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Based on medical record review and interviews, the hospital failed to make arrangements for necessary post-hospital services for 1 of 10 patients (P1) reviewed who were discharged or had a pending discharge from the hospital. P1 was to receive a Haldol injection every two weeks, which was due the day after P1 was discharged from the hospital. The hospital discharged the patient to a homeless shelter without verifying an appointment and transportation for the patient to receive the Haldol injection. Findings include:

P1's medical record was reviewed and revealed that on July 12, 2012, P1 presented to the hospital accompanied by the police from his foster group home due to escalating behaviors and agitation. P1 was admitted to the adult mental health unit. P1's diagnoses included schizophrenia and borderline intellectual functioning. Physician documentation dated July 13, 2012 at 12:23 p.m. noted the group home staff stated they did not feel they could accept P1 back. Further documentation noted the hospital was not able to find a new facility for the patient prior to time of discharge. Discharge instructions were completed and signed on July 17, 2012. The discharge instructions included an order for Haldol Decanoate 150 milligrams (mg) intramuscular every two weeks, next dose due July 18, 2012. The discharge instructions also included an appointment at the mental health clinic "as previously scheduled". P1 was discharged and transported via taxi to a homeless shelter the afternoon of July 17, 2012.

No documentation was found in the medical record noting when P1 had an appointment at the mental health clinic.

An interview was conducted with Physician (D) on September 18, 2012 at 10:38 a.m. and he verified he ordered the Haldol injection due to be administered the day after P1's discharge from the hospital.

An interview was conducted with Social Worker (E) on September 17, 2012 at 1:08 p.m. and she verified she documented the appointment at the mental health clinic as previously scheduled but did not verify with the clinic to ensure P1 had an appointment the next day to receive his medication. She said the practice would be for her to verify the appointment and transportation but she did not do this.

An interview was conducted with Nurse (F) on September 20, 2012 at 2:39 p.m. and he verified he provided P1 with the written discharge instructions and noted P1 was to have an injection the next day. He did not check to see that P1 had an appointment or transportation to receive the Haldol injection as ordered. An additional interview was conducted on September 27, 2012 at 3:21 p.m. and Nurse (F) said he did not review the discharge instructions with P1 as he did not have sufficient time to review the instructions before P1's transportation would have left the hospital. If the transportation had left without the patient, P1 would have been discharged to the street, rather than being sent to a homeless shelter.

An interview was conducted with Nurse (G) on October 2, 2012 at 9:35 a.m. and she stated she was aware of the medication order but did not verify that P1 had an appointment scheduled at the mental health clinic to receive the medication injection. She also stated she did not review the discharge instructions with P1.

Based on medical record review and interviews, the hospital failed to reassess the discharge plan to ensure it was appropriate for 1 of 10 patients (P1) reviewed who were discharged or had a pending discharge from the hospital. P1 discharged to a homeless shelter who provided no medication administration assistance, including oral and injectable medications. Findings include:


P1's medical record was reviewed and revealed P1 presented to the hospital on July 12, 2012 accompanied by the police from his foster group home due to agitation. P1 has diagnoses including schizophrenia and borderline intellectual functioning. P1 was admitted to the mental health unit. Physician documentation dated July 13, 2012, at 12:23 p.m. noted the group home staff stated they did not feel they could accept P1 back. Further documentation noted the hospital was not able to find a new living arrangement for the patient prior to the time of discharge 5 days later. Discharge instructions were completed and signed on July 17, 2012. The patient was discharged to a homeless shelter.

During the course of the investigation Case Manager (I) was interviewed. He stated P1 received medication administration at the group home for both oral and injectable medications. P1 required a group home setting due to his need for additional supervision and medication administration.

An interview was conducted with Social Worker (E)on September 17, 2012, at 1:08 p.m. and she stated P1 was not discharged to an appropriate place. She also verified she did not contact the homeless shelter and knew the homeless shelter did not manage medications.


An interview was conducted with Nurse (F) on September 21, 2012, at 12:44 p.m. and he said he was aware of P1's medication orders including a Haldol injection. Nurse (F) also stated he provided no medication teaching.


An interview was conducted with Shelter staff (H) on September 27, 2012 at 11:20 a.m. and she stated the homeless shelter was not aware P1 was being sent to the shelter. The homeless shelter does not provide medication management or assistance and stated the homeless shelter was not an appropriate placement for P1.