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 interview and record review, the facility failed to discharge a patient with a history of medication non-compliance and was designated by the court as being unable to handle his own heath concerns, including insulin administration, to a facility capable of providing continuing care for 1 of 10 sampled patients (#1).


A review of the medical record of patient #1 was performed. The patient was admitted to the facility on [DATE] at 1:40 AM.

The document "Order Appointing Successor Plenary Guardian of Person and Property (Incapacitated person - no known advance directive), dated (as an order) on 7/13/15 read, "(Person's name) is hereby appointed successor plenary guardian of the person and property of (Patient #1)." Regarding the concept of an incapacitated status, an incapacitated person is an individual for whom a guardianship proceeding is initiated. Such a person has been determined by court as lacking the capacity to manage at least some of the property or to meet at least some of the essential health and safety requirements. An incapacitated person may not be able to make or communicate responsible personal decisions. S/he exhibits an inability to meet his/her own personal needs for medical care, nutrition, clothing, shelter, or safety. A plenary guardian is a person appointed by the court to exercise all delegable legal rights and powers of the adult ward after the court makes a finding of incapacity. Wards in plenary guardianships are, by definition, unable to care for themselves.

The History and Physical (H&P), dictated by the physician on 9/20/15 at 10:29 AM read, "The patient also been leaving the ALF (Assisted Living Facility) facility without informing and found missing in the neighborhood. The patient also diabetic and noncompliant to his medications.... Very poor hygiene, neglected care.... Provisional diagnoses... Schizophrenia ... Diabetes mellitus... Plan... Discussed case manager to contact the ALF (assisted living facility) for ongoing need of treatment and collaboration for placement back once patient is stable....Collaboration with behavioral case management team needed for placement back to ALF." However, there were no specific physician orders in the record for ALF placement.

Another H&P, dictated by a different physician than the preceding one on 9/21/15 at 6:27 AM read, "Continue inpatient psychiatric treatment....Continue sliding scale insulin for diabetes coverage...."

A Case Management note of 9/28/15 at 11:19 AM read, "Clinician called patient's guardian ... to inform her that patient is being discharged today. (The guardian) stated that reportedly patient is not allowed to return to the group home... he used to live at because staff said he walked out twice in the middle of the night, and administrator feels that patient needs a locked facility. Patient's guardian asked for assistance to find a safe facility for patient."

The physician discharged the patient on 9/28/15 at 11:44 AM. The order read, "unconditional discharge." The orders did not specify discharge to any type of facility. There were no additional discharge orders in the patient's medical record. The actual discharge did not take place until 10/05/15.

A Case Management note of 9/28/15 at 2:26 PM read, "Discharge planner called VA (Veterans Administration) Medical Center... and scheduled an appointment for Tuesday September 29, 2015 at 1 PM for the next level of care. Discharge packet including admission diagnosis, discharge diagnosis, med reconciliation, and patient notes were faxed to the next level of care for follow up. Patient aware and agreeable to this plan."

The document "Patient Notes and Instructions", signed by the nurse educator and the patient on 9/28/15 at 3:51 PM read, "Signature acknowledges that patient... has received these documents and verbalizes understanding....Oral medication for Type 2 diabetes." Later text indicated the patient required Levemer insulin, an injectable medication, at discharge.

The "DC (discharge) Home Instruction" was signed by the patient on 9/28/15 at 3:51 PM and read, "Being transferred to another facility: N.... Follow-up appointments... Doctor... Tuesday September 29, 2015 at 1 PM.... VA Medical Center."

A nurse's note of 9/28/15 at 6:21 PM read, "Patient was supposed to be discharged today, all paperwork and scripts prepared, awaiting for transportation. Social worker talked to guardian and said that patient was not leaving today; guardian wanted scripts to be faxed to her first, medication list given over the phone. On-call psychiatrist made aware, order given to hold discharge."

A Case Management note of 10/01/15 at 1 PM read, "The treatment team met today with patient to discuss the plan of care. Patient reported waiting to hear on housing options for discharge. Patient was advised to follow up with discharge planner."

A Case Management note of 10/05/15 at 1:37 PM read, "Discharge planner called legal guardian for patient... Discharge planner explained to guardian (patient #1) has been psych cleared and no longer meets criteria to remain here. Patient is not a danger to self or others and denies being suicidal and homicidal. (Guardian) is aware that patient was denied at numerous assisted living facilities due to patient's criminal record and inappropriate. (Guardian) has been made aware patient will be discharged to a local shelter. Patient is agreeable to this plan."

During an interview of the Case Manager on 11/17/15 at 2:30 PM, she stated that the guardian stated that she did not know what to do in the face of an inability to find an ALF or other facility. She stated that they had been trying to find ALFs or a VA (Veterans Administration) Medical foster home. She stated that the guardian had no specific requests for action and did not object to the final destination of a homeless shelter.

A Case Management note of 10/05/15 at 1:43 PM by the Case Manager read, "Discharge planner called (another facility)... and scheduled an appointment for Tuesday October 6, 2015 at 8 AM for the next level of care. Discharge packet including admission diagnosis, discharge diagnosis, med reconciliation, and patient notes were faxed to the next level of care for follow up. Patient aware and agreeable to this plan."

A Discharge Summary, signed by the physician on 10/04/15 at 11:31 AM read, "Discharge instructions. Discharge to: home.... Follow-up: As per discharge appointments."

A nurse's note of 10/05/15 at 2:16 PM read, "Patient discharged at 2:12 PM with diagnosis of Schizophrenia and given scripts. AOX4 (alert and oriented times four), calm, cooperative, denies SI/HI, educated on follow up appointments, patient verbalized importance of compliance."

Regarding the need for injectable insulin, discharge medications included Levemir.

Thus, the insulin dependent patient with a documented history of medication non-compliance and a court-ordered designation which indicated the patient was unable to manage his own health concerns was discharged to a setting which was not capable of ensuring the administration of insulin medication according to physician discharge orders. This had the potential to result in adverse outcomes for the patient.