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ALASKA PSYCHIATRIC INSTITUTE 3700 PIPER STREET ANCHORAGE, AK Jan. 30, 2019
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


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Based on record review and interview the facility failed to identify an adequate discharge plan for 1 patient (#7), who was admitted to the facility under an Ex Parte order (Court order for temporary custody for emergency psychiatric examination/treatment for up to 72 hours from the time the Ex Parte order is signed), out of 1 Ex Parte discharge reviewed. Specifically, the facility failed to evaluate and identify a patient for whom the lack of an adequate discharge plan is likely to result in an adverse impact on the patient's health. This failed practice placed this vulnerable patient at risk to harm self or others and affected the patient's health and overall wellbeing. Findings:

Record review on 1/28-30/19 revealed that Patient #7 was admitted to the facility under an Ex Parte order due to grave disability (when a person's mental disorder prevents him/her from providing for his/her own basic life-sustaining needs, such as food, clothing, and shelter).

The Ex Parte was petitioned by the Anchorage Jail Complex after Patient #7 was detained for assaulting a police officer outside of the Brother Francis Shelter when he/she was not allowed access to the shelter. While at the jail, Patient #7 expressed thoughts of wanting to harm himself/herself and stated he/she would wrap a sheet around his/her neck. The Patient was placed on full suicide precautions during his/her stay in the jail.

Record review revealed Patient #7 was admitted into the Alaska Psychiatric Institute (API) Admissions & Screening Office (ASO) on 12/20/18 and an assessment was completed at 1:20 pm. The "ASO Assessment" indicates: " ...Concerns exists today that [he/she] is incapable of knowing how to care for [his/her] basic needs. [His/her] inability to verbalize reality-based answers is lacking ...[His/her] lack of insight regarding [his/her] mental illness, ability to care for [himself/herself], demonstration of impulsive thoughts, actions and behavior places [him/her] at a level of grave disability at this time ...[He/she] is unable to say how [he/she] would meet basic needs upon release ..."

Review of Patient #7's medical record revealed a "LIP [Licensed Individual Practitioner] Discharge Summary," dated 12/20/18 (signed 1 hour and 3 minutes after the ASO Assessment) at 2:23pm, which documented: "[He/she] clearly is able to state how [he/she] will care for [himself/herself] in the shelter setting. States [he/she] will stay at Brother Francis shelter if [he/she] is allowed to return there. Otherwise, [he/she] is aware of the HOPE ...shelter. States [he/she] can obtain food at Beans Caf...[he/she] is able to state how to get [his/her] needs met while living homeless. [He/she] clearly is not gravely disabled ...[He/she] states multiple times that [he/she] is not suicidal and has recently not been suicidal."

Additional review of the "LIP Discharge Summary," dated 12/20/18, documents Patient #7 blamed the LIP for the assault on the police officer, "You made me do it!" Also there is documentation that the Patient believed he/she was pregnant and when reminded of a negative pregnancy test, he/she cursed out the LIP. Prognosis for Patient #7 was documented as "Prognosis continues to be extremely poor due to [his/her] lack of medication compliance, history of violence, acting out when [he/she] does not get [his/her] way."

Further review revealed a final diagnoses of [DIAGNOSES REDACTED]] for Housing" and "Schizophrenia ...[A serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling]."

Review of the "SW [Social Worker] Discharge Planning Note," dated 12/20/18 at 2:03 pm, revealed: " ...LIP has ordered [patient] to be discharged from [Alaska Psychiatric Institute] and provided a cab voucher to the Brother Francis Shelter as [patient] is not currently a danger to [himself/herself] or others and does not meet criteria for admission at this time ...It is recommended that [patient] continue to follow up with [BURT - Behavioral Emergency Response Team] team."

Review of the "SW Discharge Summary," dated 12/20/18 at 4:13 pm, revealed: "DISCHARGE PLAN: Patient will be discharged on [DATE] to the Brother Francis Shelter and will take a taxi there ...[He/she] had an appointment with the BURT team on the day of [his/her] last discharge, [12/13/18], but did not make it to [his/her] appointment, despite [his/her] taxi going directly there at the time of discharge ..."

Continued review of Patient #7's medical record revealed an "ASO Assessment," dated 1/10/19 at 3:35 pm, which documented that the Patient was taken to the Alaska Native Medical Center (ANMC) via police 11 days after the 12/20/18 discharge, on 12/31/18, after attempting to assault someone at an assisted living home with a pair of scissors. The Patient had cut off all of his/her hair, was actively psychotic (with the belief he/she had [DIAGNOSES REDACTED]), and hallucinating. He/she talked to imaginary people and continued to have delusions he/she was pregnant. He/she also stated he/she needed to get his/her seven children back from the gypsies. The Patient was unable to say when he/she ate last and he/she also believed it to be Thanksgiving Day. ANMC requested an Ex Parte, which was granted on 1/1/19 at 9:37 pm, due to the likeliness that the Patient may cause serious harm to others and due to being gravely disabled. Patient #7 was readmitted to API on 1/10/19.

During an interview on 1/30/19 at 10:45 am, the Director of Psychiatry (DOP) stated Patient #7's discharge on 12/20/18 from the ASO office, was not good practice. The DOP identified Patient #7 as "very vulnerable" and the DOP stated he/she was not included in the decision to discharge the Patient from the ASO to the shelter. Upon the 1/10/19 admission, the DOP stated he/she assigned a different LIP to the Patient to ensure "better care" was provided.

Review of the facility's policy, "Screening Court-Ordered Admissions," dated 6/15/2015, revealed: "III. All persons seeking or referred for admission who are mentally ill, as defined in [Alaska Statute - AS] 47.30.915 (12), and are likely to cause serious harm to themselves or others, as defined in AS 47.30.915 (10), and/or are gravely disabled, as defined in AS 47.30.915 (7), shall be admitted to API when no less restrictive treatment alternative is available in the community consistent with the person's treatment needs. IV. Persons sent to API on an emergency detention request [i.e., on a legally correct Ex Parte order or a screening order of a Superior Court Judge (see 47.30.700)] shall be admitted for further evaluation. The screening order may be signed by a magistrate pending Superior Court Review ..."

Additional review revealed: "COURT-ORDERED REFERRALS-COMMUNITY ACQUIRED: B. All patients with community acquired Ex Parte orders that present to API are to be admitted without exception."

Review of AS 47.30.915 - Definitions, dated 2008, revealed: "(12) "mental illness" means an organic, mental, or emotional impairment that has substantial adverse effects on an individual's ability or exercise conscious control of the individual's actions or ability to perceive reality or to reason or understand; mental retardation, epilepsy, drug addiction, and alcoholism do not per se constitute mental illness, although persons suffering from these conditions may also suffer from mental illness; (10) "likely to cause serious harm" means a person who (A) poses a substantial risk of bodily harm to that person's self, as manifested by recent behavior causing, attempting, or threatening that harm; (B) poses a substantial risk of harm to others as manifested by recent behavior causing, attempting, or threatening harm, and is likely in the near future to cause physical injury, physical abuse, or substantial property damage to another person; or (C) manifests a current intent to carry out plans of serious harm to that person's self or another; (7) "gravely disabled" means a condition in which a person as a result of mental illness (A) is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, or personal safety as to render serious accident, illness, or death highly probable of care by another is not taken; or (B) will, if not treated, suffer or continue to suffer severe and abnormal mental, emotional, or physical distress, and this distress is associated with significant impairment of judgement, reason, or behavior causing a substantial deterioration of the person's previous ability to function independently."

Review of AS 47.30.700 - Initiation of Involuntary Commitment Procedures, dated 2008, revealed: "(a) Upon petition of any adult, a judge shall immediately conduct a screening investigation or direct a local mental health professional employed by the department or by a local mental health program that receives money from the department under AS 47.30.520- 47.30.620 or another mental health professional designated by the judge, to conduct a screening investigation of the person alleged to be mentally ill and, as a result of that condition, alleged to be gravely disabled or to present a likelihood of serious harm to self or others. Within 48 hours after the completion of the screening investigation, a judge may issue an ex parte order orally or in writing, stating that there is probable cause to believe the respondent is mentally ill and that condition causes the respondent to be gravely disabled or to present a likelihood of serious harm to self or others. The court shall provide findings on which the conclusion is based, appoint an attorney to represent the respondent, and may direct that a peace officer take the respondent into custody and deliver the respondent to the nearest appropriate facility for emergency examination or treatment. The ex parte order shall be provided to the respondent and made a part of the respondent's clinical record. The court shall confirm an oral order in writing within 24 hours after it is issued. (b) The petition required in (a) of this section must allege that the respondent is reasonably believed to present a likelihood of serious harm to self or others or is gravely disabled as a result of mental illness and must specify the factual information on which that belief is based including the names and addresses of all persons known to the petitioner who have knowledge of those facts through personal observation."

Additionally, upon review of the facility's policy "Screening Court-Ordered Admissions," dated 6/15/2015, it was noted the policy referred the 2008 versions of AS 47.30.915 - Definitions. Review of the updated AS 47.30.915, dated 11/15/2016, revealed "mental illness" is now located at AS 47.30.915(14), "likely to cause serious harm" is now located at AS 47.30.915(12), and "gravely disabled" is now located at AS 47.30.915(9). The terminology of all three definitions remains the same with the exception of "mental illness" which removed the term "mental retardation ..." and replaced it with "intellectual disability, developmental disability, or both ..." AS 47.30.700 - Initiation of Involuntary Commitment Procedures also had an updated version, dated 2016. The terminology remained the same.
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