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Based on record review and interview, the hospital failed to implement an effective discharge planning process that resulted in modification of the discharge plan for one of 12 patients (Patient #7).
Patient #7, who had a history of a suicide attempt, had been admitted suffering from increasing psychosis of believing to have rats in his stomach and worms in his head on 03/30/22. Despite continued patient reports of rats in his stomach, delusions and hallucinations, and feelings of hopelessness and shame shortly before discharge, the patient was set to leave the hospital on 04/11/22. The patient did not arrive at his place of residence that day and was still considered missing more than two weeks later at the time of survey.


Findings include:

Record review of Patient #7's Demographic Profile reflected the geriatric patient was admitted on 03/30/22 at 2035 as an involuntary patient.

Patient #7 's Physician Psychiatric Evaluation dated 03/31/22 at 0920 noted the patient believed he had "a rat in his stomach, and it needs to be exterminated ...has germs in his eyes and ...a hole in his head due to worms being insight his head ...feeling bugs in his eyes and neck ...tried to kill himself once when he was in a nursing home ...admits that he is a little bit depressed ..." The physician noted that the patient's increasing psychosis and recklessly dangerous behavior to himself required inpatient treatment.

Patient #7's Nursing Progress Notes dated 04/10/22 at 1000, approximately 26 hours prior to discharge, reflected the patient's report of rats living in his stomach. Nursing reported that Patient #7 suffered from delusional thinking and auditory and visual hallucinations on 04/10/22 at 2300, 13.5 hours prior to discharge.

Patient #7's Discharge Risk Assessment dated 04/11/22 at 1222 (33 minutes prior to discharge) noted the patient had experienced feelings of hopelessness, shame, hallucinations, and high anxiety during the preceding 24 hours.

Nursing Progress Notes dated 04/11/22 at 1255 reflected the patient was discharged at that time.


During an interview on 05/06/22 at approximately 1400 Hospital Personnel D stated that Patient #7 was discharged on 04/11/22. The hospital had contracted an Uber Health Driver to transport the patient to his group home. The patient did not arrive there. Instead, the Uber Health Driver dropped the patient off at a McDonald's restaurant "halfway to the group home." A missing person report was filed.

A phone interview with Non-Hospital Personnel N on 05/25/23 at 1630 revealed that Patient #7's location was still unknown.

During an interview on 05/26/22 at 1250 Hospital Personnel F stated the hospital sent patients with Uber Health when they needed to travel back home over 50 miles away and no personal ride was available. "I didn't think anything like this would happen ...that he [Patient #7] didn't make it."

Hospital Personnel J acknowledged the findings during an interview on 05/26/22 at 1300.