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Based on interviews and record review the facility failed to implement an appropriate discharge plan, reassess the patient's discharge plan, and transfer or refer the patient to an appropriate facility for follow-up care in one (SP#1) out of 6 sampled patients (SP). (Refer to A-0806, A-0821, and A-0837)

Based on interviews and record reviews the facility failed to provide a discharge planning evaluation that include evaluation of the likelihood of a patient's capacity for self-care, the likelihood of a patient needing post-hospital services and the availability of the services in 1 (SP#1) out of 6 sampled patients (SP).

Findings include:

Review of sample patient (SP) #1 Emergency Provider Report dated 10/27/18 revealed that 911 was called by a third party stating that (patient) pt. was wandering on the road. On initial evaluation showed the patient is alert, but not completely oriented and without any complaint. There were no past history noted. Physical Exam showed that pt. is unkempt and has poor hygiene. Unable to contact any family and patient may be disoriented at baseline however it is unsafe for discharge and will admit patient for observation.

Review of the "History and Physical" dated 10/27/2018 at 03:55 am showed appears patient may have had prior brain injury, patient unable to provide history (hx). The notes further stated the CM (Case Manager) consulted for further information/family contact.

Review of SP#1 Case Management Report: Discharge Planning Evaluation (DPE) dated 10/27/18 showed that information was obtained from the patient. The patient was alert and oriented, homeless, does not have medical equipment, No activity of daily living limits, and pt. is self-care. Patient on evaluation has no community services prior to admission Patient. discharge risk showed patient does not have insurance, homeless, and to discharge to shelter. Based on the information gathered, the patient's care needs can be met at the environment from which he entered from. The discharge plan was discussed with the pt.
Review SP#1 Clinical Documentation Record showed:

On 10/27/18 at 5:51 am: Admission/Shift Assessment showed patient was oriented to person, with unsteady gait and balance. SP#1 is high risk for falls. At 10:45 am, the patient with weak lower extremities. Gait is unsteady. On ambulation, SP#1 requires one person assist. Pt thought process showed disorganized, illogical, and helpless. Pt memory assessment showed unable to comprehend and follow directions.

On 10/28/18 at 5:02 AM showed the patient was in bed, with period of confusion and disorientation persist. SP#1 ambulated in the room with unsteady gait and safety was maintained.
At 10:50 am, the patient oriented to person, lower extremities weak and remains with unsteady balance and gait. Standby assist required. Falls risk assessment showed the patient is able to comprehend and follow direction and is high risk for falls. Pt intervention include supervision/assistance to ambulate.
At 10:06 PM, the patient is in bed, confuse, alert oriented, calm and cooperative. Pt unable to give personal information. Pt in close monitoring.

On 10/28/2018 at 08:48 showed SP#1 discharge order to "other facility". Then on 10/29/2018 09:05 am another order showed to discharge to home.

On 10/28/2018 at 08:48 am showed an order for a Case Management consult for discharge planning to "DC to shelter".

Another order dated 10/29/2018 at 11:19 am showed OT/Rehab Plan of care, Inpatient Rehabilitation versus Skilled Nursing Facility (SNF) for rehab.

10/29/18 at 9:20 am the Occupational Therapy (OT)/REHAB (Rehabilitation): Initial Evaluation showed the patient unable to follow command, oriented to name, patient is confused and unable to follow simple one step commands will need assistance for medication management, patient feeding with moderate assistance due to right upper extremity (RUE) tremor and decreased endurance, patient unable to locate objects in room requiring maximum verbal cues. Discharge Recommendations: Inpatient Rehab versus Skilled Nursing Facility (SNF) for rehab.

On 10/29/2018 at 1:19 pm, SP#1 was discharge home and left via wheelchair with staff on duty to the first floor.

Review of SP#1 Discharge Summary dated 10/29/18 revealed patient was determine to likely be at his baseline after thorough examination and screening. SP#1 Discharge Diagnosis showed Chronic Encephalopathy.

Review of the ED provider notes from hospital #2 showed patient SP (#1) presents to ED (Emergency department) with psychiatric evaluation onset today. Patient was brought in by (Emergency Medical Services) EMS after running through traffic on I-95 (Interstate highway). Patient was transferred to the Behavioral Health Unit (BHU) for psychiatric evaluation and discharged on 12/14/2018.

Interview on 12/10/2018 at 12:48 pm 12:11 pm with Risk Management Coordinator revealed that Risk Management was made aware of SP#1 discharge on 10/30/18 from a report. A call was received from another hospital that SP#1 was found wandering and was taken by police.


Interview on 12/10/18 at 12:40 pm with the Assistant Director for Case Management revealed that he recalls SP#1. He was covering for the case manager on that floor. He said that the patient said he lived with family, he spoke with the patient who said that he has a brother, there was no address and the patient provided telephone number of the brother to the nurse and it was not working. Patient understands the discussion and the instructions in Spanish. He recalls that information for shelter and community resources was given, and patient was discharged. The next day, a hospital (name provided) called and asked about the patient. Discharge of homeless patients, a list of shelters is provided to patient and initial call is done by case manager and the patient also has to call the shelter. The shelter space is first come first serve.

Interview with Nurse/Staff M on 12/11/2018 at 11:22 am revealed (she was the nurse assigned to SP#1 at the day of discharge) that she does not recall SP#1. Staff M explains that if patient is confused, the case manager is informed and we find a family or if there is no one available, we have to get guardianship. She said that patients are provided with discharge instructions on different topics. Transportation is arranged by case manager at discharge if it is needed.

Review of the Case Management report of SP#1 from 10/27/2018 to 10/30/2018 revealed that there was no transportation arrangement for SP#1. There was no documentation noted that shelters was contacted. There was no documentation noted that a space is available at the shelter. There was no evidence that a facility, agency or outpatient service referral was contacted for SP#1 post hospital needs.


Interview on 12:48 pm 12:11 pm with Risk Management Coordinator revealed that Risk Management was made aware of SP#1 discharge on 10/30/18 from a report. A call was received from another hospital that SP#1 was found wandering and was taken by police. The Director of Utilization Management was made aware and reviewed the case with Case Manager. The case do not have any corrective action submitted or required at this time.


Review of the Policy Title: "Advance Directives: Health Care Surrogate/Proxy, Determine of Capacity/Competency". Revision Date (07/2012) revealed the policy states that all patients are presume to be capable of making health care decision for herself or himself unless she or he is determined to be incapacitated. The Determination of Capacity: If a patient's capacity to make health care decisions is in question for herself or himself or provide informed consent is in question, the attending physician shall evaluate the patient's capacity and if the physician concludes that the patient lacks capacity, he/she will documented the findings enter the evaluation on the "Verification of Patient Incapacity to make Health Care Decisions". The facility failed to follow their own policy.

Review of the Policy Title: "Discharge Planning Process", Revision Date: (09/2017) states, Discharge Planning involves the evaluation of the patient and family needs, strengths, limitations and resources. Components of Discharge Planning are education, identification of needs, and coordination of post-hospital care in collaboration with other members of the healthcare team. (Page 4 of 4) d. Necessary referrals to post-acute services will be made by the case manager or social worker (home health agencies skilled nursing facility, LTACHs, DMEs).
e. The anticipated discharge date is discussed and confirmed with the family and preparations are finalized for discharge (transportation arrangements made, transfer to another level of care in outside facility confirmed, home health arrangements confirmed, etc.). The facility failed to follow their own policy.

Based on interview and record review, the facility failed to reassess the discharge plan for factors that may affect the continuing care needs and appropriateness of the discharge plan in one (SP#1) out of 6 sampled patients (SP).




Findings include:

Review of sample patient (SP) #1 Emergency Provider Report dated 10/27/18 revealed that 911 was called by a third party stating that (patient) pt. was wandering on the road. On initial evaluation the patient is alert, but not completely oriented and without any complaint. There were no past history noted. Physical Exam showed that pt. is unkempt and has poor hygiene. Unable to contact any family and patient may be disoriented at baseline however it is unsafe for discharge and will admit patient for observation.

Review of the "History and Physical" dated 10/27/2018 at 03:55 am showed appears patient may have had prior brain injury, patient unable to provide history (hx). The notes further stated the CM (Case Manager) consulted for further information/family contact.

Review of SP#1 Case Management Report: Discharge Planning Evaluation (DPE) dated 10/27/18 showed that information was obtained from the patient. The patient was alert and oriented, homeless, does not have medical equipment, No activity of daily living limits, and patient is self-care. Patient on evaluation has no community services prior to admission Patient discharge risk showed patient does not have insurance, homeless, and to discharge to shelter. Based on the information gathered, the patient's care needs can be met at the environment from which he entered from. Name of brother was identified but there is no cellphone number available.The discharge plan was discussed with the pt.



10/29/18 at 9:20 am the Occupational Therapy (OT)/REHAB (Rehabilitation): Initial Evaluation showed the patient unable to follow command, oriented to name, patient is confused and unable to follow simple one step commands will need assistance for medication management, patient feeding with moderate assistance due to right upper extremity (RUE) tremor and decreased endurance, patient unable to locate objects in room requiring maximum verbal cues. Discharge Recommendations: Inpatient Rehab versus Skilled Nursing Facility (SNF) for rehab.

On 10/29/2018 at 1:19 pm, SP#1 was discharge home and left via wheelchair with staff on duty to the first floor.

Review of SP#1 Discharge Summary dated 10/29/18 revealed patient was determine to likely be at his baseline after thorough examination and screening. SP#1 Discharge Diagnosis showed Chronic Encephalopathy.


On 10/30/18 at 9:57 am, SP#1 Case Management Report showed in the comments: Orders for discharge home per attending. Unable to contact next of kin, Patient at baseline per care team, provided with information of shelters and community resources. Case Management Report Documentation Updated by Assistant Director of Case Management.

Review of the ED provider notes from hospital #2 showed patient SP (#1) presents to ED (Emergency Department) with psychiatric evaluation onset today. Patient was brought in by (Emergency Medical Services) EMS after running through traffic on I-95 (Interstate Highway). Patient was transferred to the Behavioral Health Unit (BHU) for psychiatric evaluation and discharged on 12/14/2018.

Interview on 12/10/2018 at 12:48 pm 12:11 pm with Risk Management Coordinator revealed that Risk Management was made aware of SP#1 discharge on 10/30/18 from a report. A call was received from another hospital that SP#1 was found wandering and was taken by police.


Interview on 12/10/18 at 12:40 pm with the Assistant Director for Case Management revealed that he recalls SP#1. He was covering for the Case Manager on that floor. He said that the patient said he lived with family, he spoke with the patient who said that he has a brother, there was no address and the patient provided telephone number of the brother to the nurse and it was not working. Patient understands the discussion and the instructions in Spanish. He recalls that information for shelter and community resources was given, and patient was discharged. The next day, a hospital (name provided) called and asked about the patient. Discharge of homeless patients, a list of shelters is provided to patient and initial call is done by Case Manager and the patient also has to call the shelter. The shelter space is first come first serve.



Phone interview with Case Manager B on 12/12/18 at 10:47 revealed that he does not recall SP#1. (Case Manager B took part with the discharge planning of SP#1). He explains that discharge of a homeless patient, the patient is provided with a list of shelters and let them know what is on the area. He said that the patient is referred to shelter. He explains that if he runs into pt. and is a little confuse, he ask certain questions make sure they are there, ask who they live with, ask number, simple question. Get more information and if patient stumbling or hesitant, see if patient was medicated, see if there is a family to talk to. It there is no family call the doctor and see if psychiatric evaluation is appropriate. Discharge plans are discussed with doctors, patients and family and make sure that they approve. He explains his role on discharge planning such as obtaining information about patient get information and verify address of patient, and family/ nearest of kin and phone numbers. He assist and work on patient needs after discharge. He also reach out to family members about discharge plans and call family members. He also explains that transportation is arranged by case management.

Review of the Case Management report of SP#1 from 10/27/2018 to 10/30/2018 revealed that there was no transportation arrangement for SP#1. There was no documentation noted that shelters was contacted. There was no documentation noted that a space is available at the shelter. There was no evidence that a facility, agency or outpatient service referral was contacted for SP#1 post hospital needs.

Review of the Policy Titled: "Discharge Planning Process", Revision Date: (09/2017) states, Discharge Planning involves the evaluation of the patient and family needs, strengths, limitations and resources. Components of Discharge Planning are education, identification of needs, and coordination of post-hospital care in collaboration with other members of the healthcare team. (Page 4 of 4) d. Necessary referrals to post-acute services will be made by the case manager or social worker (home health agencies skilled nursing facility, LTACHs, DMEs).
e. The anticipated discharge date is discussed and confirmed with the family and preparations are finalized for discharge (transportation arrangements made, transfer to another level of care in outside facility confirmed, home health arrangements confirmed, etc.). The facility failed to follow their own policy.

Based on interviews and record review the facility failed to refer the patient to an appropriate facility for follow-up care in 1 (SP#1) out of 6 sampled patients (SP).


Findings include:

Review of sample patient (SP) #1 Case Management Report showed on 10/28/18 at 12:53 pm a Case Management consult for shelter. Case Manager-C documentation showed she met with the patient and Patient Care Assistant (PCA) and patient was given information to Shelters. Pt said that he does not have identification.

Further review of SP#1 Case Management Report showed on Comments: Orders for discharge home per Attending (physician). Unable to contact next of kin, Patient at baseline per care team, provided with information of shelters and community resources. Case Management Report Documentation Updated by Assistant Director of Case Management on 10/30/18 at 9:57 am.


Review of SP#1 Discharge Summary showed the admitting diagnosis Acute Encephalopathy. Discharge diagnosis showed Chronic Encephalopathy, patient is oriented to person only. Patient has previous history of craniotomy and found that this is his baseline mental status.

Review of the Case Management report of SP#1 from 10/27/2018 to 10/30/2018 revealed that there was no transportation arrangement for SP#1. There was no documentation noted that shelters was contacted. There was no documentation noted that a space is available at the shelter. There was no evidence that a facility, agency or outpatient service referral was contacted for SP#1 post hospital needs.

Phone interview with Case Manager-B on 12/12/18 at 10:47 revealed that he does not recall SP#1. (Case Manager B took part with the discharge planning of SP#1). He explains that discharge of a homeless patient, the patient is provided with a list of shelters and let them know what is on the area. He said that the patient is referred to shelter. He explains that if he runs into pt. and is a little confuse, he ask certain questions make sure they are there, ask who they live with, ask number, simple question. Get more information and if patient stumbling or hesitant, see if patient was medicated, see if there is a family to talk to. It there is no family call the doctor and see if psychiatric evaluation is appropriate. Discharge plans are discussed with doctors, patients and family and make sure that they approve. He explains his role on discharge planning such as obtaining information about patient get information and verify address of patient, and family/ nearest of kin and phone numbers. He assist and work on patient needs after discharge. He also reach out to family members about discharge plans and call family members. He also explains that transportation is arranged by case management.


Review of the Policy Titled: "Discharge Planning Process", Revision Date: (09/2017) states, Discharge Planning involves the evaluation of the patient and family needs, strengths, limitations and resources. Components of Discharge Planning are education, identification of needs, and coordination of post-hospital care in collaboration with other members of the healthcare team. (Page 4 of 4) d. Necessary referrals to post-acute services will be made by the case manager or social worker (home health agencies skilled nursing facility, LTACHs, DMEs).
e. The anticipated discharge date is discussed and confirmed with the family and preparations are finalized for discharge (transportation arrangements made, transfer to another level of care in outside facility confirmed, home health arrangements confirmed, etc.). The facility failed to follow their own policy.