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 interviews and record reviews, the hospital discharge planning evaluation failed to include the likelihood of a patient's capacity for self-care in the environment from which the patient came when the patient entered the hospital in 1 of 3 clinical records reviewed (#1).

The findings included:

The Interdisciplinary Assessment and Treatment Planning Overview, policy and procedure, revealed the Master Treatment Plan is initiated at the time of admission and is fully formulated by the interdisciplinary team at least by the third treatment day. A master treatment team meeting is held within 7 treatment days of admission. Subsequent treatment team meetings are held to review and modify the treatment plan as needed. The treatment team reviews the patient's progress and updates the treatment plan, as indicated, within a time frame of every 14 days or as clinically indicated.

This elderly patient was transferred from another acute hospital and admitted to the Behavioral Health Unit from 03/25/19 to 03/30/19. From 03/30/19 to 04/02/19 she was transferred to medical surgical floor. From 04/02/19 to 04/10/19, she was back on the Behavioral Health Unit.

On 04/04/19, the Case Management notes/Behavioral Health Psychosocial Update revealed the patient has inadequate coping skills, difficulty performing activities of daily living, and lives at home alone.

On 04/09/19, the Case Management note revealed the patient expressed concerns about being able to care for herself requesting that she have a full-time care taker live with her.

On 04/09/19, review of the nursing patient body system assessment revealed the patient was a Fall Risk to be supervised and assist the patient with ambulation. The patient's transport method was a wheelchair.

During an interview with the Vice President, Quality Management, on 07/26/2019 at 11:18 AM, she stated this patient fell twice, on 04/02/19 & 04//06/19, and was on 1:1 most of her admission. She stated this patient was utilizing a wheelchair while an inpatient.

The psychiatrist Discharge Summary, dated and signed the day after the patient was discharged home, revealed the patient is suspected of not taking her medications, has been doing poorly. The patient has a history of chronic kidney failure, stage 3 and [DIAGNOSES REDACTED]. Patient lives alone. Not at psychiatric baseline. She is confused and paranoid.
Discharge diagnosis is [DIAGNOSES REDACTED]
Chief Complaint is Agitation and Self Neglect . She was placed on 1:1 due to risk for falls.
Mood is irritable.
Affect is bizarre.
Language is impoverished.
Thought Process is disorganized, simplistic.
Thought Content is bizarre.

Interview with the psychiatrist, on 07/25/2019 at 1:46 PM, she stated that during this patient's admission, she was on 1:1, falling, not walking and in a wheelchair, very weak, participating in groups and at times agitated. She was discharged home with home health care. She stated the placement was inadequate, but they did send her home with home health follow up. She stated that she knew that home health was not sufficient for the patient. She stated that she did not know what else to do. She stated that she was glad to hear the patient was readmitted to another hospital and was receiving good health care.

The last Case Management entry on 04/10/2019, revealed the patient's discharge disposition is home health and physical therapy was sent in "and she can call when she gets home."

On 04/15/19, the patient was admitted to another acute hospital for medical care as she was declining and unable to care for self and her neighbor called 911.