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.

DAVIS REGIONAL MEDICAL CENTER 218 OLD MOCKSBVILLE RD PO BOX 1823 STATESVILLE, NC 28687 July 9, 2015
VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and staff interview, the hospital staff failed to ensure guardian notification prior to discharge for 1 of 1 patient (#3).

The findings include:

Review of the hospital policy, "INVOLUNTARY COMMITMENT" with a review date of November 2014 revealed, "I. Purpose: ...II. Scope: ...III. Guidelines (Procedures): ...K. Notify the family of the transfer and rational for the transfer occurring.
Closed medical record review conducted July 7, 2015 revealed Patient #3, a [AGE] year-old presented to the named hospital Emergency Department (ED) on May 21, 2015 at 0535 under Involuntary Commitment (IVC) from an acute care hospital due to mental illness and dangerous to self or others. Review of "LETTERS OF APPOINTMENT GUARDIAN OF THE PERSON" dated April 10, 2002 revealed the named patient had a legal guardian. Review revealed the Psychiatrist presented to the ED and evaluated the named patient and at 1524, the named patient was admitted to the adult psychiatric unit with an admitting diagnosis of Bipolar Disorder, Mixed (excitement and depressed). Review of progress notes revealed at 2039, the named patient reported [sibling] as Power of Attorney (POA), Payee and guardian. Review revealed on May 22, 2015 at 0830; the guardian gave verbal consent for treatment and at 0920, the Psychiatrist performed a second examination; in which the named patient status was changed to voluntary commitment. Further review of progress notes revealed at 1742, the named patient reported [sibling] was the support system. Review revealed on May 29, 2015 at 1400, the Social Worker (SW) #1 spoke with [sibling] related to discharge planning; at which time, the [sibling] stated the named patient could not live with them. Review revealed SW #1 stated referrals for Assisted Living Facilities (ALF) placement in the area (county of residence) would be sent out and the [sibling] would be updated. Review revealed on June 2, 2015 at 1700, ALF #1 visited the named patient while on the psychiatric unit and accepted the named patient as a resident to their facility. Further review revealed the anticipated discharge date and time was June 3, 2015 at 1400. Review revealed on June 3, 2015 at 1410, the named patient was discharged from the named hospital accompanied by ALF #1 staff with personal belongings and discharge instructions with prescriptions. Record review failed to reveal the guardian was notified of Patient #3 discharge from the named hospital to an ALF.

Telephone interview conducted July 8, 2015 at 1023 revealed Patient #3 discharge was performed by social worker #2. Telephone interview revealed social worker #2 failed to notify the guardian of Patient #3 discharge from the hospital to ALF.