HospitalInspections.org

Based on interviews and record reviews, the hospital failed to have an appropriate discharge plan in the patient's medical record, including the need for the patient to be discharged to a locked Assisted Living Facility, and these results of the evaluation were not discussed, in detail, with the patient's representative in 1 of 3 records reviewed (#2).

The findings Included:

Review of the Policy & Procedure for Patient Transportation to Facilitate a Safe Discharge, Extended Care Facility Transfer, and Discharge Planning revealed there is no Policy and Procedure regarding discharging patients to Boarding or Group Homes.

During the interview with the Director of Case Management, on 01/28/2020 at 1:53 PM, she agreed the hospital does not have a Policy & Procedure regarding discharging patients to boarding/group homes. She did confirm they do discharge patients to boarding/group homes.

During the interview with the Discharge Planner, on 01/28/2020 at 2:28 PM, she agreed that she discharges patients to boarding/group homes.

On 01/28/20 at 5:30 PM, the Vice President of Quality, stated the Policy & Procedure stops at Assisted Living Facilities because they do not discharge patients to Boarding or Group Homes.

Review of Patient #2's medical record, along with the Senior Risk Manager A, revealed, a 64 year old patient, arrived at the Emergency Department, via Emergency Medical Services, on 08/09/2019 at 05:58 AM. The chief complaint was altered mental status and possible Cerebrovascular Accident (CVA). The patient was admitted on the neuro unit and later transferred to a medical/surgical floor. His discharge diagnosis included acute bilateral frontal infarcts, toxic metabolic encephalopathy, alcohol abuse and acute embolic cerebrovascular accident (CVA).

During an interview with the Discharge Planner, on 01/28/2020 at 2:28 PM, she stated the patient was lethargic and when he woke up, he would say his is going home and tried to leave the hospital. Review of the record revealed the patient was then placed on a medical unit that has a psychiatric component. The nursing note revealed, a Code BERT was called, the patient was confused and trying to leave the hospital. He was not able to be re-directed.

During an interview with the Discharge Planner, on 01/28/2020 at 2:28 PM, she stated that on 11/12/19, she called the Placement Counselor and asked her to find a locked boarding home.

During the interview with the Discharge Planner, on 01/28/2020 at 2:28 PM, she stated that on 11/12/19, she called the patient's relatives and let them know that a Placement Counselor would be taking the patient to a facility in Miami. She stated the patient's family knew about the difficulty she had in placing the patient into a locked facility. She stated that she was not able to locate a locked Assisted Living Facility that would accept this patient. She further stated this is why she decided to start looking for a locked boarding home. She stated her call to the patient's relatives was sufficient notification of the patient's discharge to the family.

The Discharge Planner stated that in order to pay the facility, the Placement Counselor needed to have access to the patient's funds. The Discharge Planner told the Placement Counselor to call the patient's relatives and get the patient's ID and bank information.

The Discharge Planner notes revealed that the relative sent this information via Federal Express on 11/16/19.

On 01/28/2020, the Discharge Planner stated that the relatives knew about the Placement Counselor and her company. The Discharge Planner was reviewing her notes in the medical record and the texts that she stated both she and the Placement Counselor exchanged regularly. She stated that the Placement Counselor called her and said that she had received the patient's personal information and would be picking the patient up.

On 11/14/19, the physician wrote a discharge order to discharge the patient, " to a locked Assisted Living Facility in Miami."

On 11/17/19, the physician noted the patient is medically stable for discharge to a locked Assisted Living Facility with the Placement Counselor's company.

Review of the discharge paperwork revealed the patient was unable to sign on 11/15/19 & 11/18/19, and the Placement Counselor signed as Guardian, on 11/15/19, and received the Discharge Paperwork, including discharge instructions.

During the interview with the Discharge Planner, she stated, on 11/18/19, that she had the patient discharged with the Placement Counselor, along with the patient's discharge paperwork, to what she thought was a locked group home.

Review of the patient's Discharge Papers, revealed an address where the patient was placed. Review of this address failed to reveal this place is licensed, locked, or an assisted living facility.

On 01/28/2020 at 2:28 PM, the Discharge Planner stated that she allowed the Placement Counselor to make all the arrangements for this patient's transfer to a Group Home and to take the patient from the hospital, along with the discharge instructions. She confirmed the physician had ordered the patient to be discharged to a locked Assisted Living Facility. She stated she could not locate a locked Assisted Living Facility that would accept the patient and had to resort to a group home. She admitted that she knew that the home, where the patient was admitted, was not an Assisted Living Facility, and she did not verify if the Group Home was licensed, whether the home was locked, the services they could provide, or make any attempt to contact the Group Home to determine if the home was safe for the patient. She stated that she should have "Googled these homes" but she didn't.


During a phone interview with the patient's sister, on 01/28/20 at 12:32 PM, she stated the Placement Counselor took the patient to the bank and tried to withdraw $3000 out of the patient's account for payment to the group home.

The patient's sister stated that the Placement Counselor called the patient's brother, in Illinois, who refused to have the bank release $3000. The Placement Counselor told the patient's brother that she would go to another bank.

The patient's sister stated the Discharge Planner gave her two addresses where the patient might be placed and a person's first name and phone number. Review of these addresses failed to reveal these places are licensed, locked, assisted living facilities or group homes.

Review of the patient's Discharge Papers, revealed a third address (group home) where the patient was placed. Review of this address failed to reveal this place is licensed, locked, or an assisted living facility or group homes.

During the interview with the patient's relative, she stated, on 11/18/19, she called the phone number the Discharge Planner had given her as the place where the Placement Counselor had taken the patient. She stated that she spoke with a person who told her the patient was at her "other place". The relative further stated that, on 12/06/19, the person who was supposedly housing the patient called the family and stated that the patient had slipped out a window and she called the police, who found him, and took him to the hospital. The patient's relative confirmed he was admitted to a local hospital and stated on 12/15/19, the family found a place for the patient out of state and came down to get the patient from the hospital.