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Based on interview and document review the facility failed to reassess the patients discharge plan for one of twelve patients (#10) discharge plans reviewed, when the appropriateness of the discharge plan was questioned by staff, resulting in the potential for inappropriate discharge plans for patients with special needs treated at this facility. Findings include.

On 04/11/2018 at 1600 the medical record for the patient of concern was reviewed. The patient of concern was admitted to the emergency department (ED) on 01/25/2018 at 1955. The patient of concern was a 68-year-old male patient that was found wandering the street in Flint with altered mental status, he was not oriented to time and place. He was brought to the ED by the Flint Police Department. He was documented as disheveled, filthy, and incontinent of urine. He answered questions in the ED however he was noted as an inaccurate historian during evaluation. Per progress notes, he patient's mentation improved during his admission and he stated that he had a home, lived alone, and had a car that was recently stolen. Before discharge the patient of concern was able to recall the cross streets where he lived, where he shops and the bank he goes to withdraw his social security. His address was obtained through the face sheet from his veteran's administration (VA) records and was reviewed with the patient. The patient confirmed this being his address.

The patient endorsed preferring to go home and follow up with a veteran's hospital (VA) as they were familiar with him. He stated that he just needed transportation assistance. Case management staff S, contacted the VA hospitals in the region,however, no beds were available for transfer.

Case management and social worker worked with patient to obtain Home Health Care to come to his house and to continue with physical therapy and occupational therapy. The plan was documented for social work to come out to the patient's house upon discharge to evaluate him and his living situation. The physician documented, "Patient was stable upon discharge."

Documentation on the day of discharge, 1/31/2018, by staff R the geriatric nurse specialist documented at 0753 "Today patient of concern is at high risk for deconditioning, delirium and readmission because confusion, limited support system and adherence or ability to adhere with treatment plan." On 1/31/2018 at 1405 (55 minutes prior to discharge) staff R documented. Patient is not orientated, he is disorganized. He cannot recall his meds but states he takes 4 in the am,1 pill around noon and 1 at 5pm. XXX Home care Agency case manager staff T in room as they will follow for care transitions."

On 04/12/2018 at 1015 the home care nurse from XXX Home Care Agency staff T was interviewed by telephone. Staff T explained that she had assessed the patient of concern in his hospital room prior to his discharge. She stated that she became very concerned about his level of confusion. She explained that she reported her concerns to staff R. She further reported that she was surprised when the patient was discharged as planned. She reported that she met the patient at the reported address only to find that it was the neighbors address. Adult protective services joined her at the site and took the patient to safety.

On 04/12/2018 at 1030 staff R the geriatric Nurse specialist was interviewed. Staff R stated "I assessed the patient of concern the morning of his discharge." Staff R further explained, I had some concerns about his level of confusion and reported it to the Resident and then did nothing further about my concerns. Staff R was asked if there was a place to document concerns related to Discharge plans, she stated "In the progress notes is the only place."

On 04/12/2018 at 1100 the Attending Physician (staff U) for the patient of concern and the Resident (staff V) were interviewed. Staff U stated that he was not aware that there was a problem with the discharge. He further explained that each day when they rounded the patient (#10) seemed able to report details of his life such as receiving most of his care through the Veterans administration (VA.) Staff U further stated "We were able to verify the address the patient had given them with the medical record from the VA." He listed the services they had put in place to help this patient who wanted to go home: Home health care, skilled nursing, Physical therapy, occupational therapy, and a personal aide.

On 04/12/2018 at 1330 the policy titled "Discharge Planning Referrals" #3601 dated 11/27/2017 was reviewed. On page 1 of 2 under 5. it states "If the patient's condition or other circumstances change, the discharge plan is reassessed and revised as necessary."
On 04/12/2018 at 1345 the policy titled "Utilization Review Plan" dated January 1,2016 on page 3 of 5 under Post Hospital Care Planning Services it states "As a component of the case Management program patient condition changes are identified and the plan is reevaluated and modified to meet the patient's needs."