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, clinical record review, and facility policy review, the facility failed to provide a safe discharge, by failing to ensure post discharge services were arranged and in place prior to discharge to the community for 1 of 3 patients reviewed for discharge services (#2).


Patient #2 was a direct admit from an acute care hospital to the Behavioral Health Unit. The transfer information from the sending facility revealed the patient was discharged on [DATE] and was admitted on [DATE] on a Baker Act.

The "General Medicine Consult Note" dated 1/22/21 reflected that on December 12, 2020, patient #2 had "a closed distal radius fracture that was splinted; bilateral L5(Lumbar) TP (Transverse Process) fractures nonoperative. Pelvic fractures: bilateral sacral fractures, right pubic bone, subluxation pubic symphysis; open right ankle fracture and dislocation with subsequent surgical repair on 1/12/2021. Patient also found to have a closed left ankle fracture and dislocation with surgical repair 1/12/2021. Patient was Baker non-weightbearing for 12 weeks on both ankles....has a splint on the left wrist with surgical sutures in place....will need physical therapy, occupational therapy, and wound care...."

Documentation on the "PT (physical therapy) inpatient visit note" dated 1/23/21 at 9:55 AM read, "being d/c (discharge) 0740. Nursing called about consult and need for specialty bed. Informed PT does not order specialty beds, nursing or wound care nurse do that....0955 Spoke with nurse on unit and gave information on how to order specialty bed that PT received from unit secretary... Nurse reports pt. is being D/C from ...Behavioral Health as medically too involved for their unit. She is unsure where he is going but she is doing D/C packet now .... Pt just transferred from (name of sending hospital) yesterday with multiple orthopedic issues. Pt will need continued rehab ...."

The "Psych SW (social worker) Psychosocial Assessment" dated 1/23/21 at 1:02 PM read, "Pt's [spouse] relayed concerns for...mental health concerned with...medical care and health at this point.... Staff will arrange for outpatient follow up appts....within 7 days of discharge. Pt to follow up with (name of sending hospital) for referrals to OT (occupational therapy) and PT and possibly rehab for physical injuries ...."

The "Psych SW Note" dated 1/23/21 at 2:01 PM read, "SW telephoned Pt's [spouse].... SW explained that the Dr. met with Pt clear longer meets BA (Baker Act) requirement and would be discharged . [Spouse] expressed....did not have items [patient] would need for care....has no supplies....such as wheelchair and Hosp bed and Toilet etc.....stated...dressing needs to be changed tomorrow. SW suggested that [spouse] contact...Medical supplies and see if...can get those items. SW explained that pt is not in a medical bed here and was cleared medically from (name of sending hospital) longer meets criteria for BA....SW advised that we have arranged for (name) Transport to take...home. [Spouse] advised that the SW at (name of sending hospital) spoke....about arranging for follow-up care, home health care and possibly rehab center first to help in...recovery....SW offered to find out if there was anything else we can do here .... SW learned that since Pt was cleared medically and now psychiatrically, he has to be discharged . SW called (name) rehab Center and spoke with (name) to see if she had referral packet for pt. from (sending facility)... said no. She stated she would need entire referral pack and go through the intake process which would take until Monday. SW telephoned (sending hospital) SW to determine if any referrals had been made for rehab or home care or PT. SW left a message for SW. SW telephoned [spouse].... advised that (name) rehab center had not received a referral for Pt. SW advised.... transportation has been arranged transport Pt home and that we will be sending information for community resources for home health care and PT...she could call and request services....[spouse] stated...needed time to get services in place...."

Patient #2's discharge summary showed the following: Hospital Course: Date admitted : 1/22/21 Date discharged [DATE]. Functional status at discharge: bed bound. Discharge diagnosis: depression. Follow up with -Primary Care Physician (PCP). Disposition: Home or self- care. "Discharge Instructions" included: reason for visit: Depressive disorder. discharge date /Time 1/23/21 2:40 PM, Discharge disposition: Home or self- care, and discharge referrals: PCP.

On 5/12/21 at 2:35 PM, the Program Director and Social Service (SS) Manager for the Behavioral Unit stated patient #2 was medically cleared at the sending /referring hospital, was discharged , and was a direct admit to the Behavioral Unit, under a BA. The SS manager stated the patient was discharged on Saturday 1/23/21, and both the Program Director and she did not work that day. The SS Manager said a per diem SW contacted the patient's spouse regarding his discharge. The spouse had no concern from a psych standpoint but had concern from a medical standpoint. The SW stated the spouse was given communication for referral for home health agency (HHA) and pharmacy. The SS Manager verbalized that the per diem SW called the HHA, but since it was a weekend, no one was on site. The SS Manager stated that on 1/25/21, they realized there were concerns regarding the pt.'s discharge, when staff reported the pt.'s spouse called, and voiced concerns over the weekend. The SS Manager stated she called the sending hospital on [DATE] after the patient was discharged and spoke to the case manager (CM). The CM stated that notes indicated they were working on placement at (name) Rehab. The SW stated that information was not made known to staff at the Behavioral Unit. She said, if they were aware, they could have contacted the Rehab center and followed up with the plans that were already in place.

Review of the SW notes dated 1/23/21 at 2:01 PM indicated the Behavioral Unit SW was made aware of the previous plans during her conversation with the patient's spouse. The SW called the sending facility, contacted the Rehab center, and was informed that a referral packet would be required, and a review of the referral packet would not be completed before Monday 1/25/21. However, patient #1 was discharged home on 1/23/21 at 2:40 PM without any arrangements/coordination of the required equipment/referral/ and services required for a safe discharge.

On 5/13/21 at 9:27 AM, the Director of Quality stated the Behavioral Health Unit was under the hospital license, and if any medical needs were identified in the Behavioral Unit, the patient would be transferred to a medical unit. She said Psychiatric consults were done on the Medical Unit also, and when a patient was accepted for admission in the hospital, the hospital was responsible for the patient. This included the patients' medical needs, and discharge needs.
Patient #2's "General Medicine Consult Note" dated 1/22/21, "PT Inpatient Visit Note" dated 1/23/21, and clinical records were reviewed with the Director of Quality. This revealed that patient #2 was discharged home prior to having the recommended consultations for wound care, physical therapy (PT) and occupational therapy (OT).
The Director of Quality stated discharge planning was available on weekends.

On 5/13/21 at 10:17 AM, the Chief Nursing Officer (CNO) stated that when a patient is admitted to the hospital, the hospital is responsible for the patient and discharge needs. If required, the patient could be transferred from the Behavioral Unit to a medical bed. The CNO stated patient #2 was seen by the hospital's PT, and documentation indicated continued rehab was required for the patient. He said, the CM was at the hospital during the weekend, and the Behavioral Unit could have received assistance with the patients' discharge needs. The Program Director said the Behavioral Unit should have tried to have a transfer to the medical unit, to follow up on the patient's post discharge needs arrangements.

On 5/13/21 at 3:45 PM, the Chief Medical Officer stated that once the patient was admitted to the hospital, they were responsible for the care, and post discharge care of the patient.

The Hospital policy "Discharge Planning and Continuum of Services", revised 12/26/2019 read, "To ensure that a systematic process addresses the needs for continuing care, treatment, and services after discharge .... The Social Worker is responsible for the development and coordination of the discharge plan and safety plan. The Social Worker will coordinate family and community resources to provide optimum implementation of the discharge plan."