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Based on record reviews and interviews, the hospital failed to thoroughly investigate patients' grievances according to hospital policy for 2 of 2 grievances reviewed from a total of 3 grievances submitted from 05/01/13 through 08/14/13 (#2, #5). Findings:

Review of the hospital's policy titled "Patient Grievance Management", policy number OHS.QUAL.008, issued 08/13, and presented as the current policy for the grievance procedure by S1Assistant Vice-President of Quality, revealed that a written complaint is always considered a grievance and will follow the Patient Grievance Management procedure. Further review revealed all grievances will be reviewed and analyzed by the Patient Relations Department. When an issue/concern cannot be promptly resolved, the following steps will be taken: 1) the Patient Relations representative will initiate the grievance process by entering the data into the electronic tracking system; 2) the Patient Relations Department will send an initial letter to the patient within 7 days confirming receipt of the grievance and explaining the grievance process; 3) the Patient Relations representative will immediately forward a copy of the grievance to the appropriate investigators (Hospital Manager/Director or Physician) by electronic mail. Review of the grievance investigation revealed the following steps: 1) upon the investigator's receipt of the grievance, an investigation will begin within 24 hours to address the specific issues/concerns that were communicated by the patient/family; 2) written response of findings from the investigators will be sent via electronic mail to the Patient Relations Department within 72 hours; 3) if the response is not received from the investigators within 72 hours, the grievance will be escalated to the CNO (Chief Nursing Officer) or Medical Staff Leader, or their delegate, for resolution and written response within 72 hours; 4) the Patient Relations Department will send out an extension letter to the patient for all grievances that are not able to be finalized within 30 days.

Patient #2
Review of Patient #2's medical record revealed he was admitted to the Emergency Department (ED) on 06/08/13 at 10:36 p.m. with diagnoses of Benzodiazepine Overdose, Hypotension Arterial, and Respiratory Depression. He was transferred to the Surgical Step-down Unit of the hospital on 06/09/13 at 1:33 p.m. Further review revealed Patient #2 had a Physician Emergency Certificate (PEC) signed on 06/09/13 at 12:00 a.m. due to Patient #2 being suicidal and a danger to himself. Review of his Coroner's Emergency Certificate (CEC) signed by S31Assistant Coroner on 06/10/13 at 10:56 a.m. revealed a notation of "Dr. (doctor) wrote note about possibly cx (canceling) PEC but has not done so." Further review of the CEC revealed that S31Assistant Coroner documented that Patient #2 had a positive DWI (driving while intoxicated) and was a danger to himself.

Review of documentation from the Patient Relations Department revealed a letter dated 07/22/13 from Patient #2's wife (complainant) was received, and S23Patient Relations Specialist spoke with Patient #2's wife on 07/24/13 by phone. Further review revealed that S23Patient Relations Specialist informed the complainant that the grievance process would begin as soon as the letter was received by the hospital (complainant stated that she had explained her concerns in the letter and did not want to discuss them on their phone). Review of the letter's content revealed that the complainant complained of comments made during telephone conversations with S7Internal Medicine Resident when S7Internal Medicine Resident allegedly stated that "The state has no funds to keep him here" and accused Patient #2 of "Doctor shopping."

Review of the follow-up documented by S23Patient Relations Specialist revealed she had requested internal responses from several physicians including S10Academics Hospitalist with the Department of Medicine and staff members on 07/25/13 at 3:31 p.m. and had shared the file with several physicians and staff members including S27Vice-Chairman of Hospital Medicine. Further review revealed repeat requests were sent by S23Patient Relations Specialist for an internal response from S9Chairman and Medical Director of Psychiatry and Addictive Medicine on 08/01/13 at 10:40 a.m. and on 08/02/13 at 12:43 p.m. A repeat request was sent by S23Patient Relations Specialist for an internal response from S21Manager of Patient Relations on 08/02/13 at 9:55 a.m. and on 08/02/13 at 4:25 p.m. There was no documented evidence that an internal response was requested or that repeat requests were sent to S27Vice-Chairman of Hospital Medicine.

Review of the response documented by S10Academics Hospitalist with the Department of Medicine on 07/26/13 at 8:54 a.m. revealed that psychiatry was consulted for Patient #2's suicide attempt and found him safe to return home. She further documented that S7Internal Medicine Resident and S8Internal Medicine Intern were her residents at the time, but she wasn't present when they talked to the complainant. There was no documented evidence that her response addressed any of the alleged comments made by S7Internal Medicine Resident as reported by the complainant.

In a face-to-face interview on 08/15/13 at 1:40 p.m. with S7Internal Medicine Resident, S8Internal Medicine Intern, and S10Academics Hospitalist in the Department of Medicine present, S7Internal Medicine Resident indicated he didn't make the comment about not having state funds, because he doesn't get involved with insurance and just takes care of the patients. He further indicated Patient #2 was given Valium to treat the alcohol withdrawal, but he couldn't give him a prescription for Valium since he had overdosed with Valium while drinking alcohol. He indicated that the complainant may have interpreted his explanation as "Doctor shopping", but he didn't use those words at any time.

In a face-to-face interview on 08/15/13 at 3:45 p.m., S23Patient Relations Specialist indicated that she would not rely on the attending physician (S10Academics Hospitalist in the Department of Medicine) to review with the residents the alleged comments brought forth by the complainant but would expect the S27Vice-Chairman of Hospital Medicine to address it. S23Patient Relations Specialist confirmed that she had not received a response from S27Vice-Chairman of Hospital Medicine and had not sent a repeat request to him as she did for others from whom she had not heard. She indicated it was an oversight, and a second or third request for a response should have been made.


30172

Patient #5
Patient #5 was admitted to the hospital's emergency room on 05/27/13 from home with diagnoses of bipolar disorder and substance abuse to include: bizarre manic behaviors and auditory hallucinations. The patient was later admitted to APU (Adult Psychiatric Unit) for safety and stabilization. Patient #5 was discharged on 06/05/13 to home with continued care to include outpatient behavioral health services.

On 06/28/13 Patient #5 submitted a written grievance to the Patient Relations Department of the hospital indicating that hospital staff had washed her $800.00 leather dress while she was on the APU and ruined it.

A review of the investigative report of the grievance by the Patient Relations Department revealed the grievance was submitted to the Patient Relations Department on 06/28/13 and was resolved on 07/19/13. A letter was sent to Patient #5 on 07/19/13 indicating a thorough investigation was completed by the staff involved and the hospital was not at fault for the damage to her $800.00 leather dress and would be unable to replace the cost of the dress.

In an interview on 08/15/13 at 3:45 p.m. with S24Specialist with the Patient Relations Department, she indicated she was involved in the grievance investigation for Patient #5 regarding her ruined $800.00 leather dress. S24Specialist indicated she spoke with the charge nurse on the APU during the investigation and asked about the APU's policy of washing patient's clothes. S24Specialist indicated she was told by the charge nurse (S24 did not remember or document the charge nurse's name) that the policy indicated the patients were responsible for washing and drying their own clothes and staff were not allowed to wash or dry patient clothes. S24Specialist indicated this completed her investigation of the grievance incident. S24Specialist indicated she did not contact or involve the APU manager, S14RN or question any staff on the APU. S24Specialist further indicated she did not contact or involve the emergency room manager, S13RN or question the emergency room nurse, S29RN who initially admitted Patient #5 to the hospital and assisted the patient in the inventory of her valuables.

In an interview on 08/15/13 at 10:40 a.m. with S14RN, APU manager, she indicated she was not made aware of the grievance complaint of Patient #5 regarding her grievance that the APU staff had ruined her $800.00 leather dress, until today (08/15/13). S14RN, APU manager, indicated she should have been notified of the patient's grievance by the Patient Relations Department so she could have conducted a further investigation of the incident.

Based on record reviews and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by having one-to-one (1:1) observation by a sitter discontinued for a patient who was under a Coroner's Emergency Certificate for being a danger to himself (required by hospital policy) for 1 of 10 sampled patients' records reviewed for care in a safe setting (#2). Findings:

Review of the hospital policy titled "Providing Care for Psychiatric and Suicidal Patients Not in Psychiatry", policy number OHS.NURS.037, revised 07/12, and presented as the current policy for observation of psychiatric/suicidal patients who were not admitted to the behavioral health unit by S1Assistant Vice-President (AVP) of Quality, revealed that all suicidal PEC/CEC patients required staff to observe the patient maintaining strict visual contact at all times including during toileting and for off unit tests or procedures.

Review of the hospital policy titled "Use of Sitters, Private Duty Nurses and Volunteers", policy number OHS.NURS.043, revised 02/11, and presented as the current policy for sitters by S1AVP of Quality, revealed that a physician order is not needed for a sitter or private duty nurse. Further review revealed that when a physician or nurse believes that it is a patient's best interest to have someone present at all times, the family member(s) / significant other should be strongly encouraged to make arrangements such that the patient is never alone. If a sitter is indicated, and the family cannot commit to having a family member present with the patient at all times, the Clinical Coordinator, Operations Coordinator, Charge Nurse, or Administrative Coordinator will advise the family that a sitter will be requested.

Review of Patient #2's medical record revealed he was admitted to the Emergency Department (ED) on 06/08/13 at 10:36 p.m. with diagnoses of Benzodiazepine Overdose, Hypotension Arterial, and Respiratory Depression. He was transferred to the Surgical Step-down Unit of the hospital on 06/09/13 at 1:33 p.m. Further review revealed Patient #2 had a Physician Emergency Certificate (PEC) signed on 06/09/13 at 12:00 a.m. due to Patient #2 being suicidal and a danger to himself. Review of his Coroner's Emergency Certificate (CEC) signed by S31Assistant Coroner on 06/10/13 at 10:56 a.m. revealed a notation of "Dr. (doctor) wrote note about possibly cx (canceling) PEC but has not done so." Further review of the CEC revealed that S31Assistant Coroner documented that Patient #2 had a positive DWI (driving while intoxicated) and was a danger to himself.

Review of Patient #2's physician orders revealed an order by S8Internal Medicine Intern on 06/10/13 at 11:18 a.m. to cancel Patient #2's PEC (written after Patient #2 had a CEC signed by S31Assistant Coroner as being a danger to himself). Review of the entire medical record revealed no documented evidence that Patient #2 was re-evaluated and determined not to be a danger to himself prior to the 1:1 sitter observation being discontinued.

Review of Patient #2's "Precautionary Measures Guide to Risk Sitting Flowsheet" (form used by sitters to document every 15 minutes observations of patients) revealed a sitter documented every 15 minutes observations from 10:30 p.m. on 06/08/13 through 4:00 p.m. on 06/10/13. There was no documented evidence that Patient #2 remained on 1:1 observation while he was under a CEC as required by hospital policy.

In a face-to-face interview on 08/16/13 at 1:25 p.m., S3Vice-President (VP) of Nursing indicated that Patient #2 should have had a sitter as long as his CEC was in effect. She further indicated that the sitter was discontinued when his PEC was canceled.

Based on record reviews and interviews, the hospital failed to reassess a patient's discharge plan for factors that may affect the appropriateness of discharge as evidenced by having a patient discharged home who was under a Coroner's Emergency Certificate for being a danger to himself for 1 of 10 sampled patients' records reviewed for discharge planning (#2). Findings:

Review of the hospital policy titled "Discharge Planning Process", policy number OHS.CASEM.009, revised 03/11, and presented as the current policy for discharge planning by S5Director of Care Management, revealed that the discharge planning process was an interdisciplinary process, and the Case Management / Social Services department was responsible for the implementation of the discharge plan. Further review revealed that the case manager / social worker would make all necessary arrangements for discharge ensuring documentation was complete and that the servicing agency had the necessary information to provide continued care for the patient post-discharge. All activity related to patient assessment, re-assessment, and other discharge planning activity will be documented in the medical record.

Review of Patient #2's medical record revealed he was admitted to the Emergency Department (ED) on 06/08/13 at 10:36 p.m. with diagnoses of Benzodiazepine Overdose, Hypotension Arterial, and Respiratory Depression. He was transferred to the Surgical Step-down Unit of the hospital on 06/09/13 at 1:33 p.m.

Review of Patient #2's Physician Emergency Certificate (PEC) signed on 06/09/13 at 12:00 a.m. revealed Patient #2 was suicidal and a danger to himself.

Review of Patient #2's Psychiatric History and Physical, performed on 06/09/13 at 8:55 a.m. by S11Psychiatry Resident and reviewed and signed by S6Section Head of Child and Adolescent Psychiatry on 06/09/13 at 1:05 p.m., revealed Patient #2 denied suicidal ideation and stated that he only feels "that way occasionally while intoxicated" and wished to return home and attempt to quit drinking on his own. Further review revealed S11Psychiatry Resident's recommendations included the following: patient does not currently meet criteria for involuntary inpatient psychiatric treatment ; he denies suicidal ideation when not intoxicated; alcohol dependence and occasional suicidal ideation while drinking are a long-standing problem which will likely be unchanged by inpatient admission; patient not currently suicidal, homicidal, or gravely disabled; PEC may be rescinded; recommend that patient seek inpatient or outpatient treatment to help him to quit alcohol use; Valium taper to manage impending alcohol withdrawal; continue current PRN (as needed) Ativan orders for alcohol withdrawal.

Review of Patient #2's Coroner's Emergency Certificate (CEC) signed by S31Assistant Coroner on 06/10/13 at 10:56 a.m. revealed a notation of "Dr. (doctor) wrote note about possibly cx (canceling) PEC but has not done so." Further review of the CEC revealed that S31Assistant Coroner documented that Patient #2 had a positive DWI (driving while intoxicated) and was a danger to himself.

Review of Patient #2's physician orders revealed an order by S8Internal Medicine Intern on 06/10/13 at 11:18 a.m. to cancel Patient #2's PEC (written after Patient #2 had a CEC signed by S31Assistant Coroner as being a danger to himself). Further review revealed an order entered by S7Internal Medicine Resident on 06/12/13 at 11:43 a.m. for an inpatient consult to psychiatry with the reason for the consult being "Patient CEC'd will need you to re-evaluate." Further review revealed the psychiatry consult was canceled automatically by discharge of the patient on 06/13/13 at 7:40 p.m. Review of the entire medical record revealed no documented evidence that Patient #2 was re-evaluated by Psychiatry and determined not to be a danger to himself prior to being discharged home.

In a face-to-face interview on 08/15/13 at 1:10 p.m., S6Section Head of Child and Adolescent Psychiatry, when asked what was meant by the documentation that Patient #2 did not meet the criteria for inpatient care, indicated that status post alcohol intoxication there was no abnormality in Patient #2's mental status exam. He further indicated that Patient #2' mood was not depressed, and he had a broad affect. He further indicated that S11Psychiatry Resident found Patient #2 to be dysphoric (explained that this meant he was unhappy about being in the hospital), but he (S6Section Head of Child and Adolescent Psychiatry) "didn't see it." S6Section Head of Child and Adolescent Psychiatry indicated that Patient #2 was not suicidal, he was competent to make decisions about his care, and he was not a danger to himself or others or homicidal or gravely disabled by psychosis. He further indicated that based on this assessment, Patient #2 did not meet the legal criteria for involuntary admission. S6Section Head of Child and Adolescent Psychiatry indicated that he did not know what rescinding a PEC meant. He further indicated an automatic request was made for a CEC once a patient was PEC'd. He confirmed that he did not see Patient #2 again during his hospitalization. after the initial Psychiatry consult was completed. S6Section Head of Child and Adolescent Psychiatry indicated that ordering a second Psychiatry consult after Patient #2 was CEC'd was an appropriate plan to determine whether to discharge him or to admit him for inpatient treatment.

In a face-to-face interview on 08/15/13 at 1:40 p.m. with S7Internal Medicine Resident, S8Internal Medicine Intern, and S10Academics Hospitalist in the Department of Medicine present, S7Internal Medicine Resident indicated he ordered the second psychiatry consult to address Patient #2's CEC that was documented prior to S8Internal Medicine Intern canceling his PEC. S10Academics Hospitalist in the Department of Medicine indicated that a consult was not necessary, because this could have been handled by a phone call. S7Internal Medicine Resident indicated he could not remember who he spoke to about psychiatry having cleared Patient #2 for discharge, and he didn't document any notes of the discussion in Patient #2's medical record.

In a face-to-face interview on 08/16/13 at 10:40 a.m., S11Psychiatry Resident indicated, when asked what PEC may be rescinded meant, that it meant that Patient #2's PEC could be lifted because he didn't meet criteria for involuntary admission. She further indicated that it was the responsibility of the person who put the PEC in place or the physician in charge of the patient's care to lift the PEC. She confirmed that she never spoke with S7Internal Medicine Resident or S8Internal Medicine Intern about Patient #2's care.

In a face-to-face interview on 08/16/13 at 1:10 p.m., S9Chairman and Medical Director of Psychiatry and Addictive Medicine indicated that it's common practice that if a PEC is lifted, it lifts the CEC. He further indicated there should be a call placed to the coroner's office to tell them that the PEC is being canceled. He further indicated that he spoke with S7Internal Medicine Resident who told him that he (S7Internal Medicine Resident) spoke to S32General Psychiatry Resident and requested that he see Patient #2. He further indicated that S7Internal Medicine Resident told him that S32General Psychiatry Resident had spoken with S11Psychiatry Resident about Patient #2, and S9Chairman and Medical Director of Psychiatry and Addictive Medicine indicated that S11Psychiatry Resident told him (S9Chairman and Medical Director of Psychiatry and Addictive Medicine) that she didn't remember the conversation with S32General Psychiatry Resident. S9Chairman and Medical Director of Psychiatry and Addictive Medicine indicated that S32General Psychiatry Resident didn't remember how he ended the call, but he (S32General Psychiatry Resident) thought that he (S32General Psychiatry Resident) told S7Internal Medicine Resident if he (S7Internal Medicine Resident) wasn't comfortable, he could request someone to assess Patient #2. S9Chairman and Medical Director of Psychiatry and Addictive Medicine indicated that S32General Psychiatry Resident should have seen Patient #2. He further indicated the surveyors were "100 per cent right - he (Patient #2) had a CEC in effect" when he was discharged.

In a face-to-face interview on 08/16/13 at 1:25 p.m., S3Vice-President of Nursing indicated the second consult for psychiatry order was an automatic cancel when Patient #2 was discharged, and no staff member canceled the consult order.

Based on record reviews and interviews, the hospital failed to thoroughly investigate patients' grievances according to hospital policy for 2 of 2 grievances reviewed from a total of 3 grievances submitted from 05/01/13 through 08/14/13 (#2, #5). Findings:

Review of the hospital's policy titled "Patient Grievance Management", policy number OHS.QUAL.008, issued 08/13, and presented as the current policy for the grievance procedure by S1Assistant Vice-President of Quality, revealed that a written complaint is always considered a grievance and will follow the Patient Grievance Management procedure. Further review revealed all grievances will be reviewed and analyzed by the Patient Relations Department. When an issue/concern cannot be promptly resolved, the following steps will be taken: 1) the Patient Relations representative will initiate the grievance process by entering the data into the electronic tracking system; 2) the Patient Relations Department will send an initial letter to the patient within 7 days confirming receipt of the grievance and explaining the grievance process; 3) the Patient Relations representative will immediately forward a copy of the grievance to the appropriate investigators (Hospital Manager/Director or Physician) by electronic mail. Review of the grievance investigation revealed the following steps: 1) upon the investigator's receipt of the grievance, an investigation will begin within 24 hours to address the specific issues/concerns that were communicated by the patient/family; 2) written response of findings from the investigators will be sent via electronic mail to the Patient Relations Department within 72 hours; 3) if the response is not received from the investigators within 72 hours, the grievance will be escalated to the CNO (Chief Nursing Officer) or Medical Staff Leader, or their delegate, for resolution and written response within 72 hours; 4) the Patient Relations Department will send out an extension letter to the patient for all grievances that are not able to be finalized within 30 days.

Patient #2
Review of Patient #2's medical record revealed he was admitted to the Emergency Department (ED) on 06/08/13 at 10:36 p.m. with diagnoses of Benzodiazepine Overdose, Hypotension Arterial, and Respiratory Depression. He was transferred to the Surgical Step-down Unit of the hospital on 06/09/13 at 1:33 p.m. Further review revealed Patient #2 had a Physician Emergency Certificate (PEC) signed on 06/09/13 at 12:00 a.m. due to Patient #2 being suicidal and a danger to himself. Review of his Coroner's Emergency Certificate (CEC) signed by S31Assistant Coroner on 06/10/13 at 10:56 a.m. revealed a notation of "Dr. (doctor) wrote note about possibly cx (canceling) PEC but has not done so." Further review of the CEC revealed that S31Assistant Coroner documented that Patient #2 had a positive DWI (driving while intoxicated) and was a danger to himself.

Review of documentation from the Patient Relations Department revealed a letter dated 07/22/13 from Patient #2's wife (complainant) was received, and S23Patient Relations Specialist spoke with Patient #2's wife on 07/24/13 by phone. Further review revealed that S23Patient Relations Specialist informed the complainant that the grievance process would begin as soon as the letter was received by the hospital (complainant stated that she had explained her concerns in the letter and did not want to discuss them on their phone). Review of the letter's content revealed that the complainant complained of comments made during telephone conversations with S7Internal Medicine Resident when S7Internal Medicine Resident allegedly stated that "The state has no funds to keep him here" and accused Patient #2 of "Doctor shopping."

Review of the follow-up documented by S23Patient Relations Specialist revealed she had requested internal responses from several physicians including S10Academics Hospitalist with the Department of Medicine and staff members on 07/25/13 at 3:31 p.m. and had shared the file with several physicians and staff members including S27Vice-Chairman of Hospital Medicine. Further review revealed repeat requests were sent by S23Patient Relations Specialist for an internal response from S9Chairman and Medical Director of Psychiatry and Addictive Medicine on 08/01/13 at 10:40 a.m. and on 08/02/13 at 12:43 p.m. A repeat request was sent by S23Patient Relations Specialist for an internal response from S21Manager of Patient Relations on 08/02/13 at 9:55 a.m. and on 08/02/13 at 4:25 p.m. There was no documented evidence that an internal response was requested or that repeat requests were sent to S27Vice-Chairman of Hospital Medicine.

Review of the response documented by S10Academics Hospitalist with the Department of Medicine on 07/26/13 at 8:54 a.m. revealed that psychiatry was consulted for Patient #2's suicide attempt and found him safe to return home. She further documented that S7Internal Medicine Resident and S8Internal Medicine Intern were her residents at the time, but she wasn't present when they talked to the complainant. There was no documented evidence that her response addressed any of the alleged comments made by S7Internal Medicine Resident as reported by the complainant.

In a face-to-face interview on 08/15/13 at 1:40 p.m. with S7Internal Medicine Resident, S8Internal Medicine Intern, and S10Academics Hospitalist in the Department of Medicine present, S7Internal Medicine Resident indicated he didn't make the comment about not having state funds, because he doesn't get involved with insurance and just takes care of the patients. He further indicated Patient #2 was given Valium to treat the alcohol withdrawal, but he couldn't give him a prescription for Valium since he had overdosed with Valium while drinking alcohol. He indicated that the complainant may have interpreted his explanation as "Doctor shopping", but he didn't use those words at any time.

In a face-to-face interview on 08/15/13 at 3:45 p.m., S23Patient Relations Specialist indicated that she would not rely on the attending physician (S10Academics Hospitalist in the Department of Medicine) to review with the residents the alleged comments brought forth by the complainant but would expect the S27Vice-Chairman of Hospital Medicine to address it. S23Patient Relations Specialist confirmed that she had not received a response from S27Vice-Chairman of Hospital Medicine and had not sent a repeat request to him as she did for others from whom she had not heard. She indicated it was an oversight, and a second or third request for a response should have been made.


30172

Patient #5
Patient #5 was admitted to the hospital's emergency room on 05/27/13 from home with diagnoses of bipolar disorder and substance abuse to include: bizarre manic behaviors and auditory hallucinations. The patient was later admitted to APU (Adult Psychiatric Unit) for safety and stabilization. Patient #5 was discharged on 06/05/13 to home with continued care to include outpatient behavioral health services.

On 06/28/13 Patient #5 submitted a written grievance to the Patient Relations Department of the hospital indicating that hospital staff had washed her $800.00 leather dress while she was on the APU and ruined it.

A review of the investigative report of the grievance by the Patient Relations Department revealed the grievance was submitted to the Patient Relations Department on 06/28/13 and was resolved on 07/19/13. A letter was sent to Patient #5 on 07/19/13 indicating a thorough investigation was completed by the staff involved and the hospital was not at fault for the damage to her $800.00 leather dress and would be unable to replace the cost of the dress.

In an interview on 08/15/13 at 3:45 p.m. with S24Specialist with the Patient Relations Department, she indicated she was involved in the grievance investigation for Patient #5 regarding her ruined $800.00 leather dress. S24Specialist indicated she spoke with the charge nurse on the APU during the investigation and asked about the APU's policy of washing patient's clothes. S24Specialist indicated she was told by the charge nurse (S24 did not

Based on record reviews and interviews, the hospital failed to reassess a patient's discharge plan for factors that may affect the appropriateness of discharge as evidenced by having a patient discharged home who was under a Coroner's Emergency Certificate for being a danger to himself for 1 of 10 sampled patients' records reviewed for discharge planning (#2). Findings:

Review of the hospital policy titled "Discharge Planning Process", policy number OHS.CASEM.009, revised 03/11, and presented as the current policy for discharge planning by S5Director of Care Management, revealed that the discharge planning process was an interdisciplinary process, and the Case Management / Social Services department was responsible for the implementation of the discharge plan. Further review revealed that the case manager / social worker would make all necessary arrangements for discharge ensuring documentation was complete and that the servicing agency had the necessary information to provide continued care for the patient post-discharge. All activity related to patient assessment, re-assessment, and other discharge planning activity will be documented in the medical record.

Review of Patient #2's medical record revealed he was admitted to the Emergency Department (ED) on 06/08/13 at 10:36 p.m. with diagnoses of Benzodiazepine Overdose, Hypotension Arterial, and Respiratory Depression. He was transferred to the Surgical Step-down Unit of the hospital on 06/09/13 at 1:33 p.m.

Review of Patient #2's Physician Emergency Certificate (PEC) signed on 06/09/13 at 12:00 a.m. revealed Patient #2 was suicidal and a danger to himself.

Review of Patient #2's Psychiatric History and Physical, performed on 06/09/13 at 8:55 a.m. by S11Psychiatry Resident and reviewed and signed by S6Section Head of Child and Adolescent Psychiatry on 06/09/13 at 1:05 p.m., revealed Patient #2 denied suicidal ideation and stated that he only feels "that way occasionally while intoxicated" and wished to return home and attempt to quit drinking on his own. Further review revealed S11Psychiatry Resident's recommendations included the following: patient does not currently meet criteria for involuntary inpatient psychiatric treatment ; he denies suicidal ideation when not intoxicated; alcohol dependence and occasional suicidal ideation while drinking are a long-standing problem which will likely be unchanged by inpatient admission; patient not currently suicidal, homicidal, or gravely disabled; PEC may be rescinded; recommend that patient seek inpatient or outpatient treatment to help him to quit alcohol use; Valium taper to manage impending alcohol withdrawal; continue current PRN (as needed) Ativan orders for alcohol withdrawal.

Review of Patient #2's Coroner's Emergency Certificate (CEC) signed by S31Assistant Coroner on 06/10/13 at 10:56 a.m. revealed a notation of "Dr. (doctor) wrote note about possibly cx (canceling) PEC but has not done so." Further review of the CEC revealed that S31Assistant Coroner documented that Patient #2 had a positive DWI (driving while intoxicated) and was a danger to himself.

Review of Patient #2's physician orders revealed an order by S8Internal Medicine Intern on 06/10/13 at 11:18 a.m. to cancel Patient #2's PEC (written after Patient #2 had a CEC signed by S31Assistant Coroner as being a danger to himself). Further review revealed an order entered by S7Internal Medicine Resident on 06/12/13 at 11:43 a.m. for an inpatient consult to psychiatry with the reason for the consult being "Patient CEC'd will need you to re-evaluate." Further review revealed the psychiatry consult was canceled automatically by discharge of the patient on 06/13/13 at 7:40 p.m. Review of the entire medical record revealed no documented evidence that Patient #2 was re-evaluated by Psychiatry and determined not to be a danger to himself prior to being discharged home.

In a face-to-face interview on 08/15/13 at 1:10 p.m., S6Section Head of Child and Adolescent Psychiatry, when asked what was meant by the documentation that Patient #2 did not meet the criteria for inpatient care, indicated that status post alcohol intoxication there was no abnormality in Patient #2's mental status exam. He further indicated that Patient #2' mood was not depressed, and he had a broad affect. He further indicated that S11Psychiatry Resident found Patient #2 to be dysphoric (explained that this meant he was unhappy about being in the hospital), but he (S6Section Head of Child and Adolescent Psychiatry) "didn't see it." S6Section Head of Child and Adolescent Psychiatry indicated that Patient #2 was not suicidal, he was competent to make decisions about his care, and he was not a danger to himself or others or homicidal or gravely disabled by psychosis. He further indicated that based on this assessment, Patient #2 did not meet the legal criteria for involuntary admission. S6Section Head of Child and Adolescent Psychiatry indicated that he did not know what rescinding a PEC meant. He further indicated an automatic request was made for a CEC once a patient was PEC'd. He confirmed that he did not see Patient #2 again during his hospitalization. after the initial Psychiatry consult was completed. S6Section Head of Child and Adolescent Psychiatry indicated that ordering a second Psychiatry consult after Patient #2 was CEC'd was an appropriate plan to determine whether to discharge him or to admit him for inpatient treatment.

In a face-to-face interview on 08/15/13 at 1:40 p.m. with S7Internal Medicine Resident, S8Internal Medicine Intern, and S10Academics Hospitalist in the Department of Medicine present, S7Internal Medicine Resident indicated he ordered the second psychiatry consult to address Patient #2's CEC that was documented prior to S8Internal Medicine Intern canceling his PEC. S10Academics Hospitalist in the Department of Medicine indicated that a consult was not necessary, because this could have been handled by a phone call. S7Internal Medicine Resident indicated he could not remember who he spoke to about psychiatry having cleared Patient #2 for discharge, and he didn't document any notes of the discussion in Patient #2's medical record.

In a face-to-face interview on 08/16/13 at 10:40 a.m., S11Psychiatry Resident indicated, when asked what PEC may be rescinded meant, that it meant that Patient #2's PEC could be lifted because he didn't meet criteria for involuntary admission. She further indicated that it was the responsibility of the person who put the PEC in place or the physician in charge of the patient's care to lift the PEC. She confirmed that she never spoke with S7Internal Medicine Resident or S8Internal Medicine Intern about Patient #2's care.

In a face-to-face interview on 08/16/13 at 1:10 p.m., S9Chairman and Medical Director of Psychiatry and Addictive Medicine indicated that it's common practice that if a PEC is lifted, it lifts the CEC. He further indicated there should be a call placed to the coroner's office to tell them that the PEC is being canceled. He further indicated that he spoke with S7Internal Medicine Resident who told him that he (S7Internal Medicine Resident) spoke to S32General Psychiatry Resident and requested that he see Patient #2. He further indicated that S7Internal Medicine Resident told him that S32General Psychiatry Resident had spoken with S11Psychiatry Resident about Patient #2, and S9Chairman and Medical Director of Psychiatry and Addictive Medicine indicated that S11Psychiatry Resident told him (S9Chairman and Medical Director of Psychiatry and Addictive Medicine) that she didn't remember the conversation with S32General Psychiatry Resident. S9Chairman and Medical Director of Psychiatry and Addictive Medicine indicated that S32General Psychiatry Resident didn't remember how he ended the call, but he (S32General Psychiatry Resident) thought that he (S32General Psychiatry Resident) told S7Internal Medicine Resident if he (S7Internal Medicine Resident) wasn't comfortable, he could request someone to assess Patient #2. S9Chairman and Medical Director of Psychiatry and Addictive Medicine indicated that S32General Psychiat