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 record review and interview, in 1 (one) of 11 (eleven) medical records (MR)rewiewed, it was determined that the CPEP ( Comprehensive Psychiatric Emergency Program ) failed to ensure the safe discharge of mentally impaired psychiatric patients.

Findings include:

Review of MR #A on 9/25/15 identified that this patient, diagnosed schizophrenia with reported IQ (intelligence quotient ) of 41, was discharged alone from the CPEP to the street on 7/24/15 at 1055 AM with a Metrocard, without notifying the family or guardian. The CPEP nursing triage note written on 7/24/15 at 0003 hours ( 12:03 AM ) stated "Patient is illiterate and was unable to state his address or his correct age. Patient is a poor historian."

The documentation stated the patient was given discharge instructions which were "understood by the patient " and are signed with an " X." The mark " X " is found on multiple CPEP forms that are complex and needed to be explained to the patient and there is no documented evidence that this was done. He was given " transportation money " by the social worker" and there was no documented re-assessment of his inability to report his address or how to get home . Review of the record found no specific discharge instructions regarding medications received or prescribed or any specific follow up.

At interview with Staff #3, CPEP Psychiatric Director, on 9/30 /15 at 2:00 PM, it was stated the CPEP attending physician failed to communicate with the PA (Physician Assistant) prior to discharging the patient, as to the specific need for a family member to accompany the patient home due to mental retardation. He further stated that in his investigation of the incident that the PA was aware of the patient's guardian's specific request that he be notified of the patient's discharge in that the patient was mentally retarded.