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Based on document review and interviews, the psychiatric hospital failed to provide and or transmit necessary discharge medical information to the post acute care service provider for 1 of 10 patient (Patient #1) closed medical records reviewed. Failure to provide and/or transmit medical information pertaining to the patient's current course of illness and treatment, post discharge medications, goals of care and follow-up to Patient #1's post discharge care provider may potentially result in Patient #1 not receiving the required care, medications, and follow up Patient #1 required for optimum mental health and may result in rehospitalization or a poor mental health outcome. The Psychiatric Hospital's administrative staff identified a census of 47 patients upon entrance.

Findings include:


1. Review of Patient #1's medical record revealed Patient # 1 was admitted on 2/1/22 with schizoaffective disorder and discharged on 2/12/22 at 1:26 PM.


2. Review of a facility document titled "Complaint", dated 2/13/22, revealed Patient # 1's mother contacted the acute care psychiatric hospital because she was not satisfied with the discharge process. Patient #1 resided in a group home and Patient #1's mother felt that communication and coordination was not sufficient. Patient #1's mother complained the psychiatric hospital staff did not send medications with the patient, discharge paperwork to the group home, and neither the mother nor the group home know when the follow up appointments were scheduled.

An email attached to the complaint from the Group Home Program Director, dated 2/15/22, 3:44 PM, revealed in part, "... I wanted to reach out about some concerns I have with the recent discharge ... you let me know [Patient #1's name] would be coming with 30 days worth of medications .... was discharged with no medications what so ever ... also didn't get sent any discharge paperwork and I haven't received any either ... I had given our FAX number for these to be sent to and still haven't gotten them..."


3. Review of the policy "Discharge and Continuing Care Planning" effective 6/12/20, revealed in part, "...When making plans staff should consider the patient's living situation ... Staff should talk with the patient and family ... At the time of discharge, the licensed nurse completes the discharge instructions and summary, which includes: a list of medications the patient is to continue on, upcoming appointments, and current information on ... continuing care. Once discharge has occurred a discharge note will then be placed in the progress notes. The therapist completes the safety plan with the patient, writes a discharge note and puts the aftercare appointments into the chart. The patient is provided a copy of the safety plan with their Discharge plan. Discharge shall be coordinated with the individual, and, .... the appropriate agency, in a timely manner." The policy lacked clear guidance on the communication required with the "appropriate agency," such as a patient's post acute care provider to assure continued care as identified in the discharge plan.

4. During an interview on 2/28/2022 at 8:30 AM, the Group Home Program Coordinator for Patient #1 reported the group home has had difficulty in the past obtaining adequate post discharge information for previous patients that returned to the group home following an inpatient stay at the psychiatric hospital, so this time she emailed her concerns to Discharge Planner B. Patient #1 had been hospitalized at the psychiatric hospital for over a week and a half. The Group Home Program Coordinator contacted Discharge Planner B by phone on Friday and learned of Patient #1's planned discharge for Saturday. We talked about transportation back to the group home, I asked about medications, and stated we do not have a pharmacy open in our small community on weekends. Discharge Planner B replied a 30 day supply of medications would be sent home with Patient #1. I provided our FAX number so hospital staff could FAX the discharge paperwork to our Behavioral Health group home. Patient #1 arrived the following day, Saturday 2/12/22, at approximately 4:00 PM without prior notification that Patient #1 had actually been discharged and was en route to the group home, no medications accompanied Patient #1, and no discharge instructions were faxed or sent with Patient #1. The acute care psychiatric hospital staff assisted and the required medication was finally secured for Patient #1 by 5:30 PM, day of discharge, from a pharmacy about 20 miles away form the group home. Pertinent discharge medical information was not faxed to the post acute care provider/group home until Tuesday, February 15th, 3 days after Patient #1 had been discharged, and only after the Group Home Program Coordinator emailed Discharge Planner B that the required discharge information had not been received.

5. During an interview on 2/24/22 at 12:54 PM, Discharge Planner B reported she had talked with Patient #1's mother regarding the planned discharge for Saturday, 2/12/22. Discharge Planner B verbalized Patient #1's mother voiced concern about a weekend discharge related to the ability to obtain needed medications, transportation, and the group homes ability to take her son back on the weekend. Discharge Planner B reported she told the mother the hospital would send 30 days worth of medications with Patient #1, transportation would be arranged, and the required information sent to Patient #1's group home. Discharge Planner B reported a similar conversation with the Group Home Program Coordinator on Friday, the day before the scheduled discharge. Discharge Planner B reported she set up the transportation but did not FAX any discharge information to the group home on Friday. Discharge Planner B voiced discharge planners only work Monday through Friday and are not here on weekends. Discharge Planner B reported weekend paperwork can get complicated since the paperwork isn't all completed until actual discharge time. Discharge Planner B indicated it would be the nursing staff's responsibility to send the final paperwork to the group home.

6. During an interview on 2/28/22 at 9:16 AM, RN A reported she was Patient #1's nurse on Saturday 2/12/22. RN A noted Patient #1 was scheduled to be discharged and a 30 day supply of medications were to be sent with Patient #1. RN A revealed no medications had been obtained and noted the order had been placed within 10 minutes of the pharmacy closing for the day and was likely not received. RN A stated she contacted House Supervisor RN C to assist with the problem. RN A talked with Patient #1 and obtained the name of the pharmacy Patient #1 indicated meds could be obtained from. RN A reported she notified House Supervisor RN C and she took over from there obtaining the medication. RN A verbalized nursing doesn't call the receiving facility or FAX discharge paperwork to a receiving facility upon discharge and RN A did not call the group home to alert them that Patient #1 had indeed been discharged. RN A reported she did review the discharge continuing care plan with Patient #1, Patient #1 signed the document and sent a copy of the discharge continuing care plan with Patient #1. RN A expressed that we, as nurses, have no communication with the receiving facility unless they contact us. All communication occurred through discharge planning. RN A acknowledged the hospital discharge process needs to be improved.

7. During an interview on 2/23/22 at 3:15 PM, the Director of Clinical Services revealed Discharge Planners worked Monday through Friday. The responsibility to perform the medication piece and send the discharge transfer documents rested with RNs and not the discharge planning staff.

8. During an interview on 2/24/2022 at 8:40 AM, the Director of Nursing acknowledged the medications for Patient #1 should have been in place, a nurse to nurse report done with the group home, and the discharge packet of information faxed/provided for the patient's group home. The CNO verbalized that the staff nurse reported to him that she did send the discharge packet of information with Patient #1, so not sure why the receiving facility had not received it. We dropped the ball on this one.