HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 482.43, Discharge Planning.

Findings include:

1. The hospital failed to ensure that the discharge need to provide facility transport to Pt. #1 was completed. See A-807.

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed regarding treatment/care planning, the hospital failed to ensure that Pt. #1's state guardian participated in the care/treatment planning.

Findings include:

1. On 5/9/2025, the hospital's facility titled, "Patient Rights" (1/2025) was reviewed and included, "... Procedure... 7. Patient Rights include... a. to participate in all decisions involving the patient care or treatment..."

2. On 5/9/2025, the clinical record for Pt. #1 was reviewed. On 1/4/2025, Pt. #1 was admitted to the hospital due to suicidal ideation. The clinical record included:

- The state guardianship document indicated, " ... FINDINGS OF FACT, CONCLUSION OF LAW AND ORDER APPOINTING GUARDIAN ... 2. A plenary guardianship of the person (Pt. #1) is required because (Pt. #1) has been diagnosed with developmental disabilities ... NOW, THEREFORE, IT IS HEREBY ORDERED AND ADJUDGED ... B ... THE OFFICE OF STATE GUARDIAN should be and hereby is appointed the plenary guardian of ... (Pt. #1) ... entered (8/21/2024) ..."

- The master treatment plan on 1/05/2025 and interdisciplinary treatment plan update on 1/12/2025 and clinical record did not indicate involvement/participation of the State Guardian in the development of the treatment/care plan.

3. On 5/10/2025 at approximately 10:45 AM, findings were discussed with E #6 (Director of Risk Management and Performance Improvement). E #6 stated that state guardian should participate in the development and implementation of patient's treatment plan.

Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical records reviewed regarding administration of psychotropic medications, the hospital failed to ensure that consent was obtained from Pt. #1's state guardian.

Findings include:

1. On 5/9/2025, the hospital's policy titled, "Use of Psychotropic Drugs" (1/2025) was reviewed and included, "...III... 5. Psychotropic medications are ordered and administered following full informed consent..."

2. On 5/9/2025, the clinical record for Pt. #1 was reviewed. On 1/4/2025, Pt. #1 was admitted to the hospital due to suicidal ideation. The clinical record included:

- The state guardianship document indicated, " ... FINDINGS OF FACT, CONCLUSION OF LAW AND ORDER APPOINTING GUARDIAN ... 2. A plenary guardianship of the person (Pt. #1) is required because (Pt. #1) has been diagnosed with developmental disabilities ... NOW, THEREFORE, IT IS HEREBY ORDERED AND ADJUDGED ... B ... THE OFFICE OF STATE GUARDIAN should be and hereby is appointed the plenary guardian of ... (Pt. #1) ... entered (8/21/2024) ..."

- The medication administration records from 1/4/2025 thorough 1/16/2025 were reviewed and indicated that Pt. #1 received psychotropic medications from 1/10/2025 through 1/16/2025. However, psychotropic drug consent was not obtained from the state guardian.

3. On 5/10/2025 at approximately 10:45 AM, findings were discussed with E #6 (Director of Risk Management and Performance Improvement). E #6 stated that prior to administering the psychotropic medication psychotropic consent should have been obtained from Pt. #1's state guardian.

Based on document review and interview, it was determined that for 1 of 1 patient (Pt. #1) clinical record reviewed under state guardianship, the hospital failed to ensure that the discharge need to provide facility transport to Pt. #1 was completed.

Findings include:

1. On 5/9/2025, the hospital's policy titled, "Discharge Planning" (1/2025) was reviewed and included, "... Procedure... 2... g. Confirmation of transport modality... with facility... and outside transport services..."

2. On 5/9/2025, the clinical record for Pt. #1 was reviewed. On 1/4/2025, Pt. #1 was admitted to the hospital due to suicidal ideation.

- The discharge evaluation on 1/13/2025 indicated that Pt #1 will be discharged to (Name of Residential of Facility) on 1/16 2025 via facility transportation.

3. On 5/9/2025, the incident report for Pt. #1, dated 1/16/2025 was reviewed and indicated, " ... (Pt. #1) was escorted to the lobby and waited for transportation as the driver called to notify all patients riding on his van, (Pt. #1) then exited the lobby, approached the van, and refused to enter. (Pt. #1) immediately walked away from the van and left the property..."

4. On 5/10/2025 at approximately 9:37 AM, an interview was conducted with E #6 (Director of Risk Management and Performance Improvement). E #6 stated that following Pt. #1's incident, the hospital started a new process wherein anybody under state guardianship will not be transported in a facility van. However, when asked for audits/evaluation for effectively and sustainability of the new process, E #6 stated, "I have not done it yet."

5. On 5/10/2025 at approximately 10:47 AM, a telephone interview was conducted with E #1 (Registered Nurse). E #1 stated that when a patient is in the reception area and the patient refuses to take the van, E #1 stated that the receptionist and the van driver will take care of it.