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Based on record review, interviews, and policy review, it was determined the facility failed to ensure the results of a discharge planning evaluation were discussed with the legal guardian for Patient 1, representing 1 of 3 patients who presented to the Behavior Unit and were noted to have legal guardians. Patient 1 was discharged to a local mission/homeless shelter on 04/12/2020 without the guardian's knowledge. In addition, there was no evidence the mission/homeless shelter was informed of the discharge plan prior to the patient being transported to the shelter.

Findings included:

A review of the facility policy titled, "Process for Discharge Upon Completion Of Treatment," revised January 2017, showed the facility had discharge planning that began upon admission "because the primary goal of treatment is either independent living or placement in a least restrictive environment." The policy showed the facility would discharge the patient after the patient was deemed clinically suitable for discharge by the attending provider and interdisciplinary team. According to the policy, "A voluntary or involuntary patient may be discharged by physician order at any time." The policy showed that the "Social Worker/Mental Health Counselor shall: a. Complete Discharge/Continuing Care Plan with involvement from the patient. b. Make certain that all necessary releases of information have been signed. c. Write a Discharge Progress Note addressing each problem in the treatment plan, patient status at discharge in relation to problems, and how the logistics of moving into continuing care will occur. d. Summarize disposition, transportation, and follow-up plan. e. Forward Continuing Care/Discharge Plan to outpatient provider or referral source." Further review of the policy showed justification for discharge must be documented by all disciplines, and whenever possible, should have been discussed and documented by the treatment team on a weekly review. The policy noted, "Patients must not be discharged for exhibiting the symptoms for which they were hospitalized. Neither staff nor family convenience is a reason for discharge."

A review of Patient 1's behavior health medical record showed the patient was transported by the sheriff's office from a nearby emergency department (ED) on 04/08/2020 at 8:15 PM. The facility admitted Patient 1 with diagnoses that included bipolar disorder, moderate intellectual disability, and rule out autistic disorder. Patient 1 signed admission paperwork, and it was noted the patient had a guardian. The guardian did not come to the hospital. A review of a history and physical showed the patient had an altercation at home with a family member, who stated the patient could not return home. A review of a Social Worker note, dated 04/09/2020 at 1:02 PM, showed the Director of Social Work spoke with the guardian and both were seeking placement for the patient. A review of a case management note, dated 04/09/2020 at 4:11 PM, showed the patient's discharge plan was to discharge to a mission/homeless shelter and to follow up at a behavioral health service. The case management note showed the guardian was contacted regarding the plan and a voice message was left. A review of a discharge planning note, dated 04/09/2020 at 3:51 PM, showed a phone call was made to Patient's 1 guardian and a message was left regarding the discharge plan. On 04/10/2020, nursing staff noted another attempt was made to reach the guardian. Patient 1 was then discharged on 04/12/2020 (Sunday) after being medically cleared with no mental concerns noted by a psychiatrist. The patient was transported by a transportation company to a mission/homeless shelter. The nurse left a voice message on the guardian's phone, informing the guardian of the discharge. An electronic prescription was called to a pharmacy. However, there was no evidence a follow-up appointment with outpatient behavioral health was made and no evidence the mission/homeless shelter was informed of the discharge plan prior to transport.

An interview with a Discharge Planner (Staff SS) on 06/16/2022 at 2:50 PM revealed Staff SS was working at the time of the incident and was involved with the discharge planning for Patient 1. Staff SS stated case management could not find placement for the patient and the family would not let the patient return home. Staff SS stated the physician discharged Patient 1 and Medicaid transport conducted the transportation to the mission/homeless shelter. Staff SS gave no explanation or justification why Patient 1 discharged on a Sunday on 4/12/2020 and provided no evidence of the justification to show the discharge plan had been documented by all disciplines and/or discussed with guardianship.

During an interview with a Licensed Professional Counselor (Staff JJ) on 06/16/2022 at 3:00 PM, Staff JJ gave his professional opinion that leaving a voice message for guardianship to say a patient had been discharged was "not enough." Staff JJ stated he conducted the psychiatric-biosocial assessment for Patient 1 at the time of admission and the patient attended groups with no aggressive behaviors. Staff JJ stated law enforcement brought Patient 1 to the behavior unit for threatening behaviors at home, but Patient 1 did not act out while at the facility. Staff JJ stated he was not involved with the patient's discharge on 04/12/2020.

During an interview with Registered Nurse (Staff BB) on 06/16/2022 at 3:20 PM, Staff BB stated the facility seldom discharged patients on the weekends. Staff BB stated case management staff planned for discharges and follow up appointments. Staff BB stated when patients reported having a guardian, staff entered the guardian information, but staff did not always know when a patient had a guardian. Staff BB stated nursing staff conducted discharge education at the time of discharge to include medication education. However, the nurse for Patient 1 was not able to set up a behavioral health follow-up appointment because it was a holiday and the offices were closed. Staff BB gave no explanation why the mission/homeless shelter was not notified of the transport or why the patient was discharged without guardianship notification. Staff BB stated staff typically made attempts to reach guardians and often left voice messages because guardians seldom answered their calls.
During an interview with the Chief Nursing Officer (CNO) Staff (GG) on 06/16/2020 at 2:30 PM, Staff GG stated there was no complaint or grievance received from the guardian during April 2020 and the facility was not aware of any concerns regarding the discharge of Patient 1. Staff GG stated facility discharge planners arranged for Medicaid contractors to transport Patient 1 upon discharge, and transporters did not report any problems related to the transport. Staff GG stated guardians often got angry about discharges on weekends and holidays. Staff GG stated, "We are an acute short-term facility, so we can't just hold patients or Medicaid would want to know why." Staff GG stated April 2020 was a challenging time to find placement because all personal care homes had shut down and nursing homes were not accepting admissions. Staff GG gave no justification regarding why Patient 1 discharged on Sunday 04/12/2020 and/or why the discharge was not discussed by all disciplines and guardianship. Staff GG stated it was too far back to remember, but she believed staff just failed to properly document.

During a telephone interview with the Mission Homeless Shelter on 06/17/2022 at 9:30 AM, the Director of the Mission (Staff KK) stated the mission had so many individuals who came and went "it would be impossible to find a patient coming from the hospital in April 2020." Staff KK stated the homeless shelter was not accepting anyone from behavior units during the Covid-19 pandemic during that time. Additionally, Staff KK stated patients on psychotropic medications could not enter the homeless shelter. Staff KK stated if a patient was denied entry, it would be protocol to call the police to come pick up the patient.

A telephone interview conducted on 06/16/2022 at 12:15 PM with Patient 1's representative revealed the facility in question left a voice message on his/her phone saying Patient 1 was discharged to a mission shelter on Sunday, 04/12/2020. The representative denied receiving the phone message until he/she returned to work the following morning and stated he/she would not have approved of the discharge to the mission/homeless shelter. The representative stated Patient 1 was a ward of the state. The representative stated the mission shelter was the last location on file for discharging to and no one discussed this with the representative. The representative stated the hospital did discharge patients when hospital staff believed a patient was no longer a threat to self or others, but seldom discharged on the weekends. The representative stated the homeless shelter was on file as a location for discharging Patient 1, but noted this was on file prior to the representative taking over and the representative did not think Patient 1 could stay at a homeless shelter.