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Based on staff interviews and record review, the hospital failed to ensure a patient's representative (Court appointed Guardian) was informed and included in the decision involving an unplanned discharge for 1 applicable patient. (Patient #3) Findings include:

On 5/28/16 there was a failure of the Psychiatrist, Social Worker and RN to inform Patient #3's Guardian and also the patient's case manager for PathwaysVermont regarding the intentions and subsequent discharge of Patient #3. The lack of notification prior to discharge prevented the Guardian in collaborating with hospital staff and the patient in making an informed decision regarding a safe discharge and also ensuring housing and community support availability.

Patient #3, was admitted voluntarily to the hospital on 5/25/16 for increased mood instability and thoughts of suicide. Prior to admission, and according to community resources to include Patient #3's Public Guardian, the patient had been decompensating over the previous several weeks and sought hospitalization after receiving an emergency crisis screening. Per initial MD Assessment completed on 5/26/16, Patient #3 had a past history of attempted suicide by hanging and intentional heroin overdose. Patient #3 was assessed to have auditory hallucinations was disorganized and paranoid. For the first 48 hours after admission Patient #3 was assigned to ALSA (a low stimulation area) due to disruptive and agitated behaviors which were upsetting the milieu of the unit. On 5/27/16 a Multidisciplinary Treatment Plan was developed which stated under Patient Objectives: "Patient will consider aftercare possibilities as recommended to ensure adequate support after discharge". Multidisciplinary Interventions state: "SW (Social Worker) will meet with patient 1-2 times per week to discuss aftercare needs, will collaborate with current outpatient providers and schedule aftercare appointments as needed. SW will collaborate with Pathways case manager and guardian and provide additional recommendations as needed." Time frames for the Treatment Plan was 7 days. Per interview on the morning of 6/11/16, Social Worker #1, (identified as the supervisor for other social service staff on Tyler-2) helped develop Patient #3's Treatment Plan, confirmed after Patient #3's admission s/he had a conversation with the Public Guardian for Patient #3 and confirmed no formal plans for discharge had been created, using the tentative 7 day admission to prepare for discharge. In addition, Patient #3 was hospitalized over Memorial Day weekend, resulting in further plans for discharge to be reviewed by Social Worker #1 in collaboration with the patient's Guardian upon return on 5/31/16.

However, on 5/28/16 Patient #3 approached nursing staff and requested to be discharged. Per interview on 7/12/16 at 9:05 AM, Nurse #1 confirmed Patient #3 came to her/him at lunch time stating "...he could handle things on the outside..." and "..wanted to go home to clean his room". As per hospital policy, RN #1 contacted the Doctor On Call informing the physician Patient #3 was requesting an unplanned discharge. Hospital policy: Discharges: Unplanned/Against Medical Advice (AMA) last approved 06/2014 states: " The physician or designee is responsible for informing the patient about specific concerns and/or potential negative outcomes of leaving the hospital prior to accomplishing the objectives outlined in the patient's treatment plan." It further states after the physician has evaluated the request for unplanned discharge: "S/he will discharge the patient with a full (regular) discharge. All requirements of the discharge including adequate follow-up care...will be provided to the patient to the extent of staff's ability to provide these services on short notice." A consultation was conducted between Nurse #1 and the Doctor on Call. Nurse #1 stated s/he saw "No red flags" and although Patient #3 told Nurse #1 s/he was still feeling depressed and mood was low, the patient remained calm but continued to make paranoid comments.

Upon exam of Patient #3 on 5/28/16 at 1:32 PM the Doctor On Call writes in a Physician Progress Note: "States on interview 'I feel better. I feel safe. I don't need to be here anymore.'...States s/he has an apartment...would like to be discharged and go home...". The physician also documents upon review of records and staff interviews Patient #3's behavior had improved and was described as "...calm and in good behavioral control > 24 hours...No thought/plan or intent to harm self or others." The physician's final assessment states: " ....distress, paranoia and cognitive disorganization have improved. S/he is not willing to remain in the inpt. context for further stabilization and does not meet criteria for involuntary treatment." There was no written indication or acknowledgement by the physician the patient was receiving Guardianship services.

After being examined by the Doctor On Call, Patient #3 eventually met with Social Worker #2 who was assigned on 5/28/16 to conduct, throughout the hospital, admission assessments, oversee group therapy meetings and create Aftercare Plans. Upon arrival to Tyler-2 on the afternoon of 5/28/16 Social Worker #1 met briefly with Patient #3. Per review of Social Work Progress Note created on 5/28/16 at 2:53 PM, Social Worker #2 states: "Pt. is requesting discharge on this date and was cleared for discharge by the physician. S/he presents with anxiety voicing various delusions...S/he plans to continue his/her methadone maintenance therapy and is unsure about whether or not s/he will see a therapist, or consider other aftercare options such as psychotherapy and peer support". Per interview on 7/13/16 at 8:00 AM, Social Worker #2 stated s/he was told by RN #1 Patient #3 "...was good to go". Social Worker #2 stated the patient did not want to talk and wanted "...to go".

Although both the Initial Psychosocial History and Assessment identifies the "Community Support/ Agencies" contact to be Patient #3's court appointed Guardian and the Multidisciplinary Treatment Plan incorporates both the patient's Guardian and PathwaysVermont (housing and support services for individuals with chronic homelessness and psychiatric disabilities/with on-call team available 24/7), neither the Case Manager for PathwaysVermont or the Guardian were contacted and/or consulted by the On Call Physician, Nurse #1 or Social Worker #2 prior to the patient's unplanned discharge.

Further interview with RN #1 confirmed s/he had not reviewed the treatment plan or court ordered Guardianship documents for Patient #3 because s/he was unfamiliar where the documents were filed within the patient's medical record. The nurse further acknowledged had s/he been aware of the community resources and responsibility of notification to the Guardian prior to facilitating the discharge process, it "...probably...may have changed discharged plans...". Social Worker #2 also acknowledged s/he failed to review the patient's record, noting "...there was pressure by the patient to get out". S/he had assumed the RN and Doctor On Call had assessed the patient for safety and stated "It was my fault" I failed to review the record. Social Worker #2 stated s/he was influenced by the discharge assessment presented when s/he arrived on Tyler 2 on the afternoon of 5/28/16. As a result, the staff involved with the unplanned discharge failed to notify and consult with Patient #3's Guardian or the PathwaysVermont case manager prior to the patient's discharge. Subsequently, within approximately 24 hours following discharge from the hospital, Patient #3 committed suicide.

Based on interview and record review, there was a failure of hospital staff to appropriately reassess the discharge plan for a patient identified with developmentally disabilities, opioid dependence and psychotic disorder who was under public guardianship and receiving community support services prior to the patient's unplanned discharge. (Patient #3) Findings include:

On 5/28/16 there was a failure of the Psychiatrist, Social Worker and RN to reassess the discharge plan for Patient #3, admitted voluntarily to the hospital on 5/25/16 for increased mood instability and thoughts of suicide. Prior to admission, and according to community resources to include Patient #3's Public Guardian, the patient had been decompensating over the previous several weeks and sought hospitalization after receiving an emergency crisis screening. Per initial MD Assessment completed on 5/26/16, Patient #3 had a past history of attempted suicide by hanging and intentional heroin overdose. Patient #3 was assessed to have auditory hallucinations was disorganized and paranoid. For the first 48 hours after admission Patient #3 was assigned to ALSA (a low stimulation area) due to disruptive and agitated behaviors which were upsetting the milieu of the unit. On 5/27/16 a Multidisciplinary Treatment Plan was developed which stated under Patient Objectives: "Patient will consider aftercare possibilities as recommended to ensure adequate support after discharge". Multidisciplinary Interventions state: "SW will meet with patient 1-2 times per week to discuss aftercare needs, will collaborate with current outpatient providers and schedule aftercare appointments as needed. SW will collaborate with Pathways case manager and Guardian and provide additional recommendations as needed." Time frames for the Treatment Plan was 7 days. Per interview on the morning of 6/11/16, Social Worker #1, (identified as the supervisor for other social service staff on Tyler-2) who helped develop Patient #3's Treatment Plan confirmed after Patient #3's admission s/he had a conversation with the Public Guardian for Patient #3 and confirmed no formal plans for discharge had been created, using the tentative 7 day admission to prepare for discharge. In addition, Patient #3 was hospitalized over Memorial Day weekend, resulting in further plans for discharge to be reviewed by Social Worker #1 in collaboration with the patient's Guardian upon return on 5/31/16.

However, on 5/28/16 Patient #3 approached nursing staff and requested to be discharged. Per interview on 7/12/16 at 9:05 AM, Nurse #1 confirmed Patient #3 came to her/him at lunch time stating ".S/he could handle things on the outside" and "wanted to go home to clean his room". As per hospital policy, RN #1 contacted the Doctor On Call informing the Physician Patient #3 was requesting an unplanned discharge. Hospital policy: Discharges: Unplanned/Against Medical Advice (AMA) last approved 06/2014 states: " The physician or designee is responsible for informing the patient about specific concerns and/or potential negative outcomes of leaving the hospital prior to accomplishing the objectives outlined in the patient's treatment plan." It further states after the physician has evaluated the request for unplanned discharge: "S/he will discharge the patient with a full (regular) discharge. All requirements of the discharge including adequate follow-up care...will be provided to the patient to the extent of staff's ability to provide these services on short notice." A consultation was conducted between Nurse #1 and the physician. Nurse #1 stated s/he saw "No red flags" and although Patient #3 told Nurse #1 s/he was still feeling depressed and mood was low, the patient remained calm but continued to make paranoid comments.

Upon exam of Patient #3 on 5/28/16 at 1:32 PM the Doctor On Call writes in Physician Progress Note: "States on interview 'I feel better. I feel safe. I don't need to be here anymore.'...States s/he has an apartment...would like to be discharged and go home...". The physician also documents upon review of records and staff interviews Patient #3's behavior had improved and was described as "...calm and in good behavioral control > 24 hours...No thought/plan or intent to harm self or others." The physician's final assessment states: " ....distress, paranoia and cognitive disorganization have improved. S/he is not willing to remain in the inpt context for further stabilization and does not meet criteria for involuntary treatment." The physician did not acknowledge the patient had a Guardian or suggest a consultation with the Guardian prior to the unplanned discharge.

After being examined by the Doctor On Call, Patient #3 eventually met with Social Worker #2 who was assigned on 5/28/16 to conduct, throughout the hospital, admission assessments, oversee group therapy meetings and create Aftercare Plans. Upon arrival to Tyler-2 on the afternoon of 5/28/16 Social Worker #1 met briefly with Patient #3. Per review of Social Work Progress Note created on 5/28/16 at 2:53 PM, Social Worker #2 states: "Pt. is requesting discharge on this date and was cleared for discharge by the physician. S/he presents with anxiety voicing various delusions...S/he plans to continue his/her methadone maintenance therapy and is unsure about whether or not s/he will see a therapist, or consider other aftercare options such as psychotherapy and peer support". Per interview on 7/13/16 at 8:00 AM, Social Worker #2 stated s/he was told by RN #1 Patient #3 "...was good to go". Social Worker #2 stated the patient did not want to talk and wanted "...to go".

Although both the Initial Psychosocial History and Assessment written by Social Worker #1 identifies the "Community Support/ Agencies" contact to be Patient #3's court appointed Guardian and the Multidisciplinary Treatment Plan incorporates both the patient's Guardian and PathwaysVermont (housing and support services for individuals with chronic homelessness and psychiatric disabilities/with on-call team available 24/7), neither the Case Manager for PathwaysVermont or the Guardian were contacted and/or consulted by the On Call Physician, Nurse #1 or Social Worker #2 prior to the patient's unplanned discharge.

Further interview with RN #1 confirmed s/he had not reviewed the treatment plan or court ordered Guardianship documents for Patient #3 because s/he was unfamiliar where the documents were filed within the patient's medical record. The nurse further acknowledged had s/he been aware of the community resources and responsibility of notification to the Guardian prior to facilitating the discharge process, it "....probably....may have changed discharged plans....". Social Worker #2 also acknowledged s/he failed to review the patient's record, noting "...there was pressure by the patient to get out". S/he had assumed the RN and Doctor On Call had assessed the patient for safety and stated "It was my fault" I failed to review the record.

As a result, the unplanned discharge did not include notification and consultation with Patient #3's Guardian and also failed to notify PathwaysVermont, who provided the patient housing and case management along with community support. Subsequently, within approximately 24 hours following discharge from the hospital, Patient #3 committed suicide.