HospitalInspections.org

Based on record review and interview, the facility failed to ensure documentation of a discharge evaluation and the resulting discharge plan for each identified high risk patient. The deficient practice is evidenced by failure to address and document the post discharge housing needs for 1 (#3) of 5 (#1-#5) reviewed records of patients with housing needs post discharge.

Findings:

Review of the facility policy #5059, "Universal Discharge Planning, " revealed in part, " A case management consult is entered for patients identified as having discharge planning needs ( DMS, HH, Oxygen, SNF/IPR/NH placement, etc) or as meeting one or more of the high-risk discharge screens below. Case Management and Social Workers respond to referrals within one business day. Risks include . . .Homeless . . . The Case Manager, Social Worker, or qualified Case Management Assistant completes a discharge planning assessment on all inpatients as soon after admission as possible, but no later than 3 business days after admission." Further review revealed a description of the role of the nurse and social work case manager to include, " Document assessment and all discharge planning activity in the patient's record."

Review of the medical record for Patient #3 revealed the patient was admitted to the behavioral health service on 07/31/2023 and discharged on 08/04/2023. The admission evaluation documented the patient as "unhoused." The discharge summary states, "Able to verbalize plan for discharge as being to stay with a friend after stopping by mother's house to pick up his disability check."

Further review of the medical record failed to reveal documentation the case manager and the patient discussed a plan for housing after discharge. There was no documentation the friend noted in the discharge summary was contacted to verify suitability and agreement to provide a place for the patient to stay.

In interview on 08/29/2023 at 9:21 a.m., S5LPC verified he did not document a discharge plan established in consultation with the patient that included possible resources for safe housing as part of the plan.