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Based on policy review, medical record review, and staff interview, it was determined the facility failed to follow the discharge plan and provide a safe discharge for one (#3) of five patient records sampled.

Findings included:

A review of the policy entitled, "Discharge of Patient to Another Facility," #BH.10.07, reviewed 08/18, showed that to assure the transfer of a patient to another level of care, treatment or services, the method of transportation is based on patient's assessed needs and hospital capabilities.

A review of the policy entitled, "Discharging Planning and Continuing Care Overview," #BH.10.01, reviewed 08/18, showed discharge planning begins upon admission, and when specific placement is ordered by the Attending Physician, the Discharge Planner arranges the placement via appropriate transportation.

A review of the Emergency Department (ED) physician's history & physical (H&P) documentation, dated 12/30/18 at 3:33 PM, revealed Patient #3 was brought in by law enforcement (LEO) under a Baker Act for aggressive behavior. The documentation showed the patient had a history of Alzheimer's dementia. Patient was noted to be stable and was medically cleared at 8:46 PM and sent to Medical Center of Trinity West Pasco Behavioral Health Unit (BHU). The subject patient's husband was listed as the patient's representative, authorized decision maker, and listed a skilled nursing facility as the patient's residence.

A review of the psychiatric physician's discharge summary dated 01/02/19 at 11:13 AM showed the patient was to be discharged to, a skilled nursing facility (SNF). The note showed the patient had stabilized and was appropriate for discharge (DC).

A review of the Case Management (CM) note, dated 01/02/19 at 1:40 PM showed the patient was discharged via stretcher and transported by medical transport.

An interview with Patiennt #3's DC planner revealed that she thought the patient had been transferred via stretcher to the skilled nursing facility. The DC planner was unware the patient had been DC'd in a taxicab.

On 01/24/19 at 11:30 AM, an interview with the Director of the BHU revealed Patient #3's discharge was not appropriate and he stated that approximately three weeks ago he was contacted by the Administrator of the skilled nursing facility. The Administrator had reached out to the Director to make him aware that a confused patient arrived via a taxicab and the cab driver walked her up to the door to ensure her safety.

On 01/24/19 at 12:11 PM, an interview was performed with the subject patient's RN. The RN stated the facility utilizes a Pink Sheet of paper that shows what the DC Planner had arranged for transport. The subject patient was to go via stretcher to the skilled nursing facility via medical transport. The RN stated transport was ordered as a "will call". The RN stated she called the transfer center at 2:30 PM and was told there was still was no transportation available. The RN called the transport center at 5:30 PM and was told they would arrive in about 30 min. The RN stated the next thing that occurred was "a cab showed up for the patient." The RN did not think that was right and called transport to let them know the patient needed a stretcher and not a cab. The transporter told the RN that a cab was all they had available. The RN said she sent the patient to the facility in a cab. The RN stated this was the first time this had ever happened to her and she was not comfortable with sending this patient via a taxi and reported this to her supervisor.

On 01/24/19 at 12:18 PM, an interview with the Director of Case Management confirmed the above findings and indicated all Medicaid patients are only allowed to use medical transport. According to the Director, they have been problematic and have rerouted patient transports to another service, such as a cab. She stated, "They will find whoever they can."