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Based on interviews and document review, the facility failed to arrange for immediate post discharge needs for 1 of 2 homeless patients discharged to the streets (Patient #3).

This failure resulted in the patient returning to the emergency room the same day.

Findings include:

Policy:

According to the policy, Discharge Planning, the Care Coordination staff is responsible for providing resources based on a continuum of care needs. The patient, physicians and health care team are informed of changes in the discharge plan. The patient will receive discharge education related to the discharge plan in preparation of post-hospital care.

1. The facility failed to ensure Patient #3 had supplies available for immediate post-hospital needs and was able to manage his ileostomy post discharge.

a. Review of Patient #3's medical record revealed he was admitted on 11/28/17. According to the emergency department note, dictated by Physician Assistant (PA) #10 on 11/28/17 at 9:36 p.m., the patient was admitted with a diagnosis of acute kidney injury (sudden inability for kidneys to filter waste from the body and can cause confusion), dehydration (the body doesn't have enough fluids to carry out its normal functions) and alcohol intoxication (impaired condition caused by alcohol). PA #10 also documented the patient had an ileostomy (an artificial opening in the abdominal wall where stool was excreted) that was oozing stool and had no bag attached. PA #10 documented that Patient #3 had been seen in the emergency department on 10/12/17 and 11/27/17 for alcoholism and had significant social issues that needed to be addressed by social work.

On 11/28/17 at 8:27 p.m., Registered Nurse (RN) #11 documented in the emergency department triage note. RN #11 documented the patient had requested ostomy supplies while in the emergency room.

b. On 11/29/17 at 9:34 a.m., Occupational Therapist (OT) #13 documented an occupational therapy visit in the progress notes. OT #13 recommended the patient be discharged to a sub acute facility because the patient was not able to care for himself or his ostomy.

c. On 11/30/17 at 10:22 a.m., RN #12 documented a wound ostomy visit in the consult notes. RN #12 documented she cleansed the ostomy and applied a new bag. There was no documentation of the patient's ability to care for his ostomy or that teaching occurred. RN #10 also documented that Patient #3 would need assistance obtaining his ostomy supplies from the hotel that was holding his belongings.

d. LPC (Licensed Professional Counselor) #5 documented a care coordination note on 11/29/17 at 12:02 p.m. LPC #5 documented the patient was given the phone number of the hotel he was evicted from and was instructed to call staff to figure out what he needs to do to reclaim his possessions. LPC #5 also documented the patient was a poor historian and information the patient gave to the LPC conflicted with information in the electronic health record.

According to the discharge information, Patient #3 was discharged at 1:34 p.m., on 11/30/17. The was no documentation the patient was assessed for his ability to care for his ileostomy or if he was able to contact someone and retrieve his possessions.

e. On 1/31/18 at 9:35 am., an interview with LPC #1 was conducted. LPC #1 stated she received referrals to address complicated discharges and community resource help when a patient was admitted that lived alone, had no family or was homeless. LPC #1 stated it was the responsibility of the entire hospital team, that consisted of the case manager, doctors, physical therapy, occupational therapy and nurses to make sure Patient #3 had everything he needed prior to discharge. LPC #1 stated the patient had a Medicaid Accountability Care Collaboration (MACC) worker who could assist the patient with ostomy supplies, medical appointments and needs outside the hospital.

However, in an interview with the Manager of Community Health Improvement (Manager #2), on 1/31/18 at 2:05 p.m., he stated discharge planning was an inpatient process and the MACC worker role was as an outpatient community resource. Manager #2 reported the MACC was not a crisis response team, and the earliest they would have been able to see the patient would have been the next business day. Manager #2 further stated he would try to get the patient with an ostomy into a skilled nursing facility as he was homeless and skilled nurses did not make home health visits to homeless shelters.

f. On 1/31/18 at 2:20 p.m., an interview with the Manager of Social Work Department (Manager #3) was conducted. Manager #3 reviewed Patient #3's medical record and stated the patient did not have a good discharge plan if he did not have his supplies. Manager #3 stated she would have called the hotel to see if the patient could get his ostomy supplies and assisted the patient with supplies until he was able to obtain his. Manager #3 stated the wound care nurse could have provided immediate supplies for the patient prior to discharge.

g. Subsequently, Patient #3 returned to the emergency department on 11/30/17 at 6:35 p.m., 5 hours after being discharged. On 11/30/17 at 8:15 p.m., Licensed Clinical Social Worker (LCSW) #6 documented in the progress notes the patient was sent to the emergency room from the homeless shelter due to his inability to manage his ostomy bag and that presented a health hazard. LCSW #6 recorded the patient asked for assistance with a place to stay, but the hospital was unable to provide a free place to stay or other shelter. LCSW #6 documented the patient stated he wanted to go to a discount store to purchase needed items and LCSW #6 arranged for a taxi to take him there.

There was no documentation the facility evaluated the patient's ability to manage his ileostomy prior to discharge.

h. In the same interview with Manager #3, on 1/31/18 at 2:20 p.m., Patient #3's return visit to emergency room on 11/30/17 was reviewed. Manager #3 acknowledged LCSW #6 did not address the patient's ostomy supply issue or whether he could manage it.