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Based on interview and document review, the facility failed to ensure an appropriate and effective discharge plan for housing for 1 (#1) of 4 patients reviewed.


The findings include:


The complainant was interviewed by phone on 7/10/2018 at 3:53 PM, confirming the facility's allegation that Patient #1 was transferred to the Baker Act receiving facility on June 8, 2018 at 19:02 hours. He received medical care and services and was then discharged from the Baker Act receiving facility, only to return to the sending facility, presenting at the Emergency Department requesting assistance to reach the Coalition for the Homeless. The complainant stated that the patient presented himself at the Emergency Department in a taxi. The complainant also stated that the sending facility provided no call, no report and the patient reported that he was put in the taxi and sent back to get help finding shelter. She stated that the facility found a place for him to go. There was a bus service and he was sent to the Coalition for the Homeless from the complainant's facility and according to the complainant's report.


An interview was conducted on 7/30/2018 at 2:35 PM with Employee B, a Registered Nurse (RN) who worked in Psychiatry. Employee B reflected on Patient #1. She recalled that the Social Workers did the planning. Employee B, RN also stated that she was called by the complainant hospital where Patient #1 was sent. She stated he went into the hospital and they asked if the Baker Act receiving facility sent him to the Emergency Room and she told the complainant facility "No." She stated that Patient #1 did not want to go anywhere else and he gave no reason. Employee B stated that the complainant facility was the only address that Patient #1 would be discharged to. Employee B, RN also confirmed that it was not protocol to discharge to a hospital. Employee B, RN also stated that was the first time that she had to discharge someone to another hospital. Employee B, RN also stated that she did know the address was a hospital and knew that this was the only place that he would give the facility. He did insist that was where he wanted to go and he wanted to get further up North, and that was why we sent him with the packet of the homeless shelters given to him by the Social Worker. A safe discharge would be to ensure that the patient was going somewhere. She did not know if the patient wanted to refuse the homeless shelters, because she did not discuss whether a homeless shelter was an option for him. She confirmed again that she did not discuss these options. The Risk Manager was present for the interview. Employee B stated that there were homeless shelters near Palm Coast.


Employee A, LCSW, was interviewed on 7/30/2018 at 3:01 PM by phone. She was also reviewing the medical record and her notes for (Patient #1), the subject of the complaint. She confirmed that in her notes, she had no information documented related to her discussions with Patient #1 about options to be transported to the Coalition for the Homeless. Employee A, LCSW did confirm that she completed the psychosocial assessment for Patient #1 upon admission and documented that Patient #1 came from Orlando in April 2018 to this facility. He was discharged back to Aspire in Orlando. Employee A, LCSW stated, "If the patient was not from this area, we assumed that he wanted to return to the area he was familiar with." She read back her documentation at 3:03 PM. Employee A stated that the "Social Worker's role was to give this individual information in the area; Volusia County does not have homeless shelters in the area; Palm Coast is in Flagler and Palm Coast has limited availability; they only take patients who are registered and living in the county. We link the patient to the Homeless Coalition; so we tell them that we can transport the patient to the Homeless Coalition." She stated that she did not chart the conversation. Employee A, LCSW stated that she did not know where to send Patient #1 and he walked into the complainant's Emergency Room and the nurses up there called them. She told the staff that she gave him the list; that the patient still has to go to a community. Employee A stated that she should have gone back into the computer to chart this stuff after he left and when she got back. Employee A explained that it was on a weekend that he was discharged, and discharges were hard on weekends. She stated that she spent a lot of time working with Patient #1 and that she was a therapist who also did discharges. Employee A stated the staff also tried to conduct discharges during the weekdays, not on the weekends.


A review of the Job Descriptions for the facility Psychiatric Counselor, Job Code 65702, documents the following, "Responsible to Counselor Supervisor." Under Standards of Practice, Section E. Acts as liaison between patients, family members, staff and physicians. Assists patient, significant others and physicians in identifying health and resources needed to assure post-hospital care. Under Heading II; "Performs as an effective team member" section G. documents, "Coordinates Treatment Team meeting for multi-disciplinary staff. Reviews treatment plan with Patient. H. Communicates with physician when utilization concerns are identified. I. Communicates utilization and discharge planning information with insurance/review companies as needed. Under section IV. titled, "Clinical Skills," documents the role of Psychiatric Counselor under section E. as "Designs and implements in collaboration with patient and significant others and physicians, a safe and effective discharge plan." Under section V. Point A. Completes documentation with efficiency and accuracy. Section G. Documents attempts for discharge planning (i.e. telephone contacts with family, placements and appropriate referral agencies)."


Employee C, Nurse Manager for Adult Inpatient Services was interviewed on 7/30/2018 at 3:45 PM and she confirmed that the expectation for all discharge patients from the units should include referrals to outpatient treatment, shelter, medical care or otherwise. There should be very clear documentation reflecting efforts to safely discharge patients from the units.


A review of the Adult Bio-physical Assessment for Patient #1 that was entered by Employee A, LCSW on 6/09/2018 at 8:19 AM read that, "Patient #1 is a 47-year-old male that has no income, and was receiving Social Security disability insurance for Toretts', depression and anxiety, but has lost his benefits a while ago." The reason for admission for Patient #1 was under Baker Act; also documented that the patient stated that he was also homeless and currently in Palm Coast. He also stated that he really wished he had the medications he got here last time and also wanted them as he left the hospital, because he was unable to get them outpatient. Patient #1 stated that he was not ready, or not in the condition to return to Ohio and did not want help with relocating home. He hoped to return to the Palm Coast area, but really wanted a homeless shelter if there was one in the area of Palm Coast or St. Augustine.


A review of the Case Management note entered on 6/09/2018 at 10:20 AM, also documented as Discharge Planning entered by Employee A, LCSW revealed that Patient #1 current resides Home; lives alone and under, "other current living arrangement, homeless." Case Management's initial evaluation comments, "Outpatient in Palm Coast/St. Augustine." There were no additional notes supporting efforts to provide the subject of this complaint with alternate discharge planning, including documented contact with Homeless Coalition or any other shelter arrangement.


Review of the medical record for Patient #1 revealed a documented Discharge Summary dated 6/09/2018 at 17:30 Hours, under discharge comments: "D/C (discharge) to self. Given the homeless packet and medications to take with him. He was taken by taxi to Florida Hospital in Palm Coast per his request." This entry was documented by Employee B, RN.

A review of the facility provided "Authorization for Taxi" documented that Kings Transportation sent via fax the return voucher on 7/30/2018 at 17:13 hours for Patient #1 to receive on 6/09/2018 a fare of 53.00 to 60 Memorial Medical Parkway with the handwritten instruction reading "To Flagler Hospital, Palm Coast FL."


Interview with Employee A, LCSW, could provide no further evidence that the facility made an effort to provide for a discharge alternative for Patient #1; nor was there documented evidence revealing that Patient #1 refused all of the sending facility efforts to locate post-hospitalization placement, care and/or services.

Based on interview and document review, the facility failed to ensure an appropriate and effective Discharge Plan for housing for 1 (#1) of 4 patients reviewed.


The findings include:


The complainant was interviewed by phone on 7/10/2018 at 3:53 PM, confirming the facility's allegation that Patient #1 was transferred to the Baker Act receiving facility on June 8, 2018 at 19:02 hours. He received medical care and services and was then discharged from the Baker Act receiving facility, only to return to the sending facility presenting at the Emergency Department, requesting assistance to reach the Coalition for the Homeless. The complainant stated that the patient presented himself at the Emergency Department in a taxi. The complainant also stated that the sending facility provided no call, no report, and the patient reported that he was put in the taxi and sent back to get help finding shelter. She stated that the facility found a place for him to go. There was a bus service and he was sent to the Coalition for the Homeless from the complainant's facility and according to the complainant's report.


An interview was conducted on 7/30/2018 at 2:35 PM with Employee B, a Registered Nurse (RN) who worked in Psychiatry. Employee B reflected on Patient #1. She recalled that the Social Workers did the planning. Employee B, RN, also stated that she was called by the complainant's hospital where Patient #1 was sent. She stated he went into the hospital and they asked if the Baker Act receiving facility sent him to the Emergency Room and she told the complainant's facility "No." She stated that Patient #1 did not want to go anywhere else, and he gave no reason. Employee B stated that the complainant's facility was the only address that Patient #1 would be discharged to. Employee B, RN also confirmed that it was not protocol to discharge to a hospital. Employee B, RN also stated that was the first time that she had to discharge someone to another hospital. Employee B, RN also stated that she did know the address was a hospital and knew that this was the only place that he would give the facility. He did insist that was where he wanted to go, he wanted to get further up north, and that was why we sent him with the packet of the homeless shelters given to him by the Social Worker. A safe discharge would be to ensure that the patient was going somewhere. She did not know if the patient wanted to refuse the homeless shelters because she did not discuss whether a homeless shelter was an option for him. She confirmed again that she did not discuss these options. The Risk Manager was present for the interview. Employee B stated that there were homeless shelters near Palm Coast.


Employee A, LCSW, was interviewed on 7/30/2018 at 3:01 PM by phone. She was also reviewing the medical record and her notes for (Patient #1), the subject of the complaint. She confirmed that in her notes, she had no information documented related to her discussions with Patient #1 about options to be transported to the Coalition for the Homeless. Employee A, LCSW did confirm that she completed the psychosocial assessment for Patient #1 upon admission and documented that Patient #1 came from Orlando in April 2018 to this facility. He was discharged back to Aspire in Orlando. Employee A, LCSW, stated that if the patient was not from this area, we assumed that he wanted to return to the area he was familiar with. She read back her documentation at 3:03 PM. Employee A stated "The Social Worker's role was to give this individual information in the area; Volusia County does not have homeless shelters in the area; Palm Coast is in Flagler and Palm Coast has limited availability, and they only take patients who are registered and living in the county. We link the patient to the Homeless Coalition; so we tell them that we can transport the patient to the Homeless Coalition." She stated that she did not chart the conversation. Employee A, LCSW stated that she did not know where to send Patient #1 and he walked into the complainant's Emergency Room and the nurses up there called them. She told the staff that she gave him the list; that the patient still has to go to a community. Employee A stated that she should have gone back into the computer to chart this stuff after he left and when she got back. Employee A explained that it was on a weekend that he was discharged and discharges were hard on weekends. She stated that she spent a lot of time working with Patient #1 and that she was a therapist who also did discharges. Employee A stated the staff also tried to conduct discharges during the weekdays, not on the weekends.


A review of the Job Descriptions for the facility's Psychiatric Counselor, Job Code 65702, documents the following: "Responsible to Counselor Supervisor." Under Standards of Practice: Section E. Acts as liaison between patients, family members, staff and physicians. Assists patient, significant others and physicians in identifying health and resources needed to assure post-hospital care. Under Heading II, "Performs as an effective team member," section G. documents, "Coordinates Treatment Team meeting for multi-disciplinary staff. Reviews treatment plan with patient. H. Communicates with physician when utilization concerns are identified. I. Communicates utilization and discharge planning information with insurance/review companies as needed. Under section IV. titled, "Clinical Skills" documents the role of Psychiatric Counselor under section E. as "Designs and implements in collaboration with patient and significant others and physicians, a safe and effective Discharge Plan." Under section V. Point A. Completes documentation with efficiency and accuracy. Section G. Documents attempts for discharge planning (i.e. telephone contacts with family, placements and appropriate referral agencies)."


Employee C, Nurse Manager for Adult Inpatient Services was interviewed on 7/30/2018 at 3:45 PM and she confirmed that the expectation for all discharged patients from the units should include referrals to outpatient treatment, shelter, medical care or otherwise. There should be very clear documentation reflecting efforts to safely discharge patients from the units.


A review of the Adult Bio-physical Assessment for Patient #1 that was entered by Employee A, LCSW on 6/09/2018 at 8:19 AM read that "Patient #1 is a 47-year-old male that has no income, and was receiving Social Security disability insurance for Toretts', depression and anxiety, but has lost his benefits a while ago." The reason for admission for Patient #1 was under Baker Act; also documented that the patient stated that he was also homeless and currently in Palm Coast. He also stated that he really wished he had the medications he got here last time and also wanted them as he left the hospital, because he was unable to get them outpatient. Patient #1 stated that he was not ready or not in the condition to return to Ohio, and did not want help with relocating home. He hopes to return to the Palm Coast area, but really wanted a homeless shelter if there was one in the area of Palm Coast or St. Augustine.


A review of the Case Management note entered on 6/09/2018 at 10:20 AM also documented as Discharge Planning entered by Employee A, LCSW, revealed that Patient #1 currently resides Home; lives alone and under "Other current living arrangement, homeless." Case Management's initial evaluation comments, "Outpatient in Palm Coast/St. Augustine." There were no additional notes supporting efforts to provide the subject of this complaint with alternate discharge planning, including documented contact with Homeless Coalition or any other shelter arrangement.


Review of the medical record for Patient #1 revealed a documented discharge summary dated 6/09/2018 at 17:30 hours, documented under discharge comments: "D/C (discharge) to self. Given the homeless packet and medications to take with him. He was taken by taxi to Florida Hospital in Palm Coast per his request." This entry was documented by Employee B, RN.

A review of the facility provided "Authorization for Taxi" documented that Kings Transportation sent via fax, the return voucher on 7/30/2018 at 17:13 hours for Patient #1 to receive on 6/09/2018 a fare of 53.00 to 60 Memorial Medical Parkway, with the handwritten instruction reading "To Flagler Hospital, Palm Coast FL."


Interview with Employee A, LCSW, could provide no further evidence that the facility made an effort to provide for a discharge alternative for Patient #1; nor was there documented evidence revealing that Patient #1 refused all of the sending facility efforts to locate post-hospitalization placement, care and/or services.