The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on record review and interview, the facility failed to ensure family or legally authorized person (LAP) was notified at the time of the patient's discharge or transfer from the hospital for 2 of 10 sampled patients (#1 & 2).


1. Review of patient #1's medical record showed he was admitted from the emergency department (ED) and sent to medical-surgical unit (first floor) for altered mental status and Baker Acted on 1/02/14 at 1:15 p.m. He was medically cleared on 1/04/14 at 12:06 p.m. with the Baker Act clock starting and then discharged on [DATE] at 12:50 p.m. Documentation showed patient #1 was determined to be incompetent in 2007. At the time of the discharge, there was no documentation patient #1's legal guardian was notified and informed when or where the patient was being discharged .

Review of the case management notes dated 1/03/14 at 3:53 p.m. revealed the case manager spoke with the guardian by phone "who stated that patient comes from a nursing home and plan is for patient to return back on discharge and will fax advanced directive to case manager....Talked with the nursing home that patient may return back upon discharge if Baker Act is lifted and psychiatric medications are addressed by psychiatry." At 7:31 p.m. on 1/03/14, there was an addendum which indicated the case manager offered and faxed a skilled nursing facility choice list to the patient's guardian. The case manager also received guardian court papers from patient's guardian and placed them in patient's chart under legal section."

On 1/04/14, the case manager notes read, "Patient transferring to inpatient psych. Case manager called inpatient handoff report that discharge plan is to return to nursing home once baker act is lifted."

On 1/06/14, the case manager notes indicated the patient was to be sent to an out of the area acute care psychiatric hospital but there was no documentation of discussion or notification of the guardian either the day before or the day of the discharge.

During a phone interview on 3/03/14 at 11:30 a.m., the psychiatric intake supervisor said the patient was violent during his stay. He was denied admission to the admitting facility due to the physician review and the patient was not appropriate for the unit. She said he was too violent for admission to this unit, so he was transferred to a stand alone psychiatric and substance abuse hospital in another county. She said the physician does not usually document the reason for the denial of admission in the medical record. She also said it was determined the patient needed a private room. During a later interview, the psychiatric intake supervisor said the reason local facilities were not contacted for placement was because the patient had a diagnosis of dementia and the intake case managers know local facilities will not accept this type of patient.

During an interview on 3/03/14 at 2:10 p.m., the risk manager confirmed there was no written documentation of the notification of the patient #1's legal guardian prior to the discharge to the receiving hospital.

During a phone interview on 3/03/14 at 3 p.m., the assistant director of the business operation of Behavioral Health said there is no specific policy addressing notification of a guardian or family of a Baker Acted patient. She said legally the hospital is not obligated to notify the family or guardian. She said the receiving hospital has that responsibility to make the notifications.

During a phone interview on 3/05/14 at 12:30 p.m., the director of case management said case managers have not always been involved in the discharge transfer of all patients because sometimes it occurs after hours that a bed is found. She said currently, as of yesterday 3/03/14, it was an identified problems of not notifying family or guardians of the discharge or destination. She said staff thought they were violating HIPAA in disclosing this information to family and guardians when the patient was Baker Acted.

During an interview on 3/04/14 at 12:30 p.m., the case manager said normally Baker Acted patients are not given choices regarding where they are transfer to on discharge. She said if they are coherent and able to request a specific facility, she would notify the intake coordinator with that request. She said intake coordinators are responsible for finding the beds for the patient.

2. Review of patient #2 showed she was admitted on [DATE] 12:11 p.m. with medical clearance on 1/15/14 at 10:30 a.m. and transferred back to psychiatric medical unit. On 1/22/14, she was ordered by the court for 3 weeks of inpatient care at another acute care facility. The final discharge was on 1/23/14 at 2:51 p.m. The patient was declared incompetent on 1/16/14 at 3 p.m. A legal guardian was appointed on 1/23/14 for the patient since the family refused to be responsible. Review of the medical record showed the patient guardian was not notified until 1/24/14 at an unknown time, one day after the patient was transferred to another facility.

Review of the hospital policy "Development and Delivery of the Patient Plan of Care -Inpatient", dated as last reviewed 1/09/14, read under Interdisciplinary Screening/Assessment - Mechanisms used to identify Case Management assessment for discharge planning include, but are not limited to....Patient/family requests" and "Case Management chart reviews."

Review of the hospital "Discharge Planning", dated as last reviewed 2/28/14, read, "Case Management Responsibilities for Discharge Planning - The registered nurse, social worker, or other appropriately qualified personnel (as defined in the job description) conducts and coordinates discharge planning evaluations and high risk screenings on patients identified by their physician, families, healthcare team, or community resources", "Patient/LAPs (legally authorized persons" shall be actively involved in the discharge planning process and their choices are encouraged and supported" and "Inform patients/LAPs of their right and responsibilities including the right to appeal their discharge."

Review of the hospital policy "Patient Rights and Responsibilities", dated as last reviewed 4/24/13, read, "Participation - The patient has the right to be informed about and participate in decisions regarding his/her care. When the patient is either incompetent, incapacitated, or a minor, the patient's rights shall be exercised by the legally authorized person...."

Review of the hospital policy "Transfer to Non-Florida Hospital Medical Facility at Discharge, dated as last reviewed 11/19/13, read under Patient Consent to Transfer, "The physician shall obtain consent to transfer from the patient/legally authorized person ....The physician shall document....1-Why the transfer had to be made; 2-The patient is unable to provide consent and the legally authorized person is unavailable to provide informed consent; or 3-There is insufficient time to obtain the consent of the legally authorized person. Note: A patient under the Baker Act or Marchman Act or in legal custody may be asked but is not required to sign the Patient Transfer/Transport form."