HospitalInspections.org

Based on record review and interview, the facility failed to ensure effective discharge planning for transition from hospital to post-discharge care in 1 of 6 discharged patients receiving outpatient services/treatment (Patient #1) in a total sample of 10 records reviewed resulting in Patient #1 being discharged to an inappropriate setting without contact information for crisis or outpatient care needs and without access to prescribed medications.


Findings include:

The facility failed to accurately document addresses for outpatient services on discharge paperwork. See Tag 0813.

The facility failed to document and coordinate referrals on discharge. See Tag 0813.

The facility failed to ensure accurate pharmacies for discharge medication orders. See Tag 0813.

The facility failed to coordinate transportation to outpatient services on discharge. See Tag 0813.

The facility failed to document contact phone numbers for crisis and outpatient care needs on discharge paperwork and patient safety plan. See Tag 0813.

Based on record review and interview, the facility failed to ensure signed informed consent for Psychotropic medications (used to treat mood, thoughts, behavior or perception) was obtained for 6 of 10 patients receiving Psychotropic medications (Patient's #1, #3, # 4, #5, #6 and #7) in a total of 10 medical records reviewed.

Findings include:

A review of the facility policy, titled "Informed Consent, 1800.8", dated 07/01/2021, revealed: "Procedures: An informed medication consent must be obtained for each individual medication, not by medication class. A hospital staff member may obtain and witness the patient's signature on the consent form...The written statement of informed consent will be completed and included in the patient's medical record."

A review of Patient #1's medical record revealed: "Trileptal (used to treat mood stabilization) ordered on 05/30/2022 at 1:19 PM and administered on 05/30/2022, 05/31/2022 and 06/01/2022 without a signed, written consent form. Effexor XR (used to treat depression) ordered on 05/27/2022 at 7:05 PM and administered on 05/27/2022, 05/28/2022, 05/29/2022, 05/30/2022 and 05/31/2022 without a signed, written consent form."

A review of Patient #3's medical record revealed: "Depakote (used to treat manic depression)ordered on 5/27/2022 at 9:58 PM and administered on 5/27/2022, 5/28/2022, 5/29/2022, 5/30/2022, 5/31/2022, 6/1/2022 and 6/2/2022 without a signed, written consent form. Klonopin (used to treat anxiety) ordered on 5/27/2022 at 2:00 PM and administered on 5/27/2022, 5/28/2022, 5/29/2022, 5/30/2022, 5/31/2022, 6/1/2022, 6/2/2022 and 6/3/2022 without a signed, written consent form."

A review of Patient #4's medical record revealed: "Mirtazapine (used to treat depression and insomnia) ordered on 5/26/2022 at 8:00 PM and administered on 5/27/2022 without a signed, written consent form."

A review of Patient #5's medical record revealed: "Zyprexa (used to treat anxiety and psychosis) was ordered on 5/25/2022 at 11:53 AM and administered on 5/25/2022 and 5/26/2022 without a signed, written consent form. Prozac (used to treat depression) was ordered on 5/26/2022 at 8:17 PM and administered on 5/26/2022, 5/27/2022, 5/28/2022, and 5/29/2022 without a signed, written consent form. Trazadone (used to treat depression and insomnia) ordered on 5/25/2022 at 9:00 AM and administered on 5/25/2022, 5/26/2022 and 5/27/2022 without a signed, written consent form."

During an interview on 08/17/2022 at 2:30 PM with Nurse Educator E stated, "It is the expectation that staff will complete the medication consent form for Psychotropic medication before the end of their shift. We do document verbal consent was obtained prior to giving the medication in the medical record."



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A review of Patient #6's medical record revealed: "Klonopin (used to treat anxiety) was ordered on 08/10/2022 at 8:00 PM and administered on 08/10/2022, 08/11/2022, 08/12/2022, 08/13/2022, 08/14/2022, 08/15/2022, 08/16/2022 and 08/17/2022 without a signed, written consent form. Vyvanse (used to treat attention deficit disorder) was ordered on 08/11/2022 at 8:00 AM and administered on 8/11/2022, 08/12/2022, 08/13/2022, 08/14/2022, 08/15/2022, 08/16/2022 and 08/17/2022 without a signed, written consent form."

A review of Patient #7's medical record revealed: "Seroquel (used to treat Schizophrenia) was ordered on 08/12/2022 at 8:00 AM and administered on 08/12/2022, 08/13/2022, 08/14/2022, 08/15/2022, 08/16/2022 and 08/17/2022 without a signed, written consent form. Latuda (used to treat out of contact with reality) was ordered on 08/12/2022 at 5:00 PM and administered on 08/12/2022, 08/13/2022, 08/14/2022, 08/15/2022 and 08/16/2022 without a signed, written consent form."

During an interview on 08/17/2022 at 3:33 PM with Nurse Educator E, when asked how staff know which medications need informed consents signed, Nurse Educator E stated "It flags in the chart which meds [medications] need consents; med consents can be given verbally, but paper consents should be done within the same shift."

Based on record review and interview, the facility failed to ensure a complete and accurate discharge plan per policy in 1 of 6 discharged patients receiving outpatient services/treatment (Patient #1) in a total sample of 10 records reviewed resulting in Patient #1 being discharged to an inappropriate setting without contact information for crisis or outpatient care needs and without access to prescribed medications.

Findings include:

A review of the facility document titled, "Discharge and Continuing Care Planning", dated 07/01/2021, revealed: "...POLICY 4.0: All patients shall receive relevant information concerning their continuing health needs...PROCEDURE 4.0: The therapist/case manager in consultation with other clinical disciplines, completes the discharge plan and assures all important elements of the discharge plan/care are included..."

Email correspondence by surveyor with Pt. #1 on 07/26/2022 and 8/03/2022 for additional details revealed, "...I was transferred via ambulance to [Facility Name] on the morning of May 26th. I was discharged on June 1st. I was attempting to stay at a shelter in [City O Name] until a particular shelter in [City P Name] had availability. I was instead dropped off at an abandoned industrial park. The social worker told me she had a lot to tend to and would email me CCS [comprehensive community services] resources later. I never received an email. I was told the day of my discharge (Wednesday) that I would begin [Facility's Name] partial hospitalization program the very next day (Thursday). I was told to call their medically provided ride share number to arrange a ride from the shelter. I called on Wednesday and was told that the ride share needed 48 hours notice in order to be able to pick me up. I called [Facility Name] and relayed this information. They told me to 'come in on Monday, it's fine.' I was sent to an abandoned industrial park 48 hours removed from a documented emotional breakdown and entire medication switch. I was without medication for over 48 hours, as they were sent 50 miles away and then took another full day to be prepared and refilled at the correct location...(I never went to [Facility Name] PHP [partial hospitalization program] that following Monday)."

Review of Pt. #1's medical record revealed:

- On 06/01/2022 at 10:07 AM, Pt. #1's "Discharge Continuing Care Plan Assessment" by Social Worker L, revealed, "...Discharge Address: [Address of Pt. #1's car]; Transportation: Personal car; Accompanied by: friends; Follow-Up Appointments: 1. [Name and phone number of County Human Services Department]; Crisis didn't require a referral from us. Call the number to the left to get in touch about a screening for services [no phone number listed]; Additional Instructions for Follow-Up Appointments: I will email you more information regarding providers in your area. Staff Signature/Date/Time: e-Signed by [Social Worker L] at 06/01/2022 12:52 PM."

There was no documentation that Social Worker L emailed Pt. #1, Social Worker L no longer works at the facility.

- On 06/01/2022 at 10:17 AM, Pt #1's "My Discharge Safety Plan" by [unknown provider], revealed, "...Professional I can contact during a crisis: 1. Clinician Name: PHP [partial hospitalization program]; Phone: [no phone number listed]...4. [Name of County Crisis]; Phone: [no phone number listed]...Patient Signature/Date/Time: e-signed by [Pt. #1] at 06/01/2022 10:17 AM; Staff Signature/Date/Time: e-Signed by [no staff signature name listed] at 06/01/2022 10:17 AM."

No phone numbers listed for the PHP and County Crisis on the safety plan for Patient #1 in the discharge paperwork.

-On 06/01/2022 at 1:52 PM, Pt #1's discharge "Nursing Progress Note" by Registered Nurse M revealed, "Cooperative. Seen by provider, discharge and transfer to PHP [partial hospitalization program] orders received. Patient appropriate for discharge. Medications reviewed and agreed to, and faxed to home pharmacy. Patient leaves facility at this time. Signature/Date/Time: e-Signed by Registered Nurse M at 06/01/2022 1:55 PM."

Review of Pt. #1's "DISCHARGE MEDICATION SUMMARY" revealed that medications were were sent electronically (e-PRESCRIBED) to City (P) pharmacy, not faxed to the patient's home pharmacy in City (O) as stated.

Also, Patient #1's medical record contained no documentation regarding transfer/transportation for Pt. #1's referral made to the PHP [partial hospitalization program].

During an interview on 08/17/2022 at 1:20 PM, Director of Clinical Services A stated, "Friends picked up [Pt. #1] from the facility, we made an appointment at [Name of homeless shelter in City P] for the next day." When asked about City O's address on Pt. #1's discharge papers, Director A stated, "That address was where [his/her] car was located, not sure why the discharge planner put the address for [his/her] car instead of the address of the homeless shelter; that discharge planner no longer works here."

During an interview on 08/17/2022 at 1:54 PM, Social Worker (I) confirmed that Pt. #1 was referred to the men's homeless shelter in City (P) for an assessment appointment, though there was no documentation on Pt. #1's discharge summary that Pt. #1 was referred there and no contact information.

The discharge summary for Pt. #1 was not accurate or was not filled out completely. Pt #1 was discharged from facility on 06/01/2022 via friend's vehicle to the address listed on his/her discharge paperwork. This address was where Pt. #1's car was located, not a homeless shelter. There was no documentation in the medical record that Pt. #1 was referred to a homeless shelter in City (P), though Social Worker (I) stated he/she was referred there. The discharge summary nursing note stated Pt. #1's medications were faxed to the patient's home pharmacy in City (O), but they were sent electronically to City (P) pharmacy. Patient #1 was dropped off at a location in City O at the time of discharge with no access to the pharmacy in City P (46 miles away). There was no documentation that transportation was arranged for Pt. #1's referral made to the PHP [partial hospitalization program], along with no phone numbers listed for the PHP and Dane County Crisis on discharge paperwork.

Based on record review and interview the facility failed to follow their policy for completing the Master Treatment Plan within 72 hours of admission for 4 of 10 patients admitted to the facility (Patient's #3, #6, #7 and #8) out of 10 patients medical records reviewed.

Findings include:

A review of the facility policy, titled "Treatment Plan Acute Inpatient, #1200.9", dated 7/1/2021, revealed: "Policy: Each patient admitted to the psychiatric unit shall have an individualized treatment plan which is based on interdisciplinary clinical assessments. The multidisciplinary team is headed by the physician/provider and consists of nursing, therapists, recreational therapists and other health professions as indicated. Patients are involved in the treatment planning process and sign their treatment plans. Procedure: Master Treatment Plan: 1. Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. The Master Treatment Plan should be completed within 72 hours of the patient's admission."

A review of Patient #3's medical record revealed: Admission date 5/27/2022 and discharged on 6/3/2022. There is no evidence of a completed Master Treatment Plan.


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A review of Patient #6's medical record revealed: Admission date 08/09/2022 and discharged on 08/17/2022. There is no evidence of a completed Master Treatment Plan.

During an interview on 08/17/2022 at 10:34 AM with Patient #6, when asked about his/her involvment in his/her Treatment Plan since admission on 08/09/2022, Patient #6 stated "I have no idea what my treatment plan is, I've never seen it or have been part of it."

A review of Patient #7's medical record revealed: Admission date 08/11/2022, as of 08/17/2022 at 3:54 PM there is no evidence of a completed Master Treatment Plan.

A review of Patient # 8's medical record revealed: Admission date of 08/12/2022, as of 08/17/2022 at 12:40 PM there is no evidence of a completed Master Treatment Plan.

During record review on 08/17/2022 at 2:30 PM, Nurse Educator E confirmed the absence of the Master Treatment Plans.

During an interview on 08/17/2022 at 3:00 PM, Chief Nursing Officer (CNO) C stated, "The Master Treatment Plan is to be completed within 72 hours of admission."