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LONGLEAF HOSPITAL 44 VERSAILLES BLVD ALEXANDRIA, LA June 23, 2016
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on record review and interview, the hospital failed to meet the requirement for the Condition of Participation for Discharge Planning as evidenced by failure to ensure the patient's discharge plan was reassessed for factors affecting the continuing care needs of the patient. This deficient practice was evidenced by the hospital's discharge of Patient #F2, to her home, after the patient's mother expressed to the hospital staff, prior to patient discharge, that she did not want Patient #F2 discharged home due to the patient's violent behavior and threats Patient #F2 had made to "kill her". (See findings under tag A-0821).
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the hospital failed to ensure the patient's discharge plan was reassessed for factors affecting the continuing care needs of the patient. This deficient practice was evidenced by the hospital's discharge of Patient #F2, to her home, after the patient's mother expressed to the hospital staff, prior to patient discharge, that she did not want Patient #F2 discharged home due to the patient's violent behavior and threats Patient #F2 had made to "kill her".
Findings:
Review of the hospital policy titled Discharge Planning, Policy number TX-00-013, Last revised: 6/2/16, revealed in part:

Purpose:
Hospital discharge planning is a process that involves determining the most appropriate post hospital discharge destination for a patient: identifying what the patient requires for a smooth transition from the hospital to his/her discharge destination; and beginning the process of meeting the patient's identified post discharge needs.

Procedure:
A, Discharge plan should 1. Begin at admission 2. Prepare the patient and representative/family for the transition to next level of care. 3. Address the patient's and representative/family's need for instructions about continued treatment. 4. Delineate how progress made in the current level of care will continue after discharge. 7. Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care.
B. In developing discharge aftercare plans, the following is assessed.: 1. Aftercare service and arrangements and/or representative desires. 2. Family relationships 5. Housing and/or placement issues. 10. Personal support systems. D. Ongoing reassessments of the discharge plan based on changes in the patient's condition, changes in available support, and/or changes in post hospital care requirements will be reflected on the interdisciplinary treatment plan update every 7 days or before seven days if required.

Review of Patient #F2's medical record revealed an admission date of [DATE] and a discharge date of [DATE] with an admission diagnosis of intermittent explosive disorder.
Patient #F2's legal status was PEC on 4/26/16 at 1:10 a.m. with a history of present illness as follows: [AGE] year old brought in by police states Mom kicked her out of home, Mom told staff that pt. ran away, tried to hit mom and put on social media that she wanted to kill Mom. Further review revealed the patient was documented as currently homicidal, violent, unwilling to seek voluntary admission, and dangerous to self and others. Further review of Patient #F2's medical record revealed a legal status of CEC on 4/27/16 at 5:59 p.m. Patient status was documented as currently homicidal and violent, unable to seek voluntary admission and dangerous to others.
Review of Patient #F2's MD orders revealed the following orders:
5/2/16 7:40 p.m.: Place in 4 point mechanical restraints STAT; 1:1 observation for safety
5/2/16 7:52 p.m.: Ativan 1 mg IM STAT for severe agitation.
5/2/16 7:59 p.m. : Clarification: Ativan 1 Mg IM stat times 1 dose for severe agitation.
5/3/16 8:00 a.m.: Discharge home today on current medications with follow up.

Review of Patient #F2's psychiatric evaluation, dated 4/26/16, revealed in part:
Patient is a [AGE] year old female. She was admitted per PEC. The patient resides with mother.
History of present illness: This is first contact this hospital has had for this [AGE] year old patient with previous inpatient treatment at Hospital "a" and Substance Abuse Center "b" . Patient #F2 claims she was diagnosed with post-traumatic stress disorder, oppositional defiant disorder, conduct disorder, bipolar disorder, schizophrenia, and anxiety disorder. According to the PEC, the pt. was brought in by police after she claimed her mother kicked her out of the house but the mother expressed pt. had actually run away, tried to hit her mother and she posted on social media that she wanted to kill her mother.

Currently pt. denies feeling depressed, does not feel hopeless, helpless or worthless and has no intention of harming herself. She even minimized wanting or threatening to harm the mother stating she never posted on social media that she wanted to kill her mother. She states she was arrested twice, but does not know what for. She denies current delusions or hallucinations. There are no indications or history to suggest symptoms consistent with bipolar disorder or schizophrenia. She states she has engaged in antisocial behavior such as "doing drugs, fighting people, stealing, breaking into people's homes for money, and shooting at people".

Risk assessment: Patient is admitted as being at increased risk for harm to others (based on antisocial behavior of shooting at people, threatening others and expressing on social media that she wants to kill her mother.
Substance abuse: history: Positive for marijuana which she has been smoking "a lot on a daily basis for an unspecified length of time". Positive for Percocet and alcohol. As noted, she was at another treatment facility in 8/2015. She states she was in DCFS custody at that time, also. Previous psychotropic medications: Seroquel, Methylphenidate, Remeron, Latuda, and Clonidine.
Social history: Pt. states she lives with her mother temporarily staying with relatives due to home renovation. She reports never met biological father; Currently home schooled after she was expelled from school last year for fighting. She states she was in DCFS custody for 6 months but refused to say what for.

Mental status exam: Insight: impaired; Judgment: impaired; Impulse control: Impaired.
Provisional dx: unspecified disruptive impulse control and conduct disorder. Conduct disorder, childhood onset, Cannabis use disorder moderate; Alcohol use disorder; mild; Rule out opiod use disorder, mild, intermittent; ELOS: 7-10 days; Prognosis: guarded.
Justification for inpatient hospitalization : Potential danger to others as evidenced by threat to kill her mother. The pt. exhibits uncontrollable inappropriate behavior of poor impulse control with substance abuse, running away from home, etc.

Review of Patient #F2's family/psychosocial interdisciplinary progress notes revealed the following: 5/2/16 1:30 p.m. Social Services: SF4Counselor contacted pt's mother to discuss pt. discharging. Mother reported she did not agree with pt. discharging. SF4Counselor attempted to explain to mother that SF5Psychiatrist feels pt. has behavioral problems and not mental health problems. Therefore pt. is safe to discharge. Mother states she does not want pt. home and wants pt. sent to Long-term. Again SF4Counselor explained that this is not SF5Psychiatrist recommendations but she can send pt. for another opinion. Mother stated no and that SF4Counselor can call DCFS (Department of Children and Family Services) because pt. is not welcome to come home due to pt. threatening mother prior to admission. Mother had no other concerns or comments.
Further review of the family/psychosocial interdisciplinary progress notes revealed an entry dated 5/2/16 at 3:20 p.m. which indicated that SF4Counselor "made DCFS report due to mother stating she does not want child back in her home". There was no documented evidence to indicate who SF4Counselor was in contact with at DCFS regarding Patient #F2. In addition, there was no documented evidence to indicate that additional attempts were made to contact DCFS and speak with someone regarding the status and placement of Patient #F2. Additional review of the medical record revealed no documented evidence of attempts to place patient in any other setting other than discharge to home with mother.

Further review of Patient #F2's medical record revealed the patient was placed in 4-point restraints on 5/2/16 at 8:00 p.m. and remained in 4 point restraints until 5/2/16 at 9:30 p.m. Documentation revealed the restraints were used as a result of the patient's combative behavior including striking out at staff, throwing objects, yelling, cursing, threatening staff and doctor, thrashing about, hitting and kicking.

Review of SF5Psychiatrist's progress notes revealed the following entry: 5/2/16 7:30 p.m.: I observed Patient #F2 throw phone and tried to attack nurse. She then ran down the hall throwing objects. She was removed and put in seclusion room for medication. She started cursing, she was redirected. Then she became more agitated and came towards me as if to attack me. Thorazine 25 mg IM Benadryl 25 mg IM stat, 1:1 observation for danger to self and place in 4 point mechanical restraints for up to 2 hours.

Additional review of Patient #F2's medical record revealed the patient's discharge orders were written on 5/3/16 at 8:00 a.m. approximately 10 hours after the patient had been placed in 4 point mechanical restraints for violent and threatening behavior.

Review of Patient#F2's medical record revealed no documented evidence that a physical assessment had been performed prior to the patient's discharge. Further review revealed no documented evidence of the conditions of Patient #F2's discharge such as a summary of the discharge, inclusive of documentation of the date and time of contact with the patient's mother (prior to discharge), the patient's discharge location, mode of transportation for discharge and staff transporting the patient.

In an interview on 6/22/16 at 3:41 p.m. with SF2DON, he confirmed, after review of Patient #F2's entire medical record, there was no documented physical assessment of Patient #F2 prior to discharge and no documented narrative summarizing Patient #F2's discharge, inclusive of documentation of the date and time of contact with the patient's mother (prior to discharge), the patient's discharge location, mode of transportation for discharge and staff transporting the patient. He indicated the above referenced information should have been been documented, by the patient's nurse, in the patient's medical record.

In an interview on 6/22/16 at 8:29 a.m. with SF5Psychiatrist, he indicated Patient #F2 was a [AGE] year old who had run away from home and had been treated at several other psychiatric and substance abuse hospitals/facilities. He indicated Patient #F2's main problem was conduct disorder and violent, antisocial behavior. SF5Psychiatrist said he had witnessed Patient #F2's violent, antisocial behavior during her hospital stay. He indicated Patient #F2 had become angry, attacked a nurse, and had been coming after him. SF5Psychiatrist said he had placed Patient #F2 in 4 point restraints on 5/2/16. He indicated Patient #F2 had been engaging in antisocial behavior, prior to hospitalization , which included drug usage, stealing, home invasion, and shooting at people. SF5Psychiatrist indicated Patient #F2's diagnosis at discharge was unspecified, destructive impulse control and conduct disorder. He said pt. lies repeatedly, is manipulative, and is extremely antisocial. He said he called the patient's mother on 5/2/16 and informed the mother of his plan to discharge the patient home. SF5Psychiatrist indicated he had told the mother she could get a second opinion because he had not seen any symptoms of bipolar disorder or schizophrenia. He said a report was made to DCFS but they are slow to respond to reports. He indicated he had told Patient #F2's mother to call the police and that would get the Office of Juvenile Justice involved. He also indicated he had told the patient's mother she could petition the court to declare the patient ungovernable.

In an interview on 6/22/16 at 11:00 a.m. with SF4Counselor, she indicated she remembered Patient #F2 had acted out with SF5Psychiatrist while hospitalized . She indicated Patient #F2 ' s mom had not wanted her daughter back home. SF4Counselor said she explained the situation to SF5Psychiatrist and he told her to call DCFS to file a report, but he intended to send the patient home. SF4Counselor indicated SF5psychiatrist told her the mother can't say she doesn ' t want the child anymore based on behavioral issues. SF4Counselor indicated in the past the hospital has kept patients and had " just eaten the cost " to see if the family would calm down in order to allow discharge home. SF4Counselor indicated they did not allow the " cooling off ' period with this case. She said they have also tried, in the past, to fast track/find emergency placement but DCFS had told them they don't have emergency placement capabilities. She said they have also tried to place the patients with relatives instead of going back to into the home because DCFS is slow to find placement. She indicated no alternate placement options were explored for this patient.