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Based on interviews and records review, the Governing Body of Hospital A failed to ensure 1 of 10 patients (Patient #3's) discharge plan was appropriate to meet his post-discharge healthcare needs.


Patient #3 suffered cognitive decline due to brain injury from anoxic encephalopathy related to a cardiac arrest suffered prior to admission to Hospital A and was identified as a fall risk.


Patient #3 was discharged to a homeless shelter via taxi on 09/19/14. The homeless shelter could not provide the needed monitoring or assistance, and subsequently, Patient #3 disappeared on 9/19/14 (the same day he arrived) without shelter employees' knowledge.


On 09/20/14, Patient #3 was found on the sidewalk by police officers with an altered mental status and multiple abrasions to his face and a hematoma over the left eye. He was taken to the Emergency Department at Hospital B and admitted for further treatment.


Hospital A had left the homeless shelter be responsible for Patient #3's mental/physical needs and referrals to community resources.


Findings Included:


The Discharge Summary documented by Staff #11 dated 09/19/14 (day of discharge) at 1423 revealed that Patient #3 was diagnosed with out-of-hospital cardiac arrest, dilated cardiomyopathy, chronic systolic congestive heart failure (CHF), left ventricular ejection fraction 10%, and anoxic encephalopathy. He received ICD (Implantable Cardioverter Device)/defibrillator placement and "...continues to be a fall risk. He has cognitive decline...has had multiple falls during this hospitalization...patient is being transferred to a shelter today..."


The Case Management Reassessment documented by Staff #7 dated 09/19/14 (day of discharge) at 1539 revealed, "...Patient was D/C (discharged) to (homeless shelter) and was transported via taxi..."


During a telephone interview on 11/24/14, at 1614, non-hospital staff #26 stated that Patient #3 disappeared from the homeless shelter on the same day the hospital discharged him to the shelter via taxi on 09/19/14. "He must have gone out the gate...," she shared, but his possessions remained at the shelter and he had not been seen since.


During an interview on 12/01/14, at 1330, Staff #2 stated that he was contacted on 10/23/14, by another facility and that Patient #3 was at Hospital B.


During an interview on 12/01/14, at 1345, Staff #7 at Hospital A stated that "Patient #3 was very hard to place...fully functioning before and suffered a lot of brain injury..." from his cardiac arrest. At one time she had almost gotten Patient #3 placed in a shelter close to the hospital but he was required to be physically able to climb bunk beds and he was not. Staff #7 stated that she instructed the taxi driver to take Patient #3 to the homeless shelter and walk with him into the shelter as the patient could not just be left at the door. Staff #7 stated that due to Patient #3's "cognitive deficit" he would need assistance upon discharge.


Hospital B's Registered Nurse (RN) Emergency Department (ED) notes dated 09/20/14 at 7:01 AM included that Patient #3 "...states the year is 2013...does not remember the events of the day...does not remember the last time he was home...PEG (percutaneous endoscopic gastrostomy) tube (feeding tube) in place...denies any pain...has multiple abrasions to his face and a hematoma over the left eye...LOC (level of consciousness) unknown at this time...several masses noted to abdomen and right arm..."


Hospital B's initial "ED Plan of Care" signed by the ED physician on 09/20/14 at 10:10 AM included, "...AMS (altered mental status) and mild trauma to the L (left) face...Unclear cause of AMS..."


Hospital B's History and Physical dated 9/20/14 at 4:21 PM included the following: "...subsequent records revealed that pt (patient) likely has anoxic brain injury following a cardiac arrest 7/14..admitted to (Hospital A) and apparently discharge to a homeless shelter on 9/19/14...initially though (t) to be acute AMS, but upon review of outside records, likely is anoxic brain injury following his MI (myocardial infarction) in July...clearly does not have capacity at this time...will likely need guardianship..."


Hospital B's "Discharge Summary" for Patient #3 dated 12/05/14 at 2:08 PM included that Patient #3 was discharged to a nursing home from Hospital B on 12/05/14 in stable condition with a "feeding tube present...Lymph: L (left submand mass, R (right) axillary mass: no change in size, color, consistency during hospital, R forearm mass (likely lipoma)..." Patient #3 was noted to have activity as tolerated and a low salt diet. He was oriented to self and "partially to place and time."


During a telephone interview on 12/22/14, at 1:50 PM, with Hospital B's staff Personnel #35, Personnel #38, Personnel #40, and caretakers of Patient #3, Personnel #39 RN floor nurse, and Personnel #41 RN Emergency Department nurse, they were asked to describe Patient #3's ED visit and hospitalization.


RN Personnel #41 said that Patient #3 could not recall the events of the day or what happened. He had "multiple bruises and a PEG tube in place...not sure why since he could eat." He was not sure where he lived and was forgetful when he was talked to, but compliant when the IV (intravenous) was started and had labs and a scan carried out. Patient #3 was brought in by police on a stretcher with no history and admitted to Hospital B.


Personnel #39 and #40 said that after he was admitted to Hospital B he did ambulate and had a sitter for safety since at times he wanted to wander and they didn't want him to fall. He was discharged from Hospital B to a nursing home.


Personnel #38 said that Patient #3 was discharged from Hospital B on 12/05/14.

Based on interviews and records review, the Governing Body of Hospital A failed to ensure 1 of 10 patients (Patient #3's) discharge plan was appropriate to meet his post-discharge healthcare needs.

Patient #3 suffered cognitive decline due to brain injury from anoxic encephalopathy related to a cardiac arrest suffered prior to admission to Hospital A and was identified as a fall risk. Patient #3 was discharged to a homeless shelter via taxi on 09/19/14. The homeless shelter could not provide the monitoring or assistance required by patient, and subsequently, Patient #3 disappeared on 9/19/14 (the same day he arrived) without shelter employees' knowledge.

On 09/20/14, Patient #3 was found on the sidewalk by police officers with an altered mental status and multiple abrasions to his face and a hematoma over the left eye. He was taken to the Emergency Department at Hospital B and admitted for further treatment.

Hospital A had left the homeless shelter be responsible for Patient #3's mental/physical needs and referrals to community resources.


Findings Included:


Hospital A's Discharge Summary documented by Staff #11 dated 09/19/14 (day of discharge) at 1423 revealed: Discharge Diagnoses 1) Out-of-hospital cardiac arrest; 2) Dilated cardiomyopathy; 3) Chronic systolic congestive heart failure (CHF), left ventricular ejection fraction 10%; 4) Anoxic encephalopathy. He received ICD (Implantable Cardioverter)/defibrillator placement.


Further, it revealed that "This 60-year-old white male was hospitalized following a cardiac arrest at his workplace. He was rushed to the Emergency Room ...was resuscitated and then intubated ...was managed in ICU (Intensive Care Unit) ...required pressor support for a considerable amount of time. He was also on mechanical ventilation for an extended period ...underwent trach and a PEG (percutaneous endoscopic gastrostomy) ...Neurology was consulted for suspected anoxic encephalopathy. Fortunately, the patient showed signs of improvement and was successfully extubated. Patient was subsequently transferred to the floor. After being on PEG feeding for a considerable amount of time, the patient finally cleared swallow eval (evaluation). The PEG was pulled out and the patient's p.o. per os-by mouth) intake was resumed. His tracheostomy was also closed subsequently. The patient continues to be a fall risk. He has cognitive decline. He has had multiple falls during this hospitalization. The patient is being transferred to a shelter today ..."


The physician's note at Hospital B noted on 09/2014, at 10:21 AM, that the patient had G-tube in place when the patient arived at Hospital B's emergency department.


The Case Management Reassessment documented by Staff #7 dated 09/19/14 (day of discharge) at 1539 revealed, "...Patient was D/C (discharged) to (homeless shelter) and was transported via taxi..."


During a telephone interview on 11/24/14, at 1614, non-hospital staff #26 stated that Patient #3 disappeared from the homeless shelter on the same day the hospital discharged him to the shelter via taxi on 09/19/14. "He must have gone out the gate...," she shared, but his possessions remained at the shelter and he had not been seen since.


During an interview on 12/01/14, at 1330, Staff #2 stated that he was contacted on 10/23/14 by another facility and that Patient #3 was at Hospital B.


During an interview on 12/01/14, at 1345, Staff #7 of Hospital A stated that "Patient #3 was very hard to place...fully functioning before and suffered a lot of brain injury..." from his cardiac arrest. At one time she had almost gotten Patient #3 placed in a shelter close to the hospital but he was required to be physically able to climb bunk beds and he was not. Staff #7 stated that she instructed the taxi driver to take Patient #3 to the homeless shelter and walk with him into the shelter as the patient could not just be left at the door. Staff #7 stated that due to Patient #3's "cognitive deficit" he would need assistance upon discharge.


Hospital B's Registered Nurse (RN) Emergency Department (ED) notes dated 09/20/14, at 7:01 AM included that Patient #3 "...states the year is 2013...does not remember the events of the day...does not remember the last time he was home...PEG (percutaneous endoscopic gastrostomy) tube (feeding tube) in place...denies any pain...has multiple abrasions to his face and a hematoma over the left eye...LOC (level of consciousness) unknown at this time...several masses noted to abdomen and right arm..."


Hospital B's initial "ED Plan of Care" signed by the ED physician on 09/20/14 at 10:10 AM included, "...AMS (altered mental status) and mild trauma to the L (left) face...Unclear cause of AMS..."


Hospital B's History and Physical dated 9/20/14, at 4:21 PM, included the following: "...admitted to (Hospital A) and apparently discharged to a homeless shelter on 9/19/14...initially though (t) to be acute AMS, but upon review of outside records, likely is anoxic brain injury following his MI (myocardial infarction) in July...clearly does not have capacity at this time...will likely need guardianship..."


Hospital B's "Discharge Summary" for Patient #3 dated 12/05/14, at 2:08 PM, revealed that Patient #3 was discharged to a nursing home, from Hospital B, in stable condition with a "feeding tube present...Lymph: L (left submand mass, R (right) axillary mass: no change in size, color, consistency during hospital, R forearm mass (likely lipoma)..." Patient #3 was noted to have activity as tolerated and a low salt diet. He was oriented to self and "partially to place and time."


During a telephone interview on 12/22/14, at 1:50 PM, with Hospital B's staff Personnel #35, Personnel #38, Personnel #40, and caretakers of Patient #3, Personnel #39 RN floor nurse, and Personnel #41 RN Emergency Department nurse, they were asked to describe Patient #3's ED visit and hospitalization.


RN Personnel #41 said that Patient #3 could not recall the events of the day or what happened. He had "multiple bruises and a PEG tube in place...not sure why since he could eat." He was not sure where he lived and was forgetful when he was talked to, but compliant when the IV (intravenous) was started and had labs and a scan carried out. Patient #3 was brought in by police on a stretcher with no history and admitted to Hospital B.


Personnel #39 and #40 said that after he was admitted to Hospital B he did ambulate and had a sitter for safety since at times he wanted to wander and they didn't want him to fall. Hospital B discharged Patient #3 to a nursing home.


Personnel #38 said that Patient #3 was discharged from Hospital B on 12/05/14.

Based on interviews and records review, the hospital failed to ensure 1 of 10 patients (Patient #3's) discharge plan was appropriate to meet his post-discharge healthcare needs.


Patient #3 suffered cognitive decline due to brain injury from anoxic encephalopathy related to a cardiac arrest suffered prior to admission to Hospital A and was identified as a fall risk. Patient #3 was discharged to a homeless shelter via taxi on 09/19/14. The homeless shelter could not provide the needed monitoring or assistance, and subsequently, Patient #3 disappeared from the homeless shelter on 9/19/14 (the same day he arrived) without shelter employees' knowledge.


On 09/20/14, Patient #3 was found on the sidewalk by police officers with an altered mental status and multiple abrasions to his face and a hematoma over the left eye. He was taken to the Emergency Department at Hospital B and admitted for further treatment.


Review of the assessment notes of the Emergency Registered Nurse at Hospital B done on 09/20/14, at 7:01 AM, revealed " ...states the year is 2013 and the president is George Bush ...does not remember the events of the day ...from Frisco ...does not remember the last time he was home ...PEG (percutaneous endoscopic gastrostomy) tube (feeding tube) in place ...denies any pain ...has multiple abrasions to his face and a hematoma over the left eye ...blood on his clothes ...LOC (level of consciousness) unknown at this time ...several masses noted to abdomen and right arm ... "


Hospital A had left the homeless shelter be responsible for Patient #3's mental/physical needs and referrals to community resources.


Findings included:


Hospital A's Discharge Summary documented by Staff #11 dated 09/19/14 (day of discharge) at 1423 revealed that Patient #3 was diagnosed with out-of-hospital cardiac arrest, dilated cardiomyopathy, chronic systolic congestive heart failure (CHF), left ventricular ejection fraction 10%, and anoxic encephalopathy. He received ICD (Implantable Cardioverter)/defibrillator placement and "...continues to be a fall risk. He has cognitive decline...has had multiple falls during this hospitalization...patient is being transferred to a shelter today..."


The Case Management Reassessment documented by Staff #7 dated 09/19/14 (day of discharge) at 1539 revealed, "...Patient was D/C (discharged) to (homeless shelter) and was transported via taxi..."


During a telephone interview on 11/24/14, at 1614, non-hospital staff #26 stated that Patient #3 disappeared from the homeless shelter on the same day the hospital discharged him to the shelter via taxi on 09/19/14. "He must have gone out the gate...," she shared, but his possessions remained at the shelter and he had not been seen since.


During an interview on 12/01/14, at 1330, Staff #2 stated that he was contacted on 10/23/14 by another facility and that Patient #3 was at Hospital B.


During an interview on 12/01/14, at 1345, Staff #7 at Hospital A stated that "Patient #3 was very hard to place...fully functioning before and suffered a lot of brain injury..." from his cardiac arrest. At one time she had almost gotten Patient #3 placed in a shelter close to the hospital but he was required to be physically able to climb bunk beds and he was not. Staff #7 stated that she instructed the taxi driver to take Patient #3 to the homeless shelter and walk with him into the shelter as the patient could not just be left at the door. Staff #7 stated that due to Patient #3's "cognitive deficit" he would need assistance upon discharge.


Review of the medical record of Patient #3 at Hospital B revealed a physician's assessment done on 9/20/14 at 10:23 ED that showed " ...Hematuria w/o (without) infection ...mild elev (elevated) AG (anion gap - lab test) of 17 ...perhaps 2/2 (secondary to) dehydration or ketonemia ...CT (computerized tomography) head w/o (without) acute pathology. No facial fx (fracture) ...Prominent B (bilateral) tonsils and large lymph nodes ...CT C spine w/o acute abnormality ...need to admit ...for AMS ...removed C collar and ranged neck ...do not suspect meningitis ... "


Hospital B's initial "ED Plan of Care" signed by the ED physician on 09/20/14, at 10:10 AM, included, "...AMS (altered mental status) and mild trauma to the L (left) face...Unclear cause of AMS..."


Hospital B's History and Physical dated 9/20/14, at 4:21 PM, included the following: ".....admitted to (Hospital A) and apparently discharge to a homeless shelter on 9/19/14...initially though (t) to be acute AMS, but upon review of outside records, likely is anoxic brain injury following his MI (myocardial infarction) in July...clearly does not have capacity at this time...will likely need guardianship..."


Hospital B's "Discharge Summary" for Patient #3 dated 12/05/14, at 2:08 PM, included that Patient #3 was discharged to a nursing home in stable condition with a "feeding tube present...Lymph: L (left submand mass, R (right) axillary mass: no change in size, color, consistency during hospital, R forearm mass (likely lipoma)..." Patient #3 was noted to have activity as tolerated and a low salt diet. He was oriented to self and "partially to place and time."


During a telephone interview on 12/22/14 at 1:50 PM with Hospital B's staff, Personnel #35, Personnel #38, Personnel #40, and caretakers of Patient #3, Personnel #39 RN floor nurse, and Personnel #41 RN Emergency Department nurse, they were asked to describe Patient #3's ED visit and hospitalization.


RN Emergency Department Personnel #41 said that Patient #3 could not recall the events of the day or what happened. He had "multiple bruises and a PEG tube in place...not sure why since he could eat." He was not sure where he lived and was forgetful when he was talked to, but compliant when the IV (intravenous) was started and had labs and a scan carried out. Patient #3 was brought in by police on a stretcher with no history and admitted to Hospital B.


Personnel #39 and #40 said that after Patient #3 was admitted to Hospital B he did ambulate (walk) and had a sitter for safety since at times he wanted to wander and they didn't want him to fall. He was discharged to a nursing home from Hospital B.


Personnel #38 said that Patient #3 was discharged from Hospital B on 12/05/14.

Based on interviews and records review, the hospital failed to ensure 1 of 10 patients (Patient #3's) discharge plan was arranged for initial implementation to meet his post-discharge healthcare needs.


Patient #3 suffered cognitive decline due to brain injury from anoxic encephalopathy related to a cardiac arrest suffered prior to admission to Hospital A and was identified as a fall risk. Patient #3 was discharged to a homeless shelter via taxi on 09/19/14. The homeless shelter could not provide the needed monitoring or assistance, and subsequently, Patient #3 disappeared from the homeless shelter on 9/19/14 (the same day he arrived) without shelter employees' knowledge.


On 09/20/14, Patient #3 was found on the sidewalk by police officers with an altered mental status and multiple abrasions to his face and a hematoma over the left eye. He was taken to the Emergency Department at Hospital B and admitted for further treatment.


Review of the meical record of Patient #3 at Hospital B revealed that the Registered Nurse (RN) ED notes dated 09/20/14, at 7:01 AM, showed that the patient " ...states the year is 2013 and the president is George Bush ...does not remember the events of the day ...from Frisco ...does not remember the last time he was home ...PEG (percutaneous endoscopic gastrostomy) tube (feeding tube) in place ...denies any pain ...has multiple abrasions to his face and a hematoma over the left eye ...blood on his clothes ...LOC (level of consciousness) unknown at this time ...several masses noted to abdomen and right arm ... "


Hospital A had left the homeless shelter responsible for Patient #3's mental/physical needs and referrals to community resources.


Findings included:


Hospital A's Discharge Summary documented by Staff #11 dated 09/19/14 (day of discharge) at 1423 revealed that Patient #3 was diagnosed with out-of-hospital cardiac arrest, dilated cardiomyopathy, chronic systolic congestive heart failure (CHF), left ventricular ejection fraction 10%, and anoxic encephalopathy. He received ICD (Implantable Cardioverter)/defibrillator placement and "...continues to be a fall risk. He has cognitive decline...has had multiple falls during this hospitalization...patient is being transferred to a shelter today..."


The Case Management Reassessment documented by Staff #7 dated 09/19/14 (day of discharge) at 1539 revealed, "...Patient was D/C (discharged) to (homeless shelter) and was transported via taxi..."


Review of the medical record of Patient #3 at Hospital B revealed an H&P (History and Physical) dated 09/20/14 at 4:21 conducted by a physician that showed: " ... Pt was admitted to "Hospital A" and apparently discharge to a homeless shelter on 9/19/14 ...initially though (t) to be acute AMS, but upon review of outside records, likely is anoxic brain injury following his MI(myocardial infarction) in July ...clearly does not have capacity at this time ...will likely need guardianship ... "


During a telephone interview on 11/24/14, at 1614, non-hospital staff #26 stated that Patient #3 disappeared from the homeless shelter on the same day the hospital discharged him to the shelter via taxi on 09/19/14. "He must have gone out the gate...," she shared, but his possessions remained at the shelter and he had not been seen since.


During an interview on 12/01/14, at 1330, Staff #2 stated that he was contacted on 10/23/14 by another facility and that Patient #3 was at Hospital B.


During an interview on 12/01/14, at 1345, Staff #7 at Hospital A stated that "Patient #3 was very hard to place...fully functioning before and suffered a lot of brain injury..." from his cardiac arrest. At one time she had almost gotten Patient #3 placed in a shelter close to the hospital but he was required to be physically able to climb bunk beds and he was not. Staff #7 stated that she instructed the taxi driver to take Patient #3 to the homeless shelter and walk with him into the shelter as the patient could not just be left at the door. Staff #7 stated that due to Patient #3's "cognitive deficit" he would need assistance upon discharge.


Review of the medical record of Patient #3 at Hospital B revealed a " Discharge Summary " dated 12/05/14 at 2:08 PM that Patient #3 was discharged to a nursing home in stable condition.


Hospital B's Registered Nurse (RN) Emergency Department (ED) notes dated 09/20/14 at 7:01 AM included that Patient #3 "...states the year is 2013...does not remember the events of the day...does not remember the last time he was home...PEG (percutaneous endoscopic gastrostomy) tube (feeding tube) in place...denies any pain...has multiple abrasions to his face and a hematoma over the left eye...LOC (level of consciousness) unknown at this time...several masses noted to abdomen and right arm..."


Hospital B's initial "ED Plan of Care" signed by the ED physician on 09/20/14, at 10:10 AM, included, "...AMS (altered mental status) and mild trauma to the L (left) face...Unclear cause of AMS..."


Hospital B's "Discharge Summary" for Patient #3 dated 12/05/14, at 2:08 PM, revealed that Patient #3 was discharged to a nursing home in stable condition with a "feeding tube present...Lymph: L (left submand mass, R (right) axillary mass: no change in size, color, consistency during hospital, R forearm mass (likely lipoma)..." Patient #3 was noted to have activity as tolerated and a low salt diet. He was oriented to self and "partially to place and time."


During a telephone interview on 12/22/14 at 1:50 PM with Hospital B's staff, Personnel #35, Personnel #38, Personnel #40, and caretakers of Patient #3, Personnel #39 RN floor nurse, and Personnel #41 RN Emergency Department nurse, they were asked to describe Patient #3's ED visit and hospitalization.


RN Emergency Department Personnel #41 said that Patient #3 could not recall the events of the day or what happened. He had "multiple bruises and a PEG tube in place...not sure why since he could eat." He was not sure where he lived and was forgetful when he was talked to, but compliant when the IV (intravenous) was started and had labs and a scan carried out. Patient #3 was brought in by police on a stretcher with no history and admitted to Hospital B.


Personnel #39 and #40 said that after Patient #3 was admitted to Hospital B he did ambulate and had a sitter for safety since at times he wanted to wander and they didn't want him to fall. He was discharged to a nursing home from Hospital B.


Personnel #38 said that Patient #3 was discharged from Hospital B on 12/05/14.