HospitalInspections.org

Based on medical record review, review of policy and staff interview it was determined the hospital failed to ensure policy was followed for including the patient/health care surrogate and treatment team in the development of individualized treatment/care of one (1) of one (1) patients (patient #1) reviewed who was discharged/transferred to another psychiatric facility. This failure creates the potential for the violation of the rights of all patients to participate in care planning.

Findings include:

1. Review of the medical record for patient #1 revealed he was discharged and transferred to another inpatient psychiatric hospital on 2/14/13. The record reflected this forensic patient was deemed to lack capacity and his mother was noted as his medical health care surrogate.

2. The policy, "Treatment Planning," effective Feb/93, was provided for review. The policy states in part: "Each patient admitted to Sharpe Hospital will participate in the development of an individual treatment plan...Treatment team includes the patient, attorney (if adjudicated incompetent) all patient care staff that interacts with the patient, including family, medical decision maker, community behavioral health center staff, advocates, special advocates, physician, physician's assistant, nursing, social work, clinical social work, psychology, and rehabilitation services...All members of the treatment team are responsible for the development and implementation of the individualized treatment plan...Review treatment planning sessions shall be held every 30 days minimum...If the patient has been adjudicated as incompetent, (WV Code Chapter 27-11-1) his/her legal representative will be invited and encouraged to participate in his/her treatment planning...Discharge planning issues are to addressed at every treatment planning session, throughout the patient's stay and listed and reviewed as part of the treatment planning procedure."

The Draft Policy "Transfer to Other Inpatient Facility-Sharpe Hospital," effective date February 2012, was provided for review by the Forensic Coordinator. It states in part: "The Sharpe Hospital Forensic Coordinator (SHFC) or designee will monitor the bed availability at Mildred Mitchell-Bateman and River Park Hospitals. If there is an open bed the following will occur:
A. Patient(s) from Sharpe Hospital will be selected for possible transfer.
B. The SHFC will contact the treating psychiatrist, nurse manager or designee and unit clerk regarding patient transfer list.
C. The patient's unit within Sharpe Hospital will be notified about possible transfer.
D. The Treatment Team will meet with the patient to discuss transfer."

3. Interview was conducted with the Forensic Coordinator at 1340 on 6/10/13. She stated she received direction from the State on 2/3/13 that eighteen (18) forensic patients were to be transferred out of the hospital as soon as possible due to hospital overcrowding.

4. Review of the last Treatment Plan Review recorded for patient #1 revealed it was completed on 1/30/13. Review of the Treatment Plan Review revealed it lacked a discharge plan for the patient.

5. Review of a 2/12/13 progress note recorded by the patient's Social Worker (SW) at 1427 revealed: "I left a message today for (patient's) mother/health care surrogate to please return my phone call. I am planning to speak with her about a transfer for (patient) to River Park Hospital in Huntington. The transfer is supposed to take place on Thursday 2/14/13. I was informed of this today."

6. Review of a 2/13/13 progress note recorded by the patient's SW at 1114 revealed the SW documented in part: "The Forensic Office made the decision to divert (patient) to River Park Hospital. (Patient) was not involved in the decision making process."

7. This Treatment Plan was reviewed and discussed with the Clinical Services Coordinator at 1540 on 6/10/13. She acknowledged the medical record reflected no Treatment Plan meeting was held by the treatment team to review and discuss the patient's planned discharge/transfer with the patient/health care surrogate.

Based on medical record review, review of policy and staff interview it was determined the hospital failed to reassess the discharge plan for one (1) of one (1) patients reviewed who was transferred to a forensic unit in another psychiatric hospital (patient #1). This failure creates the potential for an adverse impact on the discharge needs of all patients who are transferred.

Findings include:

1. Review of the medical record for patient #1 revealed he was transferred to a forensic unit in another psychiatric hospital on 2/14/13.

2. The policy "Discharge Planning Process," effective 10/21/96, was provided for review. It states in part: "Each patient at the William R Sharpe, Jr. Hospital will have a discharge plan that addresses continuity of care ...Discharge planning...is an integral part of the comprehensive treatment of all patients admitted to the William R Sharpe, Jr. Hospital...All patients will have an aftercare plan and discharge planning goal...At each subsequent staffing, discharge plans will be reviewed and updated."

3. Review of the last Treatment Plan Review recorded for patient #1 revealed it was completed on 1/30/13. Review of the Treatment Plan Review revealed it lacked a discharge plan.

4. Interview was conducted with the patient's Treatment Plan Coordinator (TPC) at 1030 on 6/11/13. The 1/30/13 Treatment Plan Review was discussed. She acknowledged the patient's Treatment Review lacked a discharge plan. She stated at that point in the patient's hospitalization there was no discharge placement anticipated. The TPC acknowledged that no treatment plan review or update was conducted by treatment team members when they were notified the patient was to be discharged/transferred.

Based on review of documents and staff interview it was determined the hospital failed to reassess its discharge planning process on an on-going basis by reviewing patient discharge plans. This failure creates the potential for the quality of discharge planning services to be adversely impacted for all patients.

Findings include:

1. Review of Continuous Quality Improvement (CQI) meeting minutes for February, March, April and May 2013 revealed no indication the hospital is reviewing patient discharge plans to determine whether they were responsive to the patient's post-discharge needs.

2. These meeting minutes were reviewed and discussed with the Chief Compliance Officer at 1540 on 6/10/13. Additionally these findings were discussed with the Clinical Services Coordinator at this time. The February and April Quarterly Reports which were provided to the CQI committee by the Clinical Services Coordinator were also reviewed. The Clinical Services Coordinator acknowledged that currently patient discharge plans are not being reviewed.