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Based on medical records review, interview with staff and community professionals it was determined, that the hospital failed to have in effect a discharge planning process that applied to all patients. One of 5 samples patients (patient 1) did not receive discharge planning adequate to ensure safe and appropriate placement.

Findings include:

1.The hospital failed to provide a discharge planning evaluation which included an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital. Patient 1 who was an eighty six year old female was admitted to the facility from a nursing facility and was discharged to the homeless shelter. Refer to Tag A 809

2. The hospital failed to provide appropriate counseling to family members or interested persons to prepare them for post-hospital care. Patient 1 was discharged to the homeless shelter without the family members being notified. There was no evidence that contact was made with the homeless shelter staff prior to patient 1's arrival to ensure the patient's needs could be met. Refer to Tag A 822

3. The hospital failed to transfer or refer patient 1, along with the necessary medical information, to an appropriate facility, agency or outpatient service. Patient 1, who had psychiatric disorders and multiple medical needs, was discharged to a homeless shelter. It was undetermined if Patient 1 actually arrived at the homeless shelter and went missing for several days. Refer to Tag A 837.

Based on medical records review and interview with hospital staff, and community resource employees, it was determined that the hospital failed to provide for 1 out of 5 sample patients a discharge planning evaluation which included an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital. (Patient identifier: 1)

Findings include:

1. Review of patient 1's medical record revealed the following information about patient 1's behavior and the discharge planning process:

Patient 1, an eighty-five year old female patient was admitted to the hospital's Senior Behavioral Health Unit (SBHU) on 4/13/12, with the psychiatric diagnoses of Bipolar Disorder, Obsessive Compulsive disorder and suicidal ideation. Patient 1 was transferred to the SBHU involuntarily from the emergency room where patient 1 was evaluated by a physician and a crisis worker. The patient also had the medical diagnoses uncontrolled Diabetes Mellitus Type II, Coronary Atherosclerosis, history of Coronary Bypass (heart surgery), low blood pressure, and Atrial Fibrillation.

a. Review of the emergency room record which was included in patient 1's SBHU medical record.

The emergency room triage nurse documented that patient 1 arrived in the emergency room on 4/13/12 at 7:20 PM with the chief complaint of "Suicidal Thoughts".

Under past medical history the nurse documented that patient 1 had the diagnoses of narcosis personality disorder and was Bipolar.

The nurse documented that patient 1 came from a nursing facility. Patient 1 stated that "Someone Stole My Hat" and "I want to kill myself". The nurse described patient 1 as anxious, animated and manic.

Patient 1 was examined by the emergency room physician and crisis worker. Patient 1's medical record included a copy of the certification of involuntary commitment due to suicidal ideation as reported by the administrator of the nursing facility where patient 1 lived.

b. Review of patient 1's "Psychosocial Assessment" dated 4/18/12, signed by the SHBU social worker revealed the following information:

The social worker documented that patient 1 was referred by the administrator of a nursing facility. The social worker documented his discussion with patient 1 about why she was admitted. "Pt states that a CNA (Certified Nurse's Aide) @ (at) the care center stole her hat. Pt. then went to the administrator's office to report the theft & stated "I can't live without my hat." The social worker documented that patient 1's nursing facility administrator took her to the emergency room due to suicidal ideation. An evaluation was done by the emergency room physician which indicated that patient 1 had no present suicidal ideation but that the nursing facility refused to take her back. When questioned about past suicide attempts the patient informed the social worker that she had never tried to take her life. The social worker documented that patient 1 had a history of multiple inpatient stays due to non-compliance with medications for treatment of Bipolar Disorder. The social worker documented, when he questioned concerning discharge support, patient 1 stated that would be the politician who was a candidate running for governor. Patient 1 stated that her best friend was the administrator from the nursing facility where she lived. This was the administrator who refused to readmit patient 1. The social worker documented that the issues which were of concern due to patient 1's psychiatric illness, were safety, health and social issues. The social worker documented that patient 1 informed him she was working as a golf/tennis pro and working with significant political figures throughout history. The social worker documented that patient 1 had minimal contact with her five children and reportedly had burned many bridges with her family.

c. Review of the Psychiatric Assessment dated 4/17/12, dictated by an APRN (Advanced Psychiatric Registered Nurse) and co-signed by the psychiatrist revealed the following information:

The assessment documented that patient 1 was an "85 year old female", mother of five who was admitted from the emergency room on a blue sheet (involuntary commitment). At the nursing facility the patient became distraught because her 2002 Olympic cap with all the pins on it was stolen from her room. She mentioned to the administrator that if she could not have this hat, she did not have anything worth living for. Patient 1 was evaluated in the emergency room where it was determined that patient 1 was not suicidal. Even though patient 1 was not actively suicidal the nursing facility administrator refused to readmit patient 1 until she was admitted and assessed in an inpatient psychiatric unit. The APRN documented that patient 1 was more agitated and frustrated than depressed. The patient informed the APRN that she felt betrayed by the nursing facility administrator. The APRN documented that if anything, patient 1 was in a manic state. Patient 1 was described as very robust, tangential (communication disorder in which the speakers train of thought wanders, lacks focus and never returns to the original subject) and, persistent, and intrusive. The assessment documented that this was the same condition patient 1 exhibited during a previous hospitalization in 2011. Patient 1 was discharged from that hospitalization on mood stabilizing medications which she refused to take. The assessment documented that patient 1 still refused to take psychiatric medications. Patient 1 admitted to being somewhat manic but claimed to function highly that way and was presently out campaigning for a political candidate, was going to professional basketball games, and had friends. The patient claimed to be active her whole life and was a tennis/golf pro and played on a 1940's Olympic Basketball team. Patient 1 denied ever seeing a psychiatrist, ever being suicidal or making any suicide attempts. The assessment indicated patient 1 had a history of heart disease having had a coronary artery bypass graft. The patient had a fractured hip requiring surgery in March of 2011. The patient was described as having a hunch back with some kyphotic curvature and relied heavily on her walker to ambulate. When ambulating, patient 1 tired easily and had to sit down frequently. Patient 1's behavior was described as persistent with multiple requests. Her mind ran constantly trying to figure out things and plan things. Patient 1's speech was pressured, tangential and her mood was euphoric. Patient 1's insight was poor, judgement poor, and impulsivity was high. The APRN documented that "The patient is at high risk for danger to self just due to impulsivity."

d. Review of the physician orders revealed the following information:

The admission orders dated 4/14/12, included a Certification signed by the physician. "I certify that inpatient hospitalization is medically necessary to improve and/or maintain the patient's condition and level of functioning and that this could not be done at a less intensive level of care."

Review of the physician's orders revealed multiple medication changes and strategies to deal with patent 1's refusal of psychiatric medications.

On 5/15/12, a physician order was written to discharge patient 1 to the road home (homeless shelter) with the social worker discharge planning and assessment. There were no physicians orders prior to that day concerning discharge arrangements.

e. Review of the professional progress notes revealed the following:

4/14/12. A nurses admission note was written indicating that patient 1 denied having suicidal ideation. Patient 1 stated that she was joking when she commented about dying at the nursing facility. Patient 1 was described as being talkative and was oriented. Patient 1 informed the nurse that she was not going to take any psychiatric medications.

4/14/12. The APRN's admission note documented that patient 1 was grandiose, delusional, had no insight and was demanding. The assessment documented that patient 1 was Bipolar with mania and psychosis. The APRN documented that patient 1 would be discharged back to the nursing facility.

4/16/12. The clinical social worker documented that he received a call from the social worker at patient 1's nursing facility regarding patient 1. The social worker from the facility stated patient 1 had recently asked which medication would "due her in the quickest". The nursing facility social worker stated that they were in the process of giving patient 1 a 30 day notice of discharge and was in the process of seeking placement for patient 1 but was making little progress, She stated that other facilities knew patient 1 and that she would be a difficult placement. The social worker documented that he also spoke with the nursing facility's administrator who stated her concerns because patient 1 was giving away her belongings. The hospital social worked documented that patient 1 denied that she was suicidal or was giving her belongings away. The administrator informed the social worker that the nursing facility would not be readmitting patient

The social worker documented that he informed the administrator that no medical professional had determined that patient 1 was suicidal. He informed the administrator that patient 1 denied that she had felt suicidal now or in the past. The social worker informed the nursing facility administrator that patient 1 did not meet criteria to be in an acute hospital setting. The hospital social worker documented that he informed the administrator that because the nursing facility's social worker was in the process of discharging her, it appeared they had dumped patient 1.

4/17/12. The APRN documented that patient 1 was aware that the nursing facility was refusing to readmit her. Patient 1 informed the APRN that she was OK with that and was willing to go to another skilled nursing facility. The APRN documented that they were "unable to find assisted living facility and patient 1 was thinking of an apartment". The APRN stated that patient l had a "rosery view of self" inspite of feedback.

4/20/12. The psychiatrist noted that patient 1 did not understand why she was being turned down by the nursing facility and was now trying to figure out how to live on her own.

4/21/12. A nursing note documented that patient 1 slowly lowered herself to the floor but became entangled into her walker. No injuries were noted. Patient 1 continued to refuse psychiatric medications because she wanted to feel like that - with her mind racing. Patient 1 informed the nurse that people all around the world loved her because she always thought that way. The nurse documented that patient 1 was yelling at the staff and was abusive to her family when on the telephone.

4/22/12. The registered nurse described Patient 1 as being adamant about leaving and doing what she wanted.

4/25/12. The psychiatrist documented that patient 1 required long term placement.

4/27/12. The psychiatrist documented that patient 1 maintained that she could care for herself independently in an apartment which she has already rented. Patient 1 stated she could go back to the nursing facility she had been living in previously and that the administrator would take her to the apartment when it was ready. The psychiatrist noted that patient 1 would benefit from forced mood altering drugs if legal arrangements could be made.

4/29/12. The psychiatrist documented that the evening before patient 1 had become verbally assaultive and threatening to the nursing staff and required medication of Haldol and Ativan by injection for agitation.

4/30/12 The psychiatrist documented that patient 1 had informed him she had rented an apartment and wanted to be discharged. The note indicated that this had not been confirmed.

4/30/12. The registered nurse documented that patient 1 was found on the floor with the walker underneath her. A lump was noted on the right front aspect of her head. Patient 1 complained of pain in her neck. The nurse documented that the APRN was informed of the fall and the patient had X-Rays of her neck, head and face.

5/1/12. The psychiatrist documented that patient 1 was still waiting for discharge. He documented patient 1 had no injuries from the fall. He documented that patient 1 was paranoid and was counting her pills.

5/3/12. The psychiatrist documented that patient 1 was alert and oriented X 2 (Full orientation is 4). Patient 1 was described as demanding attention, talking, arguing and displayed no insight. The psychiatrist documented that Patient 1 was demanding discharge back to the nursing facility she came from.

5/4/12. The psychiatrist documented that there was major problems with patient 1's disposition.

5/512. The APRN documented that patient 1 was in sitting in a wheelchair. The APRN described Patient 1 as verbose, agitated, angry and hostile with staff.

5/6/12 . The APRN described patient 1 as manipulative and stated she was sending letters to her former nursing facility. Patient 1 informed the APRN that she had rented an apartment with 2 homeless people. The APRN documented that the present treatment plan would continue along with discharge planning.

5/8/12. The psychiatrist documented that the patient continued to refuse medications so was being rejected by nursing facilities and assisted living. Patient 1 stated she wanted to live in her own apartment with home health and friends support. Psychiatrist documented that patient 1's "Deposition difficult"

5/10/12. The psychiatrist documented that patient lacked insight, was not an immediate danger but still needed placement.

5/12/12. The APRN documented that patient 1 remained resistant and demanding. The APRN documented that patient was found with her pants down.

5/13/12. The APRN documented that the evening before patient 1 required medication with a Haldol and Ativan injection for agitation. Patient 1 was described as confused.

5/14/12. The psychiatrist documented that patient 1 was convinced that a staff member from the night before was going to help get discharged and arrange home health services for her. Patient 1 was described as looking at the world through paranoid eyes complicating treatment. The psychiatrist documented that discharge options were limited.

5/15/12. The psychiatrist documented that patient 1 wanted to make arrangements for discharge and was asking to see the social worker to help. The psychiatrist documented that they were still working on disposition.

5/18/12. The psychiatrist documented that patient 1 was confronted about her plan to stay in the hospital until 6/15/12. He documented that Patient 1 was finally understanding her financial issues and "would like to leave on her own recognizance - go to bank get money and rent a place". The psychiatrist documented that the problem was that the patient's check had not been deposited yet and had no money or place to live. Arrangements needed to be made to her direct deposit instructions with social security. "Patient will need to stay until financially arrangements could be made for her financially for her and a safe place to live found". There was no documentation in the medical record indicating that anyone on staff had assisted patient 1 with her finances and she had no money.

5/19/12. The APRN documented that other patients on the unit were complaining about patient 1. Patent 1 was switching from wanting to leave and wanting to stay. The APRN indicated that patient 1 was intrusive, demanding and had little insight. The APRN stated that psychiatric services would continue but there was problems with deposition because no facilities would take patient 1 and she was unsafe on her own.

5/20/12. The APRN documented that patient 1 was stable for discharge but needed placement.

5/21/12. The psychiatrist documented that patient 1 continued to be labile (mood changes), intrusive, and tangential. There was no change in the patient and she continued to refuse psychiatric medications. Patient 1 was described as "Upsetting other patients with her constant demands and attempts to manipulate". The psychiatrist documented that the patient was incontinent (unable to control urine and/or stool) at night. Patient 1 informed the psychiatrist that she planned to be discharged that day and various friends would look after her. The psychiatrist stated that patient 1 was fairly calm and thanked him several times for facilitating her discharge. The psychiatrist documented that patient 1 denied any mental illness and had zero insight. "Patient clearly does not meet criteria for inpatient psych. stay, and is not receiving psychiatric treatment here. Discharge ASAP to less restrictive environment is long overdue".

5/21/12. The clinical social worker documented that patient 1"is being discharged to the (Homeless Shelter) against social worker recommendation. At this point the treatment team has decided that the patient did not meet criteria initially, previous placement has blocked any re-admit back to their facility and no other facility is willing to admit the patient. There is no family involvement with the patient. Patient's only friend is unwilling to take her into his care. Patient does not meet criteria for acute inpatient care at this time".

f. Review of a form titled "DC (discharge) orders/summary". The physician completed the form. Patient 1 was discharged to the homeless shelter. The patient's mental health diagnosis was listed as Bipolar type 1 mixed, currently hypomania. Patient 1's medical diagnoses were Diabetes, gout, recent urinary infection (treated while in the hospital), coronary artery disease, mild enlarged heart, anemia. Patient 1 had neck pain after a fall on 5/4/12 (while in the hospital). The physician documented that patient 1 was "homeless". The instructions on the form indicated a repeat urinalysis was recommended. Finger stick blood sugars were to be done before meals and at bedtime. The instructions stated that one of the medications prescribed was oxycodone and was not to be taken with sedating drugs or alcohol due to risk of falling or respiratory depression. Patient 1's mental status was described as alert and oriented with her short term memory intact. The psychiatrist documented that patient 1 denied suicidal ideation or depression. Patient 1 was noted to be incontinent at night. The psychiatrist documented that patient 1 was denying mental illness and was refusing to take psychiatric medications. Patient 1 was described as re-directable with verbal prompts (This is incongruent with the professional teams' notes which described patient 1 as argumentative, intrusive, demanding and abusive to family and staff). Patient 1 was described as acting out by throwing the telephone, her walker and pills. Patient 1 was noted to have urinated in inappropriate places and walked around the unit without pants on. Patient 1 did not obey SBHU rules and other patient's complained about her behavior. The patient was described as needing minimal assistance with activities of daily living and used a walker or wheelchair to get around. Follow-up was to be at a charitable clinic for medical management and monitoring of medications. This was not an inpatient facility. Prescriptions were given to the patient. There was no documentation indicating that the homeless shelter or the clinic was informed about patient 1 prior to her discharge from the hospital. There was no documentation that copies of the instructions the psychiatrist wrote went with patient 1 to the homeless shelter.

g. There was another discharge instruction form completed by a nurse which indicated the patient was discharged to the homeless shelter. The nurse documented that Patient 1 was discharged from the unit by wheelchair. The form documented that patient 1 was discharged to "self". Patient 1's condition at discharge was noted to be stable, alert and oriented. The form was signed by the nurse. Where the patient was to sign it stated "patient refused". The form did not document that a staff member (social worker) accompanied the patient to the homeless shelter. During an interview conducted on 6/13/12, with the manager of quality assurance and risk she stated that patient 1 was given a taxi voucher for transportation to the shelter.

h. Review of the dictated physician's discharge summary
dated on 6/14/13, the day after the surveyors were in the hospital was reviewed an the following information was documented:

Patient 1 was admitted to the hospital on 4/13/12 and discharged on 5/21/12. The psychiatrist described patient 1 as an 86-year-old, mother of 5 who was referred to the SBHU on a blue sheet involuntary hold. Patient 1 was sent to the hospital from her assisted living facility because of presumed suicidal ideation which the patient denied.

After admission to the SBHU the patient resisted taking all psychiatric medications. Patient 1 informed the unit staff and the physician that she did not need the medications, in fact had never needed them. The physician documented that patient 1 continued to assert her right not take medications throughout her entire hospital stay. "Her hospital stay was stressful on the staff that she was demanding and intrusive and had no insight into what she was doing to other people, but is quite clear about what was wrong with everybody else. She spent a great deal of time on the telephone, trying to arrange her own discharge, stating that a friend of hers was going to pick her up and take her to an apartment, that she rented and on further evaluation, this was found to not be in reality and she did not have any place to go. Various assisted living centers were contacted and refused to admit her, partially because she had been to before and her reputation had preceded her. She continued to start providers, in particular her primary in the hospital, which was myself demanding just demented (sic) in my time, which would expand to an hour if unchecked".

The physician documented that the patient fell down on 4/21/12, hitting her head and shoulder. While in the hospital patient 1 was treated for a urinary tract infection. The psychiatrist documented that after multiple attempts to place the patient in assisted living centers the patient was eventually taken to the homeless shelter with her walker. Patient 1's mood was high, she was somewhat paranoid, and intrusive. Patient 1 denied suicidal ideation, hallucinations or depression. The psychiatrist documented that Patient 1 "has a chronic mental illness, but refuses to help if medication for her illness, continues to try to arrange her own affairs, but is unable. She has alienated her family and many of her friends. She is likely to be needed (sic) further psychiatric care at some point".

2. Interviews with hospital staff revealed the following information:

a. An interview was conducted with the SBHU manager on 6/12/12, at 11:30 AM. The manager stated that the social worker of the SBHU was responsible for discharge planning for the patients. The manager stated that the social worker had been "let go" and thus not available to interview. The manager stated that patient 1 was admitted to the hospital from the emergency department and prior to that was living at a nursing facility. The manager stated that the social worker felt that the story given by the assisted living facility that patient 1 was suicidal was inaccurate. The manager stated that patient 1 was borderline personality, manic and grandiose. The manager stated that the social worker called the nursing facility and argued with the nursing facility's administrator regarding patient 1 being suicidal. The manager stated that patient 1 was non-compliant with taking medications. The manager was questioned as to what contacts were made to facilities seeking placement for patient 1 upon discharge from the hospital. The manager stated that the social worker (who was not employed anymore) had made the contacts. The surveyor asked if there might be some documentation of the contacts made by the social worker which were not included in the medical record. The manager checked and then informed the surveyor that if the social work had working notes they had been shredded when the social worker left. The manager did not know if the homeless shelter staff were contacted prior to patient 1's discharge from the hospital. The manager was questioned about patient 1's family involvement. He stated that the patient's daughter was not involved in patient 1's care while in the SBHU. The manager stated that he thought the daughter had called the social worker 1 time after patient 1 was discharged and left a message. The manager did not know if the social worker returned the daughters telephone call. The surveyor discussed with the unit manager concerns about patient 1's safety in a homeless shelter, considering her age (86) and medical status. The medical record had indicated that patient 1 used a wheelchair or walker for mobility while hospitalized and that patient 1 had fallen two times while on the unit. The manager stated that he knew she was walking. The manager was asked if patient 1 had taken a walker to the homeless shelter. The manager stated that she must have. The manager was asked if he was familiar with the homeless shelter and what facility's were available there to meet patient 1's medical needs. He stated that he was not. The surveyor discussed the minimal documentation in the medical record concerning patient 1's discharge planning. The manager stated that the social worker documented interacting with the nursing facility's social worker and administrator. The manager stated that the unit social worker had documented that the nursing facility administrator refused to readmit patient 1.

b. The surveyor interviewed the manager of quality assurance and risk manager. The surveyor asked how patient 1 was transported to the homeless shelter. The quality assurance and risk manager left to check on it and returned stating patient 1 was given a taxi voucher.

c. The surveyor requested a copy of the physician's discharge summary. The surveyor was informed that the physician's last progress note was the discharge summary. The surveyor received a dictated discharge summary along with a copy of patient 1's full record. The discharge summary was dated 6/14/12, the day after the survey team left the facility

3. An employee from the homeless shelter was contacted by telephone to obtain information about services available for persons with medical needs. The employee stated that there was a man and woman's dormitory (6 female beds and 8 male beds. The employee stated that a person staying in the shelter had to be self sufficient with the activities of daily living. The employee stated that they were not equipped to provide care to people with incontinence (patient 1 was incontinent). The employee stated that they did not have staff trained to provide these cares. The employee stated that it was a rule that people in the medical beds had to leave the shelter at 7 AM and could return at 3 PM. This leaves people on the street 8 hours a day.

4. An adult protective services case worker was contacted by telephone on 6/14/12. The case worker stated that patient 1 had been a patient at the hospital and was difficult to place. The case worker stated that patient 1 was ultimately discharged to the homeless shelter. The case manager stated that she contacted the homeless shelter and there was no record that patient 1 had been there. The case manager stated because she had concerns she had attempted to locate patient 1. The case manager stated that she discussed patient 1's where abouts with patient 1's daughter who was also looking for patient 1. Both the daughter and the case worker filed missing persons reports. The case worker stated that eventually patient 1's daughter was contacted by someone in California who stated that patient 1 had arrived in California by bus, was safe, and was staying there.

Based on medical records review and interview with staff members and other community agency staff members it was determined that the hospital failed to transfer or refer 1 out of 5 patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care. The patient was transferred from the hospital's Senior Behavioral Health Unit (SBHU) to a homeless shelter without patient's, family members or interested persons receiving counseling to prepare them for providing post-hospital care. (Patient identifiers: 1)

Findings include:

1. Review of patient 1's medical record revealed the following information:

Patient 1 was an eighty-five year old female patient who was admitted to the hospital's Senior Behavioral Health unit (SBHU) on 4/13/12, with the psychiatric diagnoses of Bipolar Disorder, Obsessive Compulsive disorder and Suicidal Ideation. Patient 1 was admitted to the SBHU involuntarily on a blue sheet commitment from the emergency room of another acute care hospital. After evaluating patient 1 the emergency physician signed a form titled "Certificate of Emergency Commitment". The form documented that patient 1 had expressed thoughts of suicide at her nursing facility. Patient 1 also had medical diagnoses which included uncontrolled Diabetes Mellitus Type II, Coronary Arthrosclerosis, history of Aortocoronary Bypass (heart surgery), low blood pressure, and Atrial Fibrillation (heart arrythmia).

a. Review of patient 1's "Psychosocial Assessment" dated 4/18/12, signed by the clinical social worker who worked with patients on the SBHU, revealed the following:

The social worker documented that patient 1 was a referral from the nursing facility where patient 1 resided. The nursing facility's administrator took patient 1 to the Emergency Room because patient 1 had made suicidal comments. The social worker documented that patient 1 denied that she was suicidal now and never had been. The administrator at the nursing facility to take patient 1 back. The social worker documented that patient 1 had a history of multiple inpatient stays due to non-compliance with taking medications for the treatment of Bipolar Disorder.

In the "Discharge Needs" portion of the assessment the social worker documented that patient 1 made unrealistic statements concerning her support system. The social worker documented that impediments to patient 1's recovery were safety, health and social problems. The social worker documented that patient 1 had minimal contact with her five children and reports indicated that patient 1 had burned many bridges with her family.

b. Review of the Psychiatric Assessment dated 4/17/12, dictated by an APRN (Advanced Psychiatric Registered Nurse) and co-signed by the psychiatrist, revealed the following information:

An assessment dictated by an APRN and co-signed by the psychiatrist was reviewed. The APRN documented that patient 1 went to the emergency department due to suicidal ideation. The emergency room physician documented that patient 1 was not suicidal. The APRN documented that the nursing facility administrator refused to take patient 1 back until she was evaluated in an inpatient psychiatric unit. The APRN documented that Patient 1 was manic, persistant and intrusive. The assessment documented that this behavior was the same as exhibited during a previous hospitalization in June 2011. Patient 1 had consistently refused mood stabilizing medications. The APRN documented was significant, included heart disease and fractured hip. Patient 1 had a kyphotic curvature of her upper back. Patient 1 was walker dependent and tired easily when walking. Patient 1's behavior was described as persistent with multiple requests. Patient 1's mood was euphoric. Patient 1's insight and judgement were poor, and her impulsivity was high. The risk assessment documented "The patient is at high risk for danger to self just due to impulsivity."

Review of the treatment team's professional progress notes revealed the patient's progress and discharge planning as follows:

Patient 1 was refusing any medications. She was to be discharged to a nursing facility.

On 4/16/12, the clinical social worker documented that he received a call from the social worker from patient 1's nursing facility. The hospitals social work stated that the nursing facility's administrator was refusing to readmit patient 1. The facility social worker that patient 1 was being discharged and they were seeking placement. They were having difficulty because patient 1 had a reputation. The administrator reiterated that patient 1 was suicidal.

4/17/12. The APRN documented that patient 1 was aware that the nursing facility was refusing to readmit her. Patient 1 was willing to go to another nursing facility. The APRN documented that they were unable to find assisted living facility and were thinking of an apartment.

4/20/12. The psychiatrist noted that patient 1 did not realize why she was being turned down by assisted living facility and was now trying to figure out how to live on her own.

4/21/12. The APRN documented that Patient 1 continued to refuse psychiatric medications and was stating she did not want to change. Patient 1 was exhibited inappropriate behaviors, including yelling at the staff and verbally abusing her family on the telephone.

4/22/12. The registered nurse documented that Patient 1 was adamant about leaving and being able to do what she wanted.

4/25/12. The psychiatrist documented that patient 1 required long term placement.

4/27/12. The psychiatrist documented that patient 1 was maintaining that she could care for herself independently in an apartment, which she had already rented. Patient 1 stated she would return to the nursing facility and the administrator would take her to the apartment when it was ready.

4/29/12. The psychiatrist documented that patient 1 had become agitated, verbally assaultive and threatening to nursing staff. An injection was given to sedate her.

4/30/12 The psychiatrist documented that patient 1 stated she had rented an apartment and wanted to be discharged. This had not been confirmed.

4/30/12. The registered nurse documented that patient 1 fell. A lump was noted on the right front aspect of head. Patient 1complained of pain in her neck. Patient 1 continued to complain of neck pain throughout her hospital stay.

5/1/12. The psychiatrist documented that patient 1 was still awaiting discharge. Patient 1 was described as paranoid.

5/3/12. The psychiatrist documented that patient 1 was demanding attention, talking, arguing and displayed no insight. The psychiatrist documented that Patient 1 was demanding discharge back to the nursing facility.

5/4/12. The psychiatrist documented that there were major problems with arranging disposition of patient 1.

5/6/12 . The APRN documented that patient 1 informed him that she had rented an apartment along with 2 homeless people. The APRN documented that discharge planning would continue.

5/8/12. The psychiatrist documented that because patient 1 refused to take psychiatric medications she had been rejected by assisted living and nursing facilities. Patient 1 stated she wanted to live in her own apartment with home health and her friends support.

5/13/12. The APRN documented that the evening before patient 1 again required a sedating injection due to verbally abusing the staff.

5/14/12. The psychiatrist documented that patient 1 was convinced that a staff member on duty the night before would help her get discharged and arrange for home health services. Patient 1 was described as looking at the world through paranoid eyes which complicat her treatment. The psychiatrist documented that discharge options were limited.

5/15/12. The psychiatrist documented that patient 1 wanted to make arrangements for discharge and was asking to see the social worker to help. The psychiatrist documented that they were still working on disposition.

5/18/12. The psychiatrist documented that patient 1 was finally understanding her financial issues. Patient 1 informed him she would like to leave, go to bank, get money and rent a place". The psychiatrist documented that the problem was that the patient 1's check had not been deposited yet. Arrangements to change the direct deposit of her social security check had not been made. Patient 1 had no money or place to live. The psychiatrist documented that patient 1 would need to stay until financial arrangements could be made and there was a safe place for her to live.

There was no evidence in the medical record indicating that patient 1's financial issues had been addressed as part of her discharge plan. No assistance was provided so patient 1 could access her money.

5/19/12. The APRN documented that other patients were complaining about patient 1's behavior. Patient 1 was described as intrusive, demanding and having little insight. Patient 1 was a deposition problem because no facilities would take patient 1. She is unsafe on her own.

5/20/12. The APRN documented that the patient was stable to go but needed placement.

5/21/12. The psychiatrist documented that the patient continued to be labile (mood changes), intrusive, and tangential. The psychiatrist documented that the patient was incontinent (unable to control urine and or stool) at night. There was no change in patient 1's continued refusal of psychiatric medications. Patient 1's behavior was described as "Upsetting other patients with her constant demands and attempts to manipulate". The patient informed the psychiatrist that she planned to discharge that day and there were various friends who could look after her. The psychiatrist documented that patient 1 was fairly calm and thanked him several times for facilitating her discharge. Patient 1 still denied any mental illness and had zero insight. Patient clearly does not meet criteria for inpatient psych. stay, and is not receiving psychiatric treatment here. Discharge ASAP to less restrictive environment is long overdue". The psychiatrist did not mention any other options for patient 1's discharge such as contacting the local mental health authority, or other community resources for follow-up care.

5/21/12. The clinical social worker documented that patient 1"is being discharged to the (Homeless Shelter) against social worker recommendation. At this point the treatment team has decided that the patient did not meet criteria initially, previous placement has blocked any re-admit back to their facility and no other facility is willing to admit the patient. There is no family involvement with the patient. Patient's only friend is unwilling to take her into his care. Patient does not meet criteria for acute inpatient care at this time". The medical record contained documentation that the psychiatrist had signed a certification stating that patient 1 met inpatient criteria. There was no documentation about what nursing facilities were contacted, or if other community resources were sought to ensure patient 1's safety.

On 5/21/12, a psychiatrist's order was written to discharge patient 1 to the (homeless shelter) with the social worker's discharge planning and assessment.

On 5/21/12. A form titled "DC (discharge) Orders/Summary" completed by the psychiatrist was reviewed. Patient 1 was discharged to the homeless shelter. The patient's mental health diagnosis was listed as Bipolar type 1 mixed, currently hypomanic. Patient 1's medical diagnoses were Diabetes, gout, recent urinary infection (treated while in the hospital), heart disease, anemia, and neck pain after sustaining a fall on 5/4/12. Patient 1 was described as "homeless". The instructions on the form indicated a repeat urinalysis should be done. Finger stick blood sugars were to be done before meals and at bedtime. The instructions stated that the pain medication prescribed for pain (oxycodone) was not to be taken with sedating drugs or alcohol due to the risk of falling or respiratory depression. Patient 1 was described as denying suicidal ideation or depression. Patient 1 was incontinent at night. Patient 1 was denying mental illness and was refusing psychiatric medications. Patient 1 was described as redirectable with verbal prompts (This is incongruent with the professional's notes throughout patient 1's stay, which described patient 1 as argumentative, intrusive, displaying inappropriate behavior, demanding and abusive to family and staff). Patient 1 was described as acting out by throwing the telephone, walker and pills. Patient 1 did not obey SBHU rules. Other patients complained about her behavior. Patient 1 needed minimal assistance with activities of daily living and used a walker or wheelchair to get around. Follow-up was to be a charitable clinic to provide medical management and monitoring of medications. Prescriptions were given to the patient.

There was nothing in the medical record indicating that the physician knew if anyone at the homeless shelter or the clinic was notified about patient 1's medical needs. There was no documentation that either facility received discharge instructions. There was no evidence that contacts were made to ensure that patient 1's medical needs could be met at the homeless shelter. This included fingerstick blood sugars to monitor diabetes and monitoring the effects of sedating pain medication. There was no evidence that patient 1's safety in the homeless shelter would be ensured.

2. An interview was conducted with the SBHU manager on 6/12/12. The manager stated that he did not know if the homeless shelter staff were contacted and informed of patient 1's psychiatric and medical issues. The manager was questioned about patient 1's family involvement. He stated that the patient's daughter was not involved in patient 1's care while she was in the SBHU. He stated that he thought the daughter had called the social worker and left a message after patient 1 had been discharged. He did not know if the social worker returned her call. The manager stated that he thought patient 1 was walking while on the unit. The manager was asked if he was familiar with the homeless shelter and what facility's were available for persons with medical needs. He stated that he was not. The manager was asked if patient 1 took her walker with her. He stated that he assumed she had.

3. The surveyor interviewed the the hospital's manager of quality assurance and risk management on 6/13/11. The surveyor asked how patient 1 was transported to the homeless shelter. The manager left to check on it and returned stating patient 1 was given a taxi voucher.

4. An employee from the homeless shelter was contacted by telephone on 6/13/12. The employee stated that the names of shelter occupants was confidential so it is unclear whether patient 1 actually arrived at the shelter. The employee provided information about services available for persons with medical needs. The employee stated that there were some limited beds for people with medical issues. The employee stated that any person staying in the shelter had to be self sufficient with the activities of daily living. The employee stated that there was no staff trained in providing assistance with the activities of daily living including incontinence care. There was no staff available to provide nursing care such as monitoring of diabetes. According to the rules the people who occupy the medical beds must leave the shelter at 7 AM and cannot return until 3 PM. This leaves the people who occupy those beds on the streets 8 hours a day.

5. An adult protective services case worker was contacted by telephone on 6/14/12. The case worker stated that the hospital had a hard time finding placement for patient 1. Ultimately patient 1 was discharged to the homeless shelter. The case manager stated that she contacted the homeless shelter but they did not know if patient 1 was ever there. The case manager stated that she attempted to locate patient 1 due to concerns about her safety. The APS case manager talked with patient 1's daughter who was also looking for her mother. Both the daughter and the case worker filed missing person reports. The case worker stated that eventually some one in California contacted patient 1's daughter by telephone. Patient 1's daughter was safe, and was staying there.

There was no evidence that hospital staff communicated with patient 1's daughter concerning discharge disposition. Even though patient 1 had a poor relationship with her daughter the daughter was concerned when she could not find her mother. She filed a missing person report.

Based on medical records review, interview with staff and community service staff, it was determined that the hospital failed to transfer or refer 1 out of 5 sampled patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care. The patient was transferred from the hospital's Senior Behavioral Health Unit (SBHU) to a homeless shelter where the patient's psychiatric and medical needs and safety could not be met. (Patient identifier: 1)

Findings include:

1. Review of patient 1's medical record revealed the following information:

Patient 1 was an eighty-five year old female patient who was admitted to the hospital's Senior Behavioral Health unit (SBHU) on 4/13/12, with the psychiatric diagnoses of Bipolar Disorder, Obsessive Compulsive disorder and Suicidal Ideation. Patient 1 was admitted to the SBHU involuntarily on a blue sheet commitment from the emergency room of another acute care hospital. Patient 1 had multiple medical conditions including heart disease, diabetes, spinal curvature and diabetes. The professional notes in the medical record revealed that patient 1 used a walker or wheelchair for mobility

a. Review of patient 1's "Psychosocial Assessment" dated 4/18/12, signed by the clinical social worker who worked with the patients on the SBHU, revealed the following:

Patient 1 was admitted to the SBHU from the emergency department for alleged suicidal ideation. Upon admission patient 1 denied ever being suicidal. Patient 1 had multiple admissions for treatment of Bipolar Disorder due to non-compliance with medications.

In the "Discharge Needs" portion of the assessment the social worker documented that there were issues which negatively impacting patient 1's recovery. This included safety needs, health needs and social problems. The social worker documented that patient 1 appeared to have minimal contact with her five children having burned many bridges.

b. Review of the Psychiatric Assessment dated 4/17/12, dictated by an APRN (Advanced Psychiatric Registered Nurse) and co-signed by the psychiatrist, revealed the following information:

Patient 1 was evaluated in the emergency department and was deemed not to not be suicidal. The APRN documented that the nursing facility administrator refused to take patient 1 back until she was admitted to an inpatient psychiatric unit. Patient 1 was described as being more agitated and frustrated than depressed. Patient 1's assessment documented that patient 1 was in a manic state, persistent, and intrusive. The assessment documented that this was the same way the patient was during a previous hospitalization in June of 2011. Patient 1 was discharged from that hospitalization on mood stabilizing medications which she refused to take. The assessment documented that patient 1 still refused to take medications. The APRN documented that patient 1's medical history included heart disease, history of surgery for a fractured hip and a kyphotic curvature of her upper back. The APRN documented that Patient 1 relied heavily on her walker to ambulate and tired easily. The APRN documented that Patient 1's insight and judgement were poor, and her impulsivity was high. The risk assessment documented "The patient is at high risk for danger to self just due to impulsivity."

c. Review of the physician orders revealed the following information:

The admission orders dated 4/14/12, included a certification signed by the physician. "I certify that impatient hospitalization is medically necessary to improve and/or maintain the patient's condition and level of functioning and that this could not be done at a less intensive level of care."

d. Review of the treatment team's professional progress notes revealed the following:

Patient 1 was resistant to taking psychiatric medications.

4/14/12. The APRN's admission note documented that patient 1 was grandiose, delusional, had no insight and was demanding. The assessment documented that patient 1 was Bipolar with mania and psychosis. The APRN documented that patient 1 would be returning to the nursing facility.

4/16/12. The nursing facility's social worker stated that the nursing facility had been in the process of discharging patient 1, and were having a hard time obtaining placement because she had reputation in the community. The administrator informed the hospital's social worker that the nursing facility would not readmit the patient.

4/17/12. The APRN documented that patient 1 was aware that the nursing facility was refusing to readmit her. Patient 1 was OK with that and was willing to go to another skilled nursing facility. The APRN documented that they were unable to find an assisted living facility who would admit patient 1 and patient 1 was considering an apartment.

4/20/12. The psychiatrist noted that patient 1 did not realize why she was being turned down by assisted living facility and was now trying to figure out how to live on her own.

4/21/12. A nursing note documented that patient 1 fell and was entangled in her walker. No injuries were noted. Patient 1 continued to refuse psychiatric medications. Patient 1 exhibited behaviors which included yelling at the staff and verbally abusing her family on the telephone.

Patient 1 repeatedly stated she wanted to leave so she could do what she wanted.

4/25/12. The psychiatrist documented that patient 1 required long term placement.

4/27/12. The psychiatrist documented that patient 1 was maintaining that she could care for herself independently in an apartment.

4/29/12. The psychiatrist documented that patient 1 had become verbally assaultive and threatening to the nursing staff. Sedative medications were administered by injection.

Patient 1 made multiple comments to the staff about unrealistic discharge plans such as renting an apartment with two homeless people.

4/30/12. The registered nurse documented that patient 1 was found on the floor with the walker underneath her. A lump was noted on the right front aspect of head. Patient 1 complained of pain in her neck. Patient 1 continued to complain of neck pain throughout her hospital stay.

Patient was described as demanding, attention seeking, talking, arguing, hostile, agitated and displayed no insight. Patient 1 demanding discharge back to the nursing facility (the facility had refused to readmit her).

The APRN documented several times that when he visited patient 1 she was in a wheelchair.

5/12/12. The APRN documented that patient 1 remained resistant and demanding and displaying inappropriate behavior (patient found with her pants down).

5/13/12. The APRN documented that the evening before patient 1 again required an injection of Haldol and Ativan due to verbally abusing the staff.

5/14/12. The psychiatrist documented that patient 1 was convinced that a staff member would help her get discharged and arrange for home health services. Patient 1 was described as looking at the world through paranoid eyes complicating her treatment. The psychiatrist documented that discharge options were limited.

5/15/12. The psychiatrist documented that patient 1 wanted to make arrangements for discharge and was asking to see the social worker to help. The psychiatrist documented that they were still working on disposition.

5/18/12. The psychiatrist documented that patient 1 was finally understanding her financial issues and wanted to leave on her own recognizance. Patient 1 wanted to go to bank get money and rent a place. The problem was that patient 1's check had not been deposited and arrangements needed to be made to change the direct deposit of her social security check. Patient 1 had no where to live. The psychiatrist documented that patient 1 would need to stay until financial arrangements could be made and there was a safe place for her to live". There was no evidence in the medical record indicating that patient 1's financial issues were addressed or assistance provided to ensure patient 1 could access her money.

The medical record included documentation that other patients on the unit were complaining patient 1's behavior. There was ongoing documentation that patient 1 was a deposition problem. No nursing facilities would take patient 1. The professional notes also documented that patient 1 was unsafe on her own. Patent 1 switched between wanting to leave and wanting to stay.

5/20/12. The APRN documented that the patient was stable to go but needed placement.

5/21/12. The psychiatrist documented that the patient continued to be labile (mood changes), intrusive, and tangential. The psychiatrist documented that the patient was incontinent at night. There was no change in patient 1's continued refusal of psychiatric medications. Patient 1's behavior was described as "Upsetting other patients with her constant demands and attempts to manipulate". The patient informed the psychiatrist that she planned to discharge that day and there were various friends who could look after her. The psychiatrist documented that patient 1 was fairly calm and thanked him several times for facilitating her discharge. Patient 1 still denied any mental illness and had zero insight. "Patient clearly does not meet criteria for inpatient psych. stay, and is not receiving psychiatric treatment here. Discharge ASAP to less restrictive environment is long overdue". The psychiatrist did not mention any other options for discharge such as contacting the local mental health authority for follow-up care or other community alternatives.

On 5/21/12, a psychiatrist's order was written to discharge patient 1 to the (homeless shelter) with the social worker's discharge planning and assessment.

5/21/12. The clinical social worker documented that patient 1"is being discharged to the (Homeless Shelter) against social worker recommendation. At this point the treatment team has decided that the patient did not meet criteria initially, previous placement has blocked any re-admit back to their facility and no other facility is willing to admit the patient. There is no family involvement with the patient. Patient's only friend is unwilling to take her into his care. Patient does not meet criteria for acute inpatient care at this time". The medical record contained documentation that the physician had certified that patient 1 met inpatient criteria. There was no documentation by the social worker which facilities were contacted, or if other community resources were sought to ensure patient 1's safety.


e. A form titled "DC (discharge) Orders/Summary" dated 5/21/12, completed by the psychiatrist was reviewed. Patient 1 was to be discharged to the homeless shelter. The patient's mental health diagnosis was listed as Bipolar type 1 mixed, currently hypomanic. Patient 1's medical diagnoses were Diabetes, gout, recent urinary infection, heart disease, anemia, and neck pain due to a fall on 5/4/12. Patient 1 was described as "homeless". The instructions on the form indicated a repeat urinalysis was recommended. Finger stick blood sugars were to be done before meals and at bedtime. The instructions stated that the pain medication prescribed for pain (oxycodone) was not to be taken with sedating drugs or alcohol due to the risk of falling or respiratory depression. Patient 1 was noted to be incontinent at night. Patient 1 was denying mental illness and was refusing psychiatric medications. Patient 1 was described as redirectable with verbal prompts (This is incongruent with the professional's notes throughout patient 1's stay, which described patient 1 as argumentative, intrusive, displayed inappropriate behavior, demanding and abusive to family and staff". Patient 1 did not obey SBHU rules and other patient's complained about her behavior. Patient 1 was described as needing minimal assistance with activities of daily living and using a walker or wheelchair to get around. Out patient follow-up was to be a charitable clinic for medical management and monitoring of medications. This charitable clinic is not an inpatient facility. Prescriptions were given to the patient. There was nothing in the note indicating that the physician contacted anyone at the homeless shelter or the clinic to ensure patient 1's needs could be met. This included fingerstick blood sugars and monitoring the effects of sedating pain medication.

f. Another discharge instruction form completed by the nurse indicated patient 1 was discharged to the homeless shelter. Patient 1 was discharged from the unit by wheelchair. The form indicated that patient 1 was accompanied by "self". Patient 1's condition at discharge was noted to be stable, alert and oriented. The form was signed by the nurse. Where the patient was to sign indicated "patient refused." The form did not document that a staff member, such as the social worker, accompanied patient 1 to the homeless shelter. When the manager over quality assurance and risk was questioned about the patient's transportation to the shelter she stated "taxi voucher".

g. Review of the dictated physician's discharge summary, revealed the following:

Patient 1 was admitted to the hospital on 4/13/12, and discharged on 5/21/12. The physician described the patient as an 86-year-old mother of 5 who was referred to the SBHU on a blue sheet involuntary hold.

After admission to the SBHU the patient resisted taking all psychiatric medications. The physician documented that patient 1 continued to assert her right not take medications throughout her entire hospital stay. "Her hospital stay was stressful on the staff that she was demanding and intrusive and had no insight into what she was doing to other people, but is quite clear about what was wrong with everybody else. She spent a great deal of time on the telephone, trying to arrange her own discharge, stating that a friend of hers was going to pick her up and take her to an apartment, that she rented and on further evaluation, this was found to not be in reality and she did not have any place to go. Various assisted living centers were contacted and refused to admit her, partially because she had been to many before and her reputation had preceded her". Patient 1 continued to demand attention from the staff in the hospital. The psychiatrist documented that patient 1 demanded his, which would expand to an hour if unchecked. The physician documented that the patient fell down on 4/21/12, hitting her head and shoulder. While in the hospital patient 1 was treated for a urinary tract infection. The physician documented that after multiple attempts to place the patient in an assisted living centers the patient was eventually taken to the homeless shelter with her walker accompanied by the social worker. (The nursing discharge summary stated the patient was accompanied by "self"). Patient 1 was described as "Patient has a chronic mental illness, but refuses to help with medication for her illness, continues to try to arrange her own affairs, but is unable. She has alienated her family and many of her friends. She is likely to be needed (sic) further psychiatric care at some point". Again there was no evidence that other options for discharge follow-up were considered including community resources other than nursing facilities or assisted living centers.

2. Interviews with hospital staff revealed the following information:

a. An interview was conducted with the SBHU manager on 6/12/12, at 11:30 AM. The manager stated that the social worker of the SBHU was responsible for discharge planning. The manager stated that the social worker who handled patient 1's case had been "let go" and thus not available to be interviewed. The manage stated that patient 1 had borderline personality, and was manic and grandiose. The manager stated that the social worker called the nursing facility and was told they would not readmit patient 1. The unit manager stated that patient 1 was non-compliant with taking medications. The unit manager was questioned as to which long term care facilities or assisted living facilities were contacted to obtain placement for patient 1. The manager stated that the social worker (who was not employed anymore) had made the contacts. The surveyor asked if there might be some informal notes concerning contacts made by the social worker which may not included in the medical record. The manager checked and then informed the surveyor that if the social worker had notes they had been shredded when he left. The manager did not know if the homeless shelter staff were contacted prior to patient 1's discharge from the hospital. The manager was questioned about patient 1's family involvement. He stated that the patient's daughter was not involved in patient 1's care while she was in the SBHU. The manager stated that he thought the daughter had called after patient 1 was discharged and left a message on the social worker's voice mail. The surveyor discussed with the unit manager concerns about patient 1's safety in the homeless shelter considering her age (86) and medical status. The medical record had indicated that patient 1 had used a wheelchair or walker for mobility while hospitalized and had fallen twice. The manager stated that he thought she was walking while on the unit. The manager was asked if he was familiar with the homeless shelter and what facility's were available to care for persons with medical needs. He stated that he was not. When asked if patient 1 took her walker the manager stated that he thought she did.

3. An employee from the homeless shelter was contacted by telephone on 6/13/12, to obtain information about the services available for persons with medical needs. The employee stated that there were 14 beds available. The employee stated that a person staying in the shelter had to be self sufficient with performing the activities of daily living. The employee stated that they were not equipped to provide care to people with incontinence (patient 1's medical record documented she had incontinence). The staff person stated that people who occupied the medical beds, according to the rules, had to leave the shelter at 7 AM and could not return until 3 PM. This means people like patient 1 would out of the shelter 8 hours a day.

4. An adult protective services case worker was contacted by telephone on 6/14/12. The case manager stated that patient 1 was discharged to the homeless shelter. The case manager stated that the homeless shelter was contacted but did not have any record that patient 1 was ever there. The case manager stated that APS attempted to locate patient 1 due to concerns about her safety. The APS case manager stated that she discussed patient 1's situation with her daughter. The daughter had informed the case manager that she was also looking for her mother. Both the daughter and the case worker filed missing person reports. The case worker stated that eventually some one in California notified the daughter by telephone that patient 1 had arrived in California by bus, was safe, and was staying there.

There was no evidence that the hospital provided discharge planning to ensure patient 1 could access her finances and find safe placement. The patient was discharged to the homeless shelter without assurance that her medical needs could be met. There was no evidence that the homeless shelter staff were made aware patient 1 would be coming.