HospitalInspections.org

Based on review of 4 open medical records and 6 closed medical records it was determined the hospital failed to provide a safe discharge for patient #1.

Patient#1 was a 25+ year old who presented to the hospital's emergency department with an emergency petition for verbal threats to do harm and pulling a knife on someone. Two days later, patient #1 was admitted to the hospital's inpatient behavioral health unit as an involuntary admission. Patient #1 had a long history of a primary mental illness with psychotic features and had not been taking his/her medication. Patient#1 was currently homeless.

On Day 6 after initial presentation (third day of inpatient admission), patient #1 stated they wanted to go home. Patient #1 was told he/she had a hearing date (where an administrative law judge would determine if patient #1 would be retained for treatment) set up a week later. At that time patient #1 became angry, combative and threatening towards staff necessitating seclusion for 1 hour and 15 min.

The following day, a registered nurse's (RN) progress note at 13:59 stated they assumed care of patient at 11:00. Per the RN, patient #1 was "verbally threatening towards peers and staff." Patient #1's team attempted to initiate a behavioral plan but patient#1 refused and threatened to go on a hunger strike.

Per the same RN note mentioned above, the patient was discharged that same day at 13:30. Per the discharge summary, the provider stated patient "continued to be labile and disruptive and threatening to staff." The discharge summary failed to mention if patient #1 was stable for discharge or that they denied homicidal ideations.

Patient #1 was still demonstrating behaviors for which they were admitted. Further, patient #1, who agreed to take an antipsychotic during their admission, was given no prescriptions at discharge to continue the antipsychotic medication. Patient#1 was discharged with information for self-initiated appointments to a shelter and a homeless organization. A bus token was given for patient to take public transport.

In summary, the documentation failed to demonstrate that this was a safe and appropriate discharge of a patient who was admitted for threats to harm others as there was no documented reassessment of risk to self or others.