HospitalInspections.org

Based on record review, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure that the hospital's Discharge Planning system operated in a responsible manner to ensure a coordinated effort between the hospital's medical, nursing, and case management entities to ensure an appropriate discharge destination for a medically fragile homeless patient by identifying the patient's needs for a smooth and safe transition from the hospital setting to the patient's discharge destination for 1 of 30 patient charts reviewed for discharge services. (Patient #1)

The findings are:

Cross Reference to A 0115: The hospital failed to effect an appropriate discharge in that a medically fragile patient was placed in an Uber vehicle without a designated living destination wearing a hospital gown for 1 of 30 patient records reviewed for lack of care and services related to fragmented coordination of the patient's discharge planning between nursing, medical staff, and case management. (Patient #1)

Cross Reference to A 0385: The hospital's nursing service failed to ensure its staff coordinated with the hospital's medical staff and case management staff to effect the safe discharge needs for a medically fragile homeless patient's to a safe destination for 1 of 30 patient charts reviewed. (Patient #1)

Cross Reference to A 0799: The hospital failed to ensure a coordinated effort between the hospital's medical, nursing, and case management entities to ensure an appropriate discharge destination for a medically fragile homeless patient by identifying the the patient's needs for a smooth and safe transition from the hospital setting to the patient's discharge destination for 1 of 30 patient charts reviewed for care and services related to discharge planning. (Patient #1)

Policy and Procedure
Hospital's policy and procedure, titled, "Continuity of Care, Care Coordination", dated 9/5/17, reads, "PURPOSE: Interdisciplinary hospital-wide process available to patients and their families to ensure continuity of care.
RESPONSIBILITY: Any hospital employee involved in the assessment and treatment of the patient.
POLICY/PROCEDURE: Continuity of care requires thoughtful preparation by the entire healthcare team. Each patient's needs is assessed upon admission and reassessed as indicated throughout their hospital stay by the healthcare team. This assessment may begin prior to admission, but no later than at the time of the admission nursing assessment. All disciplines involved in the assessment and planning for post discharge healthcare needs of the patient and/or family including, but not limited to: Members of the medical staff, Nursing staff members, Rehabilitation services professionals, Social Workers, Respiratory Care Practitioners, Pharmacists, Case Managers. The discharge planning function focuses on meeting the patient's continuing healthcare needs after discharge. The goal is to identify a patient's unique needs for continued physical care, emotional support, or social needs. These services may include: Skilled nursing home care, Home health ...Hospice ...Outpatient Care Services ... Support groups, Community agency services, Community mental health, Protective Services ...
PROCEDURE: The initial assessment for discharge planning needs is conducted during the nursing admission assessment or prior to the admission for patient's with a designated plan of care. Upon admission, all patients will be screened by nursing services. The purpose of the initial screen it to identify "high risk" patients for discharge planning purposes. All "high-risk", Medicare, Medicaid, Medicare managed care of self-pay patients will be assessed by the discharge planner or case manager within three business days of admission. The social worker or case manager will conduct an individual assessment of these patients. The discharge planning assessment is located in the electronic medical record. The patient's social, emotional, functional and financial status are detailed in order to formulate a discharge plan to meet the patient's needs. The social worker or case manager will form an initial discharge plan based on needs identified in the individual assessment. Staff will coordinate resources to achieve post-discharge continuity of care. The plans should ensure participation by the patient/family/legal representation and the physician.

Each discipline assesses needs for after care as part of their ongoing assessment and reassessment processes. It is the responsibility of each discipline assessing discharge planning needs to document associate assessment findings within the medical record.
Based on this assessment, some patients will demonstrate more complex discharge planning needs. This can include: ...
Additionally, discharged planning for all "high risk" patients begin at admission.
Adult high-risk patients include but is not limited to: Any patient over the age of 65. All patients in from skilled nursing facilities ....Multi trauma patients ...or other chronic conditions (CHF, COPD, renal failure), Those patients identified as homeless, ...

Patients referred to Care Coordination for discharge planning, receive the initial discharge-planning interview within three business days of admission. A social worker is also available on call 24 hours a day, 7 days a week. The Care Coordination staff will coordinate discharge planning efforts by all disciplines for those patients identified as high-risk or patients that demonstrate more complex discharge planning needs. All pertinent information shall be documented in the patient's medical record. Any specific psychosocial concerns or crisis intervention needs will be addressed by the discharge planner. Discharge planning activities are integrated into the patient's Plan of Care."

Based on record reviews and interview, the hospital failed to effect an appropriate discharge in that a medically fragile patient was placed in an Uber vehicle without a designated living destination wearing a hospital gown for 1 of 30 patient records reviewed for lack of care and services related to fragmented coordination of the patient's discharge planning between nursing, medical staff, and case management. (Patient #1)

The findings are:

Cross Reference to A 0144: The hospital failed to effect an appropriate discharge in that a medically fragile patient was placed in an Uber vehicle without a designated living destination wearing a hospital gown for 1 of 30 patient records reviewed for lack of care and services related to fragmented coordination of discharge planning between nursing, medical staff, and case management. (Patient #1)

Cross Reference to A 0392: The hospital's nursing staff failed to ensure a medically fragile patient's needs were met as those needs relate to discharge services for 1 of 30 patient charts reviewed and nursing failed to document patient assessments per the hospital's policy and procedure for 1 of 30 patient charts reviewed for care and services. (Patient #1)

Cross Reference to A 0800: The hospital failed to ensure the discharge planning needs for 1 of 30 patient charts reviewed for discharge planning needs received the necessary care and services and coordination of services for effective discharge planning for a medically fragile patient between nursing, physician services, and case management to meet the patients' continuing healthcare needs post discharge.
(Patient #1)

Policy and Procedure
Hospital's policy and procedure, titled, "Continuity of Care, Care Coordination", dated 9/5/17, reads, "PURPOSE: Interdisciplinary hospital-wide process available to patients and their families to ensure continuity of care.
RESPONSIBILITY: Any hospital employee involved in the assessment and treatment of the patient.
POLICY/PROCEDURE: Continuity of care requires thoughtful preparation by the entire healthcare team. Each patient's needs is assessed upon admission and reassessed as indicated throughout their hospital stay by the healthcare team. This assessment may begin prior to admission, but no later than at the time of the admission nursing assessment. All disciplines involved in the assessment and planning for post discharge healthcare needs of the patient and/or family including, but not limited to: Members of the medical staff, Nursing staff members, Rehabilitation services professionals, Social Workers, Respiratory Care Practitioners, Pharmacists, Case Managers. The discharge planning function focuses on meeting the patient's continuing healthcare needs after discharge. The goal is to identify a patient's unique needs for continued physical care, emotional support, or social needs. These services may include: Skilled nursing home care, Home health ...Hospice ...Outpatient Care Services ... Support groups, Community agency services, Community mental health, Protective Services ...
PROCEDURE: The initial assessment for discharge planning needs is conducted during the nursing admission assessment or prior to the admission for patient's with a designated plan of care. Upon admission, all patients will be screened by nursing services. The purpose of the initial screen it to identify "high risk" patients for discharge planning purposes. All "high-risk", Medicare, Medicaid, Medicare managed care of self-pay patients will be assessed by the discharge planner or case manager within three business days of admission. The social worker or case manager will conduct an individual assessment of these patients. The discharge planning assessment is located in the electronic medical record. The patient's social, emotional, functional and financial status are detailed in order to formulate a discharge plan to meet the patient's needs. The social worker or case manager will form an initial discharge plan based on needs identified in the individual assessment. Staff will coordinate resources to achieve post-discharge continuity of care. The plans should ensure participation by the patient/family/legal representation and the physician.

Each discipline assesses needs for after care as part of their ongoing assessment and reassessment processes. It is the responsibility of each discipline assessing discharge planning needs to document associate assessment findings within the medical record.
Based on this assessment, some patients will demonstrate more complex discharge planning needs. This can include: ...
Additionally, discharged planning for all "high risk" patients begin at admission.
Adult high-risk patients include but is not limited to: Any patient over the age of 65. All patients in from skilled nursing facilities ....Multi trauma patients ...or other chronic conditions (CHF, COPD, renal failure), Those patients identified as homeless, ...

Patients referred to Care Coordination for discharge planning, receive the initial discharge-planning interview within three business days of admission. A social worker is also available on call 24 hours a day, 7 days a week. The Care Coordination staff will coordinate discharge planning efforts by all disciplines for those patients identified as high-risk or patients that demonstrate more complex discharge planning needs. All pertinent information shall be documented in the patient's medical record. Any specific psychosocial concerns or crisis intervention needs will be addressed by the discharge planner. Discharge planning activities are integrated into the patient's Plan of Care."

Based on record reviews and interview, the hospital failed to effect an appropriate discharge for a patient in that the medically fragile patient was placed in an Uber vehicle without a designated living destination wearing a hospital gown for 1 of 30 patient records reviewed for lack of care and services related to fragmented coordination of the patient's discharge planning for a medically fragile patient who was also identified as homeless between nursing, medical staff, and case management. (Patient #1)

The findings are:

Interview with the Uber Driver
On 12/11/2019 at 6:38 PM, an interview was conducted with the Uber Driver who transported Patient #1 from Hospital #1 after the patient's discharge on 10/26/2019. The Uber Driver reported, "When asked what had happened with the patient pickup from the hospital for the patient, the Uber driver stated that he received a message from the hospital for a ride request and to meet the patient at the front entrance. The Uber Driver reported that he sent a text to the hospital letting them know that he was there. Then, the Uber Driver reported that he called the hospital and the nurse said the patient would be down in a minute. Then, the Uber Driver reported that he saw a hospital employee coming out of the door to the hospital pushing the patient in a wheelchair. The Uber Driver reported the patient was saying "Why are they doing this? Why are they making me leave?" The Uber Driver reported that the patient could barely stand, and another lady came up to the car, (she may have been a nurse), and helped the nurse get the patient in the car. The Uber Driver reported that the nurse said to him "she is going to the pharmacy to get medication." The Uber driver reported that he asked the nurse where should he take the patient after the pharmacy, and the nurse said, "maybe she can go to her sister's house. She(the patient) can probably tell you where." The Uber Driver reported that the patient kept saying, "God help me." The Uber Driver reported that he went through the drive through at CVS, but the pharmacy was closed, and he sat in the drive through with the patient. The Uber Driver reported that nobody at the hospital gave him any information as to where to take the patient. The Uber Driver stated that he asked the patient for the sister's address and he drove to the sister's address. The Uber Driver reported that he went to the door of the sister's house and knocked and finally a young lady came to the door and asked him what he needed. The Uber Driver stated that another lady(Sister) came to the door in a wheelchair, and he explained the situation to her. The Uber Driver stated the lady agreed to take the patient. The Uber Driver reported the patient was so weak that he had to pick the patient up out of the car and carry her inside the house and put her in another wheelchair."

Patient #1
On 12/10/2019 at 10:00 AM, review of Patient #1's chart revealed the patient was identified as homeless upon admission to the hospital on 10/23/2019 by the hospital's medical staff, case management staff, and nursing staff. On 10/26/2019, documentation showed the patient was discharged from the hospital wearing a hospital gown with a voucher for medication and no arrangements for housing although all disciplines involved with patient's care documented the patient was homeless.

Emergency Department
On 12/10/ 2019 at 10:00 AM , review of Patient #1's chart revealed the 59 year old patient presented to the hospital's emergency department via an ambulance on 10/22/2019 at 8:22 PM with a chief complaint of "shortness of breath and back pain. Pt (Patient) states she fell a couple hours ago and hurt her back, elbow, hand, and knees. Pt states she did not hit her head or lose consciousness. Pt reports a little bit of chest pain. Pt denies dizziness." After a medical screening examination, the patient was referred for admission to the hospital.

History and Physical
Review of the patient's history and physical dated 10/23/2019 at 5:52 AM revealed "presenting with complaints of worsening shortness of breath along with cough with productive sputum and congestion. She also endorses having pain with coughing on the right side of her chest. She denies pressure and heaviness and the pain does not radiate and seems exacerbated by coughing only. ....She has noticed increased swelling of her lower extremeties as well. She has an extensive past medical history including hospitalization a month ago with pneumonia. She also has chronic DVT (Deep Vein Thromboses) for which she takes Xarelto, congestive heart failure with an ejection fraction of 20 - 25 %(percent), COPD(Chronic Obstructive Pulmonary Disease). She is currently homeless and not using any oxygen outside of the hospital. Work up in the emergency room reveals a right sided pneumonia worrisome for healthcare associated pneumonia so she was given Vancomycin and Zosyn and referred to the internal medicine service for admission. Past medical history: asthma, congestive heart failure, COPD, diverticula of colon, hypertension, myocardial infarction, arthritis, awareness under anesthesia, cancer, Carbapenem - resistant Enterobacteriacae infection, corneal injury, coronary artery disease, diabetes mellitus, ....... past drug history of cocaine and crack cocaine" Physical Exam: General: she is frail and cachectic appearing." ABG(Arterial Blood Gas): PO 2 ABG(Partial Oxygen Arterial Blood Gas) 60, PCO2(Partial Carbon Dioxide)38.9. Radiology review: chest x-ray reveals Cardiomegaly and a consolidated right lower lobe pneumonia."

Physician Progress Notes
Review of Physician #2's Progress Note, dated 10/23/2019 at 1:45 PM, reads, " .....Subjective: Alert and alert and awake and following commands; feels and looks extremely weak and debilitated; complaining of pain all over; dysnea on minimal exertion and leg swelling; no nausea; ....".Doesn't look like she will be able to take care of at home. Patient care coordinator is consulted."

Review of Physician #2's Progress Note, dated 10/24/2019 at 1:36 PM, reads, "Has a lot of cough and dysnea on exertion, continues to have a lot of pain all over body, remains extremely weak and debilitated,..... Still has active medical issues such as pneumonia and CHF, not ready for discharge, Hope to discharge in the next day or two."

Review of Physician #1's Progress Note, dated 10/25/2019 at 2:14 PM , reads, " Remains extremely weak and debilitated, has less cough and shortness of breath, and no nausea, vomiting/fever or chills. Review of systems: .....Respiratory: positive for shortness of breath and wheezing, Cardiovascular: positive for leg swelling, Neurological: positive for weakness. Severe physical debility; continue PT(physical Therapy)and OT (Occupational Therapy), Patient is homeless and has no place to go. Patient care coordinator consulted, Once medically stable, then we will discharge and see if we can provider her with some help. "

Physician Interviews
Physician #1
On 12/10/2019 at 2:07 PM, an interview was conducted with Physician #1 who reported, "Her(Patient #1) diagnosis is severe Cardiomyopathy, COPD. Mainly when she comes in it is respiratory and complications from CHF". For discharge planning the hospital has a multidisciplinary team that consist of the physician, the nurse, case manager. We do daily rounding. If the patient has no medication we provide this. If they have no ride, we provide this for them. We make sure the patient is safe to go. We have offered multiple times. She never agreed to go to these places. She came to the nursing station while I was there asking for pain pills. She found me. I had discontinued her pain medication. The x-rays and test came back negative for where her pain is coming from."

Physician #2
On 12/12/19 at 09:00 AM, an interview was conducted with Physician #2 who reported,"We sent the patient home on antibiotics and the patient would get follow up at their appointment. I believe the patient was getting up and getting a shower, walking around room and in hall. I examined her prior to discharge, and told her I was going to stop pain medications. She came to find me at the desk wanting a prescription for pain medication. She knew I had discharged her. " Physician #2 reported, "....he had gone to another floor, made sure all arrangements had been made and was ok, from the prescriptions to the ride. When asked how he had made sure all this was ready, Physician #2 said he had spoken with social services (Case Management) that morning and said to make sure the patient goes to a safe place. When he called back to the floor later that day, whomever he spoke with, said "the patient did not have a place to go", and that was when he told the staff (nurse) that the patient could stay another night if they did not have a place to go." Review of physician orders and nursing documentation in Patient 1's chart dated 10/26/2019 revealed there was no documentation in the patient's chart stating the physician's instructions related to delaying the patient's discharge for another day.

Case Management
Review of the registered nurse's/case management's initial patient assessment for Patient #1 dated 10/23/2019 at 9:57 AM revealed, .....Patients living accommodations - no residence, Financial status - pending Medicaid, Discharge needs- proposed/ alternative discharge plan, discharge to previous living situation. Met with patient at the bedside to discuss discharge plan. Patient is homeless and is independent with ADLs(Activities of Daily Living) Patient has no home equipment or home services. Patient has no insurance or RX (therapy) coverage, and will need medication assistance at discharge. Patient's discharge plan is to be discharged back to previous living situation. " Review of the patient's discharge notes revealed Patient #1's "living arrangement/type of residence" was listed as "Homeless" and in the section identified as "Support System" was listed "Friends/Neighbors".

Case Management Multidisciplinary rounds note dated 10/23/2019 at 10:00 AM revealed, "Discharge plan remains to d/c (discharge) to prior living situation." There was no documentation what the patient's prior living situation was" Case Management Multidisciplinary rounds note dated 10/24/2019 at 12:09 PM Rounding Team showed "No notes recorded". Case Management Multidisciplinary rounds note dated 10/25/2019 at 11:50 AM revealed , "Met with patient at bedside to further discus DC(discharge) planning. She declines referral to salvation army, states tentatively a friend is going to pick her up at D/C. "

Case Management note dated 10/26/2019 at 12:18 PM, reads, "Voucher for Augmentin, Synthroid, and Prednisone provided to patient to pick up medications at .....pharmacy through patient assistance fund. Nurse request ride at discharge for a patient to get medications from pharmacy, per nursing patient appropriate for Uber ride. Patient declines referral to Salvation Army."

Interviews
Case Manager #3
On 12/11/2019 at 1:30 PM, Case Manager #3 confirmed that he/she was the on call Case Manager on 10/26/2019 when Patient #1 was discharged. Case Manager #3 reported, "I was on call that weekend. The RN (Registered Nurse) called me and informed me that the patient was discharged. I got a report from Case Manager #1. Case Manager #3 reported that she obtained vouchers for the patient's prescription medications. Case Manager #3 reported that nursing called her and said the patient needed a ride and she secured a ride with Uber because the bus did not run on the weekend. Case Manager #3 reported, "I contacted Uber. They respond and tell us what car and who the driver is."

Case Manager #2
On 12/11/2019 at 1:58 PM, Case Manager #2 reported, "I' had her(Patient #1) before. I spoke with her on admission. She has been living with a friend. She is homeless. She is independent with ADLs. She had no plans for discharge. She wanted to think about it. I followed up with her on 10/24/19. She was in bed that day. We continue to follow up until the patient makes her own decision as to where the patient wants to go."

Case Manager #1
On 12/11/2019 at 10:50 AM, Case Manager #1 reported, "Case management partners with social work. We are referred by physician order. The Registered Nurse (RN) does an initial screening during the nursing admission assessment. Nursing screens for DME(Durable Medical Equipment), ADL's (Activities of Daily Living), psychosocial, medical, and family history. All patients are screened, but not all patients get an evaluation unless there is a trigger. On evaluation, case management does a deeper dive. For discharge plan, we look at baseline ability such as ADLs, living environment, financial status, follow up care with physician, assess social support, and assess the patient's discharge plan. We involve the patient as much as possible. We can involve their support system. We discuss realistic alternatives. For the patient's discharge plan, staff discuss the patient's discharge plan with the nurse and physician. We develop a discharge plan with the RN, physician, case manager and social worker. For Uber, we (Case manager or social worker) put in their(patient) name and where the patient is going. .... For this patient, we didn't make arrangements with her sister. The tentative plan was to discharge the patient to a friend's house."

Nursing
Review of Patient #1's chart on 12/10/2019 at 11:00 AM revealed a nurse note dated 10/26/2019 at 09:01 AM that reads, "Discharge Disposition: Home: Self Care, Discharge Needs: Med Assist, Discharge Transportation: Other Uber." Review of the section labeled, "Neurological" on 10/26/2019 at 09:30 AM showed "Drowsy; Easily aroused" and at 9:43 AM reads, "Alert Awake Crying". In the section labeled Neuro Symptoms, at 09:42 AM showed "Forgetful", and at 09:43 AM showed "Anxiety Agitation", and at 03:37 PM showed "Forgetful".

Interview RN #1
On 12/11/2019 at 8:42 AM, a telephone interview was conducted with Registered Nurse(RN) #1 who verified he/she was assigned to the patient on 10/26/19, and reported, "She(Patient #1) came in with CHF(Congestive Heart Failure) exacerbation. She's not compliant with her meds(medications). She was complaining of abdominal pain and had a CAT(Computerized Axial Tomography- looks at layers of body tissues) scan, and the doctor said it was normal. She walked to the wheelchair. She was taking pain and anxiety meds and the doctor felt she was too drowsy to talk about discharge. He(Physician #2) said she was medically stable. He(Physician #2) said her lung sounds were adequate for discharge. She could move her hips because I helped her on the bedpan because she was too drowsy to get up. She stood up to get in the car, and I stood by her side to help her. She wouldn't give an address where she wanted to go. She had been staying at the Salvation Army. Then, when she got in the car, she was spitting out the address to the driver. I called the sister before we went down and had to leave a voice message for her to call me back. When patients are discharged, some people get free meds and 2 bus tickets for future appointments. Her(the patient) destination was ..... pharmacy and they close at 6:00 PM on Sunday[sic]. The patient gave the address for the sister. As soon as I got back to the floor, she (Patient's sister) called me back and said it was OK for her sister to come. Early that morning the doctor saw her, said she was too drowsy for the pain and anxiety meds and to hold them. He said when she wakes up, call me. He said her CHF was under control and he was OK with it. She (Patient 1) gave us the run around. Said she had nowhere to go. Her vital signs were normal at 9:30 AM. He (Physician 2) came back that afternoon. He waited until I called him. The patient was more alert. He called me back later and said it was fine if she stayed another night." Since she was medically stable, I went over her discharge. Charge Nurse told me that Uber was here and to get her ready. CNA(Certified Nursing Assistant) helped me with discharge. I only had her that one day. I was getting her ready. Her clothes were dirty, and she didn't have any more. I put a hospital gown on front and one on back. I put one hospital blanket around her shoulders and another one in her lap. She was hollering out complaining of pain when she was getting in the Uber car. I told him she stayed at the Salvation Army, and then she spit out the sister's address. I did tell him about the Salvation Army. I'm not sure about anyone calling the Salvation Army prior to her discharge. RN #2 called the case manager on call about the vouchers and the ride.

Interview RN #2(Weekend Charge Nurse)
On 12/11/2019 at 10:00 AM, RN #2 reported, "The doctor put in the discharge that morning. The patient wouldn't have a ride until 4:00 PM or 5:00 PM that afternoon. The discharge papers were completed. The patient has Good Rx. We give co-pay cards. She didn't have a ride so I contacted the case manager on call. I was told to go to 6S, look in a folder to get bus tickets. I called security, was told the bus doesn't run on Saturday. I called the case manager on call to contact Uber. Her prescriptions were given on discharge. On her discharge paperwork, she was to go to ....pharmacy and to the free clinic. RN #2 stated the patient wanted to talk to the doctor, didn't say why.

Interview with Patient Care Technician(PCT) #1
On 12/11/2019 at 1:47 PM, PCT #1 reported, "I took care of her on the day of her discharge. The doctor went in and assessed her, and then talked to her nurse. I helped her get ready. I don't know where her clothes were. She usually has on a tank top when she comes in, and the ED(Emergency Department) cuts it off her. I put her in a hospital gown, and she was OK with the hospital gowns."

Discharge Summary 10/26/2019 at 2:44 PM
Patient is a 59-year-old female presenting with complaints of worsening shortness of breath along with cough with productive sputum and congestion. She also endorses having pain with coughing on the right side of her chest. She denies any pressure or heaviness in the pain does not radiate and seems to be exacerbated by coughing only. She does not hurt to take a deep breath. She has noticed increased swelling of her lower extremities as well. She has an extensive past medical history including hospitalization a month ago with pneumonia. She also has chronic DVT for which she takes Xarelto, congestive heart failure within ejection fraction of 20-25%, COPD. She is currently homeless and not using any oxygen outside of the hospital. She was admitted to telemetry bed and was started on IV(Intravenous - via vein), Lasix and CHF pathway and pneumonia pathway were initiated. She was started on IV antibiotic's and appropriate cardiac medications. GI(Gastrointestinal) and DVD prophylaxis and nutritional support was begun. Her urine drug screen was positive for cocaine, amphetamine, and opiates. While in the hospital, she continues to be asking for narcotics. Her symptoms improved very nicely and her shortness of breath got much better. She diuresed well and subsequently was switched to buy mouth antibiotics and by mouth. Condition at Discharge: Stable, Discharge Disposition: Home, Final Impression and Discharge Instructions


Policy and Procedure
Hospital's policy and procedure, titled, "Continuity of Care, Care Coordination", dated 9/5/17, reads, "PURPOSE: Interdisciplinary hospital-wide process available to patients and their families to ensure continuity of care.
RESPONSIBILITY: Any hospital employee involved in the assessment and treatment of the patient.
POLICY/PROCEDURE: Continuity of care requires thoughtful preparation by the entire healthcare team. Each patient's needs is assessed upon admission and reassessed as indicated throughout their hospital stay by the healthcare team. This assessment may begin prior to admission, but no later than at the time of the admission nursing assessment. All disciplines involved in the assessment and planning for post discharge healthcare needs of the patient and/or family including, but not limited to: Members of the medical staff, Nursing staff members, Rehabilitation services professionals, Social Workers, Respiratory Care Practitioners, Pharmacists, Case Managers. The discharge planning function focuses on meeting the patient's continuing healthcare needs after discharge. The goal is to identify a patient's unique needs for continued physical care, emotional support, or social needs. These services may include: Skilled nursing home care, Home health ...Hospice ...Outpatient Care Services ... Support groups, Community agency services, Community mental health, Protective Services ...
PROCEDURE: The initial assessment for discharge planning needs is conducted during the nursing admission assessment or prior to the admission for patient's with a designated plan of care. Upon admission, all patients will be screened by nursing services. The purpose of the initial screen it to identify "high risk" patients for discharge planning purposes. All "high-risk", Medicare, Medicaid, Medicare managed care of self-pay patients will be assessed by the discharge planner or case manager within three business days of admission. The social worker or case manager will conduct an individual assessment of these patients. The discharge planning assessment is located in the electronic medical record. The patient's social, emotional, functional and financial status are detailed in order to formulate a discharge plan to meet the patient's needs. The social worker or case manager will form an initial discharge plan based on needs identified in the individual assessment. Staff will coordinate resources to achieve post-discharge continuity of care. The plans should ensure participation by the patient/family/legal representation and the physician.

Each discipline assesses needs for after care as part of their ongoing assessment and reassessment processes. It is the responsibility of each discipline assessing discharge planning needs to document associate assessment findings within the medical record.
Based on this assessment, some patients will demonstrate more complex discharge planning needs. This can include: ...
Additionally, discharged planning for all "high risk" patients begin at admission.
Adult high-risk patients include but is not limited to: Any patient over the age of 65. All patients in from skilled nursing facilities ....Multi trauma patients ...or other chronic conditions (CHF, COPD, renal failure), Those patients identified as homeless, ...

Patients referred to Care Coordination for discharge planning, receive the initial discharge-planning interview within three business days of admission. A social worker is also available on call 24 hours a day, 7 days a week. The Care Coordination staff will coordinate discharge planning efforts by all disciplines for those patients identified as high-risk or patients that demonstrate more complex discharge planning needs. All pertinent information shall be documented in the patient's medical record. Any specific psychosocial concerns or crisis intervention needs will be addressed by the discharge planner. Discharge planning activities are integrated into the patient's Plan of Care."

Based on record reviews and interviews, the hospital's nursing service failed to ensure its staff coordinated with the hospital's medical staff and case management staff to effect the safe discharge needs for a medically fragile homeless patient's to a safe destination for 1 of 30 patient charts reviewed. (Patient #1)

The findings are:

Cross Reference to A 0392: The hospital's nursing staff failed to ensure a medically fragile patient's needs were met as those needs relate to discharge services for 1 of 30 patient charts reviewed and nursing failed to document patient assessments per the hospital's policy and procedure for 1 of 30 patient charts reviewed for care and services. (Patient #1)

Cross Reference to A 0396: The hospital failed to develop care plans to promote communication and coordination among the health disciplines and failed to address alternatives to the patient's living situation for one (1) of thirty (30) patient records reviewed for care and services. (Patient 1)

Based on record reviews, interviews, and review of the hospital's policies and procedures, the hospital's nursing staff on the telemetry unit failed to ensure a medically fragile patient's needs were met as those needs relate to discharge services for 1 of 30 patient charts reviewed and nursing failed to document patient assessments per the hospital's policy and procedure for 1 of 30 patient charts reviewed for care and services. (Patient #1)

The findings are:

Cross Reference to A 0144: Based on record reviews and interview, the hospital failed to effect an appropriate discharge in that a medically fragile homeless patient was placed by nursing in an Uber without a designated living destination wearing a hospital gown for 1 of 30 patient records and the hospital failed to ensure coordination of discharge planning with medical, nursing, and case management services. (Patient #1)

On 12/10/19 at 2:30 PM, the review of Patient #1's chart revealed the nurse documented the patient's assessment on 10/26/2019 at 3:37 AM, and a shift assessment at 9:42 AM. There were no other nursing assessments documented on 10/26/2019. On 12/12/19 at 2:30 PM, the Chief Nursing Officer(CNO)verified verified the findings, and stated, "Shift assessments are to be done every eight hours and four hours prior to discharge."

On 12/11/2019 at 6:38 PM, an interview was conducted with the Uber Driver who transported Patient #1 from Hospital #1 after the patient's discharge on 10/26/2019. The Uber Driver reported, "When asked what had happened with the patient pickup from the hospital for the patient, the Uber driver stated that he received a message from the hospital for a ride request and to meet the patient at the front entrance. The Uber Driver reported that he sent a text to the hospital letting them know that he was there. Then, the Uber Driver reported that he called the hospital and the nurse said the patient would be down in a minute. Then, the Uber Driver reported that he saw a hospital employee coming out of the door to the hospital pushing the patient in a wheelchair. The Uber Driver reported the patient was saying "Why are they doing this? Why are they making me leave?" The Uber Driver reported that the patient could barely stand, and another lady came up to the car, (she may have been a nurse), and helped the nurse get the patient in the car. The Uber Driver reported that the nurse said to him "she is going to the pharmacy to get medication." The Uber driver reported that he asked the nurse where should he take the patient after the pharmacy, and the nurse said, "maybe she can go to her sister's house. She(the patient) can probably tell you where." The Uber Driver reported that the patient kept saying, "God help me." The Uber Driver reported that he went through the drive through at CVS, but the pharmacy was closed, and he sat in the drive through with the patient. The Uber Driver reported that nobody at the hospital gave him any information as to where to take the patient. The Uber Driver stated that he asked the patient for the sister's address and he drove to the sister's address. The Uber Driver reported that he went to the door of the sister's house and knocked and finally a young lady came to the door and asked him what he needed. The Uber Driver stated that another lady(Sister) came to the door in a wheelchair, and he explained the situation to her. The Uber Driver stated the lady agreed to take the patient. The Uber Driver reported the patient was so weak that he had to pick the patient up out of the car and carry her inside the house and put her in another wheelchair."

On 12/11/2019 at 8:42 AM, Registered Nurse(RN) #1, who verified he/she was assigned to the patient on 10/26/19, reported, "She(Patient #1)came in with CHF(Congestive Heart Failure) exacerbation. She's (Patient #1) is not compliant with her meds(medications). She (Patient #1) was complaining of abdominal pain and had a CAT(Computerized Axial Tomography)scan, and the doctor said it was normal. She was taking pain and anxiety meds, and the doctor felt she was too drowsy to talk about discharge. He(Physician #2) said she was medically stable. She(Patient #1) could move her hips because I helped her on the bedpan because she was too drowsy to get up. She stood up to get in the car, and I stood by her side to help her. She wouldn't give an address where she wanted to go. She had been staying at the Salvation Army. Then, when she got in the car, she was spitting out the address to the driver. I called the sister before we went down and had to leave a message for her to call me back. When patients are discharged, some people get free meds, and 2 bus tickets for future appointments. Her(Patient #1) destination was ..... pharmacy and they close at 6:00 PM on Saturday. The patient gave the address for the sister. As soon as I got back to the floor, she (Patient's sister) called me back and said it was okay for her sister to come. Early that morning the doctor saw her, said she was too drowsy for the pain and anxiety meds and to hold them. He said, when she wakes up, call me. He said her CHF was under control and was okay with it. She (Patient 1) gave us the run around. Said she had nowhere to go. He (Physician #2) came back that afternoon. He waited until I called him. The patient was more alert. He called me back later and said it was fine if she stayed another night. Since she was medically stable, I went over her discharge. Charge Nurse told me that Uber was here and to get her ready. CNA(Certified Nursing Assistant) helped me with discharge. I only had her(Patient #1) that one day. I was getting her(Patient #1) ready. Her(Patient #1) clothes were dirty and she didn't have any more. I put a hospital gown on front and one on back. I put one hospital blanket around her shoulders and another one in her lap. She was hollering out complaining of pain when she was getting in the Uber car. I told him she stayed at the Salvation Army, then she spit out the sister's address. I did tell him about the Salvation Army. I'm not sure about anyone calling the Salvation Army prior to her discharge."

Review of Physician #2's progress note, dated 10/23/2019 at 1:45 PM, reads, " .....Subjective: Alert and alert and awake and following commands; feels and looks extremely weak and debilitated; complaining of pain all over; dysnea on minimal exertion and leg swelling; no nausea; ....".Doesn't look like she will be able to take care of at home. Patient care coordinator is consulted."

Review of Physician #2's progress note, dated 10/24/2019 at 1:36 PM, reads, "Has a lot of cough and dysnea on exertion, continues to have a lot of pain all over body, remains extremely weak and debilitated,..... Still has active medical issues such as pneumonia and CHF, not ready for discharge, Hope to discharge in the next day or two."

Review of Physician #1's progress note, dated 10/25/2019 at 2:14 PM , reads, " Remains extremely weak and debilitated, has less cough and shortness of breath, and no nausea, vomiting/fever or chills. Review of systems: .....Respiratory: positive for shortness of breath and wheezing, Cardiovascular: positive for leg swelling, Neurological: positive for weakness. Severe physical debility; continue PT(physical Therapy)and OT (Occupational Therapy), Patient is homeless and has no place to go. Patient care coordinator consulted, Once medically stable, then we will discharge and see if we can provider her with some help. "

Interviews
On 12/12/19 at 09:00 AM, Physician #2 reported," ....he had gone to another floor, made sure all arrangements had been made and was okay, from the prescriptions to the ride. When asked how he had made sure all this was ready, Physician #2 said he had spoken with social services (Case Management) that morning and said to make sure the patient goes to a safe place. When he called back to the floor later that day, whomever he spoke with, said the patient did not have a place to go, and that was when he told the staff that the patient could stay another night if they did not have a place to go. " Review of the patient's chart revealed the nurse did not chart the physician order stating the patient could stay another night if they did not have a place to go. There was no documentation that the nurse shared this communication with other staff members or case management. Documentation showed the nurse continued with the patient's discharge and the nurse did not document coordination with the Case Manager related to the patient's living arrangements.

Case Management Multidisciplinary rounds note dated 10/23/2019 at 10:00 AM revealed, "Discharge plan remains to d/c (discharge) to prior living situation." There was no documentation what the patient's prior living situation was" Case Management Multidisciplinary rounds note dated 10/24/2019 at 12:09 PM Rounding Team showed "No notes recorded". Case Management Multidisciplinary rounds note dated 10/25/2019 at 11:50 AM revealed , "Met with patient at bedside to further discus DC(discharge) planning. She declines referral to salvation army, states tentatively a friend is going to pick her up at D/C. "

Case Management note dated 10/26/2019 at 12:18 PM, reads, "Voucher for Augmentin, Synthroid, and Prednisone provided to patient to pick up medications at .....pharmacy through patient assistance fund. Nurse request ride at discharge for a patient to get medications from pharmacy, per nursing patient appropriate for Uber ride. Patient declines referral to Salvation Army."

Case Manager #3
On 12/11/2019 at 1:30 PM, Case Manager #3 confirmed that he/she was the on call Case Manager on 10/26/2019 when Patient #1 was discharged. Case Manager #3 reported, "I was on call that weekend. The RN (Registered Nurse) called me and informed me that the patient was discharged. I got a report from Case Manager #1. Case Manager #3 reported that she obtained vouchers for the patient's prescription medications. Case Manager #3 reported that nursing called her and said the patient needed a ride and she secured a ride with Uber because the bus did not run on the weekend. Case Manager #3 reported, "I contacted Uber. They respond and tell us what car and who the driver is."

Hospital Policy, titled, Nursing admission assessment - Reassessment policy, reads,
"Purpose: To provide expectations of staff regarding frequency of assessment/reassessment on patients admitted to hospital and defined outpatient
Scope: all admitted patients and defined out patients
Responsibility: RN
Policy/procedure: admission assessment: baseline assessment, vital signs, will be verified by a registered nurse and documented on the nursing admission assessment at the time of admission, unless otherwise specified. Vital signs may be taken by non-licensed assistive personnel
Admission assessment is completed in a timely fashion based on the condition of the patient and according to these guidelines. The baseline assessment will include physical, psychological and social data and will serve as a basis for the plan of care.
Reassessment: the patient will be reassessed at periodic intervals based on changes in the patient condition/individualized plan of care. Reassessment will be documented on the appropriate Flowsheets/nurses notes. The time between reassessment should never be greater than
Antepartum/postpartum care 8 hours
Critical care 4 hours
Telemetry care 8 hours
Labor/delivery care 30 minutes unless on Pitocin, magnesium or epidurals, then every 15 minutes
Neonatal care 8 hours
General nursing care 8-12 hours
Behavioral healthcare 8- 12 hours
Pediatric care 8 hours.
The plan of care will be reviewed and revised based on the analysis of the reassessment data
Discharge reassessment: reassessment of the patient within four hours of discharge is to be completed and documented in daily record."

Based on review of patient care plans, interviews, and review of the hospital's policies and procedures, the hospital failed to develop care plans to promote communication and coordination among the health disciplines and failed to address alternatives to the patient's living situation for one (1) of thirty (30) patient records reviewed for care and services. (Patient 1)

The findings are:

On 12/10/19 at 10:30 AM, review of Patient #1's plan of care for discharge planning revealed there was no problem identified for the patient's homeliness. There was no plan in place identifying the patient's needs related to the patient's homeliness for the patient's discharge. Review of the patient's nursing assessment revealed the patient was homeless and stays at the Salvation Army sometimes and sometimes with a friend.

Cross Reference to A 0144: Based on record reviews and interview, the hospital failed to effect an appropriate discharge for a medically fragile patient who is also homeless in that the patient was placed in an Uber without a designated living destination wearing a hospital gown for 1 of 30 patient records reviewed for care and services. (Patient #1)

Hospital's policy and procedure, titled, "Continuity of Care, Care Coordination", dated 9/5/17, reads, "PURPOSE: Interdisciplinary hospital-wide process available to patients and their families to ensure continuity of care.
RESPONSIBILITY: Any hospital employee involved in the assessment and treatment of the patient.
POLICY/PROCEDURE: Continuity of care requires thoughtful preparation by the entire healthcare team. Each patient's needs is assessed upon admission and reassessed as indicated throughout their hospital stay by the healthcare team. This assessment may begin prior to admission, but no later than at the time of the admission nursing assessment. All disciplines involved in the assessment and planning for post discharge healthcare needs of the patient and/or family including, but not limited to: Members of the medical staff, Nursing staff members, Rehabilitation services professionals, Social Workers, Respiratory Care Practitioners, Pharmacists, Case Managers. The discharge planning function focuses on meeting the patient's continuing healthcare needs after discharge. The goal is to identify a patient's unique needs for continued physical care, emotional support, or social needs. These services may include: Skilled nursing home care, Home health ...Hospice ...Outpatient Care Services ... Support groups, Community agency services, Community mental health, Protective Services ...
PROCEDURE: The initial assessment for discharge planning needs is conducted during the nursing admission assessment or prior to the admission for patient's with a designated plan of care. Upon admission, all patients will be screened by nursing services. The purpose of the initial screen it to identify "high risk" patients for discharge planning purposes. All "high-risk", Medicare, Medicaid, Medicare managed care of self-pay patients will be assessed by the discharge planner or case manager within three business days of admission. The social worker or case manager will conduct an individual assessment of these patients. The discharge planning assessment is located in the electronic medical record. The patient's social, emotional, functional and financial status are detailed in order to formulate a discharge plan to meet the patient's needs. The social worker or case manager will form an initial discharge plan based on needs identified in the individual assessment. Staff will coordinate resources to achieve post-discharge continuity of care. The plans should ensure participation by the patient/family/legal representation and the physician.

Each discipline assesses needs for after care as part of their ongoing assessment and reassessment processes. It is the responsibility of each discipline assessing discharge planning needs to document associate assessment findings within the medical record.
Based on this assessment, some patients will demonstrate more complex discharge planning needs. This can include: ...
Additionally, discharged planning for all "high risk" patients begin at admission.
Adult high-risk patients include but is not limited to: Any patient over the age of 65. All patients in from skilled nursing facilities ....Multi trauma patients ...or other chronic conditions (CHF, COPD, renal failure), Those patients identified as homeless, ...

Patients referred to Care Coordination for discharge planning, receive the initial discharge-planning interview within three business days of admission. A social worker is also available on call 24 hours a day, 7 days a week. The Care Coordination staff will coordinate discharge planning efforts by all disciplines for those patients identified as high-risk or patients that demonstrate more complex discharge planning needs. All pertinent information shall be documented in the patient's medical record. Any specific psychosocial concerns or crisis intervention needs will be addressed by the discharge planner. Discharge planning activities are integrated into the patient's Plan of Care."

Based on record reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure a coordinated effort between the hospital's medical, nursing, and case management entities to ensure an appropriate discharge destination for a medically fragile homeless patient by identifying the the patient's needs for a smooth and safe transition from the hospital setting to the patient's discharge destination for 1 of 30 patient charts reviewed for care and services related to discharge planning. (Patient #1)

The findings are:

Cross Reference to A 0800: The hospital failed to ensure the hospital met the discharge planning needs for 1 of 30 patient charts reviewed for discharge planning needs. (Patient #1) The hospital failed to ensure a medically fragile homeless patient received the necessary care and services and coordination between nursing, physician services, and case management to effectively develop and meet the patient's safe discharge needs. (Patient #1 )

Policy and Procedure
Hospital's policy and procedure, titled, "Continuity of Care, Care Coordination", dated 9/5/17, reads, "PURPOSE: Interdisciplinary hospital-wide process available to patients and their families to ensure continuity of care.
RESPONSIBILITY: Any hospital employee involved in the assessment and treatment of the patient.
POLICY/PROCEDURE: Continuity of care requires thoughtful preparation by the entire healthcare team. Each patient's needs is assessed upon admission and reassessed as indicated throughout their hospital stay by the healthcare team. This assessment may begin prior to admission, but no later than at the time of the admission nursing assessment. All disciplines involved in the assessment and planning for post discharge healthcare needs of the patient and/or family including, but not limited to: Members of the medical staff, Nursing staff members, Rehabilitation services professionals, Social Workers, Respiratory Care Practitioners, Pharmacists, Case Managers. The discharge planning function focuses on meeting the patient's continuing healthcare needs after discharge. The goal is to identify a patient's unique needs for continued physical care, emotional support, or social needs. These services may include: Skilled nursing home care, Home health ...Hospice ...Outpatient Care Services ... Support groups, Community agency services, Community mental health, Protective Services ...
PROCEDURE: The initial assessment for discharge planning needs is conducted during the nursing admission assessment or prior to the admission for patient's with a designated plan of care. Upon admission, all patients will be screened by nursing services. The purpose of the initial screen it to identify "high risk" patients for discharge planning purposes. All "high-risk", Medicare, Medicaid, Medicare managed care of self-pay patients will be assessed by the discharge planner or case manager within three business days of admission. The social worker or case manager will conduct an individual assessment of these patients. The discharge planning assessment is located in the electronic medical record. The patient's social, emotional, functional and financial status are detailed in order to formulate a discharge plan to meet the patient's needs. The social worker or case manager will form an initial discharge plan based on needs identified in the individual assessment. Staff will coordinate resources to achieve post-discharge continuity of care. The plans should ensure participation by the patient/family/legal representation and the physician.

Each discipline assesses needs for after care as part of their ongoing assessment and reassessment processes. It is the responsibility of each discipline assessing discharge planning needs to document associate assessment findings within the medical record.
Based on this assessment, some patients will demonstrate more complex discharge planning needs. This can include: ...
Additionally, discharged planning for all "high risk" patients begin at admission.
Adult high-risk patients include but is not limited to: Any patient over the age of 65. All patients in from skilled nursing facilities ....Multi trauma patients ...or other chronic conditions (CHF, COPD, renal failure), Those patients identified as homeless, ...

Patients referred to Care Coordination for discharge planning, receive the initial discharge-planning interview within three business days of admission. A social worker is also available on call 24 hours a day, 7 days a week. The Care Coordination staff will coordinate discharge planning efforts by all disciplines for those patients identified as high-risk or patients that demonstrate more complex discharge planning needs. All pertinent information shall be documented in the patient's medical record. Any specific psychosocial concerns or crisis intervention needs will be addressed by the discharge planner. Discharge planning activities are integrated into the patient's Plan of Care."

Based on record reviews and interviews, the hospital failed to ensure the hospital met the discharge planning needs for 1 of 30 patient charts reviewed for discharge planning needs. (Patient #1) The hospital failed to ensure a medically fragile homeless patient received the necessary care and services and coordination between nursing, physician services, and case management to effectively develop and meet the patient's discharge needs. (Patient #1 )

The findings are:

Cross Reference to A 0144: The hospital failed to effect an appropriate discharge for a patient in that the medically fragile patient was placed in an Uber vehicle without a designated living destination wearing a hospital gown for 1 of 30 patient records reviewed for lack of care and services related to fragmented coordination of the patient's discharge planning for a medically fragile patient who was also identified as homeless between nursing, medical staff, and case management. (Patient #1)

History and Physical
Review of the patient's history and physical dated 10/23/2019 at 5:52 AM revealed "presenting with complaints of worsening shortness of breath along with cough with productive sputum and congestion. She also endorses having pain with coughing on the right side of her chest. She denies pressure and heaviness in the pain does not radiate and seems exacerbated by coughing only. ....She has noticed increased swelling of her lower extremeties as well. She has an extensive past medical history including hospitalization a month ago with pneumonia. She also has chronic DVT (Deep Vein Thromboses) for which she takes Xarelto, congestive heart failure with an ejection fraction of 20 - 25 %(percent), COPD(Chronic Obstructive Pulmonary Disease). She is currently homeless and not using any oxygen outside of the hospital. Work up in the emergency room reveals a right sided pneumonia worrisome for healthcare associated pneumonia so she was given Vancomycin and Zosyn and referred to the internal medicine service for admission. Past medical history: asthma, congestive heart failure, COPD, diverticula of colon, hypertension, myocardial infarction, arthritis, awareness under anesthesia, cancer, Carbapenem - resistant Enterobacteriacae infection, corneal injury, coronary artery disease, diabetes mellitus, ....... past drug history of cocaine and crack cocaine" Physical Exam: General: she is frail and cachectic appearing." ABG(Arterial Blood Gas): PO 2 ABG(Partial Oxygen Arterial Blood Gas) 60, PCO2(Partial Carbon Dioxide) 38.9. Radiology review: chest x-ray reveals Cardiomegaly and a consolidated right lower lobe pneumonia."

On 12/12/19 at 09:00 AM, Physician #2 reported," ....he had gone to another floor, made sure all arrangements had been made and was okay, from the prescriptions to the ride. When asked how he had made sure all this was ready, Physician #2 said he had spoken with social services (Case Management) that morning and said to make sure the patient goes to a safe place. When he called back to the floor later that day, whomever he spoke with, said the patient did not have a place to go, and that was when he told the staff that the patient could stay another night if they did not have a place to go. " Review of the patient's chart revealed the nurse did not chart the physician order stating the patient could stay another night if they did not have a place to go. There was no documentation that the nurse shared this communication with other staff members or case management. Documentation showed the nurse continued with the patient's discharge and the nurse did not document coordination with the Case Manager related to the patient's living arrangements. The nurse failed to record the physician's order to delay the patient's discharge.

Case Management note dated 10/26/2019 at 12:18 PM, reads, "Voucher for Augmentin, Synthroid, and Prednisone provided to patient to pick up medications at .....pharmacy through patient assistance fund. Nurse request ride at discharge for a patient to get medications from pharmacy, per nursing patient appropriate for Uber ride. Patient declines referral to Salvation Army."

Case Manager #3
On 12/11/2019 at 1:30 PM, Case Manager #3 confirmed that he/she was the on call Case Manager on 10/26/2019 when Patient #1 was discharged. Case Manager #3 reported, "I was on call that weekend. The RN (Registered Nurse) called me and informed me that the patient was discharged. I got a report from Case Manager #1. Case Manager #3 reported that she obtained vouchers for the patient's prescription medications. Case Manager #3 reported that nursing called her and said the patient needed a ride and she secured a ride with Uber because the bus did not run on the weekend. Case Manager #3 reported, "I contacted Uber. They respond and tell us what car and who the driver is."

Review of Physician #2's Progress Note, dated 10/23/2019 at 1:45 PM, reads, " .....Subjective: Alert and alert and awake and following commands; feels and looks extremely weak and debilitated; complaining of pain all over; dysnea on minimal exertion and leg swelling; no nausea; ....".Doesn't look like she will be able to take care of at home. Patient care coordinator is consulted."

Review of Physician #1's Progress Note, dated 10/25/2019 at 2:14 PM , reads, " Remains extremely weak and debilitated, has less cough and shortness of breath, and no nausea, vomiting/fever or chills. Review of systems: .....Respiratory: positive for shortness of breath and wheezing, Cardiovascular: positive for leg swelling, Neurological: positive for weakness. Severe physical debility; continue PT(physical Therapy)and OT (Occupational Therapy), Patient is homeless and has no place to go. Patient care coordinator consulted, Once medically stable, then we will discharge and see if we can provider her with some help. "

Review of the registered nurse's/case management initial patient assessment for Patient #1 dated 10/23/2019 at 9:57 AM revealed, .....Patients living accommodations - no residence, Financial status - pending Medicaid, Discharge needs- proposed/ alternative discharge plan, discharge to previous living situation. Met with patient at the bedside to discuss discharge plan. Patient is homeless and is independent with ADLs(Activities of Daily Living) Patient has no home equipment or home services. Patient has no insurance or RX (therapy) coverage, and will need medication assistance at discharge. Patient's discharge plan is to be discharged back to previous living situation. " There was no documentation of what the patient's previous living situation was except "homeless".

On 12/11/2019 at 8:42 AM, Registered Nurse(RN) #1, who verified he/she was assigned to the patient on 10/26/19, reported, "She(Patient #1)came in with CHF(Congestive Heart Failure) exacerbation. She's (Patient #1) is not compliant with her meds(medications). She (Patient #1) was complaining of abdominal pain and had a CAT(Computerized Axial Tomography)scan, and the doctor said it was normal. She was taking pain and anxiety meds, and the doctor felt she was too drowsy to talk about discharge. He(Physician #2) said she was medically stable. She(Patient #1) could move her hips because I helped her on the bedpan because she was too drowsy to get up. She stood up to get in the car, and I stood by her side to help her. She wouldn't give an address where she wanted to go. She had been staying at the Salvation Army. Then, when she got in the car, she was spitting out the address to the driver. I called the sister before we went down and had to leave a message for her to call me back. When patients are discharged, some people get free meds, and 2 bus tickets for future appointments. Her(Patient #1) destination was ..... pharmacy and they close at 6:00 PM on Saturday. The patient gave the address for the sister. As soon as I got back to the floor, she (Patient's sister) called me back and said it was okay for her sister to come. Early that morning the doctor saw her, said she was too drowsy for the pain and anxiety meds and to hold them. He said, when she wakes up, call me. He said her CHF was under control and was okay with it. She (Patient 1) gave us the run around. Said she had nowhere to go. He (Physician #2) came back that afternoon. He waited until I called him. The patient was more alert. He called me back later and said it was fine if she stayed another night. Since she was medically stable, I went over her discharge. Charge Nurse told me that Uber was here and to get her ready. CNA(Certified Nursing Assistant) helped me with discharge. I only had her(Patient #1) that one day. I was getting her(Patient #1) ready. Her(Patient #1) clothes were dirty and she didn't have any more. I put a hospital gown on front and one on back. I put one hospital blanket around her shoulders and another one in her lap. She was hollering out complaining of pain when she was getting in the Uber car. I told him she stayed at the Salvation Army, then she spit out the sister's address. I did tell him about the Salvation Army. I'm not sure about anyone calling the Salvation Army prior to her discharge."

On 12/10/19 at 10:30 AM, review of Patient #1's plan of care for discharge planning revealed there was no problem identified for the patient's homeliness. There was no plan in place identifying a destination in place for the patient's discharge. Review of the patient's care plan revealed the patient was homeless and stays at the Salvation Army sometimes and sometimes with a friend.

Policy and Procedure
Hospital's policy and procedure, titled, "Continuity of Care, Care Coordination", dated 9/5/17, reads, "PURPOSE: Interdisciplinary hospital-wide process available to patients and their families to ensure continuity of care.
RESPONSIBILITY: Any hospital employee involved in the assessment and treatment of the patient.
POLICY/PROCEDURE: Continuity of care requires thoughtful preparation by the entire healthcare team. Each patient's needs is assessed upon admission and reassessed as indicated throughout their hospital stay by the healthcare team. This assessment may begin prior to admission, but no later than at the time of the admission nursing assessment. All disciplines involved in the assessment and planning for post discharge healthcare needs of the patient and/or family including, but not limited to: Members of the medical staff, Nursing staff members, Rehabilitation services professionals, Social Workers, Respiratory Care Practitioners, Pharmacists, Case Managers. The discharge planning function focuses on meeting the patient's continuing healthcare needs after discharge. The goal is to identify a patient's unique needs for continued physical care, emotional support, or social needs. These services may include: Skilled nursing home care, Home health ...Hospice ...Outpatient Care Services ... Support groups, Community agency services, Community mental health, Protective Services ...
PROCEDURE: The initial assessment for discharge planning needs is conducted during the nursing admission assessment or prior to the admission for patient's with a designated plan of care. Upon admission, all patients will be screened by nursing services. The purpose of the initial screen it to identify "high risk" patients for discharge planning purposes. All "high-risk", Medicare, Medicaid, Medicare managed care of self-pay patients will be assessed by the discharge planner or case manager within three business days of admission. The social worker or case manager will conduct an individual assessment of these patients. The discharge planning assessment is located in the electronic medical record. The patient's social, emotional, functional and financial status are detailed in order to formulate a discharge plan to meet the patient's needs. The social worker or case manager will form an initial discharge plan based on needs identified in the individual assessment. Staff will coordinate resources to achieve post-discharge continuity of care. The plans should ensure participation by the patient/family/legal representation and the physician.

Each discipline assesses needs for after care as part of their ongoing assessment and reassessment processes. It is the responsibility of each discipline assessing discharge planning needs to document associate assessment findings within the medical record.
Based on this assessment, some patients will demonstrate more complex discharge planning needs. This can include: ...
Additionally, discharged planning for all "high risk" patients begin at admission.
Adult high-risk patients include but is not limited to: Any patient over the age of 65. All patients in from skilled nursing facilities ....Multi trauma patients ...or other chronic conditions (CHF, COPD, renal failure), Those patients identified as homeless, ...

Patients referred to Care Coordination for discharge planning, receive the initial discharge-planning interview within three business days of admission. A social worker is also available on call 24 hours a day, 7 days a week. The Care Coordination staff will coordinate discharge planning efforts by all disciplines for those patients identified as high-risk or patients that demonstrate more complex discharge planning needs. All pertinent information shall be documented in the patient's medical record. Any specific psychosocial concerns or crisis intervention needs will be addressed by the discharge planner. Discharge planning activities are integrated into the patient's Plan of Care."