The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on document review and interview, it was determined for 1 of 2 (Pt #1) patients with legal guardians, the Hospital failed to ensure the guardian was involved in the patient's discharge plan.

Findings include:

1. The Hospital's policy entitled, "Patient Rights and Responsibilities" (reviewed 10/29/12) required, "...Patients, parents, and legal designated representatives are responsible for making it known whether they clearly comprehend a contemplated course of action...A patient, parent or legal designated representative is responsible for following the treatment plan recommended by the practitioner primarily responsible for the patient's care..."

2. The clinical record for Pt #1 was reviewed on 12/7/15 at approximately 11:00 am and included: Pt #1 was a [AGE] year old male who was brought to the Hospital's emergency department (ED) by ambulance on 11/18/15 after police picked Pt #1 up and requested a psychiatric evaluation. Pt #1 had absconded from a rehabilitation facility several days earlier and had been reported as a missing person by his state guardian. The ED RN (E #1) contacted the Office of State Guardian and obtained consent for treatment. Pt #1 was seen by the ED physician (MD #1). Lab work was completed and within normal limits, and Pt #1 was assessed by the Behavioral Health Intake Counselor (E #2). MD #1 discussed Pt #1 with E #2, determined Pt #1 was not a harm to himself or others, required no psychiatric follow up, and ordered for Pt #1 to be discharged home. MD #1's and E #2's notes lacked communication with Pt #1's guardian. Pt #1 was given discharge instructions by E #6 (ED RN) to return to the ED only if needed, provided with information on understanding mood disorders, and discharged from the Hospital at 1:56 am. The discharge instructions were signed by Pt #1. Pt #1's guardian was not informed of, or included in, the discharge plan for Pt #1.

3. On 12/8/15 at approximately 11:20 am, an interview was conducted over the telephone with Pt #1 ' s State Guardian (C #1). C #1 stated the Hospital failed to include C #1 in the discharge planning for Pt #1. C #1 stated temporary guardianship had been assigned to Pt #1 when Pt #1 was brought to another hospital as homeless, beaten up resulting in brain injury/swelling, and unable to give his name. C #1 gave consent for Pt #1 to be transferred from that hospital to a rehabilitation facility. Pt #1 absconded from the facility on 11/12/15 and had been reported by C #1 as a missing person. The Office of State Guardian received a call from the police on 11/18/15 that Pt #1 had been found and taken to the Hospital. The Hospital contacted the Office of State Guardian to obtain consent to treat Pt #1. The guardian on call gave consent and left a message for C #1 that Pt #1 had been found and was at the Hospital. C #1 stated that she contacted the social worker and the risk management department of the hospital on [DATE], and neither would give C #1 information regarding Pt #1 saying they didn't know Pt #1 had a guardian. C #1 told the Hospital they did know because the Hospital called to obtain consent for treatment for Pt #1. C #1 stated C #1 should have been included in the care and discharge planning for Pt #1, and Pt #1 should have been sent to a rehabilitation facility. Per C #1, the facility Pt #1 absconded from said they would take Pt #1 back. C #1 stated Pt #1 remains missing at this time (12/8/15).

4. On 12/8/15 at approximately 1:20 pm, an interview was conducted with the Social Worker (SW)(E #5) for the ED. Although E #5 was not on duty at the time of Pt #1 ' s ED visit, E #5 reviewed Pt #1 ' s record and stated the ED should've contacted the rehabilitation facility where Pt #1 had been a patient and requested the guardianship paper and contact information. E #5 stated Pt #1 should've been returned to the facility from which he came. The ED RN should've contacted the facility and arranged transportation for the patient. If the facility would not take the patient back, the guardian should have been notified and asked what arrangements could be made. The SW or the covering social worker/case manager from the sister hospital would've worked with the guardian on placement for the patient during the off hours of E #5. E #5 stated that Pt #1's guardian should have been notified of Pt #1 ' s discharge plan.

5. During an interview on 12/8/15 at approximately 12:00 pm with the ED Nurse Manager (E #3), E #3 stated she did not know informing the guardian of a patient's discharge was required. E #3 stated this will be discussed with the ED staff.