HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 (Pt. #1) patient records reviewed for discharge planning the Hospital failed to re-evaluate the patients discharge needs and adjust discharge plans. This failure resulted in a patient being transport to a group home care Facility in a cab, without a staff escort.

Findings include:

1. On 2/3/2020, the Hospital's policy titled "Patient/Family Discharge and Aftercare Plan" (revised by the Hospital 10/2018) was reviewed. The policy required, "The Program Therapist/RN identifies initial post discharge needs on the Initial Nursing Treatment Plan...Ongoing assessment for any changes in aftercare/discharge needs will be identified and modified in the weekly review of Plan of Care, Treatment and Services form."

2. On 2/3/2020, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 12/8/19 with a diagnosis of schizoaffective (mental health disorder) disorder.

-The "Assessment and Referral Services Admission Screening" dated 12/7/19, indicated that Pt. #1 was from a group home and had history of eloping daily from the group home. Pt. #1 was homicidal and suicidal and was placed on safety precaution for assault and homicide on admission to the Hospital.

-The Case Management note dated 12/12/19 at 11:15 AM, indicated that Pt. #1 would return to group when 1:1 could be provided.

-The Case Management note dated 12/18/19 at 4:30 PM, included, "Therapist [E #3] spoke with patient's [Pt. #1] case manager ...at [group home] as she called to let this writer know that the transport that took patient home let him [Pt. #1] off at a gas station and gave him [Pt. #1] money and that he [Pt. #1] walked home from the gas station..."

-The "Interdisciplinary Aftercare Plan," dated 12/18/19, indicated that Pt. #1 was discharged to a group home treatment Facility via an insurance provided taxi cab without a staff escort.

3. On 2/3/2020 at 2:11 PM, an interview was conducted with the Program Therapist (E #3) with the Chief Clinical Officer (E #2) present. E #3 stated that the (QIDP) at the group was contacted and asked to send a group home staff member to transport Pt. #1 for discharge to the group home. E #3 stated that the QIDP at the group home stated that a group home staff member would not be available to transport Pt. #1 back to the group home and asked if E #3 would set up transportation for Pt. #1. E #3 stated that Pt. #1's transportation to the group home after discharge was set up by Pt. #1's insurance company who provided a cab for Pt. #1's transport. E #3 stated that no staff escorted Pt. #1 to the group home.