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LIFESTREAM BEHAVIORAL CENTER 2020 TALLY RD LEESBURG, FL 34748 Aug. 21, 2012
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure appropriate placement and continuity of care for one of 10 discharged patients (patient #1).

Findings:

A review of Patient #1's records revealed the patient had told staff he had thoughts of suicide and as recently as 06/23/2012 the Licensed Practical Nurse (LPN) noted the patient answered yes to a question about suicidal ideation's and homicidal ideation's. On 06/27/2012 he communicated through his interpreter that he had thoughts of killing himself. The patient was on suicide precautions from January 2012 until July 12, 2012. He was discharged on [DATE].

On 08/21/2012 at 11:30 AM an interview with the Recovery Specialist was conducted. She stated she had problems finding placement for the patient due to the patient's medical status and his psychiatric illness. She contacted a placement company to assist with locating a suitable facility. She stated she sent the records to them and they found placement for him in an Assisted Living facility. She stated the 1823 Health Assessment and face sheet were sent to the Assisted Living facility at their request.

On 08/21/2012 at 1:50 PM during an interview with the Geriatric Specialist, Health Care Administrator for the placement company, he stated he evaluates the patients and if they are a distance away, he evaluates them by virtual sessions. He further stated he did not evaluate the subject of the complaint prior to placement. He also stated it was the responsibility of the discharging hospital and the Assisted Living Facility to exchange information regarding the patient. He said he received verbal information from the case manager about the patient and did not receive paperwork from the hospital. He had difficulty locating a facility because of income and diagnosis of schizophrenia.

On 09/04/2012 at 10:10 AM a telephone interview was conducted with the Assistant Administrator for the Assisted Living facility in Hialeah. She stated when a resident is being admitted to the facility, the forms requested are the Health Assessment information (1823) and the face sheet.

On 09/04/2012 at 2:30 PM a telephone interview was conducted with the administrator of the Assisted Living facility in Hialeah, Florida. She stated prior to accepting the patient she had talked with the Recovery Specialist, but was not told of the risk of suicide.

A review of the psychiatric evaluation revealed the patient came to the facility under a COP initiated by the physician at a medical hospital on [DATE]. The patient was admitted because he was threatening with scissors the church couple who were trying to help him. He was hallucinating auditory and visual and stated he did not take his medications regularly. He was placed on suicide precautions and was under visual observation.

A review of the Psychiatric Hospital Discharge Operational Procedure (dated 04/2009) revealed:
III. The Clinical Specialist is responsible for securing placement, setting up discharge appointments and other non-medical referrals as appropriate, discussing these arrangements with the individual and documenting the discharge arrangements on the appropriate forms and in the progress notes. The Continued Care Summary shall be completed and a copy given to the individual at the time of departure.
V. The Clinical Specialist is responsible for discharge placement and/or transportation arrangements as needed, except that this function may be performed by a case manager under other agreement. Discharge packets are forwarded to the appropriate follow-up facility via Medical Records.

A review of the Psychiatric Hospital Suicide Precautions Operational Procedure (dated 12/07) revealed:
I. Individuals identified as dangerous to self shall have suicide precautions implemented.
II. The following constitutes suggested criteria for suicide precautions: (c) any overt statement of suicidal intent made subsequent to admission to the facility.
VII. Discharge or leaves of absence from the facility shall not be granted to individuals on suicide precautions. Suicide precautions should be discontinued twenty-four hours before discharge.
VIII. Individuals on suicide precautions shall be assessed by the physician every twenty-four hours.
IX. The modification or removal of suicide precautions shall require clinical justification determined by an assessment and shall be specified by the attending psychiatrist and documented in the clinical record.

Review of the physician's order dated 07/12/2012 by the physician (MD) revealed an order to discontinue suicide precautions, continuous visual observation and the patient was to be discharged [DATE].

A review of the Health assessment dated [DATE] and signed by the MD, revealed the patient needed medication supervision, special precautions: seizures, was independent with ambulation, bathing, dressing, eating, self-care (grooming), toileting, transferring. The form indicated the patient had HIV, did not pose a danger to self or others, did not require 24 hour nursing or psychiatric care. The Health Assessment also indicated the individual's needs could be met in an assisted living facility which is not medical, nursing or psychiatric. Further review revealed the individual needed assistance to perform self-care tasks such as preparing meals, shopping, making phone calls, handling personal affairs, and handling financial affairs. The Health Assessment also indicated the patient was to be observed daily for his whereabouts. The Self-Care and general oversight assessment-medications indicated the date of examination was 07/12/2012.

The Continued Care Summary dated 07/12/2012 and with a discharge date of [DATE] revealed a diagnosis: Schizophrenia, Paranoid Type and in the heading Psychosocial/Emotional: appears stable at this time. The summary did not mention risk of suicide.

A review was conducted of a copy of the fax that was sent to the Assisted Living facility in Hialeah by the hospital. The fax did not include information on the risk of suicide. It included the patient's diagnosis. Discharge destination: group home.

Based on information obtained from the complaint, patient #1 committed suicide on 07/15/2012 two days after being admitted to the Assisted Living Facility.