HospitalInspections.org

Based upon reviews of 1 of 7 medical records (patient #3), hospital policies and procedures, information supplied by the State of Louisiana Department of Health and Hospitals-Health Standards Section, and staff interviews, the hospital failed to ensure an ongoing discharge planning reassessment was conducted on patient #3 (based upon information the hospital had received) prior to the patient (#3) being discharged back to her home. Findings:

Review of patient #3's medical record revealed S5 Director of Community Education/Intake had documented the following information on a form titled "Record of Admission" (located on page 1): 14 year old female admitted by S3 Psychiatrist on 07/24/12 at 18:50 (6:50pm) with the admitting diagnosis of Psychosis. This was a voluntary admission for patient #3 and her mother had full legal custody. Further review revealed patient #3 had been referred by a mental health clinic located in Amite County, Mississippi.

On 07/25/12 at 9:43am, S4 Social Worker completed the Psychosocial Assessment on patient #3 and initiated discharge planning. Review of page 6 of 7, from the form titled "Child/Adolescent Psychosocial Assessment", revealed: "Discharge Plan Potential Discharge Date: 10-14 days (8-3-12)" and an "X" was placed in the box next to "Transportation" along with the written word "needed". Interview, on 08/22/12 at 10:20am, with S4 Social Worker confirmed this was her documentation.

Further review of the medical record (patient #3) revealed there were copies of electronic (e) mails that had been sent to the hospital from S12.

Review of an e-mail, dated Thursday August 02, 2012 at 11:22AM, sent from S12 revealed the following: "TO ALL STAFF @ (NAME OF HOSPITAL), Please, please do not release (name of patient #3) to her mother (name of patient #3's mother)...Any other family member can come and pick her up..." S12 made allegations of physical and sexual abuse against patient #3's mother and a male (it was not known for fact if this male was a family member or significant other of patient #3's mother).

Interview, on 08/23/12 at 10:00am, with S2 Director of Nursing (DON), S4 Social Worker, and S9 Social Worker (Director of Social Services) confirmed that once S3 Psychiatrist had written the discharge order patient #3 was discharged back to her mother's custody. S4 Social Worker stated she had conducted an individual session, on 08/02/2012 at 2:00pm, with patient #3.

Review of "Interdisciplinary Progress Notes", dated 08/02/12 at 2:00pm, revealed S4 Social Worker documented the following: "SW (social worker) completed individual session with pt (patient). Pt discussed feeling upset because other pts called her a 'liar'. SW provided supportive counseling. SW asked pt if pt felt safe going home. Pt's response was 'yeah I feel safe going home' and pt gave no nonverbal signs of distress or concern that SW could detect. SW again inquired about any form of abuse which pt again denied..."

Subsequent interviews, on 08/23/12 at 10:40am, with S4 Social Worker and S9 Social Worker confirmed that patient #3 was discharged home to her mother's custody after the hospital had received information (e-mail sent to hospital on 08/02/12) on allegations of physical and sexual abuse. It was also confirmed the allegations were not forwarded (until 08/03/12 at 10:45am) to the Mississippi Department of Protective Services (DPS) which was after patient #3 had been discharged (08/03/12 at 9:45am).