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.

NEW HANOVER REGIONAL MEDICAL CENTER 2131 S 17TH ST BOX 9000 WILMINGTON, NC 28402 Jan. 23, 2019
VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, closed medical record review, and staff interviews, the facility staff failed to discuss the patient's treatment plan with the legal guardian in 1of 1 (Patient #6) patients.

The findings include:

Review of the hospital policy, "Patient Bill of Rights and Responsibilities" with revision date of 08/2017, revealed "...Parents and guardians have the right and responsibility to participate in the treatment process. This includes planning and course of treatment, remaining informed about the progress of the treatment and physical participation in the delivery of certain types of care and treatment...."

Review of closed medical record on 01/24/2019 revealed named patient (Patient #6) a [AGE] year old male with history at named hospital for psychosis, delusions and depression was admitted on [DATE] via IVC (Involuntary Commitment) for "currently illogical and delusional and hard to follow in conversation." Review of Psychiatry History and Physical dated 11/30/2018 at 1122 revealed patient was "homeless and living in the woods in a tent." Review of letter written by psychiatrist dated 12/12/2018 revealed "...Patient has had several psychiatric hospitalization s related to untreated psychosis and nonadherence with medication. He is homeless in large part due to his delusional beliefs about himself and the world. He does not believe that he needs to take the steps required to secure the necessities of daily life to maintain health and well being. His decision-making is guided by his delusional beliefs, which are immutable. Therefore, in my professional opinion he (1) lacks capacity to manage his affairs, to make important decisions regarding his person, family, property, and (2) lacks capacity to secure and maintain his basic daily personal needs to maintain health and well-being..." Review of the "Letter of Appointment Guardian of the Person" with date of qualification from "Judge of Probate" of document was signed on 01/14/2019 indicating Patient #6 was deemed "incompetent." Review of the guardian document revealed "...The guardian of the person is fully authorized and entitled under the laws of North Carolina to have the custody, care and control of the ward,..." Review of discharge instructions dated 01/17/2019 at 1130 revealed Patient #6 signed document confirming "Patient received a copy of the After Visit Summary."

Review of Social Worker note dated 01/17/2019 at 1009 revealed "Sw (sic) spoke with attending MD (physician) this morning regarding pts (Patient's) discharge plan. Plan is for pt to meet with (Mental health outpatient department) at 1030 this morning then discharge to (shelter). (County DSS--Department of Social Services) is planning to be here for the meeting with the (Mental health outpatient department); they will need to sign paperwork as his guardian....Sw (sic) contacted charge nurse to request a sitter during pts intake with the (mental health outpatient) Team."

Review of Progress notes dated 01/17/2019 at 1148 (18 minutes after patient discharge) by involved social worker (SW #1) revealed "Sw brought (outpatient mental health team member) and (named hospital's social workers) and pt into a room for meeting. 10:30-11:30 am. Pt discharged to (shelter) following meeting...Sw informed (outpatient mental health department team member) on the phone..."

Interview on 01/24/2019 at 1143 with involved social worker (SW #1) revealed the meeting was held on day of discharge with social workers, who were the guardians. Interview revealed patient was discharged to shelter after the meeting. Further interview revealed guardians who attended the meeting were not told during the meeting of the plan to discharge the patient to the shelter that day.

Discharge nurse was not available for interview.

Interview on 01/24/2019 at 1255 with involved APS (Adult Protective Services-evaluates reports of abuse and protects citizens) worker revealed on the day of the meeting, the discharge plan for the patient to be discharged to a shelter was not discussed. Interview revealed they "never told us that he would be leaving that day" to a shelter.

Interview on 01/24/2019 at 1330 with CNO (Chief Nursing Officer) revealed patient's guardian should have been made aware of the plan to discharge patient to a shelter. Interview revealed patient should not have signed the discharge paperwork due to the patient's incompetent status and having a guardian. Interview revealed documentation in the chart of the guardian status and the staff was aware of the guardian status.

NC 682
NC 327