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Based on interview and record review, the facility failed to ensure their discharge policies and procedures (P&P) were followed for five of 10 sampled patients (Patient 5, Patient 6, Patient 20, Patient 23, and Patient 29). This failure had the potential to result in unmet discharge needs and resources for the homeless patient.

Findings:

1. During a review of Patient 5's "Facesheet [FS]," dated 12/8/24, the FS indicated Patient 5 was admitted to the Emergency Department (ED) on 12/8/24 at 4:16 p.m. and was homeless.

During a concurrent interview and record review on 1/28/25 at 3:34 p.m. with Emergency Department Nurse Manager (EDNM), Patient 5's electronic medical record (EMR) "ED Discharge Note [EDN]," dated 12/9/24 was reviewed. The EDN indicated mode of transportation, accompanied by, and transportation screen were blank. Patient 5's EMR "Discharge Planning for Homeless Patients [DCP]," 12/9/24 was reviewed. EDNM stated all screens on the ED discharge note and DCP should have been completed by the Registered Nurse (RN). EDNM stated the RN documentation in the medical record is expected to be accurate and complete.

During an interview on 1/29/25 at 12:58 p.m. with Director of Education (DOE), DOE stated all screens in the EMR are to be completed, not just the hard stop questions. Discharge RNs are expected to review, document, and complete each step on the discharge planning and discharge screens.

During a review of Patient 5's "FS," dated 12/9/24, the FS indicated Patient 5 was admitted to the ED on 12/9/24 at 12:24 p.m. and was homeless.

During a concurrent interview and record review on 1/29/25 at 2:30 p.m. with RN 1 and EDNM, Patient 5's EMR "EDN," dated 12/9/24 was reviewed. The EDN indicated mode of transportation, accompanied by, and transportation screens were blank. Patient 5's EMR "DCP," dated 12/9/24 was reviewed. The DCP indicated, "Patient offered" Infectious disease screening N/A Vaccination Screening N/A Meal Offered, N/A Transportation within 30 mins [minutes]/30 miles N/A, Discharge medications provided to patient screen blank,Written prescription(s) provided screen blank, Physician determined follow-up is medically necessary screen blank. Physician determined behavioral health follow up is necessary screen blank, Patient referred to screen blank, Behavioral health follow-up notification blank, Patient referred to screen blank. RN 1 stated she thought it was done so she did not review the information for completeness. RN 1 stated she overlooked the screens and they should have been completed before Patient 5 was discharged.

2. During a review of Patient 6's "FS," dated 12/3/24, the FS indicated Patient 6 was admitted to the ED on 12/3/24 at 11.27 a.m.

During a review of Patient 6's "ED Physician Notes [PN]," dated 12/3/24, the PN indicated, "Patient lives in a shelter."

During a concurrent interview and record review on 1/29/25 at 1:20 p.m. with Quality Patient Safety Program Manager (QPSPM). Patient 6's EMR "DCP," dated 12/9/24 was reviewed. The DCP indicated, "Patient Offered" Infectious disease screening N/A (non applicable-does not apply), Vaccination Screening N/A, Meal Offered N/A, Transportation within 30 mins/30 miles N/A, Patient arrived with weather appropriate clothes No. QPSPM stated there was no documentation which stated why N/A was documented on Patient 6's DP form.



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3. During a review of Patient 20's "FS," dated 12/24/24, the FS indicated Patient 20 was admitted to the ED on 12/24/24 at 8:35 p.m.

During a concurrent interview and record review on 1/29/25 at 3:52 p.m. with EDNM Patient 20's "DCP" dated 12/24/24, was reviewed. The DCP indicated, "Patient Offered" Infectious disease screening N/A, Vaccination Screening N/A, Transportation within 30 mins/30 miles N/A. EDNM stated the nurse is responsible to verify the completion of each answer on the screening. EDNM stated the nurse should have entered a comment for each answer marked N/A or put accepted or declined. EDNM stated she was unable to provide documentation that indicated why NA was marked on Patient 20's DCP. EDNM stated she was unable to provide documentation that indicated why NA was marked on Patient 20's DCP

4. During a review of Patient 23's "FS," dated 12/26/24, the FS indicated Patient 23 was admitted to the ED on 12/26/24 at 10:16 p.m. and was homeless.

During a concurrent interview and record review on 1/29/25 at 3:56 p.m. with EDNM, Patient 23's "DCP" dated 12/30/24 was reviewed. The DCP indicated, "Patient Offered" Infectious disease screening N/A, Vaccination Screening N/A, Meal Offered N/A, Transportation within 30 mins/30 miles N/A. EDNM stated there should have been comments for any answer marked N/A. EDNM stated she was unable to provide documentation that indicated why NA was marked on Patient 23's DCP.

5. During a review of Patient 29's "FS," dated 1/14/25, the FS indicated Patient 29 was admitted to the ED on 1/14/25 at 11:33 a.m. and was homeless.

During a concurrent interview and record review on 1/29/25 at 3:58 p.m. with EDNM, Patient 29's "DCP" dated 1/14/25 (updated 1/16/25) was reviewed. The DCP indicated, "Patient Offered" Infectious disease screening N/A, Vaccination Screening N/A, Meal Offered N/A, Transportation within 30 mins/30 miles N/A. EDNM stated she was unable to provide documentation that indicated why NA was marked on Patient 29's DCP. EDNM stated there was no determination that these items were offered to the patient 29 prior to discharge.

During a review of the facility's policy and procedure (P&P) titled, "Safe Discharge for High Risk Patients," dated 1/28/18, the P&P indicated, "Particular attention is paid to high risk and vulnerable populations by assessing, intervening, and providing basic needs of a person identified as homeless and/or in need of services or resources prior to discharge. . .The nursing staff is responsible for. . .Communicating the referral and discharge plan, including transportation arrangements, to the patient/family and other personnel involved in the patient's plan of care. . .Each homeless patient will be offered the following services prior to discharge. Acceptance or declination of each of these will be documented. . . The homeless patient will be offered food/a meal prior to discharge. . .The homeless patient will be offered weather appropriate clothing if the patient's clothing is inadequate. The homeless patient will be offered or referred to screening for infectious disease common to the region. . .The homeless patient will be offered vaccinations. . .The hospital will offer the homeless patient transportation to his/her post-discharge destination as identified in the discharge plan.

During a review of the facility's P&P titled, "Accurate and Proper Documentation of Medical Records," dated 2/25/22, the P&P indicated, "The purposes of this policy are: A. To serve as an accurate and detailed record for planning patient care, ant to accurately record services ordered and/or provided by all involved providers, nurses and ancillary personnel. B. To document the patient's medical evaluation, treatment. . .during the hospital stay. . .or emergency visit."

During a review of the facility's P&P titled, "Written Community Plan: Discharge Planning Unsheltered Patients," dated 1/21/25, the P&P indicated, "In compliance with California Senate Bill 1152, all three [facility names and county name] have created and implemented this written community plan when discharging unsheltered individuals. . .This written plan is in alignment with the hospital's Safe Discharge for the High Risk Patients Policy. . .that addresses unsheltered patient discharge planning."