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Based on interview, documentation reviewed in 1 of 1 medical record reviewed of a mental health patient (Patient 5) who presented to the ED with suicidal and behavioral symptoms, and review of ED policies and procedures, it was determined the hospital failed to ensure it enforced its ED discharge policies and procedures.
* The plan to discharge Patient 5 to an AFH was not carried out, and instead the patient was dropped off at an NWSDS office.

Findings included:

1. The following policies and procedures were provided in response to a request for ED discharge policies and procedures:

a. The policy and procedure titled "Discharge Planning for Patients Seen in the ED for Mental Health Treatment" dated effective "03/2019" was reviewed. It reflected:

* The "Policy Content" section reflected "It is the policy of Salem Health to engage in discharge planning for patients discharged from the Salem Health Emergency Department ... for mental health treatment who are in a behavioral health crisis. Discharge planning begins when the patient is admitted to the facility to support timely discharge, effective post-discharge care and documented (sic) in the medical record."

* "Conduct a needs assessment to understand the long-term needs of the patient. At minimum, the assessment should help the provider determine: The patient's need for community based services: (sic) The patient's capacity for self-care. To the extent practicable, whether the patient can be properly cared for in the place where the patient resided at time of admission."

b. The policy and procedure titled "Acute Care Discharge Planning" dated effective "June 2019" was reviewed. It reflected:

* The "Functions of Care Management in Discharge Planning" section reflected "Development of and participation in systems that ensure timely and efficient identification of patients who require discharge planning services ... Assessment of continuity of care needs. Collaboration with the multidisciplinary team to assess, plan, implement and evaluate patient discharge planning. Plan development ... Plan coordination and implementation ... Care Managers are responsible for providing patient and/or patient representative with resource education to assist with making discharge-planning decisions designed to maximize quality of life and continuity of care."

* The "Plan Development" section reflected "Changes in a patient's condition or available supports may warrant adjustments to the discharge plan and would be noted through medical records review or notification from a member of the care team."

* The "Plan Coordination & Implementation" section reflected "Coordination with multidisciplinary team regarding medical/psychosocial needs ... Coordinate completion of appropriate discharge orders and referrals."

2. The policy and procedure titled "Patient Rights and Responsibilities" dated effective "01/2019" was reviewed. It reflected:

* The "Be involved in care decisions:" section reflected "To involve the patient in making decisions about their care."

* The "Contunuity of care:" section reflected "To participate in decisions affecting the patient's care and planning for when the patient leaves the hospital."

3. The ED record of Patient 5 was reviewed and reflected that the patient presented to the ED by ambulance on 02/28/2019 at 1005 for SI and behavioral issues.

On 02/28/2019 at 1017 the ED MD completed a Suicide and Behavioral Health assessment and charted "decided low risk due to living in AFH."

On 02/28/2019 at 2111 an "ED Note" by a CM reflected "I contacted AFH provider by phone to confirm [he/she] was coming to assess Pt as [he/she] had agreed to do. [He/she] stated to me on the phone that [he/she] would come asses Pt but not likely to accept [him/her] back to the AFH."

The CM note reflected that the ED RN made contact with the AFH manager when he/she came into the ED. The AFH Manager left a note on the chart that the patient's NWSDS Manager would need to make a new placement at a level 3 home.

The CM note also reflected "Met with patient along with RN and Korean language interpreter by audio. Pt now saying [he/she] does not want to return to [his/her] AFH but wanting to stay at SH. Pt informed by RN that [he/she] would stay the night with a plan for new placement."

On 03/01/2019 at 1145 an ED Note written by a CM reflected "Patient medically clear and ready for discharge. Geropsych (sic) evaluation complete - no further psychiatric intervention identified. AFH did not issue legal eviction notice, therefore patient has right of return to AFH. WC transport arranged ... Elite Medical Transport is present and ready to transport."

On 03/01/2019 at 1202 an ED Note written by a CM reflected "Consulted with ED RN and MD, Pt is ready for d/c from a medical and psychiatric standpoint. TC to CM Leadership as AFH continues to refuse to take him back, yet, have not issued an eviction notice to Pt. TC to NWSDS, [he/she] is working on placement. Decision made by CM Leadership to have Pt returned to AFH, and if they refuse to take PT, to have Pt transferred to NWSDS office for placement."

On 03/01/2019 at 1159 an ED note written by the ED RN reflected "Attempted to call report at pt's AFC, was told by supervisor that [patient] was unable to return to facility. CM notified, received update that pt is returning to facility ... Elite Transport arrived. Pt changed into personal clothing, stood and pivoted to get into WC."

During interview with CM on 09/18/2019 during the medical record review, it was confirmed that Patient 5 was transported to his/her AFH where the patient was refused entry and transport then dropped the patient off at NWSDS office as instructed by Salem Hospital.

The medical record reflected:
* ED staff discharged the patient to an AFH despite knowing the AFH would not accept the patient.
* When the patient arrived at the AFH, he/she was refused entry.
* Transport then took the patient to the NWSDS office at the direction of hospital staff, and left him/her there in the lobby.

In addition, the medical record lacked documentation that the hospital's ED policies and procedures were carried out. For example:
* There was no documentation that available supports were evaluated and adjustments made when the AFH indicated they would not accept the patient.
* The record lacked documentation that the patient was involved in discharge planning as there was no follow up to "patient informed [he/she] would stay the night with a plan for new placement."
* The record lacked documentation the patient's family member was updated on the AFH refusal to take the patient and that the patient was taken to the NSWSD office and dropped off.

During interview with CM, EDM and EDD on 09/18/2019 at 1530, these findings were reviewed and confirmed.