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Based on review of records, policies, and interviews, the hospital failed to: (1) develop and implement an effective procedure for the safe discharge of homeless patients with medical and psychiatric needs from the Emergency Department (ED); and (2) ensure signed acknowledgement of the discharge instructions by patients discharged from the ED.

Findings include;

(1) The hospital discharged a patient without previous history of homelessness to a municipal shelter without appropriate arrangements in place.
(2) The hospital failed to include in the patients' records, signed documentation reflecting the patients' understanding of the discharge instructions given.

Refer to details noted under TAG A1103.

33309


Based on observation, staff interviews, and review of documents and procedures, the facility failed to ensure there was communication and coordination between the Emergency Department (ED) and other hospital services designed to meet the needs of patients being discharged from the ED. Specifically, the hospital failed to: (1) Ensure coordination with the Social Work department in implementing and documenting procedures and discharge plans for the safe and appropriate discharge of homeless patients from the ED; and (2) Ensure coordination with the Medical Records Department to have completed and signed discharge instructions scanned into the electronic medical record.
The failure to implement procedures and provide safe arrangements for discharge of a homeless patient was identified in (1) of twelve medical records reviewed and the lack of scanned discharge instructions was found in (7) seven out of (12) twelve medical records reviewed.

Findings include:

1. In one of twelve medical records reviewed, the hospital failed to ensure the safe discharge of a patient to a shelter who had no prior history of homelessness. It was subsequently reported by a family member that the patient never went to the shelter and is missing.

Review of the Electronic Medical Records (EMR) on 3/31/15 revealed:

Patient MR #1 - The medical record noted this 57 year old female, with no previous history of homelessness and a self-reported history of Bipolar Disorder, was discharged to a municipal shelter on 2/8/2015. There was no documented verification by hospital staff to confirm availability of shelter or services to address her identified needs before release.

This patient was brought in by ambulance to the ED on 2/8/2015. The family member reported to the emergency ambulance staff that the patient had destroyed property in the home. In contrast, the patient on interview, reported she was cleaning the house. The patient admitted to have stopped taking her medication for a week to prove that she did not need them. The patient stated her children also had a diagnosis of bipolar disorder. Social Work assessment of the patient revealed she did not want to return to her son' s or daughter' s residences and preferred to go to a shelter. The patient also expressed that her son had asked her to pay $1000 per month for rent and that she could not reside with her daughter since the daughter perceived the patient's presence as a "trigger" to her own symptoms.

The medical record has no evidence the patient signed a discharge form. The PES (Psychiatric Emergency Service) Assessment written by Social Worker (SW), Staff #1, indicated the patient was to receive a referral to the woman's shelter upon discharge and that a second Social Worker , working during the "Tour II" shift (a reference to the time of shift covering daytime), was to follow up and complete the discharge summary. A note from the Tour II SW, however, indicated the "patient was discharged with community supports in place." The SW did not identify the program to which the patient was referred. There was no record the social worker had contacted the shelter to confirm the arrangements for discharge and the availability of a bed or services.

No additional documentation regarding the discharge plan was found in the medical record. The record also lacked completed and signed discharge instructions in the medical record to validate that the patient received, accepted, and understood the discharge instructions given.

During interview on 4/1/2015 at approximately 10:30 AM, Staff #1 stated that patients in need of emergency housing are given the name and directions of the shelter, along with a Metro card, and are advised to go there. The patient is given a "referral" , which is a one page list of available resources/shelters for homeless persons. The patient is advised to go to the appropriate shelter. The Social worker acknowledged there is no communication with the shelter, and that no other documentation is given to the patient. Staff #1 also stated that the facility does not have a policy to govern the discharge of homeless patients from the ED.

At interview, on 4/01/2015, at approximately 11:00 AM, Staff #2 stated the physician will complete the discharge instructions in the computer and two copies are printed; one copy is given to the patient for signature and the signed copy is then scanned into the computer.

At interview on 4/01/2015, at approximately 11:30 AM, Staff #3 stated it is the practitioner's responsibility to place the printed and (now) signed document into the patient file for scanning, however, upon investigation with the Medical Records Department, it was determined that there is no record that this document was received and scanned into this patient's EMR.

Review of procedures on 4/1/2015 for "Discharge Planning Process", "Discharge Planning for Patients with Disabilities (Olmstead Decision)", "Social Work Assessment and Reassessment", and "Discharge from Psychiatric Emergency Services (PES)" found there was no specific procedures for discharge of homeless patients from the ED requiring emergency shelter. None of the procedures reference steps to be taken to ensure that patients with medical and psychiatric issues are properly discharged to a safe and appropriate residential setting. There is no procedure which requires staff to confirm acceptance of the patient by the shelter before discharge and which ensures the type of residential shelter placement is appropriate for the patient's identified medical and/or psychiatric needs.

2. The facility failed to ensure the completion of signed discharge instructions which detailed aftercare plans for high risk patients discharged from the hospital's Emergency Department (ED). This finding was evident in (7) seven out of (12) twelve medical records reviewed.

Examples include:

Patient MR #2: On 2/24/2015 at 00:40 (12:40 AM), this homeless, 32 year male walked into the Adult Emergency with presenting complaints of: Depressed, Hearing Voices, Suicidal Ideation; patient was known to the facility from prior ED visits; history of Schizoaffective Disorder and Substance Abuse. The patient remained in the ED and received medical, psychiatric and social work evaluation and reevaluation. At 10:26 AM, on 2/24/15, the patient was deemed medically and psychiatrically stable for discharge by the ED physician, with Follow-up at the Lincoln Recovery Center. The Discharge Summary by the SW at 11:23 AM on 2/24/15 stated: patient was discharged with a referral to Bellevue Men's Shelter and to the Substance Abuse Program, Lincoln Recovery Center. It was noted by the surveyor, that the patient's discharge document was not in the EMR.

Staff #4 who was present at the time of the review, acknowledged this finding and stated that a copy of the discharge document could be printed. The printed document, "Discharge and Aftercare Plans," that was presented to surveyor at approximately 10:00 AM on 4/01/2015, was not a signed copy.

At interview on 4/01/2015, at approximately 11:30 AM, Staff #3 stated it is the practitioner's responsibility to the place the printed and (now) signed document into the patient's file for scanning, however, upon her investigation with the Medical Records Department, it was determined that there is no record that this document was received and scanned into this patient's EMR.


Patient MR #3: On 2/25/2015 20:48, this homeless 39 year old male presents to the ED with Chief Complaint of Hearing Voices and Suicidal Ideation x 10 days; patient reports he is homeless and wants to get off the street. The patient was deemed medically and psychiatrically stable for discharge by the ED physician, and will be referred to a Substance Abuse treatment facility, and patient was discharged from the facility 2/26/2015 08:20. However, a signed Discharge and Aftercare Plan was not in the EMR.

At interview on 4/01/2015, approximately 11:30 AM, Staff#3 stated, upon her investigation with the Medical Records Department, it was determined that there is no record that this document was received and scanned into this patient's EMR.