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Based on record review and interview, the hospital failed to ensure the appropriate arrangements for post-hospital care were made before discharge as evidenced by failing to ensure the receiving entity was aware of the patient's discharge and transfer for 1 (#1) of 5 patients out of a total sample of 5 (#1, #2, #3, #4, #5).

Review of Hospital Policy/Procedure 10584428 titled, "Discharge Planning" revealed in part: Policy - It is the responsibility of the assigned social worker/therapist to coordinate the discharge plan, including scheduling of necessary aftercare appointments in collaboration with the family/support. Each patient is presented with an individualized aftercare plan that meets their specific needs. Purpose - To ensure continuity of care through effective discharge planning and to ensure timely, efficient, appropriate discharge of patients.

In an interview on 03/08/2022 at 11:55 a.m. S3Transport stated they took Patient #1 to Marshall, Texas to State Office Building on morning of 03/03/2022. She took the patient and his paper work to the inside of the building. The receptionist got two office staff and they tried to find patient's case worker. S3Transport talked to the two ladies and gave them the paperwork from the hospital and patient's mother was listed as emergency contact. While the office staff attempted to find out who case worker was S3Transport went back to sit with patient. About ten minutes later, they came out of the office and stated she could not find case worker and believed patient was a Louisiana resident and patient said he lived in New Orleans. Office staff stated they were still unsure who case worker was and asked S3Transport is patient was supposed to be there and S3Transport stated that was the address given by the hospital for the patient's transport. Lady returned to office and S3Transport left patient inside the building and went to speak with S4Transport who was parked and waiting in the van. S3Transport told S4Transport the ladies were trying to find the patient's case worker. S3Transport told S4Transport we can't just leave him here until we find out what's going on. Texas staff member came out to the van and said the contacts listed could not be reached. Staff stated again if Patient #1 is from Louisiana and S3Transport told her the patient has a Texas probation officer and the Texas staff said "oh, they are trying to build a case". S3Transport told Texas staff we are just the drivers and we have to leave and go back. Texas staff said nothing at this time and returned to the office building with the patient's paper work. The patient had remained inside the building. S3Transport stated she and S4Transport left at this time because the staff did not ask them to stay any longer and after she commented regarding "building a case" she thought everything was okay. Texas staff did not inform S3Transport they could not leave the patient there and she and S4Transport returned to the hospital. She stated they were there over an hour.

In an interview on 03/08/2022 at 9:40 a.m., S2Counselor stated he had not spoken with Texas CPS prior to Patient #1's discharge and acknowledged the transfer to the Texas CPS was not in the patient's discharge plan.

In an interview on 03/08/2022 at 9:55 a.m., S1Director of Clinical Services stated the hospital had not contacted Texas CPS prior to Patient #1's discharge and acknowledged the transfer to the Texas CPS was not in the patient's discharge plan.