HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to provide a safe discharge and post-hospital plan for follow-up care, for one discharged patient (#16) reviewed whose identity was unknown. The hospital also failed to have a discharge planning process that included the appropriate steps to take for non-trauma patients who were unable to be identified prior to their discharge. These failures had the potential to lead to unsafe discharges, inappropriate transition of care and result in poor outcomes, and could affect all non-trauma patients who were unable to be identified before discharge.

The severity and cumulative effects of these systemic failures resulted in the hospital being out of compliance with 42 CFR 482.43 Condition of Participation: Discharge Planning.

Based on interview, record review, and policy review, the hospital failed to provide a safe discharge plan for one discharged patient (#16) whose identity was unknown, of one discharge reviewed. The hospital also failed to have a discharge planning process that included the appropriate steps to take for non-trauma patients who were unable to be identified prior to their discharge. These failures had the potential to lead to discharges that were not safe, and could result in readmission, poor outcomes, deterioration or death, and could affect all patients. The hospital census was 601.

Findings included:

1. Review of the hospital's policy titled, "Voluntary and Involuntary Admission - Transfer - Release of Psychiatric Patients," revised 04/2017, showed that mental disorders were any organic (naturally occurring), mental, or emotional impairment, which had substantial adverse effects of a person's cognitive (term used to describe impairment in an individual's mental processes), volitional (relating to the use of one's will), or emotional function which constitutes a substantial impairment in a person's ability to participate in activities of normal living.

Review of the hospital's policy titled, "BHS (Behavioral Health Services) CARE COORDINATION Discharge Process," revised on 05/2017, directed the staff to do the following:
- The psychosocial assessment of the patient should identify anticipated discharge needs, including physical, emotional, housing, transportation, social and any other needs and follow up care.
- The patient's care partner should be consulted with, and informed as to, the patient's discharge needs/options.
- Individuals or organizations previously involved with the patient's care should be consulted if appropriate for information about patient discharge needs.
- The Care Coordination Team should identify and coordinate appropriate community follow-up care, taking into consideration the patient's individual benefit options.
- If within 48 hours of an admission, the discharge plan was not clear, contact with the care partner, placement facility and or the Division of Family Services/Deputy Juvenile Officer (DFS/DJO) as a resource to pursue discharge plans and options, contact with the physician to review/assess discharge plan options and continued follow up thereafter to review status of discharge until the plan was resolved, will all be documented.
- A member of the nursing staff will review discharge directions concerning any medical issues, medication or diet restrictions.
- Prescriptions will be provided by the physician.

Although requested, the hospital failed to provide a policy for unidentified patients.

Review of Patient #16's admission medical record showed the following:
- She was a "119" year old female who presented to the emergency department with a chief complaint of needing to get back on her medication, specifically Depakote (a drug used to treat bipolar disorder [a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks]) and Risperidone (medication used to manage thought disorders, such as seeing/hearing things that were not there, and false ideas about what is taking place).
- She told the physician that she recently traveled by bus to St Louis from Seattle, Washington.
- She had a past medical history of psychosis (a disorder characterized by false ideas about what is taking place or who one is).
- She was disoriented to her birthday and stated that her birth year was "10012."
- She was delusional (false ideas about what is taking place or who one is).
- She met with a Licensed Clinical Social Worker (LCSW), on 11/08/19, for the initial evaluation and told her she used to be a shoemaker.
- On 11/09/19, she met with Staff GGG, LCSW, who documented that the patient was currently homeless in St. Louis and was unable to reliably state whether she knew of any relatives or friends in the area. She was highly disoriented and unable to say where she had lived or was living. She was not currently able to take care of herself. The patient's goal was to go back on her Depakote and Risperidone for 30 days. The patient told her that she had been traveling by bus and went to St. Louis from Everett, Washington, and mentioned Seattle and Billings Montana. The patient reported to her that she was traveling with friends and listed James, LeRoy, Nielson, Claud, Pappatoni, Jefferson, Madison, Monroe, Allah, Jehovah, Noah, Wales, Shakespeare, Nostradamus, Plato, Rosenthal, Goldmine, and Goldstein. The patient gave her name, and then told her that she sometimes spells it differently, she was unable to give a reasonable birth date, and had no identification. The patient would need to follow up with outpatient mental health providers upon discharge. The patient was unable to comprehend what she would have signed. The patient was involuntarily admitted with a 96-hour hold (court ordered evaluation by a behavioral specialists to determine if a person is safe to themselves and others) ending on 11/15/19 at 4:15 PM.
- On 11/10/19 Staff UU, Doctor of Medicine (MD), documented that the patient had been compliant with her medications. She remained delusional, provided her name, and that she was from Washington State. She provided her care partner's name and phone number in Seattle Washington. The patient still needed continued inpatient treatment due to the severity of her illness and unstable condition for outpatient care.
- On 11/11/19 at 6:13 AM, her mental health assessment referred to her as psychotic (actions related to psychosis), delusional, disoriented and unable to provide coherent history or description.
- On 11/11/19 at 12:40 PM, Registered Nurse (RN) documentation showed that Patient #16 was still delusional, and unable to give her name.
- On 11/11/19 at 3:04 PM, Staff UU, MD, documented that Patient #16 remained delusional. She still needed continued inpatient treatment due to the severity of her illness and unstable condition for outpatient care.
- On 11/12/19 at 6:05 AM, RN documentation showed that the patient was still psychotic, delusional and disoriented and unable to provide coherent history or description of her symptoms.
- On 11/12/19 at 11:51 AM, Staff CCC, Licensed Professional Counselor (LPC), Case Manager, documented that the patient reported she would be able to use a bus pass and would like a list of the warming centers in St. Louis. They discussed the importance of psychiatric follow up and medication adherence following her discharge. The patient verbalized understanding of the discharge plans and safety plans and the patient felt safe to leave the hospital.
- On 11/12/19 at 5:59 PM, Staff AAA, RN, documented that the patient was given education in verbal and written form regarding discharge medications, follow up appointments, and outpatient and /or crisis resources available to her. She was discharged with her belongings to a warming shelter (shelter provided for homeless to intermittently warm during extreme cold temperatures) via cab voucher. She was also given white tennis shoes and a winter coat, which she threw away and refused to take.

Review of Patient #16's psychiatry discharge summary, dated 11/12/19 at 2:47 PM, by Staff UU, MD, showed:
- She was treated with medications that she tolerated well and responded with improved conditions (the medications were not listed).
- There were no psychotic behaviors observed during her admission.
- She wanted to stay in the hospital until December 3rd because that was when she would get paid.
- Her insight and judgement were fair, her senses were clear, and she was alert and oriented times three (to be aware of who you are, where you are, and the approximate time).
- She was prescribed Divalproex (Depakote) 500 milligrams (mg) delayed release tablets, one tablet three times a day, and Risperidone 4 mg tablets, two tablets once daily at bedtime. The name on the prescriptions was "Mississippi Medical," with a date of birth of "01/01/1900."
- There were no follow up appointments made for the patient.

During an interview on 01/06/20 at 4:10 PM, Staff XX, RN, stated that if a patient did not know their name they would not be safe to be discharged.

During an interview on 01/07/20 at 11:11 AM, Staff ZZ, RN, stated that alert and oriented times three would mean that a patient knew who they actually were, where they were and the time. If a patient did not know their name they would not have been safe to discharge.

During an interview on 01/07/20 at 3:51 PM, Staff AAA, RN, stated that she did not know how Patient #16 would have had her prescriptions filled because the prescriptions were written for "Mississippi Medical" and a birth date of "01/01/1900."

During an interview on 01/07/20 at 4:45 PM, Staff YY, Behavioral Health Unit (BHU) Nurse Manager, stated:
- The patient could have only filled her prescriptions at the hospital pharmacy (under the written name "Medical Mississippi"), and there was no record they were filled.
- She was unsure if a retail pharmacy could have or would have filled the prescriptions.
- Sometimes they offered to fill prescriptions for patients who were not be able to fill their prescriptions or were likely to not fill them. They did not do this for Patient #16.
- Patient #16 was unstable.

During an interview on 01/08/20 at 9:30 AM, Staff CCC, LPC, Case Manager, stated:
- It was a concern for her that Patient #16 did not know who she was when she was discharged.
- Patient #16 was not alert and oriented times three at discharge.
- It would have been very difficult to fill a prescription with the name "Mississippi Medical" and a date of birth of "01/01/1900."
- An actual date of birth would have been required to pick up Depakote and Risperidone.
- Patient #16's discharge was not anticipated for that day, and the physician decided toward the end of the day to discharge her.
- She was unaware of the patient's reported social worker (care partner) in Seattle.
- Typically, patients with mental health issues ended up back in the hospital because they did not take their medications, and she had concerns that Patient #16 would end up back in the hospital.
- She expressed concerns with the physician about discharging Patient #16.

During an interview on 01/08/20 at 10:10 AM, Staff DDD, Pharmacy Technician, stated that there was a program in the hospital called "Meds to Beds" that could have been used by any patient. They filled prescriptions for discharged patients and delivered those medications to the patient's room before leaving the hospital. They did not provide this service for Patient #16.

During an interview on 01/08/20 at 10:15 AM, Staff EEE, Pharmacist, stated that he could not have filled a prescription that had a name like "Medical Mississippi" or a date of birth of "01/01/1900."

During an interview on 01/08/20 at 11:20 AM, Staff GGG, BHU Manager, stated:
- She thought that Patient #16 would have been on the unit for a while because she was so sick.
- She did not feel that Patient #16 could safely take care of herself.
- Patient #16 had a 96-hour hold that didn't end until 11/15/19.
- Someone who didn't know their name would not have been safe to discharge.
- It would have been very important for Patient #16 to take her medications.
- Patient #16 would have had a difficult time filling a prescription that was written for "Mississippi Medical" and a date of birth of "01/01/1900."
- Setting up medications should have been a part of the discharge planning.
- Appointments made for the patient would have been listed on the discharge sheet.

During an interview on 01/08/20 at 1:30 PM, Staff HHH, RN, stated:
- He had taken care of Patient #16.
- He was surprised to see she had been discharged.
- If a patient did not know their name, they would not have been safe to care for themselves.
- Psychiatric patients need to take their medications, and usually end up in the hospital because they don't take their medications.
- A prescription for "Medical Mississippi" with a date of birth of "01/01/1900" would have been impossible to fill.

During an interview on 01/08/20 at 2:05 PM, Staff UU, MD, stated:
- He took care of Patient #16 and he remembered her very clearly.
- Patient #16 was not psychotic and just needed a place to stay.
- Alert and oriented times three meant that a patient knew where they were, the date and had a good recollection of events.
- He had called a shelter system in Seattle once (regarding the patient) but got no answer, and did not leave a message.
- He did write prescriptions for Patient #16, the chart was electronic and automated, so the prescriptions would have been under "Mississippi Medical."
- A safe and appropriate discharge meant that a patient was not a harm to themselves or others and agreed to be compliant with their medications.
- It would have been very important for Patient #16 to be compliant with her medications.
- Patient #16 was just looking for a place to stay for secondary gain.
- He felt Patient #16 was malingering (faking psychological or physical symptoms for secondary gains).

During an interview on 01/08/20 at 3:30 PM, Staff RR, Chief Nursing Officer (CNO), stated that she would expect a prescription to be written for a patient using the patient's correct name, and added that they needed a process for the discharge planning of "Jane Doe" patients.

Based on interview, record review, and policy review, the hospital failed to a provide appropriate post-hospital follow-up care for one discharged patient (#16), of one discharged patient reviewed for post-hospital follow-up care. This had the potential to lead to readmission, poor discharge outcomes, deterioration or death, and could affect all patients discharged from the hospital. The hospital census was 601.

Findings included:

1. Review of the hospital's policy titled, "BHS (Behavioral Health Services) CARE COORDINATION Discharge Process," revised on 05/2017, directed the staff to do the following:
- The psychosocial assessment of the patient should identify anticipated discharge needs, including physical, emotional, housing, transportation, social and any other needs and follow up care.
- The patient's care partner should be consulted with and informed as to the patient's discharge needs/options.
- Individuals or organizations previously involved with the patient's care should be consulted if appropriate for information about patient discharge needs.
- The Care Coordination Team should identify and coordinate appropriate community follow-up care.
- If within 48 hours of an admission, the discharge plan was not clear, contact with the care partner, placement facility and or the Division of Family Services/Deputy Juvenile Officer (DFS/DJO) as a resource to pursue discharge plans and options, contact with the physician to review/assess discharge plan options and continued follow up thereafter to review status of discharge until the plan was resolved, will be documented.
- A member of the nursing staff will review discharge directions concerning any medical issues, medication or diet restrictions.
- Prescriptions will be provided by the physician.

Review of Patient #16's admission medical record showed the following:
- She was a "119" year old female, with a past history of psychosis (a disorder characterized by false ideas about what is taking place or who one is) who presented to the emergency department with a chief complaint of needing to get back on her medication, specifically Depakote (a drug used to treat bipolar disorder [a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks]) and Risperidone (medication used to manage thought disorders, such as seeing/hearing things that were not there, and false ideas about what is taking place).
- She was delusional (false ideas about what is taking place or who one is) and disoriented to her birthday, and stated that her birth year was 10012.
- On 11/09/19 she met with Staff GGG, Licensed Clinical Social Worker (LCSW), who documented that the patient was currently homeless and was unable to reliably state whether she knew of any relatives or friends in the area. She was highly disoriented and unable to say where she had lived or was living. She was not currently able to take care of herself. The patient's goal was to go back on her Depakote and Risperidone for 30 days. The patient reported she was traveling with friends and listed James, LeRoy, Nielson, Claud, Pappatoni, Jefferson, Madison, Monroe, Allah, Jehovah, Noah, Wales, Shakespeare, Nostradamus, Plato, Rosenthal, Goldmine, and Goldstein. The patient gave her name, and then told her that she sometimes spells it differently, she was unable to give a reasonable birth date, and had no identification. The patient would need to follow up with outpatient mental health providers upon discharge. The patient was unable to comprehend what she would have signed, and the patient was involuntarily admitted with a 96-hour hold (court ordered evaluation by a behavioral specialists to determine if a person is safe to themselves and others) ending on 11/15/19 at 4:15 PM.
- On 11/10/19 Staff UU, Doctor of Medicine (MD), documented that the patient remained delusional, provided her name, and that she was from Washington State. She provided the name and number for her care partner contact in Seattle Washington. The patient still needed continued inpatient treatment due to the severity of her illness and unstable condition for outpatient care.
- On 11/11/19 at 6:13 AM, her mental health assessment referred to her as being psychotic (behaviors of psychosis), delusional, disoriented and unable to provide coherent history or description.
- On 11/11/19 at 12:40 PM, Registered Nurse (RN) documentation showed that Patient #16 was still delusional, and unable to give her name.
- On 11/11/19 at 3:04 PM, Staff UU, MD, documented that Patient #16 remained delusional. She still needed continued inpatient treatment due to the severity of her illness and unstable condition for outpatient care.
- On 11/12/19 at 6:05 AM, RN documentation showed that the patient was still psychotic, delusional and disoriented and unable to provide coherent history or description of her symptoms.
- On 11/12/19 at 11:51 AM, Staff CCC, Licensed Professional Counselor (LPC), Case Manager, documented that the patient reported she would be able to use a bus pass and would like a list of the warming centers in St. Louis. They discussed the importance of psychiatric follow up and medication adherence following her discharge. The patient verbalized understanding of the discharge plans and safety plans and the patient felt safe to leave the hospital.

Review of Patient #16's discharge documentation showed the patient was discharged on 11/12/19 at 5:59 PM, with a cab voucher to a warming bus (bus provided to homeless, to intermittently warm themselves during extreme cold temperatures) with no follow up appointments scheduled. She was prescribed Divalproex 500 milligrams (mg) delayed release tablets, one tablet three times a day, and Risperidone 4 mg tablets, two tablets once daily at bedtime. The name on the prescriptions was "Mississippi Medical," with a date of birth of "01/01/1900." She was also given white tennis shoes and a winter coat, which she threw away and refused to take. She was given a list of homeless shelters and resource centers (required the patient to initiate treatment on her own).

There was no follow-up plan to ensure the patient reached safe housing, received post-discharge follow-up care or treatment, or if she was able to obtain her prescribed medications when she was discharged .

During an interview on 01/08/20 at 9:30 AM, Staff CCC, LPC, Case Manager, stated:
- She was concerned that Patient #16 did not know who she was when she was discharged.
- Patient #16 was not oriented times three (to be aware of who you are, where you are, and the approximate time) at discharge.
- It would have been very difficult to fill a prescription with the name "Mississippi Medical" and a date of birth of "01/01/1900."
- A valid date of birth would have been required to pick up Depakote and Risperidone.
- Patient #16's discharge was not anticipated for that day, and the physician decided toward the end of the day to discharge her.
- Neither Staff UU, MD, nor Patient #16 told her about a social worker (care contact) in Seattle.
- Typically, patients with mental health issues end up back in the hospital because they did not take their medications, and she had concerns that Patient #16 would end up back in the hospital.
- If someone thought they were an explorer from the 1700's they could not safely take care of themselves.
- She expressed concerns with the physician about discharging Patient #16.

During an interview on 01/08/20 at 11:20 AM, Staff GGG, Behavioral Health Unit Manager, stated:
- She thought that Patient #16 would have been on the unit for a while because she was so sick.
- She did not feel that Patient #16 could safely take care of herself.
- Patient #16 had a 96 hour hold that didn't end until 11/15/19.
- Someone who didn't know their name would not have been safe to discharge.
- It would have been very important for Patient #16 to take her medications.
- Patient #16 would have had a difficult time filling prescriptions that were written for "Mississippi Medical" with a date of birth of "01/01/1900."
- Setting up medications should have been a part of the discharge planning.
- Appointments made for the patient would have been listed on the discharge sheet.