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Based on record reviews and interviews, the hospital failed to inform the patient's representative, in advance, of discharging a patient for one (Patient #1) of 10 patient records reviewed.

The findings included:

Patient #1

05/31/17 - Review of the record, of Patient #1, revealed the patient presented to the emergency room complaining of left wrist pain and left shoulder pain. She reported having an abscess on her right calf. The patient was triaged by a nurse and treated while in the emergency room.

06/01/17 - Review of the record, revealed she was admitted to the hospital with right leg cellulitis.

06/01/17 - Review of the case management report, revealed the discharge plan was for the patient to be discharged home.

During an interview with Daytime Charge Nurse on the medical/surgical floor, on 06/20/17 at approximately 3:00 PM, she stated she remembers the case. She stated that she met the patient's guardian while she was visiting the patient. She stated the guardian gave her business card to her and said the patient had been here before in the pavilion. She stated she told her that she would pull the guardianship document and put it in the patient's chart. She stated she received a copy of the Plenary Guardianship from medical records. She placed the document into the paper chart and notified the physician.

During an interview with Staff A, on 06/21/17 at approximately 10:15 AM, she stated that she discharged the patient by herself with a bus pass to go home. She stated that she did not look at the hard copy chart to see if there were legal documents.

Review of the Guardianship Document confirmed plenary guardianship of the patient.

During an interview with the Director of Patient Safety and Risk Management, on 06/20/17 at 2:30 PM, she confirmed the staff had failed to notify the responsible party, Plenary Guardian of the patient's discharge

During an interview with the Chief Nursing Officer, on 06/20/17 at 3:45 PM, she confirmed the guardian should have been notified of the patient's discharge.

Based on record reviews and interviews, the hospital failed to develop or supervise the development of a discharge plan when there was an indication of a need for a discharge plan for one (Patient #1) of 10 patient records reviewed.

The findings included:

Patient #1

05/31/17 - Review of the record, of Patient #1, revealed the patient presented to the emergency room complaining of left wrist pain and left shoulder pain. She reported having an abscess on her right calf. The patient was triaged by a nurse and treated while in the emergency room.

06/01/17 - Review of the record, revealed she was admitted to the hospital with right leg cellulitis.

06/01/17 - Review of the case management report, revealed the discharge plan was for the patient to be discharged home.

During an interview with the Case Manager, on 06/20/17 at approximately 2:09 PM, she stated regarding Patient #1, she checked to see if the patient met criteria for admission. She stated that she did not talk to the patient because the patient was refusing to speak to staff. She explained the physician usually orders discharge planning when the patient has a guardian and that is her trigger to work with the patient regarding the discharge. She stated that unless she has received a discharge referral, she would not have seen or known about the patient's Guardianship. She stated all legal documents in hard copy are placed in the patient's hard copy chart that is kept at the nursing station. She stated the case managers rarely look at the hard copy charts. The documents are scanned into the patient's electronic medical record when the patient is discharged.

During an interview with Daytime Charge Nurse on the medical/surgical floor, on 06/20/17 at approximately 3:00 PM, she stated she remembers the case. She stated that she met the patient's guardian while she was visiting the patient. She stated the guardian gave her business card to her and said the patient had been here before in the pavilion. She stated she told her that she would pull the guardianship document and put it in the patient's chart. She stated she received a copy of the Plenary Guardianship from medical records. She placed the document into the paper chart and notified the physician.


During an interview with Staff A, on 06/21/17 at approximately 10:15 AM, she stated that she discharged the patient by herself with a bus pass to go home. She stated that she did not look at the patient's face-sheet for the address. She acknowledged, that had she looked at the face-sheet, she would have noticed she was giving a bus pass to a patient whose address is Hilton Head, South Carolina. She stated that she did not look at the hard copy chart to see if there were legal documents, and she did not remember attending a 2- day training session regarding appropriately discharging patients.

During an interview with the Director of Patient Safety and Risk Management, on 06/20/17 at 2:30 PM, she confirmed the staff had failed to notify the responsible party, Plenary Guardian, failed to appropriately discharge the patient by discharging her with a bus pass and not having the Plenary Guardian arrange for patient's transportation and destination upon discharge.

During an interview with the Chief Nursing Officer, on 06/20/17 at 3:45 PM, she confirmed the patient was not appropriately discharged, the guardianship should have been included on the face sheet, the guardian should have been notified of the patient's discharge, and the discharge plan should have been developed to include the guardianship.