Improperly Discharged Brooke Glen Patient found psychiatrically unstable and staying in homeless shelters

Brooke Glen Behavioral Hospital was issued a 6-month provisional license by the Pennsylvania Department of Human Services (DHS, formerly the Dept. of Public Welfare) after the facility was cited for deficiencies related to adequate treatment, treatment plans, consensual release to third parties, and patient rights. DHS found that Brooke Glen discharged a patient despite a physician order for a therapeutic hold and an uncompleted treatment plan. The patient was given money and instructions to the train station to go to his brother’s home, even though staff did not call the patient’s brother about the upcoming discharge. The patient never made it to his brother’s home and was subsequently found psychiatrically unstable and staying in homeless shelters in Northeast Philadelphia.

Pennsylvania regulations state that “every patient has the right to reside and be treated in a setting which preserves and promotes his physical and psychological dignity.” DHS found that Brooke Glen behavioral violated these patient rights regulations after discharging an individual from the facility “even though all treatment goals had not been met.” DHS found “notes indicat[ing] that Consumer A was responding to internal stimuli, required PRN medication due to kicking a wall, and pointed his finger at his head and mimicked pulling a gun trigger.” However, DHS found that “Consumer A was discharged the following day.” The inspection report also wrote:

“Despite having a plan to discharge Consumer A to his brother’s home, hospital staff failed to notify the brother about the discharge. Consumer A’s social worker directed Consumer A to walk to the train station, and give him funds and instructions on how to take public transportation to his brother’s home. Consumer A never arrived at his brother’s home, and it is unknown whether or not he even boarded the train. Because Consumer A’s brother did not know to expect Consumer a, he did not realize that Consumer A was missing. Consumer A was eventually found in Northeast Philadelphia. Consumer A had been staying in homeless shelters, was not psychiatrically stable, and was subsequently admitted to a different inpatient hospital.”

DHS found that the Consumer was discharged despite having a “psychiatric progress note completed by the physician…that [indicated] Consumer A was in a therapeutic hold because he was aggressive and hit a BGBH Mental Health Technician.” Also, a note written by the social worker indicated that the patient “assaulted a staff over the weekend.” Lastly, the patient was discharged despite a note that stated “consumer A did not attend any groups on this day and was not positive with peers.”

DHS also cited the facility for violations of treatment plan regulations. Specifically, DHS found that “part of Consumer’s A’s treatment plan repeatedly referred to him as “her,” suggesting that this plan was not individualized.” DHS also noted that “Consumer A’s treatment plan was not based upon diagnostic evaluation. A medical history, physical examination and biopsychosocial evaluation were not completed upon intake” and “the agency failed to complete these documents at a later time.” DHS revealed that “at the time of discharge, on 3/18/14, these documents had still not been completed.” Consumer A was readmitted 6 days after the first discharge but “neither his medical history nor a physical examination was completed” and “no further efforts were made to complete these documents.”

DHS also cited the facility because “Consumer A’s treatment plan and subsequent treatment plan updates were not the result of collaborative recommendation from the patient’s interdisciplinary team.” The inspection report noted that “the second treatment plan update was signed by the patient and social worker on 3/17/14, but the nurse did not sign this updated plan until 3/18/14, and the doctor failed to review and sign this plan.”

In the plan of correction, the facility agreed to conduct a review of discharge planning processes, provide training, and develop a plan to “ensure continued monitoring for quality discharge planning and the counseling of patients and their families.”