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8550 HUEBNER ROAD

SAN ANTONIO, TX 78240

DISCHARGE PLANNING - PT RE-EVALUATION

Tag No.: A0802

Based on a review of facility policies and procedures, medical record and interviews, the facility failed to ensure that for one of one patients (Patient #1), a discharge plan was updated as needed to reflect changes after re-evaluation of the patient's condition that identified changes that required modification.

Findings included:

A review of the facility policy entitled Discharge Planning, effective 07/15/2014 and last revised 04/28/2021, revealed but was not limited to the following:

All patients leaving the hospital shall have a formal discharge plan that is initiated at the time of admission, based on input from the patient, family/significant other and the treatment team.

A. At the time of admission: 1. Discharge planning shall be a focus of the initial data collection and psychosocial assessment process. Information will be obtained from the patient and/or family member, physician, medical record and other information available. Information may include: a. the patient's home environment b. the patient's ability to function independently before current hospitalization c. what type of situation the patient will be discharged to d. patient's optimal level of functioning outside of the hospital e. patient's current support system and f. follow-up care needed i.e, therapist, specific program.

Potential for out-of-home placement will be assessed and appropriate level of care options for long term care will be explored with the patient and family.

The Social Worker shall attempt to find adequate and appropriate resources for patients prior to discharge.

Prior to discharge, the nurse or social worker shall ensure that receiving agenices or family/caretakers are aware of the upcoming discharge.

B. At the time of discharge
2. The case manager will contact the family/guardian to notify them of the discharge and determine the approximate time the patient will be ready for departure.
4. Either the physician, RN, and/or social worker will review the discharge plan with the patient/family and provided instructions. The discharge plan will be completed and signed by the patient/guardian and staff, and a copy givent ot he patient/guardian.

Review of Patient #1's Letters of Guardianship revealed that his mother was orignally appointed guardian of the person on 01/06/2015, Patient #1 was considered an incapacitated person and the guardianship expires 05/05/2022.

Review of Patient #1's Intake Assessment, dated 08/04/2021 at 2157, revealed he was brought to the hospital by emergency detention because he cut his left arm with knife because he "was mad". Patient did not want to return to his group home. Patient also said he wanted to hurt his staff "with the knife". Patient stated he wanted to kill himself as well. Patient is seeing "scary" shadows, has "fights with staff and the other clients" and has insomina with nightmares.

Review of Patient #1's Psychiatric Evaluation, not dated, revealed the following: Primary Diagnosis: Bipolar D/O deferred and Secondary Diagnosis: IDD (Intellectual Developmental Disabilities)/mild/autism

Review of Licensed Professional Counselor Associate's (LPC-A) Progress Note, dated 08/13/2021 at 1032 revealed but was not limited to the following: Patient stated when he was running away from the group home, staff at group home pushed him inside the house. Patient tried to escape again and staff pushed him again inside the house. Patient stated he had no injuries but refused to go back to the group home. She made an APS (Adult Protective Services) report.

Review of Patient #1's Case Manager Progress Notes, dated 08/13/2021 but not timed and signed by Case Manager #1 revealed but was not limited to the following: "I confirmed the client by name and date of birth. I introduced myself as their assigned case manager and explained I will be assisting them in the connection process from (hospital). We need to work together to ensure I know how they will be transporting from (hospital), where they will be going to and where they can follow up for outpatient services. Client is discharging today. Client has confirmed transportation with group home. Talked to mom and she is working to obtain new group home." There was also documentation regarding her contacts regarding a different group home placement but it appeared that placement could not occur for at least 2 weeks.

Review of Patient #1's Discharge/Aftercare Plan, dated and signed by Case Manager #1 on 08/13/2021, revealed that he was to be discharged back to his previous group home on 08/13/2021. Transportation was to be provided by the group home driver.

Interview with Case Manager #1 on 11/16/2021 at 3:30 PM revealed but was not limited to the following: She confirmed that Patient #1's mother was his guardian but she did not remember details of his discharge. She stated that if her paperwork showed that Patient #1 was transported to the group home by the group home driver, that is what happened. She denied calling an Uber for Patient #1 to go to his previous group home. She called Patient #1's mother in the presence of this surveyor. Patient #1's mother informed her that he was transported from the hospital to his previous group home by an Uber driver because he had refused to get into the group home driver's van when it arrived. She stated that at some point in the drive from the hospital to the previous group home, Patient #1 asked the Uber driver if he could call his mother. The Uber driver allowed him to call his mother and he told his mother he did not want to return to the group home. Patient #1's mother indicated that she had been told prior to his actual discharge that the facility was going to ask the physician to hold off on his discharge for the weekend due to Patient #1 not wanting to return to his previous group home. Patient #1's mother indicated that no one had called her to inform her that he was going to be sent to his previous group home and that he was going to be transported by Uber to that group home.

Interview on 11/18/2021 at 1:16 PM with Patient #1's mother and legal guardian revealed but was not limited to the following: She confirmed the above interview with Case Manager #1. She further added that Case Manager #1 nor anyone from the facility contacted her to inform her that Patient #1 (her son) had actually physically left the facility by being placed in an Uber vehicle to be returned to his prior group home where she alleged he had been abused. She had understood that he would remain over the weekend at the facility pending finding him a different group home. She stated that she learned that he was being returned to the previous group home when Patient #1 called her from the Uber vehicle. She further stated that she learned after he got out of the Uber that he did not immediately go into the group home. She stated that he "roamed" the neighborhood until he was brought back to the group home by the police at around 8:30PM that night.

Interview on 11/18/2021 at 2:16 PM with Uber Driver #1 confirmed that he had picked up Patient #1 at the faciltiy on the afternoon of 08/13/2021 sometime after 4:00PM. He stated that an unknown female staff member from the facility had stood by Patient #1 when he got into the Uber vehicle. He further stated that the unknown staff member told him that "she would be following behind him in another car". He stated that at some point in the drive to the group home, Patient #1 asked to call him mother. Uber Driver #1 stated that Patient #1 seemed very upset so he allowed him to use his personal cell phone to call his mother. In addition, Uber Driver #1 indicated that Patient #1 got out of the Uber vehicle near his group home but did not go into his group home at the time he dropped him off. He stated at that point, he was no longer responsible for Patient #1.

Record reveiw of Uber bill, dated August 13, 2021 confirmed that the facility paid a bill for an Uber on this date. The address the Uber drove to was the address of Patient #1's group home.