Lake Behavioral Hospital

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 36774 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.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 36774 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.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 36774 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.”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 36774 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.”