HospitalInspections.org

Based on document reviews and interviews, it was determined that the facility's discharge planning evaluation and plan failed to include discussions with the patient's representative (co-guardian) prior to discharge for one (1) of ten (10) patients reviewed (Patient #3).

Finding:

The MaineHealth "Consent to Treat for Procedures, Interventions, and Treatment" policy states, in part the following, ..."Consent by Authorized Representatives ... Constent obtained from Guardian ... A guardian is a person appointed by a court to make decisions for a person who has been determined by the court to lack sufficient understanding or capacity to make or communicate responsible decisions for themselves, usually as a result of mental illness or deficiency, physical illness or disability, or chronic substance abuse. In limited circumstances, the State of Maine itself can serve as guardian for a patient. When a guardianship is in force, the guardian, not the patient, has the power to give or withhold consents or refusals related to medical or other professional care, counseling and treatment for the patient ... ."

On 2/23/2021, the State of Maine Androscoggin County Probated Court granted limited adult co-guardianship to Patient #3's parents. This court order established the following:
- custody for Patient #3's place of abode, and custody to place Patient #3 in any hospital or other institution for care in the same manner as otherwise provided by law; and
- to give or withhold consents or approvals related to medical or other professional care, counsel treatment or services for Patient #3.

On 7/02/2024 at approximately 11:00 AM, a review of Patient #3's medical record revealed in part the following:
- On 03/08/2024, Patient #3 was admitted to Southern Maine Medical Center's Behavioral Health Unit with psychosis and agitation as the primary diagnosis;
- On 05/20/2024 at 8:51 AM, Social Worker ("SW") #1 had contact with the co-guardian, who stated that she did not want Patient #3 discharged to a shelter;
- On 5/20/2024 at 2:31 PM, Patient #3 was discharged to a shelter; and
- On 05/22/2024 at 2:55 PM, SW#1 notified the co-guardian that Patient #3 had been discharged, however, she did not disclose the location, per Patient #3's request.

On 7/02/2024 at 12:07 PM, SW #1 stated she was aware that Patient #3 had a guardian. She was asked if she obtained permission from either co-guardian of Patient #3 to be discharged, she stated, "No."