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.

THE VINES HOSPITAL 3130 SW 27TH AVE OCALA, FL 34474 Aug. 1, 2017
VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
Based on interview, medical record and policies/procedures review, the facility failed to discuss the results of the discharge evaluation with the individual acting as the patient's representative for 1 of 9 patients (Patient #5).

Findings:

A record review was conducted for Patient #5. The review showed that Patient #5 was Baker Acted by the Sheriff's Office for being a danger to herself and others. History included dementia with behavioral problems. Patient #5 had been living with her son for the past 6 months. In the 48 hours prior to being admitted to the facility, Patient #5 was having hallucinations Patient #5 also expressed homicidal ideation toward her son and thought he was not her son. Patient #5 took a knife her son. Review by psychiatric physician showed that Patient #5 is is unable to take care of herself and does have a homicidal risk because of her aggression, psychosis and impulsivity. Patient #5 had to be hospitalized in an acute psychiatric unit as she was considered a danger to herself and others. A loose piece of paper in the chart showed that Patient #5 had taken a knife to her son and cut his arm, Patient #5 was verbally abusive toward her son, and Patient #5 has a history of 3 suicide attempts. Review of daily shift nursing sheet showed that on 7/19/2017 Patient #5 was determined to not be able to take care of herself. On 7/19/2017, Patient #5 was sent by taxi to her home that she shared with her son. A well being check was requested by the facility. When the police arrived to the home of Patient #5, she told the police that she was scared and did not want to get out of the cab. Patient #5 was then Baker Acted to the facility on ce again.

During an interview on 07/31/17 at 2:52 PM, the Director of Clinical Services/Social Services stated she contacted the son on 7/13/2017. The son stated Patient #5 could not come home due to pulling a knife on him.
On 7/17/2017 at 8:30 AM, Therapist tried to contact son, message left.
On 7/18/2017 at 11:10 AM, Therapist again tried to aging reach son and message left.
On 7/19/2017 at 4:15 PM, Therapist contacted the police for a well check to the home, when the police arrived at home the home health RN was at the home. At the time that Patient #5 was at the home, there was no one at home, messages left with son by the Sheriff's Office. The Sheriff's Deputy then Baker Acted the patient back to the facility at 11:08 PM.

During an interview on 8/1/2017 at 1:00 PM, Director of Clinical Services and Social Services stated that Patient #5 needed to be discharge, there was no further services from the facility needed. Since this was the address on her face sheet, she was discharged to the address. When asked if they had talked to the son since 7/13/2017, the Director of Clinical Services/Social Services stated she had only left messages for the son, but felt this was a safe discharge. The Director of Clinical Services/Social services stated that home health would be at the home and the Sheriff's Office would do a well check on Patient #5. The patient was discharged in a cab with child proof locks.

Review of the discharge planning notes and collateral contact notes showed there was no contact with the son of Patient #5 after 7/13/2017, but only messages were left and Patient #5 was discharged home on 7/19/2017 with no contact made with the son.

A review of facility's policy titled "Discharge planning" revised 4/2017 showed criteria for discharge is determined by the Treatment Plan, the process of discharge planning immediately following the evaluation of all patients. The Treatment Team determines individualized criteria for discharge at the time the treatment plan is started. If patient is returning to a stable family and/or living arrangement, or if the patient is returning home, both patient and family have to have been involved in discharge planning.