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Based on observation, interview and record review, the facility failed to provide an evaluation of the needs related to discharge planning for 1 of 96 sampled patients (Patient 40). The deficient practice may create adverse health consequences for patients at risk, who did not receive adequate discharge planning.

Findings include:

Patient 40 (P40) arrived by ambulance to the Emergency Department (ED) on 09/16/2023 with chief complaints of dizziness and worsening right sided extremity weakness.

The ED Medical Provider Note dated 09/17/2023 included a history and physical exam (H&P). The H&P indicated the patient reported a recent history of a stroke with symptoms of right-sided weakness of the arm and the leg. The patient reported vision loss to both eyes over the past several years. The patient reported using insulin to treat diabetes. The note indicated P40's past medical history included back pain, stroke, diabetes, and high blood pressure. The record indicated current medications for P40 included Lisinopril orally for high blood pressure, and insulin by injection for diabetes. The note indicated the patient reported losing all medications and had not taken any over the past week, and the patient had become homeless.

The ED Provider Notes regarding medical decision making documented P40 was homeless and presented to the ED due to dizziness and weakness. The note indicated P40 would need case management support for medication care. The note indicated the patient stated having no resources and was homeless. The note indicated the patient spoke with case management. The note documented the case manager furnished P40 with options for the patient to navigate to acquire housing, medications, and other social support services. Discharge follow up recommendations provided to P40 included to schedule an appointment at the hospital outpatient clinic in one day. The note documented P40 was discharged on 09/17/2023 in stable condition with diagnoses of dizziness and homelessness. The note lacked the mode of transportation, destination, or mobility status of the patient.

A Case Management note dated 09/17/2023 at 9:26 AM documented, met with patient at bedside. Patient did not know the name of medications currently taking and does not know the daughter's phone number to verify. Patient's phone does not turn on at this time, no battery life and no charger available. Primary RN (Registered Nurse) aware. Discount medication recourses {sic} given to patient. P40's record lacked a case management assessment.

A Nurse's Note dated 09/17/2023 at 10:29 AM, indicated the patient was given discharge information, along with a taxi voucher and community resources that included possible discounts for prescription medications. The note indicated P40 left the ED on 09/17/2023 at 10:45 AM. The record lacked the mode of transportation the patient used upon discharge. The record lacked an address the patient was discharged to.

On 07/26/2024, in the morning, the Case Management Manager verbalized case management staff visited for discharge needs for all patients in all areas of the hospital. The Case Management Manager revealed case management screened patients within 24 hours, including all patients in the ED. The Case Management Manager revealed providers and nurses could order a case management consultation at any time. The Case Manager stated nurses could also prepare a discharge plan if case management did not prepare the discharge plan. The Case Management Manager verbalized if the nurse identified a need, then it triggered a consultation and assessment to address the need. The Case Management Manager reported, social deterrents of health which were not medical conditions but affected the patient's well-being, would trigger a consultation. The Case Manager verbalized homelessness was a social deterrent of health.

On 07/26/2024, in the morning, the Case Management Manager reviewed P40's medical record and verbalized the following:

- P40's medical record lacked a case management assessment to determine the patient's need. The case management assessment should have been completed due to the patient being homeless and the provider having indicated a need for the consultation.

-Case management tasks included obtaining family member phone numbers from the past record on file. The hospital practice was to reach out to family members for input on discharge planning. P40's record lacked documentation this had been done.

-The hospital discharge process included assisting patients to obtain prescription medications. P40's record lacked documentation the patient had been assisted to obtain prescription medications including insulin. The medications should have been called in to the patient's pharmacy of choice, and transportation provided to the pharmacy to pick up the medications.

-P40's record documented the patient was given a taxi voucher. Taxi vouchers were issued to patients who needed transportation to a destination. A taxi voucher would only be given if the patient had an address to be sent to. The provider notes indicated the patient was homeless. A copy of the taxi voucher would be maintained in the patient's record. P40's record lacked a copy of a taxi voucher.

-The discharging planning process should include an assessment of the patient's mobility. P40's record lacked documentation the patient's mobility was assessed, for instance as to whether the patient could walk or propel self in a wheelchair.

-The hospital discharge options included referring homeless patients to a specific shelter which offered many support services upon discharge. P40's record lacked evidence of a referral to this shelter.

The Case Management Manager verbalized the hospital failed to perform a case management assessment per the hospital policy and procedure. The Case Management Manager indicated the lack of the assessment resulted in an unsafe discharge for P40 which carried a risk for an adverse outcome.

On 07/26/2024 at 2:20 PM, an Emergency Department Registered Nurse (RN) verbalized, upon discharge the RN must assess and document each patient's mobility status to ensure the patient was safe to discharge.

The hospital policy and procedure titled Transition of Patients, final approval date of 05/2022, indicated the transition planning process utilized an interdisciplinary team approach, began upon admission and continued throughout the hospitalization. A patient's specific needs and outcome goals would be identified by the team through assessments on admission. Transition Planning Criteria included patients who expressed concern over financial and/or environmental problems.

Case Management Responsibility included:
-Screen daily admissions for Transition Planning needs, barriers, and plans.
-Collaborate with all members of the healthcare team, develop a realistic timely discharge plan based upon input from medical staff, nursing staff, and other members of the hospital and patient/family.
-Arrange non-medical support services as needed or requested.

Transition Planning Procedure included

-Primary responsibility for screening for transition planning rests with Case Management.
-At the time Case Management responds to the referral, he/she would evaluate for the need to complete and assessment and evaluate the need for post hospitalization services.
-All transition planning should include input from the patient and family prior to implementation
-The plan should be recorded in the Case Management section of the patient's medical record.

The policy and procedure titled Discharging Patients from the Adult Emergency Department dated 02/2024, indicated to ensure all patients were discharged from the Emergency Department in stable condition and to provide for patient safety upon discharge, for all patients being discharged, the primary care nurse will ensure the patient can ambulate or move at baseline.

The policy and procedure titled Ambulation on Discharge in the Adult Emergency Department, dated 07/2023, indicated ED staff shall test and document patient ambulation status upon discharge from the Emergency Department to minimize patient morbidity and mortality. The policy indicated patients discharged from the ED would be assessed for their ability to ambulate independently or with the assistive device prescribed (i.e. crutches) or present during triage. The patient being discharged from the Emergency Department would be asked to ambulate to assure their ability to stand and walk independently. During the discharge process, the nurse should assure there was a sufficient, unobstructed area for the patient to use, ask the patient to walk 5-10 steps (may use a mobility device such as a walker, cane, or crutches). Document the patient's ability to ambulate (note any assistive devices). If any unexpected difficulties in ambulating, the nurse must interrupt the discharge process and immediately notify the physician of the patient's ambulation status.