treatment program. "The patient did not appear motivated for this."

The medication reconciliation report dated 12/13/12, verified the patient was discharged to (name of address) in Hollywood, California and to follow up with outpatient substance abuse program.

The discharge order dated 12/13/12, documented to" discharge the patient at 1:00 PM. Taxi voucher for taxi to leave here at 1:00 PM to Greyhound bus station to catch the 2:45 PM bus to Los Angeles. Give enough Ensure for 6 hour trip."

On 5/6/13, a Licensed Nurse indicated there was no documentation the patient's family was contacted regarding POU admission or the discharge plans to California.

The clinical record lacked documentation an attempt was made to contact the patient's parents regarding discharge. There was no documentation on the discharge instructions of the addresses of the patient's family or homeless shelter. There was no documentation regarding referrals to Alcoholics Anonymous or substance abuse treatment programs. There was no documentation as to how the patient was going to get to the destination after arriving at the bus station in Los Angeles.

Patient #38

Patient #38 presented to the POU on 01/06/13 on a legal hold for psychosis and delusions. The diagnoses included psychotic disorder and rule out schizophrenia.

The psychiatric evaluation dated 01/07/13, documented the patient was brought in on a legal hold due to an "inability to care for self." The "patient was recently discharged from POU on 01/03/13." The patient stated she was on a bus to California, when the bus driver kicked her off the bus for talking. The patient indicated she was just walking around when the paramedics picked her up. The patient did not know why she was in the hospital. Patient denied auditory and visual hallucinations. Denied feeling sad or depressed. Denied suicidal or homicidal ideation. The patient did speak of her "enemies and said that multiple people were trying to separate her from her family." The patient was focused on someone owing her money. Diagnosis included psychotic disorder, rule out schizophrenia.

The patient was re-evaluated on 01/08/13. The patient denied suicidal or homicidal ideations, denied any current hallucinations or delusions. The patient stated her brother-in-law would try to wire her money so she could buy another bus ticket, but wanted to know if the facility could provide her with some identification that would allow her to pick up the money. Assessment was schizophrenia, rule out schizophrenia paranoid versus residual type.

The patient was re-evaluated on 01/09/13. No behavioral disturbances or medication side effects. "Collateral information was obtained from her brother-in-law yesterday". The patient may require a picture identification (ID) to pick up her money, which she did not have. Denied suicidal or homicidal ideation. The patient did not appear to be at imminent risk of self harm or harm to others, would plan for discharge today by bus back to Los Angeles.

The discharge summary dated 01/09/13, included the diagnosis of schizophrenia, Risperdal (antipsychotic) 2 mg twice a day for psychosis, follow up counseling in Los Angeles, family involved, and condition stable.

The medication reconciliation report dated 01/09/13, documented the address on discharge was Los Angeles, California. The patient was advised of location of facility for medication clinics and outpatient follow services in California. Written instructions included "follow up in California, continue own supply of Risperdal, refer to own medical doctor for any medical problems."

The psychosocial assessment dated 01/09/13, documented the patient presented with many birth dates and had been admitted under various last names. Emergency contact was listed as the patient's brother-in-law in Claremont, California, a phone number was provided. The patient presented as disorganized, responding to internal stimuli, affect mood elevated, irritable labile of mood.

The patient had a prior admit on a legal hold as she was found wandering by paramedics. Patient presented with loose associations, delusions, paranoid and disorganized with auditory hallucinations present. Patient stated her brother-in-law was her SSI payee and was homeless in California. The patient had been in Las Vegas for 3 weeks, would return to a shelter in California when she was discharge. "Patient reported family in Compton, California was supportive." Patient was not oriented to reality, not compliant with medications, did not have positive coping skills, did not have a strong social support. The patient was being discharged out of state to Claremont, California to a homeless shelter. Discharge plan was to "provide the patient with a Greyhound bus ticket to return to Los Angeles County with a referral to Compton Mental Health Clinic."

The discharge note dated 01/09/13, documented the patient was to be discharged back to Los Angeles, California. Patient was a California resident and received California based benefits. The patient was an unreliable historian. Patient was discharged via taxi to Greyhound bus station to return to Los Angeles. The patient was to follow up with outpatient Mental Health Services with Compton Mental Health Center, patient was provided with contact information. Patient was encouraged to follow up with family and access to funds upon return to California.

The facility lacked documentation the patient was discharged to a safe environment. There was no documentation follow up appointments were made or attempted to be made in California. There was no documentation regarding the name, address, telephone number, contact person for the mental health facility/services in California. There was no documentation of a discharge address for the patient. In addition there was no documentation the patient was provided with nourishment or med