Patient Sent Home in Taxi Without Notification to Legal Guardian was Involuntarily Admitted for Aggressive Behavior the Next Day

The Ridge Behavioral Health System was cited by the Kentucky Office of Inspector General (Kentucky OIG) and the Centers for Medicare and Medicaid Services (CMS) for deficiencies related to discharge planning and medication delivery. The Kentucky OIG determined “the facility failed to reassess the patient’s discharge plan when there were factors that affected the continuing care needs or the appropriateness of discharge for … Patient #5.” Kentucky OIG noted::
“The facility discharged a patient from the hospital and was sent home by a taxi, although the patient was known to the hospital staff to be non-compliant with medication and had an emergency legal guardian.”
Documents reviewed by Kentucky OIG showed that the patient’s sister had obtained emergency guardianship because, “due to significant mental problems the patient was unable to care for self and her/his Physician felt she/he needed help in taking care of self and finances.” The patient’s Continuing Care Discharge Plan indicated that if he was discharged home, his sister would monitor his compliance with medications and lock up lethal weapons including guns and knives. The patient’s sister stated that these measures were never discussed with her by the facility, and she had been expecting the patient to be discharged a day later. The Attending Physician admitted “it was a mistake to send the patient home without notification to the emergency guardian.” Kentucky OIG found that one day after discharge, the patient was admitted on an involuntary basis for psychiatric evaluation and treatment at an acute care hospital, following an incident at a bank. The plan of correction included a revision to the facility’s discharge process policy and a compliance review with Discharge Planning in 30% of all inpatient discharged charts monthly. After investigating another complaint, Kentucky OIG and CMS found:
“[t]he facility failed to ensure drugs were administered in accordance with the orders of the practitioner responsible for the patient’s care and accepted standards of practice.”
One patient had orders for Sliding Scale Insulin to be administered after meals and at bedtime, but examination of the Medication Administration Record (MAR) and interviews with staff “revealed the incorrect dosage of insulin was administered on several occasions in [September 2012].” The correction plan included a review process completed by a second nurse to review the correct medicine dosage and the verification of all information used to calculate the insulin dosage. The plan of correction also included a review of 100% of the Medication Administration Records containing insulin.