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.

TRIANGLE SPRINGS 10901 WORLD TRADE BLVD RALEIGH, NC July 12, 2019
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of the facility's Quality Improvement Plan, restraint and seclusion data collection, restraint and seclusion logs, qualiity indicator data, policy review, Medical Staff Rules and Regulations review, medical record reviews and staff interview, the hospital's Governing Body failed to provide oversight and have systems in place to ensure an organized and effective, data driven quality assessment and improvement program; and failed to provide oversight of active treatment for behavioral health patients.

The findings included:

1. The facility's leadership staff failed to maintain an effective, hospital-wide, data-driven quality assessment and performance improvement program by failing to accurately measure, analyze and track quality indicators related to restraints and seclusion; failing to show measurable improvement associated with grievance response and patient treatment plan weekly reviews; and failing to monitor and track hospital readmissions

~cross refer to CFR 482.21 Condition: Quality Assurance Performance Improvement, Tag A0263

2. The facility failed to provide active treatment that was inclusive of complete cranial nerve examinations performed by a physician; Comprehensive Psychiatric Evaluations performed within 60 hours of admission; individualized comprehensive treatment plans that included medical needs; a substantiated psychiatric diagnosis that served as the primary focus for the treatment plan; specific measurable short-term and long-term patient centered goals based on individual patient problems; a focus of treatment based upon the patient's presenting symptoms; documentation of an evaluation of patients' individualized treatment plan progress toward goals; and coordination and documentation of post discharge housing, medication and appointment arrangements. The cumulative findings identified a failure to have a systemic system in place to provide active treatment to behavioral health patients.

~cross refer to 482.61 Condition: Special Medical Record Provisions for Psychiatriac Hospitals, tag B0103
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, grievance file review and staff interview, the facility staff failed to provide a written response to grievances for 2 of 2 grievance files reviewed (#10 and #1).

The findings included:

Review of the facility's "General Grievances and Patient Advocacy" policy effective 2/2018 revealed "... Patient grievance is defined as a written or verbal complaint (when a verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, or issues related to the Hospital's compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR (Code of Federal Regulations) 489. ... Patient complaints typically involve minor issues, such as but not limited to, housekeeping or food preferences, which do not require an investigation or involve a restriction of patient's rights. Any complaint submitted in writing is always considered a grievance and will be handled as such. ... Staff present includes any staff present at the time of the complaint or who can quickly be at the patient's location to resolve the patient's complaint. If that individual comes and resolves the complaint, it is no longer considered a patient grievance. ... Social Services/Nursing Staff ... Assists the patient with completion of the patient's complaint form for any complaint issues. The complaint form is given to the nurse on the unit and either the nurse or the staff designee talks with the patient and tries to resolve the complaint. If the complaint cannot be resolved, it is passed to the Nursing Manager or therapist, whichever is appropriate to try to resolve. If the complaint has not been resolved, it will be passed to the Patient Advocate to address. When resolved at any level, it will be signed by the Director of Nursing, Director of Clinical Services and the CEO and returned to the Patient Advocate within 48 hours. The patient and/or family member will be notified in writing of the results no longer than 20 business days from when the complaint was received. ..."

1. Review of Patient #10's medical record revealed a [AGE] year-old female admitted on [DATE] with schizoaffective disorder, bipolar type. Review of the record revealed the patient had chronic pai[DIAGNOSES REDACTED], hypertension and gastroesophageal reflux disease. Review of notes recorded by Therapist #3 on 04/26/2019 at 1843 revealed the therapist met with the patient to complete the intake information and the patient reported wanting assisted living or independent living housing. Review revealed the patient repeatedly identified her housing as a stressor and requested assistance with placement after discharge. Review revealed the patient had no support system and lived alone. Review of notes recorded by the patient from a "Mental Wellness: Coping" group meeting revealed the patient requested information regarding "Independent Housing Management." Review of notes recorded by the patient on 05/01/2019 revealed she wanted information from the therapist on independent housing regarding a clean and safe environment. Review of notes documented by the patient on 05/02/2019 recorded the patient continued to request information regarding housing after discharge. Review of the Discharge Plan documented by Therapist #3 revealed the patient left ambulatory via Uber transportation to go to a shelter. Review revealed no name of the facility where the patient was sent. Review of the record revealed the patient was discharged to a shelter on 05/02/2019.

Review of a written grievance filed by Patient #10 on 05/01/2019 revealed "My problem with the therapist is that they are trying to send me to a house or assistant facility without checking out the place itself. Last time the independent house was freezing and cold and there was sewage backing up in the toilet, bathtub and even unto the floor and there were broken pipes in the kitchen. ... I've not had a one on one yet to discuss my problem. I am physically handicapped, disabled and require certain things." Review of the grievance revealed a patient advocate documented that she talked with the patient's therapist and they had researched and found two boarding homes and provided the owners contact name and phone numbers to assist the patient. Review revealed the advocate visited the patient around 1400 on 05/01/2019 and the patient was calling the homes to determine which home she would be living in. Further review of the grievance revealed the patient was requesting assistance with transportation to appointments and obtaining groceries. Review revealed no evidence which housing was selected or if the patient was provided assistance to determine her needs would be met. Review of the medical record revealed the patient continued to request assistance with finding housing on 05/02/2019. Review of the grievance revealed no written response to the patient's grievance was completed.

Interview on 07/10/2019 at 0845 with Therapist #3 revealed she was the therapist working with Patient #10. Interview revealed she sent the patient to a shelter and failed to document the name or address of the shelter. Interview revealed the therapist was unable to remember the name of the shelter where the patient was sent. Interview revealed the patient was not satisfied with going to a shelter, but she was out of resources.

Interview on 07/11/2019 at with Patient Advocate #4 revealed she had talked with Patient #10 regarding her grievance. Interview revealed the patient continued to have the same issue with housing until her discharge. Interview revealed the grievance was not resolved. The staff member stated she did not provide a written response to the grievance. Interview revealed the advocate "only provided a grievance letter if the patient filed the grievance after discharge. In house complaints do not get a letter." Interview revealed the patient advocate had been in her role since she started in January 2019 and was oriented by the Quality Director regarding grievances. The staff member reported that no grievance letters had been sent to patients or family members since she started in January 2019.





2. Review of Patient's #1's medical record revalued a [AGE] year old female admitted on [DATE] at 2023 for Major Depressive Disorder and Post Traumatic Stress Disorder after ingesting 5-10 Ambiens, (sleeping agent), 2 Wellbutrins (antidepressant) and 1 Cymbalta (antidepressant and antianxiety) in a suicide attempt. Review of the MD #1's History and Physical dated 04/09/2019 at 0700 revealed Ablation (cardiac procedure for decreasing heart rate) for SVT (Supra[DIAGNOSES REDACTED]--Rapid heart rate) and GERD (Gastrointestinal reflux disease).

Review of a "Patient Advocate: Report and Follow-up" dated 04/09/2019 revealed "Pt. (patient) reports that upon arrival she was assured that she would be admitted on to (named patient care floor) but was sent to (named patient care unit) instead. Pt. stated that the team lied to her by telling her that she was on (named patient care unit) when she really wasn't. She feels that trust has been broken. Also, pt reports that she was asked to undress in front of a nurse and PCA (Patient care assistant) and expressed that she was very uncomfortable....Pt states that the nurse brushed her off in a rude manner. She is also unable to bathe/shower due to no one being able to locate her belongings. Pt has not slept all day and appears very emotional. ACTIONS TAKEN THUS FAR: Pt. advocate has checked every unit and front desk for pt. belongings. Checked with patient and found out that belongings are w/ pts mother who will be bringing them on 04/09. Informed DON and CEO of patients concerns. FOLLOW-UP REQUESTED BY PATIENT: Pt. wants leadership to be aware of incidents and report that she does not trust any staff members. RESOLUTION: Pt. was moved to a new unit (named patient care unit) w/ a small group in order to give pt. opportunity to rest and feel safe during the remainder of her stay. This pt. advocate visited the pt. on (named patient care unit) on 04/11 to ensure that the pt was doing well. Pt informed me that she was feeling well and much happier." Review revealed the form was dated 04/11/2019 at 1:15 pm by Patient Advocate #4. Review of the advocate's report failed to reveal a letter of grievance response to the patient.

Review of an email written by Patient Advocate #4 dated 04/09/2019 at 3:22 pm revealed "Hi (CNO and CEO), I really hate to write this type of information to you in an email but, it has been a very busy day for everyone. I spoke with (Patient #1), who wanted to speak with me to report that upon arrival last night that she lost trust in the staff when she was told that she was being admitted on to (Patient care unit) and not (Patient care unit) as she previously requested. She stated that when she asked if she was on (patient care unit) that one of the staff members lied to her and told her yes. Since then the patient has been moved to the correct unit. She also reports that when she was in intake she was asked to undress in front of an African Nurse and a skinny light skinned PCA, which she understood she would have to do but, informed the nurse that her cycle was on and that she didn't feel very comfortable. She stated that the nurse made a very rude comment and brushed her off and insisted that she get undressed...I have filled out a Patient Advocated Report and Follow-up form if you would like to keep this email in rotation until we come up with a resolution...."

Interview on 07/10/2019 at 1440 with RN #5 revealed an investigation was done. "I asked the supervisor" about the incident. Interview revealed no documentation of the investigation was available. Interview revealed no letter was sent to the patient after the investigation.

Interview on 07/10/2019 at 0930 with Patient Advocate #4 revealed patient #1 was "upset about the unit she was placed on" Interview revealed the Director of Nursing is responsible for investing complaints. Interview revealed no letter was sent to the patient after the investigation. Interview revealed the advocate "only provided a grievance letter if the patient filed the grievance after discharge. In house complaints do not get a letter." Interview revealed the patient advocate had been in her role since she started in January 2019 and was oriented by the Quality Director regarding grievances. Patient Advocate #4 reported that no grievance letters had been sent to patients or family members since she started in January 2019. Interview revealed the patient should have been notified by a letter of the investigation. Interview revealed the patient has a right to know of the investigation and the outcome.
VIOLATION: QAPI Tag No: A0263
Based on review of the facility's Quality Improvement Plan, restraint and seclusion data collection, restraint and seclusion logs, qualiity indicator data, and staff interviews, the facility's leadership staff failed to maintain an effective, hospital-wide, data-driven quality assessment and performance improvement program.

The findings included:

The hospital staff failed to accurately measure, analyze and track quality indicators related to restraints and seclusion; failed to show measurable improvement associated with grievance response and patient treatment plan weekly reviews; and failed to monitor and track hospital readmissions.

~cross refer to CFR 482.21(a)(b)(1)(b)(2) (i)(b)(3) Standard: Qapi Data Collection and Analysis, Tag A0273
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on review of the facility's Quality Improvement Plan, restraint and seclusion data collection, restraint and seclusion logs, qualiity indicator data, and staff interviews, the hospital staff failed to accurately measure, analyze and track quality indicators related to restraints and seclusion; failed to show measurable improvement associated with grievance response and patient treatment plan weekly reviews; and failed to monitor and track hospital readmissions.

The findings included:

Review of the "Organizational Quality Improvement Plan" approved August 2018 revealed the purpose was to " ... ensure the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk. ... The primary goals of the Organizational Quality Improvement Plan are to continually and systematically plan, design, measure, access and improve performance or critical focus areas, improve healthcare outcomes and reduce and prevent medical/health care errors. ...The status of identified problems and action plans is tracked to assure improvement or problem resolution. ... The scope of the organizational quality improvement program includes an overall assessment of the efficacy of quality improvement activities with a focus on continually improving care provided, and patient safety practices conducted, throughout the hospital. ... Collaborative and specific indicators of both processes and outcomes of care are designed, measured and assessed by all appropriate departments/services and disciplines of the hospital in an effort to improve patient safety and organizational performance. These indicators are objective, measurable, based on current knowledge and experience and are structured to produce statistically valid, data driven, performance measures of care provided. This mechanism also provides for evaluation of improvements and the stability of the improvement over time. ..."

1. Review of the restraint and seclusion aggregated data collection for April and May 2019 revealed a target of 90% compliance with this quality indicator, with a sample size of "All." Review of the data for April 2019 revealed there were zero (0) restraints or seclusion. Review of the data results for May 2019 revealed there were zero (0) restraints or seclusion.

Review of the restraint and seclusion log for April 2019 revealed a total of five (5) restraint episodes and one (1) seclusion had occurred (total of six (6) interventions). Review of the restraint and seclusion log for May 2019 revealed a total of two (2) restraints and one (1) seclusion had occurred (total of three (3) interventions).

Review of the restraint and seclusion log data failed to match the restraint and seclusion data collection that was presented on the quality improvement log.

Interview on 07/11/2019 at 1600 with the Director of Quality revealed the restraint and seclusion data was collected by nursing staff and submitted to the Director of Nursing (DON) or designee for review. Interview revealed the DON or designee aggregated and submitted the data to the Director of Quality. The Director of Quality formulated the data into a report that was presented to the Quality Committee and Governing Body for review and suggested actions. Interview revealed the restraint data collection was not done correctly for January through May 2019. Interview revealed the sample size of "all" referenced 100% of restraints or seclusion episodes conducted. Interview revealed nursing staff had instead reviewed thirty (30) random patient records and found no restraints or seclusion episodes. Interview revealed the data collection had been collected incorrectly since January 2019 and was inaccurate.

2. Review of a quality indicator regarding written response within seven days to a grievance revealed there were zero (0) letters sent for a total of six (6) grievances received in April 2019. Review revealed there were zero (0) letters sent for a total of six (6) grievances received in May 2019, showing 0% compliance.

Interview on 07/11/2019 at with Patient Advocate #4 revealed she was responsible for sending written response letters to complainants. The staff member stated she did not provide a written response to grievances when the patient was still in the facility. Interview revealed the advocate "only provided a grievance letter if the patient filed the grievance after discharge. In house complaints do not get a letter." Interview revealed the patient advocate had been in her role since she started in January 2019 and was oriented by the Quality Director regarding grievances. The staff member reported that no grievance letters had been sent to patients or family members since she started in January 2019.

Interview on 07/11/2019 at 1600 with the Director of Quality revealed the facility had been tracking the number of grievances and the number of written responses. Interview revealed the failure to provide a written response to a grievance was not compliant with facility policy. Interview revealed there had been no action plan identified to make improvements to the ongoing lack of compliance with providing a written response to a grievance.

3. Review of quality indicators revealed an indicator regarding monitoring of patient treatment plans for weekly updates. Review revealed a goal of 90% compliance was targeted. Review of April 2019 data revealed a 36% compliance rate for the week of 04/22/2019 through 04/26/2019. Review of the May 2019 data revealed 0% compliance for the week of 05/01/2019 through 05/03/2019; 0% compliance for the week of 05/06/2019 through 05/10/2019; 11% compliance for the week of 05/11/2019 through 05/17/2019; 0% compliance for the week of 05/20/2019 through 05/24/2019; and 50% compliance for the week of 05/27/2019 through 05/31/2019. Review of the June 2019 data revealed a 40% compliance for the week of 06/03/2019 through 06/07/2019; 24% compliance for the week of 06/10/2019 through 06/14/2019; 60% compliance for the week of 06/17/2019 through 06/21/2019; and 75% compliance for the week of 06/24/2019 through 06/28/2019.

Interview on 07/11/2019 at 1600 with the Director of Quality revealed the facility had been tracking the number of treatment plan weekly updates for compliance. Interview revealed the failure to provide a written treatment plan update was not consistent with facility policy. Interview revealed there was minimal improvement to the ongoing lack of compliance with ensuring weekly treatment plan updates occurred.

4. Review of hospital's discharge planning quality improvement data from January 2019 through May 2019 failed to reveal documentation of tracking and analysis of patients readmitted to the hospital within thirty (30) days of previous discharge.

Interview on 07/10/2019 at 1430 with the Director of Clinical Services revealed the hospital did not monitor data of patients that readmitted within 30 days of previous discharge for assessment and evaluation of the discharge planning process. Interview revealed there was no process in place to identify preventable readmissions in order to reassess the discharge planning process.
VIOLATION: DIETS Tag No: A0630
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, reviews of medical records, and interviews with staff and patients, the facility failed to ensure a correct diet was served to a patient with diet restrictions in 1 of 1 patients observed. (#5).

The findings included:

Observation on 07/10/2019 at 1200 of the cafeteria serving line revealed Patient #5 receiving her lunch consisting of only a ham and cheese sandwich. Observation revealed no food substitutions were given to Patient #5. Observation revealed no substitutions were offered to Patient #5. Observation revealed Patient #5 walked to the dietary table and began eating the ham and cheese from the bread. Observation revealed no dietary staff approached the table to speak to Patient #5 to offer any other food items.

Interview on 07/10/2019 at 1201 of Patient #5 revealed the patient had spoken to the Dietary manager this morning about the lunch menu of ham and cheese sandwich. Interview revealed the dietary manager informed Patient #5 of the lunch choices. Patient #5 informed the dietary manager of the bread restriction. Interview revealed the dietary manager would have something else prepared for lunch for Patient #5. Interview revealed Patient #5 was instructed by the surgeon to avoid eating bread due to the swelling of the bread in her stomach, possibly requiring surgery to remove it.

Review of closed medical record of Patient #5 revealed a [AGE] year old female admitted on [DATE] for Major Depressive Disorder with a Suicide plan. Past medical history is significant for recent gastric bypass surgery requiring a special diet. Review of a Nutritional assessment dated [DATE] revealed "ASSESSMENT SUMMARY: Reasons for consult: BMI > 30, gastric bypass, poor po (oral) intake....Met with Pt (Patient) in consult room. Pt reported she is 7 weeks s/p (status post) gastric bypass. She reported she is on the soft foods part of the diet. Discussed high protein snacks....Discussed pt with dietary....Interventions: 1) High protein snacks tid (three times daily) r/t (related to) gastric bypass surgery..." Review of physician's diet order written on 07/07/2019 at 1157 revealed "Regular diet: No bulk forming foods, No crispy, crunchy, sticky."

Interview on 07/10/2019 at 1215 with RN #5 revealed the dietary staff member serving the food had been off work for 3 days and was unaware of the diet that the patient was ordered. Interview confirmed of dietary staff was not informed of the special diet ordered for the patient.

Interview on 07/10/2019 at 1555 with Dietary manager revealed the dietary staff member was not told this morning (07/10/2019) before preparing trays of the special diet. Interview confirmed the manager is responsible for informing the dietary staff of the special diets before trays are prepared in the morning. Interview revealed the lunch served of the ham and cheese sandwich did not meet the requirements of the ordered diet.

Interview on 07/11/2019 at 1140 with Director of Psychiatric Services revealed Patient #5 was on restrictive diet due to recent gastric bypass surgery. Interview revealed the patient should not ingest certain foods due to a very small stomach due to surgery. Interview revealed ingesting restricted foods, such as bread could be harmful to the patient. Interview revealed the diet served of ham and cheese sandwich did not meet the requirements of the ordered diet.
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, outside document review and staff interviews, the facility staff failed to make appropriate discharge arrangements for 1 of 3 sampled patients discharged to a community setting (#4).

The findings included:

Review of the facility's "Discharge and Transition Planning" policy revised 03/2019 revealed "... The Facility engages in ongoing transition planning at the start of services, throughout the course of treatment and at the time of discharge. This information will be facilitated by using the Discharge Planning Form. ... The form will be initiated at admission and indicate when and where a; discharge information is documented in the chart. It is very important that all steps of discharge are documented. Information that will be documented in the chart minimally includes: ... Information of living arrangements; Transportation information and needs; ... Aftercare plans to include provider and therapy appointments. ... The patient's discharge plan should include the following information: ... Next provider of care to include name, address, phone and appointment time; ... Medical appointments if needed; ... Type of place patient was discharged to ..."

Review of Patient #4's medical record revealed a [AGE] year-old female admitted on [DATE] with schizoaffective disorder, bipolar type, auditory hallucinations, and self-harm intent. Review of the record from the transferring emergency department (ED) revealed the patient had nine previous admissions since the beginning of the year for psychosis, multi-substance abuse that included alcohol, tobacco, marijuana, and "severe" cocaine dependence, she was homeless, and supported herself through prostitution. Her medical history included coronary artery disease with vascular stenting, hypertension, and chronic obstructive pulmonary disease. Review of the provider note recommended admission to a (Named) Alcohol and Drug Abuse Treatment Center in the area. Review revealed Patient #4 was admitted to an acute care behavioral hospital with mental health and substance abuse treatment programs. Review of a psychosocial assessment dated [DATE] at 1130 indicated the patient had two recent behavioral health hospitalization s which had resulted in her seeking help related to drug abuse, housing, and financial instability. Review of a "Screening Assessment" recorded by a therapist on 05/16/2019 at 1535 listed Patient 4's address as "homeless" and the patient stated, " I'm here to seek help for drugs and everything." Review revealed the patient reported she smoked cigarettes and $100 of cocaine daily but had refused to answer many of the screening questions. Review of Patient #4's "Multidisciplinary Treatment Plan" dated 05/16/2019 at 1630 revealed "Reason for Admission: Cocaine use disorder, severe - Pt was admitted due to AH (auditory hallucinations) commanding Pt to commit suicide ...Diagnoses: cocaine use disorder, severe and Bipolar I disorder, manic." Further review of the multidisciplinary treatment plan listed "Liabilities" as "Housing, drugs and finances," and "Pt will be linked to a long term substance program. Pt will be linked to a safe living environment." Review of notes recorded by weekend Therapist #4 on 05/19/2019 at 1355 revealed the therapist met with the patient to complete the intake information and the patient reported wanting "to go to a long term substance use rehab. Patient is motivated to continue sobriety once DC (discharged )." Review of notes recorded by primary Therapist #3 on 05/20/2019 at 1000 and 1100 revealed Patient #4 wanted to go to an unidentified homeless shelter in her local area and a Psychiatrist/Therapist appointment at a (Named) local area community health center had been scheduled for 06/03/2019 at 1430. Review revealed the patient repeatedly identified homelessness as a stressor and requested assistance with long term placement at discharge. Review revealed despite having children and an ex-spouse, the patient had no support system. Review of the Inpatient Discharge Plan signed by Therapist #3 (date and time not entered) and signed by the patient and a staff nurse on 05/22/2019 at 1045 revealed the patient left ambulatory to "Home." "Continued Treatment Needs" included AA/NA (alcoholics anonymous/narcotics anonymous)" and "intensive outpatient therapy." The mode of transportation, and name of the provider were not indicated on the plan. Review of a "Discharge Summary" dated 05/22/2019 and signed 05/27/2019 at 1000 by MD #1 revealed "Patient will be discharged to a shelter." (and) "Patient will be followed up by (blank) Community Center on June 3, 2019 at 1430." Review of the record revealed no name or address of the shelter where the patient was reportedly sent had been documented.

Review of outside public information revealed the community health center provider name provided by Therapist #3 during interview was a primary care physician. Review revealed the homeless shelter at the address identified by Therapist #3 during interview provided safe house services to victims of domestic abuse.

Request for interview with MD #1 revealed he was not available.

Telephone interview on 07/11/2019 at 1830 with Therapist #4 revealed she had worked with Patient #4 on the weekend of May 18-19, 2019 but was not involved in the discharge plan. Interview revealed Patient #4 had expressed a desire for treatment in a long term treatment facility and had mentioned specific facilities that were of interest to her. Therapist #4 stated "The last thing she wanted, was to go to a shelter" but did not know where Patient #4 had gone at discharge.

Interview on 07/10/2019 at 0845 with Therapist #3 revealed she had worked with Patient #4. Interview revealed Patient #4 was "homeless and she wanted to stay here until her disability check came, but she was clinically stable, and we couldn't keep her." Interview revealed Patient #4's ex-spouse had indicated he would provide transportation from the facility but that "fell through" and "I had to get an Uber for her." Therapist #3 stated she had documented the information in the record, but on review, she confirmed there was not documentation of the name of the shelter, its location, or the staff with whom she had communicated to secure discharge arrangements. Interview confirmed the name of the post discharge mental health provider was also not in the record.

Interview on 07/10/2019 at 1110 with Therapist #2 (Director of Clinical Services) revealed there should have documentation in the medical record to identify the name and address of the location of the shelter where Patient #4 was directed to at the time of discharge as well as the name of the shelter staff who had participated in the arrangements. Interview revealed the lack of documentation was not consistent with the facility policy.

Telephone interview on 07/11/2019 with shelter director at the facility identified by Therapist #3 revealed the shelter's mission was providing safe house services for female victims of domestic abuse and their children. Interview revealed Patient #4 had arrived unexpectedly at the facility on 05/22/2019, and the shelter had arranged for a night's hotel lodging for her. Interview revealed the shelter provided homeless services for women, "rarely," and only if space was available. Interview revealed communication between facilities, and approval of services by the shelter were required before an individual could receive homeless services from them. Interview revealed shelter staff had contacted the facility to obtain information about Patient #4's needs but had been unsuccessful.

NC 557; NC 595; NC 265; NC 779; NC 889