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 interview, record review and review of facility policy, the facility failed to notify a patient legal guardian, and failed to notify the receiving facility of a patient discharge prior to the patient's discharge for 1 of 6 sampled patients (#1).


Patient #1's record revealed he was admitted to the facility under a Baker Act by Law enforcement. The psychiatric examination documented a diagnosis of [DIAGNOSES REDACTED]" A Certification of Competence was completed by the physician on 4/16/19 that documented the patient as "Incompetent".

The Therapist's notes, dated 4/16/19 at 8:12 AM, reflected an assessment of the patients previous living arrangements which revealed a group home placement with name address, and contact name and telephone number. The note documented the patient's grandmother by name and phone number. There was no mention of a guardian for the patient.

A Therapist note dated 4/16/19 at 9:20 AM, documented the grandmother stated she was aware the patient was at the hospital, discussed why he needed the group home, gave the name of his therapist and stated, "That's where he needs to be discharged to." There was no documentation regarding guardianship of the patient.

A Therapist note dated 4/16/19 at 9:23 AM documented the patient's Therapist was contacted, was aware the patient was at the hospital, and stated the patient could return to their facility upon discharge. The note documented that "transportation can be provided for client at discharge". There were no further Therapist notes for the patient prior to his discharge in the record.

Review of the physician's orders showed a discharge order was entered in the medical record on 4/17/19 at 4:06 PM.

A post discharge hospital Therapist note, dated 4/17/19 at 4:43 PM, read, "Contacted client's inform him that the client was discharged from (name of hospital) and while in off the transportation before reaching his destination." The note also indicated the receiving facility therapist stated he had not received fax information of the patient's medication record. The note reflected that the information had already been faxed.

A post-discharge hospital Therapist note, dated 4/17/19 at 4:45 PM, reflected that the therapist attempted to contact the guardian, left a voice message informing the client was discharged to his group home via hospital transportation, and "got off the transportation before arriving to his destination". There were no further Therapist or discharge planning notes in the patient's medical record.

On 8/13/19 at 12:15 PM, the Risk Manager (RM) and the Vice President (VP) of hospital acute care related that after the patient was discharged , he was taken downstairs by staff and escorted by staff to their hospital van that was outside the front door of the hospital. He was placed in the van with the driver to go to his group home. They related the patient refused to be transported to the group home and got up and out of the van and started walking towards the street. They related the driver immediately called his supervisor who in turn called the discharging unit to inform the Therapist and nursing staff. They related the Therapist called the group home to report the event and it was decided that the group home would call the police, and the Therapist would call the patient's guardian.

Patient #1's medical record did not reflect that neither the group home nor the guardian were contacted by the therapist or a hospital representative, to inform them of the patient's final discharge order, arrangements for transportation, and the date and time of expected discharge prior to the actual discharge. Patient #1 was documented as incompetent on the competence evaluation, and had a guardian in place prior to his hospitalization .

Review of facility's policy "Discharge/Transition Planning for Acute Care Programs" revised 11/27/18, read that the "The purpose of the procedure is to provide a process for discharge/transition panning for clients to begin upon admission and continue through discharge form an inpatient setting. The primary goal of discharge/transition planning is to facilitate the client's return to the community by linking with needed community services and decrease the need for readmission....The assigned staff person will review the discharge/transition plan with the client at the time of discharge."