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 document review and interview, it was determined that for 1 of 3 patient records (Pt #3) reviewed for discharge planning, the Hospital failed to ensure that Pt #3 was discharged to the appropriate facility.

Findings include:

1. On 12/3/19, the Hospital's policy titled, "Discharge of a Patient" (revised 2/2017) was reviewed and required, "...Discharge Instructions should include: Condition of patient at time of discharge i.e vital signs...Time and method of leaving the unit and accompanied by whom..."

2. On 12/3/19, Pt #3's medical record dated 10/9/19 was reviewed and indicated:

" -Pt #3 is a [AGE] year old male presented to the inpatient setting with a history of poorly controlled Bipolar Disorder. Pt #3 is an unreliable historian. Pt #3 presented with a plan to overdose on medications. Pt #3 reports he has been non-compliant with his medications. Pt #3 admits having irritable mood, racing thoughts, agitation, insomnia (problems falling asleep and staying asleep) and aggressiveness. At times, Pt #3 appears to be somewhat difficult redirectable and has very pressured speech. At times, Pt #3's behavior seems to be volatile and unpredictable. In addition, Pt #3 appears to be responding to internal stimulation ..."

-The "Psychiatric Progress Note" dated 10/13/19 at 9:13 AM indicated, " ...Pt #3's mood appears to be more stable. Pt #3 is not as agitated or restless. Pt #1 is easier to redirect ..."

-The discharge order dated 10/14/19 at 7:27 AM indicated " ...Physically optimal for discharge, follow up with PCP (primary care physician) in one week...:

-The discharge instructions dated 10/14/19 at 10:50 AM noted, " ...Pt #3 will be discharged to self to a nursing home by Elite ambulance transportation ...Discharge instructions printed and given related to Discharge Medications ..."

3. On 12/3/19 at 1:00 PM, an interview was conducted with the BMU (Behavioral Medicine Unit) RN (Registered Nurse) (E #2). E #2 stated that he discharged Pt #3 on 10/14/19. E #2 stated that he did not know that Pt #3 was to be discharged to a nursing home on 10/14/19. E #2 stated that he discharged Pt #3 on 10/14/19 with a bus pass. E #2 stated that he realized Pt #3 was supposed to be discharged to a nursing home when the ambulance showed up at the Hospital a few hours after Pt #3 was already discharged .

4. On 12/3/19 at 1:15 PM, an interview was conducted with the Discharge Planner for BMU (E #5). E #5 stated that he did the discharge planning for Pt #3. E #5 stated that he talked to Pt #3 on the morning of discharge and told Pt #3 that an ambulance would pick him up at 4:00 PM on 10/14/19 and take him to the nursing home. E #5 stated that he also talked to the nursing home about Pt #3's discharge. E #5 stated that Pt #3's nurse (E#2) was busy on 10/14/19 so E #5 did not tell E #2 about the ambulance transporting Pt #3 to the nursing home. E #5 stated that around 1:30 PM on 10/14/19, E #5 went into Pt #3's room to remind him of the ambulance pick up and Pt #3 had already been discharged . E #5 stated that he immediately contacted his supervisor (E#4) and reported that Pt #3 had been discharged to the street and not to the nursing home as planned. E #5 stated that he also contacted Pt #3's mother to inform her that Pt #3 was discharged to the street instead of the nursing home.