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Based on interview and record review facility failed to provide appropriate discharge in 1 of 4 residents (Resident # 1) reviewed.


Patient # 1:

Review of Patient # 1 discharge notes was placed in an unlicensed facility( Not in Florida Health Finders) that could not match the patients' needs of assistance of daily living, administration of medications or patient supervision. Prior placement in group home settings have been unsuccessful.

The psychiatric evaluation conducted on 9/10/19 by facility Psychiatrist and reads as follows: Patient # 1 admitted under Baker Act (BA) by a Physician. The BA states that patient is unable to make decision and is psychotic. Patient is only Spanish speaking and had no understanding of her situation. Patient has been BA twice. Patient is almost mute and unable to maintain eye contact the words spoken is irrational.

Diagnosis of Brief Psychotic episode: Major Neurocognitive Disorder with behavior problems.

Review of daily psychiatrist note from 9/11/19 to 1/8/2020 notes reflect a patient who is mostly mute, difficulty in concentration but does not appear to be responding to internal stimuli, eating and sleeping, no behaviors noted. Patient is pacing hallways some Extrapyramidal Symptoms (EPS) was noted in with adjustment made to medication. The psych progress noted compliant with medications, she does speak limited English and is quoted as "I am OK" on several notes. There was a period of adjustment to medications and the facility during the first 2-3 weeks. There was intermittent behavior outburst with agitation that required administration of as needed medication.

Admission Biopsychosocial completed 9/11/19 by Staff G Registered Clinical Social Worker Intern, reads: Patient 1 did not answer any questions, she appears confused, per nursing assessment arrived from Ocala Health system. Per Ocala Health she was brought there by The Vines, where she was admitted voluntarily and discharged to a group home. She began acting psychotic and the group home sent her back to The Vines who in turn brought her to Ocala Health for medical clearance. Department of Children and Family is involved in investigation in the transfer of care. It is unknown of family or what group home she was previously living in.

Case Manager notes on 1/13/20 at 4:39 PM Staff H, therapist attempted to meet with patient for safe discharge planning. Therapist used translator patient refused to follow therapist to office. Patient will be discharged to a Group Home and will follow up with a Mental Health appointment set for 1/14/20 at 8:00 AM. Due to discharge location patient will not have access to weapons.

Agency for Health Care Administration form 1823
Section 2 A
Self-Care and General Oversight Assessment
A. Ability to perform self-care task: Needs Assistance commented as total
B. General Oversight: Task: Daily
Section 2 B
Self-Care and General Oversight Assessment-Medications
B. Does the individual need help with taking his or her medication? Is answered as YES
Both boxes are checked: Needs assistance with self-administration and Needs medication administration has error above check mark with no initials

During an interview conducted on 1/30/20 at 2:00 PM, with Risk Manager. She stated "Yes we are supposed to discharge to a licensed facility/group home. Risk Manager was asked if all her Case Managers and Social Workers knew that, yes they should."

During an interview on 1/30/20 at 11:16 AM. with Assistant Director of Nursing (ADON), states the patient did have to be redirected at times mostly when she didn't get her way. Not violent. The language when she did speak was nonsensical, we have Spanish speaking staff and she did not make sense. ADON was asked if this patient can administer her own medication and be independent? ADON states "in my nursing judgement no I would not state that she could administer her own medication or be independent."

During an interview conducted on 1/30/20 at 10:55 AM, with Staff A, Director of Clinical Services states "the group home is not licensed. No, we are not mandated to use licensed group homes. Diagnosis was explained as routine, we did not have behavior problems with her on the unit."

Discharge Planning Policy NUR 4:044 SS-023 Revision Date 3/17/18 FM.
10. The Social Services staff providing case management will, to the best of their ability match the patients' needs with an appropriate level of placement. If the patient requires additional assistance of daily living, administration or assistance with medications or patient supervision, Social Services will ensure the facility is licensed to provide such services. `