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Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) clinical records reviewed for a grievance related to the discharge process, the Hospital failed to ensure that the written notice of the decision, resolution of the grievance, and the date of completion was provided as required.

Findings include:

1. On 06/06/2023, the Hospital's policy titled, "Patient Rights/Grievance Process" dated 02/2023, was reviewed and included, " ...A ...verbal complaint ... promptly investigate, resolve complaints and grievances ...and respond in a timely manner ...The person receiving the grievance will forward to the Risk Management ...Risk Management will call the patient within two working days to inform of having received grievance ...A response will be conveyed to the complainant in writing within 7 days ...steps taken on behalf of the patient to investigate the grievance, and results of the process ...anticipated date of completion ...Patient Rights and Grievance Process: ...A written response is sent to patient within 30 days of grievance filed ..."

2. On 06/05/2023 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed. On 3/31/2023 at 6:30 PM, Pt. #1 presented via ambulance to the Emergency Department from a Nursing Home for psychiatric evaluation. Pt. #1 was admitted to the Adult Behavioral Health Unit (ABHU) on 03/31/2023 at 10:54 PM, with a diagnosis of schizoaffective mania bipolar disorder (mental health disorder- abnormal thought process and unstable mood). The clinical record included:
-Legal documentation that Pt. #1 had a plenary guardian due to being disabled (effective date 12/17/2010).
- The discharge nurse (E #6) note dated 04/05/2023 at 12:50 PM, included, " ...Patient [Pt. #1] is being discharged home today ...patient was issued a bus pass ..."
-The Behavioral Health Unit Social Worker (E #2) documentation on Patient Update note dated 04/05/2023 at 6:06 PM, included, " ...SW [E #2] spoke with mom (plenary guardian) who states patient was admitted by ambulance as a direct admit from [Name of the Nursing Home] ...deemed to return however, patient [Pt. #1] was discharge home instead of nursing home..."

3. On 06/06/2023 at approximately 9:55 AM, the Hospital provided a Summary of Incident (completed by E #5/Director of Quality & Care Transitions), dated 4/6/2023, and included, "The [Name of the Nursing Home] advocate visited [Name of Hospital] on April 5, 2023, and asked to speak with a social worker to check in on the patient before discharge. (E #1) informed the advocate that (Pt.#1) had been discharged home (address on face sheet not the Nursing Home). (E #1) reported that (Pt. #1) was improperly discharged ... was on petition and no one notified ... legal guardian ... Once it was discovered that the patient was improperly discharged (E #1) contacted the guardian to inquire whether or not the patient was at home."

4. On 06/05/2023 at approximately 10:15 AM, the Risk Manager (E #3) was interviewed. E #3 stated that the patient (Pt. #1's) mom presented to the front desk on 04/05/2023 after she was notified that Pt. #1's discharge. E #3 stated that the mom was the plenary guardian and was upset that patient was discharged to the apartment instead of the nursing home originally where the patient came from to the hospital. E #3 stated that she failed to complete an acknowledgement letter for the verbal grievance for Pt. #1. E #3 stated that she forgot to send a resolution letter to the patient's family member after the closure of the grievance on 04/12/2023.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) clinical records reviewed for right to participate in the development of a plan of care, the Hospital failed to ensure that Pt. #1's guardian participated in the development of the plan of care.

Findings include:

1. On 06/06/2023, the Hospital's policy titled, "Patient Rights/Grievance Process" dated 02/2023, was reviewed and included, "... Exercise Patient Rights ... A. The right to participate in the development and implementation of the plan of care: B. Patient or representative (as allowed under state law) has the right to make informed decisions regarding his or her care... rights include being informed of their health status, being involved in care planning and treatment."

2. On 06/06/2023, the Hospital's policy titled, "Multi-disciplinary Treatment Plan" dated 01/2023, was reviewed and included, " ...The multidisciplinary team will ...coordinate care of patients across disciplines ... patient and family involvement in the treatment planning process shall be ongoing and documented in the medical record ...identify goals ...identify projected discharge date ...determine aftercare plans ...Discharge plans should be correlated with goals ...evaluation dates must be included ...all members of the care planning team should make entries on the treatment plan ..."

3. On 06/05/2023 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the Emergency Department on 03/31/2023 at 6:30 PM via ambulance from (Name of Nursing Home) for a psychiatric evaluation and admitted to the Adult Behavioral Health Unit (ABHU) on 03/31/2023 at 10:54 PM, with a diagnosis of schizoaffective mania bipolar disorder (mental health disorder- abnormal thought process and unstable mood). The clinical record included a legal document that indicated that Pt. #1 had a legal guardian.(effective 12/17/2010).
The clinical record lacked documentation of any contact from the multidisciplinary team with (Pt. #1's) legal guardian or involvement in the development of the care plan during the patient's hospitalization.

4. On 06/05/2023 at approximately 1:00 PM, the Director of Clinical Administrative Services (E #9) was interviewed. E #9 stated that the patient should not have signed... the treatment plan. E #9 stated that all forms should have been signed by the plenary guardian, since patient (Pt. #1) was considered as mentally unstable.

5. On 06/06/2023 at approximately 9:38 AM, the Mental Health Nurse Practitioner (E #10) was interviewed. E #10 stated that she failed to notice that patient (Pt. #1) had a plenary guardian. E#10 stated that the patient's family member should have been notified regarding the discharge planning process.

Based on document review and interview it was determined that for 1 of 2 (Pt. #1) clinical records for informed consent, the Hospital failed to obtain consent for treatment and psychotropic medication from the patient's guardian to make informed decisions of patient's care.

Findings include:

1. On 06/05/2023 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted from the emergency department to the Adult Behavioral Health Unit on 03/31/2023 at 10:54 PM, with a diagnosis of schizoaffective mania bipolar disorder (mental health disorder- abnormal thought process and unstable mood). Pt #1's information from the Nursing Home, included a document that Pt. #1 had a guardian for disabled person effective 12/17/2010, with the information of the guardian. The clinical record included the following:

-Rights of individual's receiving mental health" signed and dated by the patient (Pt. #1) on 03/31/2023, the consent for psychotropic medications signed and dated by the patient (Pt. #1) on 04/03/2023 at 10:45 AM.

-Physician's order dated 3/31/23 at 7:46 PM, "Haloperidol (anti-psychotic) 5mg (milligrams) IM (intramuscular) for agitation." The MAR (Medication Administration Record) indicated that the medication was given 3/31/23 at 7:45 PM.

2. On 06/06/2023, the Hospital's policy titled, "Informed Consent Medications/Psychoactive" dated 07/2020, was reviewed and included, "...The patient and/or parent/guardian will sign the informed consent after reading ...The physician shall determine and state in writing whether the recipient has the capacity to make a reasoned decision about the treatment ...the recipient's substitute decision maker, if any ...the guardian is authorized to consent to the administration of psychotropic medication ...physician shall advise the guardian in writing ...a qualified professional shall make reasonable accommodation of any physical disability of the recipient..."

3. On 06/05/2023 at approximately 11:40 AM, E #7 (Behavioral health Unit Admitting Registered Nurse) was interviewed. E #7 stated that she was not aware that the patient was unable to sign the psychotropic medication consent.

4. On 06/05/2023 at approximately 1:00 PM, the Director of Clinical Administrative Services (E #9) was interviewed. E #9 stated that the patient should not have signed the patient rights form, the psychotropic medications consent, and the treatment plan. E #9 stated that it should all have been signed by the plenary guardian, since patient (Pt. #1) was considered as mentally unstable.

Based on document review and interview, it was determined that the Hospital failed to ensure appropriate discharge planning services. As a result, the Condition of Participation, 42 CFR 482.43, Discharge Planning was not in compliance.

1. The Hospital failed to ensure the guardian was involved in discharge planning for a disabled patient. See A-0800.

2. The Hospital failed to ensure that home health services were secured prior to discharging a patient that required home health care. See A-801.

3. The Hospital failed to re-evaluate patients' discharge needs and adjust discharge plans. See A-802.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) discharged patient clinical records reviewed for discharge planning services, the Hospital failed to ensure the guardian was involved to ensure a safe discharge planning for a disabled patient.

Findings include:

1. On 06/05/2023 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed. On 3/31/2023 at 6:30 PM, Pt. #1 was admitted to the Adult Behavioral Health Unit (ABHU) on 03/31/2023 at 10:54 PM, with a diagnosis of schizoaffective mania bipolar disorder (mental health disorder- abnormal thought process and unstable mood). Pt. #1 was brought via ambulance to the emergency room for psychiatric evaluation. Pt. #1 lived in a Nursing Home. Pt #1's clinical record included:
-Legal documentation that indicated that Pt. #1 had a guardian for disabled person effective 12/17/2010. The document included the information of the legal guardian.

-The multi-disciplinary treatment plan dated 4/1/2023 signed Pt. #1 on 4/1/2023 and by the ABHU Social Worker (E #2) on 44/3/2023 and 4/5/2023 was incomplete. The plan did not include the identification of patient problems, if they were resolved, unresolved, a target date, patient support system, interventions, and update on patient disposition or that Pt. #1's guardian was informed/involved in Pt. #1's treatment plan.

-The initial psycho-social assessment by Intake Social Worker from ED dated 04/03/2023 at 1:02 PM, included, " ...Pt. [Pt. #1] will be returning to her apartment... [Address of the Apartment listed in the face-sheet] (not the nursing home address)...pt. [Pt. #1] said she won't need transportation just a bus card...can benefit from receiving a referral for Mental Health Tx [treatment] ..." The assessment failed to include that Pt. #1 had a guardian and that Pt. #1 resided in a nursing home.

2. On 06/06/2023, the Hospital's policy titled, "Multi-disciplinary Treatment Plan" dated 01/2023, was reviewed and included, " ...The multidisciplinary team will ...coordinate care of patients across disciplines...patient and family involvement in the treatment planning process shall be ongoing and documented in the medical record...identify projected discharge date ...determine aftercare plans ...Discharge plans should be correlated with goals ...evaluation dates must be included ...all members of the care planning team should make entries on the treatment plan ..."

3. On 06/06/2023 at approximately 9:38 AM, the Mental Health Nurse Practitioner (E #10) was interviewed. E #10 stated that she failed to notice that patient (Pt. #1) had a plenary guardian. E #10 stated that it all depends on the team, or the social worker who looked and reviewed the patient's chart. E #10 stated that multi-disciplinary rounds are done daily in the morning between Monday to Friday. E #10 stated the patient's family member should have notified regarding the discharge planning process.

4. On 06/06/2023 at approximately 10:00 AM, the Director of Quality and Care Transitions (E #5) was interviewed. E #5 stated that they should have documented in the multi-disciplinary plan of care for the patient (Pt. #1). E #5 stated that she was not sure why all the columns in the treatment plan were all left blank. E #5 acknowledged that there is documentation of the discharge planning and disposition of the patient in the treatment plan and that there was no documentation that the patient's guardian was involved.

Based on document review and interview, it was determined that for 1 of (Pt. #6) 6 clinical records reviewed for discharge planning services, the Hospital failed to ensure that home health services were confirmed upon the request of a patient's physician for arrangement of discharge to home with home health services.

Findings include:

1. On 06/05/2023, the Hospital 's policy titled, "Post Hospital Discharge Planning " (revised 3/2023) was reviewed and required, "Patients who require HH (home health) ... SNF (skilled nursing facility) or follow-up care services during their inpatient observation transition plan as indicated by the assessment ... Documentation will include ... facility acceptance. "

2. On 06/05/2023, the clinical record for Pt. #6 was reviewed and included:

-4/14/23 at 4:09 PM, Case Manager note indicated, " ... met with patient at bedside ... states lives in a boarding home (rents a room in an apartment) ... does not have any nursing for wound care management and is requesting to go to (name of SNF). Living arrangements: Boarding Home. Services used prior to Admission: Home Health Nurse, has commode, wheelchair at home"

-4/15/23 at 5:12 PM, Social Service note (entered by E #1/Supervisor of Social Services) "Patient requesting placement... Patient has home health services (name of home health agency) ... per home health RN (registered nurse) patient needs 24-hour care, a paraplegic needs assistance with caring for self with wounds."

-4/25/23 at 2:43 PM, Social Service note, "Contacted (name of SNF) for status on patient referral. Facility denied patient referral ... will continue to follow up with patient as needed for placement. "

-5/2/23 at 1:01 PM, "Care team has been unsuccessful with placement because of patient ' s history ... patient is receiving IV antibiotics he cannot be sent out into the community. " On 5/17/23, IV antibiotic switched to oral antibiotics.

-5/18/23 at 2:59 PM, Social Service note, " ... discharge for today 5/18/23 ... to home ... with home health services (name of previous home health agency). Contact (name of agency) no answer ... leave voice message to return phone call and provide fax number for updated clinical. "

-Physician's order dated 5/18/23 at 11:30 AM, included, " Discharge to home with home health. "

-5/18/23 at 4:47 PM, Nursing note, " Patient discharged, discharge paperwork provided and reviewed with patient ... " The clinical record lacked documentation that the home health agency returned call and accepted the patient prior to the patient being discharged to home.

3. A Patient Grievance Form dated 06/05/2023, was reviewed and included " Mode of Grievance: verbal by phone ... Description of grievance: received voicemail message form (Pt. #6) on 5/23/23 at 2:24 PM, stated he was discharged on 05/18/2023 and was to have hhc (home health care) and to date has not been to his home. He has multiple wounds that require dressing changes and have not been changed since discharge. Immediate actions taken ... attempted to contact member and left a voicemail to discuss HHC agency on 5/25/23, 5/30/23, and 5/31/23 ... Findings ... SW (social worker should have located an alternative HHC during admission to assure services would restart prior to discharge ... upon review and attempt to contact patient, (Pt. #6) is currently in the ED as of 6/5/23. "

4. On 06/06/2023 at 9:20 AM, an interview was conducted with the Supervisor of Social Services (E #1). E #1 stated that the social worker should have confirmed that the home health agency was secured with a date and time of start before the patient discharged to home (boarding house). E #1 confirmed that the clinical record lacked documentation that the HHC agency confirmed acceptance of the patient. E #1 stated that (Pt. #6) could not be placed due to prior history.

Based on document review and interview, it was determined that for 2 of 2 (Pt. #1 and Pt. #6) clinical records reviewed for discharge planning services, the Hospital failed to re-evaluate the patients' discharge needs and adjust discharge plans.

Findings include:

1. On 06/06/2023, the Hospital's policy titled, "Post Hospital Discharge Planning" dated 03/2023, was reviewed and included, " ...Services are appropriate for the patient's needs and discuss the plan of care with the physician and the patient and/or patient representative...A member of the Care Transitions team will explain the nature of the post-acute services planned ...will work with patient/representatives and the representatives from the selected entities."

The following findings are related to Pt. #1

1. On 06/05/2023 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted from nursing home to the Adult Behavioral Health Unit (ABHU) on 03/31/2023 at 10:54 PM, with a diagnosis of schizoaffective mania bipolar disorder (mental health disorder- abnormal thought process and unstable mood). The clinical record included:

-Pt. #1 had a legal guardian with an effective date of 12/17/2010. The form included the guardian's information.

-The initial psycho-social assessment by Intake Social Worker from ED dated 04/03/2023 at 1:02 PM, included, " ...Pt. [Pt. #1] will be returning to her apartment ... [Address of the Apartment listed in the face-sheet] (not the address of the nursing home) ...pt. [Pt. #1] said she won't need transportation just a bus card ...can benefit from receiving a referral for Mental Health Tx [treatment] ..." The assessment did not include that Pt. #1 had a guardian.

-The Behavioral Health Unit Social Worker (E #2) discharge note dated 04/05/2023 at 12:15 PM, included, " ...Pt. [Pt. #1] is being discharged today, 04/05/2023 ...discharged home to her home address. Not to the nursing home.

The multidisciplinary team failed to identify that (Pt. #1) had a guardian. The clinical record did not include documentation that Pt. #1's guardian was contacted or involved in the patient's assessment of needs, care, treatment, and discharge planning.

2. On 06/06/2023 at approximately 9:55 AM, the Hospital provided a Summary of Incident (completed by E #5/Director of Quality & Care Transitions), dated 4/6/2023, and included, "The [Name of Nursing Home] advocate visited [Name of Hospital] on April 5, 2023, and asked to speak with a social worker to check in on the patient before discharge. (E #1) informed the advocate that (Pt.#1) had been discharged home (address on face sheet not the Nursing Home). (E #1) reported that (Pt. #1) was improperly discharged ... was on petition and no one notified ... legal guardian ... Once it was discovered that the patient was improperly discharged (E #1) contacted the guardian to inquire whether or not the patient was at home."

3. On 06/05/2023 at approximately 10:15 AM, the Risk Manager (E #3) was interviewed. E #3 stated that the patient's (Pt. #1's) mom presented to the front desk on 04/05/2023 regarding Pt. #1's discharge. E #3 stated that the mom was the plenary guardian and was upset that patient was discharged to the apartment instead of the nursing home originally where the patient came from to the hospital.

4. On 06/05/2023 at approximately 11:15 AM, the Supervisor of Social Services (E #1) was interviewed. E #1 stated that the initial psycho-social assessment was completed by the social worker in the emergency room, she documented the patient to be returning to the apartment upon discharge with a bus pass. E #1 stated that the social worker (E #2) on the ABHU should have reviewed the patient's (Pt. #1) chart and made discharge planning process correctly for the patient.

The following findings arerelated to Pt. #6.

1. On 06/05/2023, the clinical record for Pt. #6 was reviewed and included:

-4/14/23 at 4:09 PM, Case Manager note, "... met with patient at bedside ... states lives in a boarding home (a room that Pt. #6 rents in an apartment) ... does not have any nursing for wound care management and is requesting to go to (name of SNF). Living arrangements: Boarding Home. Services used prior to Admission: Home Health Nurse, has commode, wheelchair at home"

-4/15/23 at 5:12 PM, Social Service note (entered by E #1/Supervisor of Social Services) "Patient requesting placement... Patient has home health services (name of home health agency)... per home health RN (registered nurse) patient needs 24-hour care, a paraplegic needs assistance with caring for self with wounds."

-4/25/23 at 2:43 PM, Social Service note, "Contacted (name of SNF) for status on patient referral. Facility denied patient referral ... will continue to follow up with patient as needed for placement. "

-5/17/23 at 3:47 PM, Infectious Disease Progress note, indicated that intravenous antibiotic were change to oral antibiotics.

-5/18/23 at 2:59 PM, Social Service note, "... discharge for today 5/18/23 ... to home...with home health services (name of previous home health agency). Contact (name of agency) no answer... leave voice message to return phone call and provide fax number for updated clinical."

-Physician's order dated 5/18/23 at 11:30 AM, included, " Discharge to home with home health."

-5/18/23 at 4:47 PM, Nursing note, "Patient discharged, discharge paperwork provided and reviewed with patient..." The clinical record lacked documentation that the home health agency returned call and accepted the patient prior to the patient being discharged to home without securing a home health agency for wound care.
2. A Patient Grievance Form dated 06/05/2023, was reviewed and included "Mode of Grievance: verbal by phone ... Description of grievance: received voicemail message form (Pt. #6) on 5/23/23 at 2:24 PM, stated he was discharged on 05/18/2023 and was to have HHC (home health care) and to date has not been to his home. He has multiple wounds that require dressing changes and have not been changed since discharge. Findings ... SW (social worker) should have located an alternative HHC during admission to assure services would restart prior to discharge ... upon review and attempt to contact patient, (Pt. #6) is currently in the ED as of 6/5/23."

3. On 06/06/2023 at 9:20 AM, an interview was conducted with the Supervisor of Social Services (E #1). E #1 stated that the social worker should have confirmed that the home health agency was secured with a date and time of start before the patient discharged to home (boarding house). E #1 confirmed that the clinical record lacked documentation that the HHC agency confirmed acceptance of the patient.