HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 patients' (Pt. #1) clinical records reviewed for discharge planning, the Hospital failed to re-evaluate the patient's needs, to ensure modification in discharge placement was safe.

Findings include:

1. On 01/17/23 at approximately 1:00 PM, the clinical record of Pt. #1 was reviewed. Pt #1 was admitted from 07/12/22 through 07/15/22 to the hospital with diagnoses of "Schizophrenia (mental disorder), Homicidal Ideations and adverse effects of amphetamines." The clinical record included:

- A Progress Note by psychiatrist (MD #1) on 7/14 stated, "PRESENT ILLNESS: the patient reports (Pt #1) is doing all right ... (Pt #1) denies being suicidal or homicidal ... MENTAL STATUS EXAMINATION: ... (Pt #1's) mood is all right, but affect is flat. (Pt #1) did not make eye contact ...."

- A nursing note completed by Behavioral Health Therapist (E#3) on 7/15 at 11:08 AM stated, "The patient's biological father called this morning and stated that this patient threatened to kill him and his new wife and also have sex with her. He reports that he is afraid of what (Pt #1) might do to him and his wife. This writer informed that pt will be discharged today. This writer informed him that I will call (Local) police department for duty to warn. This writer advised the father to file a complaint with the police department so they will be aware. (father) requested counseling service for himself, this writer referred him ...."

- The Discharge Summary completed by MD #1 stated, "REASON FOR ADMISSION AND HOSPITAL COURSE: The patient came to the hospital because of homicidal ideation towards someone who (Pt #1) believed that beat somebody else. The patient was admitted to the closed psych unit. (Pt #1) was provided education, support and therapy. (Pt #1's) Depakote level was also done. At the time of discharge the patient is doing well. (Pt #1's) mood is pleasant. Affect is appropriate to mood. (Pt #1) denies being suicidal or homicidal. (Pt #1) denies any side effects to the medication. (Pt #1) said that (Pt #1) is ready for the discharge. We did call (Pt #1's) mother also. She is going to pick (Pt #1) up and the patient does have a psychiatrist .... CONDITION AT THE TIME OF DISCHARGE: Improved. The patient is not psychotic or manic. (Pt #1) is not suicidal or homicidal. DISPOSITION: Home. (Pt #1) lives between (Pt #1's) mother and father. Follow up with (Pt #1's) psychiatrist ...

The record lacked documentation that MD #1 was notified of the homicidal threats to the father and stepmother. The record lacked documentation of re-assessment of discharge plan.


2. On 01/18/23 at approximately 10:00 AM, the Hospital's policy titled, "Duty to Warn (revised 01/2019)" was reviewed. The policy stated, " ... Procedure: 1. If a patient, at any time during hospitalization, verbalized a specific plan to harm an identified victim, the therapist assigned to that patient, the Nursing Manager, the Clinical Program Manager, and the BHS (Behavioral Health Services)Administrator must be notified. 2. The patient's attending psychiatrist will be notified and informed of the patient's threat(s) of violence ... 4. If the harm is reasonably foreseeable as established in the above criteria, (Hospital) staff will make every effort to fulfill the duty to warn by: ... 3, Making every reasonable effort to obtain hospitalization of the patient ..."

3. On 01/18/23 at approximately 1:30 PM, an interview was conducted with the Administrator of Behavioral Health (E #2). E #2 reviewed Pt #1's record. When asked about discharging of a behavioral health patient who had expressed homicidal threats, E #1 stated, "Once a threat is heard, the expectation is that the team should be aware of it. The physician should be notified. Then a duty to warn should be done. If we have a patient that expressed a target threat, we will notify the local police and the person that the threat is against (if we have their contact information). The provider would then make the decision to continue with the discharge, sign out against medical advice or complete a 5-day notice. We would have 5 business days to petition the court to prolong the stay. We did not do a 5-day notice on (Pt #1). There is no documentation in the record that the physician was notified of the homicidal threat. The physician should have been notified and then would decide if discharge was appropriate."

4. On 01/18/23 at approximately 2:00 PM, an interview was conducted with E #3. E #3 stated, "(psychiatrist-MD #1) had told me upon admission that we would need to do a duty to warn call at discharge of (Pt #1). When the dad called (the day of discharge) and told me of his concerns and the threats to him and his wife, I told him (the dad) that the patient was being discharged that day. After the patient was discharged, I had called the (local) police department regarding the homicidal threats." When asked if E #3 could recall notifying the physician of the father's concern regarding Pt #1 threatening to kill him and his wife, E #3 stated, "I do not recall notifying the physician."