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Based on review of the medical record, policy review, and staff interview, it was determined that the facility failed to ensure that a safe, effective, and appropriate discharge plan was implemented to meet identified needs following hospitalization for two (#5 and #7) of ten patients sampled.

Findings include:

1. According to the medical record, Patient # 5 was transported from an inpatient mental health facility via ambulance to the hospital for complaints of chest pain on 06/08/2017 at 5:44 p.m. According to the provider's History and Physical, the patient has Schizophrenia, depression, problems walking, and a newly diagnosed Ascending Thoracic Aneurysm.

According to nursing documentation in the medical record, the patient is incontinent of urine, needs assistance during toileting, and is a moderate to high risk for falls. The documentation reflects the patient was placed on fall precautions.

On 06/09/2017 at 1:28 p.m., a case manager documented patient #5 is confused, has memory impairment, mental illness, and ineffective coping. A note from the case manager indicated the patient is unable to return to the mental health facility because of her medical condition.

The medical record indicates the patient has no insurance, no prescription coverage, and poor financial management. The patient does not have a primary care physician. Based on this, the patient was identified as needing discharge planning.

According to the Discharge Summary, patient #5 was discharged to a homeless shelter on 06/09/2017. The patient was provided a cab voucher and written prescriptions for two new medications, two changed medications, and four unchanged medications. The patient was instructed to follow-up with primary care provider within one week.

An interview with Social Worker A on 07/03/2017 at approximately 12:30 p.m. was conducted. According to the Social Worker, a homeless shelter would not be an appropriate discharge location for a patient that is medically complex and needs assistance with activities of daily living.

According to an interview with supervisor B of case management, on 07/03/2017 at approximately 2:50 p.m., for patients without prescription coverage and no means to obtain prescriptions, the hospital fills the prescriptions prior to the patient's discharge. The exception to this is psychiatric medications, which are not provided. There was no documentation in the medical record that indicated the patient was provided the medications prescribed prior to discharge. No physician follow-up appointments were made for this patient prior to discharge.

2. According to the medical record, Patient # 7 came to the Emergency Room of the facility for complaints of chest pain on 06/07/2017 at 5:38 p.m. According to the provider's History and Physical, the patient had excessive thirst and urination and a glucose level of 504 milligrams per deciliter (normal range 70-99).

According to the physician's Discharge Summary dated 06/14/2017, Patient #7 is a newly diagnosed Diabetic.

According to the Medication Administration Record, the patient was on routine daily insulin, in addition to, sliding scale insulin (insulin that is dosed based on each blood glucose result). The record shows patient #7 needed additional insulin coverage on the following dates/times:
06/07/17 at 10:12 p.m.
06/08/17 at 1:11 p.m.
06/08/17 at 5:17 p.m.
06/08/17 at 9:19 p.m.
06/09/17 at 4:56 p.m.
06/10/17 at 8:28 a.m.
06/10/17 at 12:34 p.m.

According to a Care Coordination note dated 06/09/17 at 2:27 p.m., a Social Worker attempted to meet with the patient to assess for Discharge needs but the patient was not in the room and the Social Worker would follow-up later.

The patient was discharged home on 06/10/17 at 2:14 p.m. with written prescriptions for Insulin Pen, Syringes, a Diabetic glucometer, and two types of Insulin. Discharge Planning needs were not assessed by a Case Manager or Social Worker prior to Discharge.

The medical record indicates the patient has no insurance, no prescription coverage, and no primary care physician. Based on this, the patient was identified as needing discharge planning.


According to an interview with the supervisor B of case management on 07/03/2017 at 3:05 p.m., the patient was provided a follow-up appointment with an Endocrinologist one week after discharge but did not leave the facility with any diabetic supplies or medication.

An interview with the Supervisor B of Case Management on 07/03/17 at approximately 3:15 pm confirmed the above findings after review of Patient's #5 and #7 medical records.

According to the facilities policy titled "Discharge Planning" BC-CC-104, revised 03/2017, the Hospital Care Coordinator will provide a discharge planning evaluation to the patient identified by the nursing assessment as a patient likely to suffer adverse health consequences upon discharge if there is not adequate discharge planning. The discharge planning evaluation will include the likelihood of a patient needing post-discharge services and the availability of those services. The evaluation will include the patient's capacity for self-care. A discharge planning evaluation will be completed on a timely basis so that appropriate arrangements for care are being made before discharge.

The facility Discharge Plan for Patient # 5 and #7 failed to include the likelihood of the patient needing post-hospital services, the availability of the services, and the likelihood of a patient's capacity for self-care.

Based on record review and staff interview it was determined the facility failed to ensure one (#4) of 10 sampled patients received written discharge instructions that enabled the implementation of an effective discharge plan coordinated with the physician plan of care.

Findings Include:
The record for Patient #4 included the patient was being discharged on 7/3/17. The Physician Orders dated 7/3/17 and signed by the attending physician included directions for the patient to follow-up with the Health Department after discharge.

The Discharge Summary of Care (written discharge instructions) dated 7/3/17 at 12:00 noon were reviewed on 7/3/17. The Follow up Instructions indicated Patient #4 was to call a specific privately funded community clinic to arrange an appointment within 5 days. The address of the community clinic was a jumble of numbers that were not the correct address of the clinic.

The follow up instructions also indicated Patient #4 was to call the Health Department within 5 days to arrange an appointment. A telephone number was provided. The surveyor called the telephone number on 7/3/17 at 3:00 p.m. in the presence of the Quality Coordinator. The number rang for several minutes with no answer and no message until it eventually disconnected.

An interview was conducted with the Quality Coordinator and Social Worker B on 7/3/17 at 3:30 p.m. They confirmed the finding the physician order to have the patient follow up with the Health Department reflected a lack of coordination with the social services discharge plan to follow up with the private community clinic. The Social Worker confirmed the Health Department does not make appointments and patients are seen on a first-come, first-served basis each morning. She confirmed the finding the written discharge instructions provided to Patient #4 were not effective in implementing the patient's discharge plan.