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Based on review of facility policy, Notice of Patient Rights and Responsibilities, Medical Staff Rules and Regulations, medical record review, CHOICES (a State Medicaid program which includes nursing facility services and home and community-based services for adults 21 years of age and older with a physical disability and seniors, age 65 and older) Care Coordinator documentation, and interviews the facility failed to provide a safe discharge plan for 1 patient (Patient #1) of 4 patients reviewed.

The findings include:

Patient #1 who resided in hotels and was intermittently homeless, living in a tent at times with family presented to the Emergency Department (ED) by ambulance on 11/20/2022 with complaint of increased shortness of breath. The patient reported she had not been feeling well for the past few days and reported a dry cough and shortness of breath which worsened with exertion. Diagnostic testing was ordered and performed. Patient #1 was admitted to the Intensive Care Unit (ICU) with diagnoses including Sepsis (infection), Respiratory Distress (difficulty breathing), Pneumonia (lung infection), and Hypokalemia (decreased potassium). Patient #1 underwent a Cholecystectomy (removal of gall bladder) on 11/21/2022. The patient remained on the ventilator (breathing machine) until 11/28/2022. On 12/2/2022, Patient #1's CHOICES Care Coordinator spoke with the patient's ICU Case Manager regarding the patient's report of an attempted kidnapping that occurred prior to being hospitalized "...as well as unsafe discharge home as well as [Patient #1] agreeing to NF [nursing facility] placement for skilled nursing and LTC [long term care] placement..." The ICU Case Manager verbalized understanding and reported she would follow up with NF referral on Monday (12/5/2022). Adult Protective Services (APS) was also involved with the patient. Patient #1 was transferred to the Stepdown Unit on 12/3/2022, then transitioned to swing bed (term used to describe a hospital room that can switch from inpatient acute care status to skilled care status) status on 12/5/2022. Patient #1 was evaluated by Psychiatry and was deemed incompetent to make medical decisions on 12/15/2022. Patient #1 was readmitted as an inpatient due to vomiting on 1/29/2022. Patient #1 was re-evaluated by Psychiatry on 1/31/2023 and was deemed competent to make medical decisions. An upper endoscopy (procedure to examine the inside of the esophagus, stomach, and small intestine) was performed on 2/1/2023 and showed moderately severe esophagitis (inflammation of the esophagus). Psychiatry re-evaluated Patient #1 again on 2/8/2022 and determined she continued to be competent to make medical decisions. Discussions between Patient #1's CHOICES Care Coordinator and her hospital Case Manager regarding the patient's discharge plan occurred on 1/30/2022, 12/2/2022, 12/6/2022, 12/7/2022, 12/9/2022, 12/12/2022, 12/13/2022, 12/15/2022, 12/19/2022, 1/24/2023, and 1/27/2023. A discharge plan was in place to discharge the patient home with family on 2/9/2023. On 2/9/2023 the family informed the facility they could not take the patient home. The patient's hospital Case Manager was notified of the failed discharge plan the afternoon of 2/9/2023. Patient #1's CHOICES Care Coordinator was notified the patient was being discharged to a homeless shelter on 2/9/2023 at 4:07 PM. The CHOICES Care Coordinator and Care Coordinator Supervisor advised the Case Manager they were willing and able to assist with short term arrangements for Patient #1 but were told the patient's discharge could not be delayed. The investigation revealed the facility failed to arrange a safe alternate discharge plan and discharged Patient #1 to a homeless shelter on 2/9/2023 without reassessing the patient's needs. On 2/10/2023, Patient #1 experienced a fall at the homeless shelter and was transported to a different Acute Care Hospital where it was discovered the patient had an acute (new onset) Lumbar 3 (lower spine) Compression Fracture (a break caused by pressure). Patient #1 was admitted to the second hospital for treatment and was discharged to a Skilled Nursing facility (SNF).

Refer to A-0802.

Based on review of facility policy, Notice of Patient Rights and Responsibilities, Medical Staff Rules and Regulations, medical record review, CHOICES (a State Medicaid program which includes nursing facility services and home and community-based services for adults 21 years of age and older with a physical disability and seniors, age 65 and older) Care Coordinator documentation, and interview the facility failed to reassess 1 patient (Patient #1) after a failed discharge plan and prior to discharging the patient to a homeless shelter of 4 patients reviewed for discharge.

The findings include:

Review of the facility's policy "Discharge Planning Policy" revised 12/10/2019 showed "...All patients admitted to Tennova Healthcare will be assessed for discharge needs on admission and throughout his/her hospital stay. Discharge planning will address how the patient needs will be met as they move to the next level of care, treatment and services. This plan will be adjusted as needed throughout the patient's stay based on assessed needs and the desires of the patient/family...A complete patient assessment will be completed within 24 hours of admission to provide baseline date...Data collection sources include but are not limited to...Patient and family interviews...Current and historical medical record (internal and external when available)...Physicians, nurses, and other members of the health care team...Patient Components to consider when assessing patients and developing the plan of care: A. Physical...Age (High-Risk >65 or pediatric cases)...Admitting diagnoses...Functional capacity and ability to perform ADLS [Activities of Daily Living] safely...Medications...Nursing care/therapy needs...Exercise and activity tolerance...B. Emotional/Cognitive/Behavioral...Level of consciousness, orientation, memory, competence, judgement...Motivation and readiness for self-care...Learning ability...Presence of confusion, dementia, depression, anxiety...Coping mechanisms...C. Psychosocial...Adequacy of living arrangements/caregivers...Familial and social support systems...Availability of community resources..."

Review of the facility's policy "Case management High Risk Screening for Discharge Planning Procedure" revised 9/30/2022 showed "...PURPOSE: To identify inpatients at an early stage of hospitalization who may have high risk discharge planning needs necessitating case management intervention in order to minimize the likelihood of adverse health consequences upon discharge...The Case Manager will screen all applicable inpatients, on the day of admission (at a minimum within one working day of admission), for potential discharge planning needs, utilizing a High-Risk Screening tool ...The adult screening criteria to be used included the following...Age...Prior hospitalization...ED visit history...Health Barriers (those other conditions/situations that may impact health status, i.e. cognitive deficits, financial concerns, home/environmental issues...)...Medications...Principal diagnosis...Comorbidities...Functional Impairment...If the patient initially demonstrates a low risk score and then their medical/physical condition, family situation, or discharge plans change in the course of the hospital stay, case management will re-screen the patient and initiate a comprehensive discharge planning assessment..."

Review of the facility's policy "Case management Plan for Discharge Planning Policy" revised 9/30/2022 showed "...Case management will reassess the discharge planning process on an ongoing basis for those patients with identified needs. This may include a review of discharge plans to determine if the discharge plans meet the needs of patients..."

Review of the facility's Medical Staff Rules and Regulations, undated showed "...The discharge process and corresponding documentation shall provide for continuing care based on the patient's assessed needs at the time of discharge...If any questions as to the validity of discharge from the facility should arise, the subject shall be referred to the Physician Advisor or Chief of Staff or his/her designee for assistance..."

Medical record review of Emergency Department (ED) documentation showed Patient #1 presented by ambulance to the facility's ED on 11/20/2022 with complaint of increased shortness of breath. Patient #1 lived in a motel with her family. The patient received a medical screening exam on 11/20/2022 at 1:48 PM.
The patient's physical exam showed Patient #1 was tachycardic (fast heart rate) and she was tachypneic (breathing fast). She was in moderate respiratory distress (difficulty breathing) and her breath sounds had crackles scattered throughout the lungs and wheezing when she breathed out. Patient #1 was alert and oriented to person, place, time, and situation while in the ED. After a complete and thorough evaluation and treatment in the ED, Patient #1 was admitted to the facility's Intensive Care Unit (ICU) with diagnoses including Sepsis (infection), Respiratory Distress, Pneumonia (lung infection), and Hypokalemia (decreased potassium).

Medical record review of a history and physical dated 11/20/2022 at 4:41 PM showed Patient #1 presented to the facility's ED after experiencing shortness of breath, cough, and fever for 2 weeks. The history and physical documented the patient was a very poor historian. The patient also complained of abdominal pain "...that is generalized, she thinks is just the muscles from 'coughing' but again is very poor historian is difficult on her exam to evaluate what is actually hurting..." The patient reported she used oxygen at home 3-4 liters but only when she needed it. The patient reported she had a seizure disorder and Chronic Obstructive Pulmonary Disease (COPD) but could not remember any other medical history. A stat (immediately) Computed Tomography Angiogram (CTA-a detailed x-ray using a special dye to produce pictures of blood vessels and tissues) was ordered and general surgery was consulted related to the patient's abdominal pain. Patient #1 was admitted to the facility with diagnoses including Sepsis with Acute (sudden onset) Hypoxic (decreased oxygen) Respiratory Failure, Acute Abdominal (stomach) Pain, Pneumonia, COPD, Electrolyte Depletion, Seizure Disorder, and Sinus Tachycardia. The discharge plans were pending clinical course.

Medical record review showed Patient #1 was in the Intensive Care Unit (ICU) from 11/20/2022-12/3/2022.

Medical record review of an Operative Report showed Patient #1 had Cholecystectomy (gall bladder removed) on 11/21/2022. Due to her underlying pulmonary (breathing) issues, she was unable to be weaned from the ventilator (breathing machine) and was taken to the ICU still ventilated.

Medical record review of a Hospitalist (a physician who only works inside a hospital) Note showed the ventilator was removed from Patient #1 on 11/28/2022.

Review of CHOICES Care Coordinator documentation dated 11/30/2022 at 2:31 PM showed Patient #1's daughter spoke with the CHOICES Care Coordinator and notified her of the patient's hospitalization. The CHOICES Care Coordinator contacted the facility's ICU Case Manager who reported Patient #1 had been removed from the ventilator the previous day (11/29/2022) and continued to have supplemental oxygen. The patient remained critically ill. The discharge plan at the time was to discharge Patient #1 to a rehabilitation hospital or a skilled nursing facility. The ICU Case Manager was encouraged to communicate with the CHOICES Care Coordinator regarding Patient #1's progress and for assistance with discharge planning for the patient.

Review of CHOICES Care Coordinator documentation dated 12/2/2022 (no time) showed Patient #1 needed additional "...skilled therapy at a nursing facility which is currently in the process for potential discharge on Monday [12/5/2022]..." The CHOICES Care Coordinator spoke with Patient #1's ICU Case Manager regarding the patient's report of an attempted kidnapping that occurred a few months prior "...as well as unsafe discharge home as well as member [Patient #1] agreeing to NF [nursing facility] placement for skilled nursing and LTC [long term care] placement..." The ICU Case Manager verbalized understanding and reported she would follow up with NF referral on Monday (12/5/2022).

Medical record review showed Patient #1 was transferred from the ICU to the Stepdown Unit on 12/3/2022.

Medical record review of a Discharge Summary (from inpatient status) dated 12/5/2022 showed Patient #1 transferred from the ICU to an inpatient unit where the patient worked with physical therapy but remained extremely weak "...Once stable the patient would like to go home but she is really too weak to be able to do well at home. I discussed with patient regarding skilled nursing facility and she and her daughter are willing to go that route. She is being discharged to swing bed [a hospital room that can switch from inpatient acute care status to skilled care status] for continuation of physical therapy due to significant weakness while awaiting skilled nursing facility approval..." The patient was transitioned to swing bed status on 12/5/2022.

Review of CHOICES Care Coordinator documentation dated 12/6/2022 showed the CHOICES Care Coordinator and facility Case Manager had discussed Patient #1's inpatient stay as well as discharge planning. Patient #1 had selected to transition to swing bed status at the facility. The CHOICES Care Coordinator requested the patient's history and physical as well as therapy notes.

Medical record review of a hand-written Social Worker progress note dated 12/7/2022 at 1:28 PM showed the Case Manager was working with Patient #1's Blue Care CHOICES Care Coordinator to place the patient in a skilled nursing facility for transition to long-term care. The CHOICES Care Coordinator was to submit a Preadmission Screening and Resident Review (PASRR-federal requirement to help ensure that individuals are not inappropriately placed in nursing homes) for Preadmission Evaluation (PAE) approval. Adult Protective Services (APS) had notified the Case Manager there was an open case for Patient #1 due to the patient's living situation.

Review of CHOICES Care Coordinator documentation dated 12/8/2022 (no time) showed Patient #1's case was discussed with APS. APS and law enforcement planned to visit Patient #1 on 12/9/2022 regarding the APS referral. The CHOICES Care Coordinator also spoke with the ICU Case Manager regarding the previous request for the patient's history and physical and therapy notes.

Review of CHOICES Care Coordinator documentation dated 12/9/2022 (no time) showed the CHOICES Care Coordinator, APS worker, and law enforcement met with Patient #1 in the patient's room. The patient informed them she had now decided she wanted to be "...discharged back to the motel with her daughter...and daughter's significant other..." The police officer verbalized his concerns with Patient #1 regarding her not receiving the appropriate care but the patient continued to decline placement at a skilled nursing facility and long-term care placement. When asked, Patient #1 was unable to provide the year nor the name of the current hospital where she was admitted. The CHOICES Care Coordinator, APS worker, and officer spoke with Patient #1's Case Manager regarding the patient's cognitive deficit. APS requested that Patient #1 have a psychiatric evaluation to determine if the patient was competent to make safe decisions independently. The CHOICES Care Coordinator voiced concerns with unsafe discharge home with the patient's daughter.

Medical record review of a Case Manager (CM) Note dated 12/9/2022 at 3:22 PM showed Patient #1 had an APS worker due to the patient's living situation and concerns with the patient's daughter. On the morning of 12/9/2022, the CM had spoken with APS, a detective with the police department, and the patient's CHOICES Care Coordinator who reported Patient #1 was refusing placement at a Skilled Nursing Facility (SNF). The CM had requested a psychiatric consult to determine the patient's mental status and ability to make decisions.

Medical record review of a Hospitalists Note dated 12/9/2022 showed Patient #1 refused to go to a skilled nursing facility because her family could take care of her "...We discussed that given her current condition, her family would have to be willing to complete most tasks for her. She was encouraged to call them to make arrangements for discharge mid next week. We became aware today that APS is involved with her case but [Patient #1] claims she did not know either and does not know why..."

Medical record review of a Psychiatry Consultation Note dated 12/15/2022 at 1:38 PM showed Patient #1 was evaluated for her competency to make medical decisions. The patient had been noted to be "...very slow in her responses, often very somnolent [drowsy], often seeming confused during this admission. She is also recently refused transfer to a rehab facility despite the fact that there is no other practical disposition available..." The examination showed the patient was lying in bed with very little spontaneous movement. "...Patient's IQ was estimated to be borderline normal range but this is very difficult because she has severe psychomotor slowing. The most striking aspect of her mental state is that she has very little emotional expression at all and when she is asked a question she stares at the examiner for long periods of time before responding...The patient is not oriented in space and when I push her about where she lives she eventually says she lives here in this building but she does not know what this building has..." The patient was unable to tell the physician the date or month. "...She is not able to tell me why she is in the hospital and she really was not able to tell me what was done when she had her surgery. Insight and judgment are quite poor...Based on the patient's extremely poor memory and severe psychomotor slowing, she does not have the capacity to make medical decisions at this time. She does not understand that she is in the hospital and cannot tell me why she is here or what her operation entailed..." The documented diagnoses based on Patient #1's evaluation included Major Depression and Probable Dementia, type unknown.

Review of CHOICES Care Coordinator documentation dated 12/15/2022 (no time) showed the facility's Case Manager notified the CHOICES Care Coordinator the psychiatric physician had documented that Patient #1 did not have the capacity to make "...safe/sound decisions..." and APS had been contacted to obtain surrogate information.

Medical record review of a CM note dated 12/16/2022, not timed, showed Patient #1 had been deemed incompetent by a psychiatrist. "...She was refusing placement but now must go to a SNF because she is unable to care for herself. Updates sent to SNF and additional facilities applied to today. CM following..."

Medical record review of a CM note dated 12/19/2022 at 1:50 PM showed the CM was working on an application for public guardianship "...as patient [Patient #1] is unable to make decisions for herself and daughter is not safe to make decisions for patient..." Updates were given to Patient #1's APS worker and her CHOICES Care Coordinator.

Medical record review of a Social Services Note dated 12/20/2022 at 2:44 PM showed the Social Worker/Case Manager spoke with the Assistant to the Public Guardian for East Tennessee Region on 12/19/2022 regarding possible conservatorship/public guardianship application for Patient #1. The Social Worker/Case Manager was made aware that Patient #1 did not meet the age requirement, but she may qualify for a court-appointed guardian. The Social Worker/Case Manager was working on the application for a public guardian with the assistance of Patient #1's CHOICES Care Coordinator and APS.

Medical record review of a CM note dated 1/6/2023 at 9:20 AM showed Patient #1 "...has been deemed incapable for making safe/informed medical decisions by psychiatry, per APS patient's daughter is not safe to make decisions for patient. CM working diligently on state appointed guardianship for patient, however complicated due to patient's age. CM following..."

Medical record review of a CM note dated 1/23/2023, not timed showed Patient #1 was asking to go home "...but she is homeless and was going between staying in a motel and in a tent in the woods PTA [prior to arrival]. She does not have a safe place or person to be released to. State process continues..."

Medical record review of a Discharge Summary (from swing bed) dated 1/29/2023 at 2:38 PM showed Patient #1 had to be readmitted as inpatient status for further evaluation of nausea and vomiting.

Medical record review of a CM note dated 1/30/2023, not timed, showed the process continued for state guardianship and Patient #1 remained incompetent of making decisions and was not safe for discharge.

Medical record review of a Psychiatry Progress Note dated 1/31/2023 (16 days after Patient #1's initial psychiatric evaluation) showed the patient was "...much improved. The severe psychomotor slowing that was present the past is almost completely resolved. Patient may have some minor memory difficulties. She cannot think of the name of the president and she has difficulty getting numbers, but she is quite coherent..." The patient had no difficulty telling the physician about her living situation or the names of her family members. Patient #1 reported her daughter would be responsible for her when she was not able to make her own decisions. "...Patient [Patient #1] is fully oriented and the recent and remote memory are largely intact. She understands the nature of her condition, the nature of the proposed intervention, and, to a reasonable...extent the risks and benefits involved. At this point in my opinion the patient certainly does have the capacity to make medical decisions on her own behalf..."

Medical record review of an Inpatient Physical Therapy (PT) Evaluation dated 2/3/2023 (6 days prior to discharge) at 12:34 PM showed Patient #1 had been evaluated for transfers/mobility and was assessed as modified independence (requires an assistive device or aid but does not require physical assistance) for moving from lying on back to sitting, sitting to laying down, scooting, and walking. Patient #1 required use of bed rails for bed mobility and bedrail/arm rest for transfer into a bedside chair. She was able to ambulate 150 feet using a rolling walker. The evaluation indicated Patient #1 did not require skilled acute PT interventions at the time of the evaluation. Discharge planning showed "...Equipment Anticipated or Recommended: Rolling walker 2 wheels. Recommended Discharge Location: Home with home health..."

Medical record review of a CM note dated 2/6/2023, not timed, showed Patient #1 was re-evaluated by Psychiatric services and showed "...that she is much improved and is now competent to make her own medical decisions. Need to have discussion with team about new plan for d/c [discharge], since appointing a guardian was only happening because she was not competent to make her own decisions and care for herself..."

Medical record review of a Psychiatry Progress Note showed Patient #1 was re-evaluated on 2/8/2023. The patient was "...fully alert and her speech is fluent and coherent...She is cognitively intact. Insight and judgment are adequate..."

Medical record review of a CM note dated 2/8/2023 showed "...[Patient #1] can d/c today. Trying to reach daughter so that we can get their new address to arrange Lyft for patient to go to her house. Left message..."

Medical record review of a Hospitalist Progress Note dated 2/8/2023 at 9:20 PM showed the hospitalist had discharged the patient "...but due to family issues, she ended up not leaving. Apparently, her daughter and daughter's husband/fiancé are currently living with his aunt as an apartment is being renovated. Case management is working on getting her discharge, hopefully to the same location, as she used to live in a tent or hotel..."

Medical record review of Activities of Daily Living flow sheets from 1/29/2023-2/9/2023, showed Patient #1 was at high risk for falls with injury.

Medical record review of Psychosocial Assessment flow sheets from 1/29/2023-2/9/2023, showed Patient #1 was alert and oriented times 4, with the exceptions of 1/29/2023 at 8:00 PM; 2/1/2023 at 11:05 AM and 10:39 PM; and 2/2/2023 at 8:35 AM, where Patient #1 was disoriented to time only, and 2/3/2023 at 9:51 AM and 7:40 PM, where Patient #1 was disoriented to time and situation. During all these reviewed date ranges her mood and behaviors were calm and appropriate.

Medical record review of a nursing note dated 2/9/2023 at 12:00 PM showed Patient #1 and the patient's daughter agreed the patient would go to the daughter's boyfriend's aunt's house for discharge at 9:00 AM on 2/9/2023. The patient's daughter left for a doctor's appointment at 11:00 AM and then returned requesting to speak with nursing administration. "...Team leader an [and] 4th floor director notified. Team leader spoke with daughter whom refused to take patient with her for discharge. Case manager, security, and house supervisor then spoke with patient and her daughter. It was then agreed that patient would be taken to [named homeless shelter]..."

Review of CHOICES Care Coordinator documentation dated 2/9/2023 showed "...Incoming contact received on Thursday 2/9/2023 at 4:07 PM from Case Manager...informing CC [Care Coordinator] that [Patient #1] is being discharged to the homeless shelter with a...ride scheduled for pickup within 4 minutes. CC questioned CM...regarding the inappropriate discharge planning with [CM] informing CC that [Patient #1] was re-evaluated last week by Psychiatrist and deemed competent. CC questions the timeline of evaluations for incompetent to now competent with [CM] informing CC that she was unable to continue [Patient #1's] admission. [CM] informs CC that discharge plan was attempted with [Patient #1] to be discharged with daughter...however at time of discharge [Patient #1's] daughter had left the facility reporting that she was not able to provide care for [Patient #1] at her current location this being the reason of discharging [Patient #1] to the homeless shelter. CM informs CC that member is up in her room with her walker at times and then noncompliant with her walker at times. CC questions [CM] if APS rep [representative]...has been made aware of the newly discharge plan with [CM] informing CC that APS has not been notified...CC 3 way called [CM] at [named facility] with Blue Care CHOICES Supervisor regarding the situation of poor discharge planning. CC and CCS [Care Coordinator Supervisor] advised [CM] that CC is able and willing to assist with short term stay however [CM] reports that she is unable to delay [Patient #1's] discharge. CC informs [CM] of the current Quality of Care Concern with CCS reaching out to the hospital CNO [Chief Nursing Officer]...leaving a voicemail requesting a return call back for discussion of inappropriate discharge..." The CHOICES Care Coordinator also notified Patient #1's APS worker of the inappropriate discharge. The APS worker reported she was not informed of Patient #1's re-evaluation and questioned the timeline of results.

Review of CHOICES Care Coordinator documentation dated 2/10/2023 (no time) showed Patient #1's daughter notified the CC that she had "...received a call from the shelter informing her that her mother was admitted to the shelter last night and has fallen this am [morning]. [Patient #1's daughter] informs CC that an ambulance has been called and is currently transporting [Patient #1] to [named hospital] for evaluation...CC has encouraged [Patient #1's daughter] to reconsider NF placement to ensure of [Patient #1's] safety and care that is needed to prevent further harm, decline or even death. CC encourages daughter to assist with appropriate discharge planning for her mother as her mother's needs are unmet at this time and that [Patient #1] is not safe..."

Medical record review showed no documentation to indicate Patient #1's discharge needs were reassessed before the patient was discharged to the homeless shelter.

Review of an Emergency Medical Services (EMS) Patient Care Report showed EMS was dispatched to the homeless shelter for a fall with injury on 2/10/2023 at 8:21 AM. EMS arrived on scene at 8:34 AM and found Patient #1 in a bathroom stall on the floor. The patient reported she became dizzy and fell and lost consciousness when she hit her head. Patient #1 complained of back pain with a documented pain level of 10/10 (scale of 0-10, with 10 being the worst possible pain). The patient was transported to another hospital's ED (Facility B).

Medical record review of Facility B's hospital ED Physician Documentation showed Patient #1 presented to the ED on 2/10/2023. The patient reported she lost consciousness when she fell the morning of 2/10/2023. The patient reported pain in her tailbone and back. A Computed Tomography (CT) (detailed x-ray) scan of the head and brain was performed and showed no acute intracranial findings. A CT of the Cervical spine (neck) showed no cervical spine fracture. A CT scan of the Lumbar Spine (lower back) was performed on 2/10/2023 at 3:28 PM and showed an acute (new onset) Lumbar 3 (middle of the five lumbar vertebrae in the lower back portion of the spinal column) Vertebral Compression Fracture (break caused by pressure). Medical Decision Making showed "...Patient presentation...Pt [patient] reports h/o [history of] falls, most recently this morning as she was walking to the bathroom at [named homeless shelter]. Pt is not a great historian and appears slightly confused...Case discussed with ER [emergency room] case manager. She has been in communication with APS and BlueCare [CHOICES] case manager. They are attempting to place pt in SNF [skilled nursing facility] emergently today. She was just discharged from [Facility A] yesterday after a 3 month stay...Pt has known h/o L1 [top section of lower spine] compression fx [fracture]. L3 compression fracture appears acute per radiology reports..." Patient #1 was admitted to Facility B with diagnoses including Pneumonia, Compression Fracture of L3 Vertebra, and Generalized Weakness.

During an interview on 2/13/2023 at 3:55 PM, in the conference room, CM #1 stated Patient #1 was homeless, living in tents and motel rooms prior to being hospitalized. CM #1 stated the patient had been deemed incompetent to make medical decisions earlier in the admission and confirmed a CHOICES Case Worker and APS were involved with the patient. The plan was to get a state appointed guardian with the hope that she would be able to have safe housing and resources. CM #1 reported the patient's mental status improved, she was doing well, and wanted to go home. At some point, the patient was re-evaluated and it was determined she was competent and could make her own decisions. CM #1 stated the plan for guardianship "...went away..." when she could make decisions for herself. CM #1 stated she explained to Patient #1 and her daughter that Patient #1 would have to be discharged to a homeless shelter if she was unable to live with family. She reported a skilled nursing facility would not accept the patient because there was not a discharge plan.

During a telephone interview on 2/14/2023 at 10:30 AM, Registered Nurse (RN) #1 stated she recalled Patient #1 was supposed to be discharged the day before (2/8/2023) she was actually discharged because her family could pick her up the next day (2/9/2023). RN #1 stated Patient #1 had been told if she was not able to stay with family she would have to be discharged to the homeless shelter. RN #1 stated Patient #1 expressed a lot of anxiety about going to the shelter.

During a telephone interview on 2/15/2023 at 8:38 AM, the CHOICES Supervisor stated the CHOICES program had been working on securing SNF placement for Patient #1 prior to the patient's hospitalization. She reported Patient #1 was a vulnerable adult who had not been in a safe place. The CHOICES Supervisor stated the process for SNF placement was put on hold when the patient was deemed incompetent and waiting on conservatorship. The hospital CM notified Patient #1's CHOICES Care Coordinator the patient was being discharged to a shelter 15 minutes before the patient's transportation arrived. The CHOICES Supervisor reported the hospital CM told her there was nothing she could do about the patient's discharge. The CHOICES Supervisor stated Patient #1 was still at the hospital but had already been discharged and was waiting on transportation. The CHOICES Supervisor stated she told the CM if they would give them until the next day they would be able to secure short-term placement for the patient. The supervisor stated she and the patient's Care Coordinator called the facility back at 4:30 PM but the patient was already gone. The CHOICES Supervisor stated the Care Coordinator received a call the following morning from Patient #1's daughter who reported the patient had fallen and was being taken to another hospital. The supervisor stated they had secured placement for Patient #1 at a nursing facility by Friday evening (2/10/2023). The supervisor stated "...We could have moved forward with placement if they [facility] had called the first day she was deemed competent..."

During a telephone interview on 2/15/2023 at 9:40 AM, Patient #1's CHOICES Care Coordinator stated Patient #1 was homeless and had been living in hotels and tents with her daughter. She reported APS was involved with the patient due to concern for financial exploitation. The Care Coordinator stated Patient #1 had been deemed incompetent. The Care Coordinator told CM #2 she could not do anything until a conservator for the patient was designated and asked the facility's case manager to keep her informed. On 2/9/2023 at 4:08 PM, the CHOICES Care Coordinator received a call from CM #1 "...she was in tears..." because she was having to discharge the patient and that her hands were tied because Patient #1 had been deemed competent to make decisions. CM #1 told the CHOICES Care Coordinator she had to discharge Patient #1 to a shelter and transportation had been called for the patient. The CHOICES Care Coordinator asked CM #1 when transportation would be arriving and was told in 4 minutes. The CHOICES Care Coordinator told CM #1 she could do a short term stay the next day and asked her to please keep Patient #1 until the next day so she could make arrangements. The CHOICES Care Coordinator stated if she had been notified that Patient #1 had been deemed competent, she "...could have gone straight to the hospital and spoken with the patient and the patient's daughter and given them the option of a SNF for short term placement..." Patient #1's daughter called the CHOICES Care Coordinator the morning after the patient was discharged and informed her Patient #1 had fallen and was being transported to another hospital.

During a telephone interview on 2/15/2023 at 11:33 AM, CM #1 (with CM #2 present) stated she did not think there was anything she could do since the plan was for the patient to be discharged with her daughter and the daughter told her she had housing that would be available soon. She and the patient were going to be living with family until then. On the morning of discharge, Patient #1's daughter told the facility she would be back after lunch to pick up her mother. When she returned, she informed the staff she could not take Patient #1 home with her. CM #1 stated she was on the phone with the CHOICES Care Coordinator when transportation arrived to pick up Patient #1 to take her to the shelter. CM #1 stated she quickly "...Googled...tried to look for resources closer to Claiborne County..." so the patient could be closer to her daughter, but she could not locate anything. CM #1 stated she did not talk to anyone about postponing Patient #1's discharge because she had been medically stable and ready for discharge. CM #1 reported the patient's CHOICES Care Coordinator had said she might be able to arrange emergency placement for the patient but did not specifically ask her to hold the patient another day. CM #1 stated "...can't hold [discharge] for 3 days when CHOICES and APS has had 3 months to work on placement..." CM #1 stated she told the patient's physician what was going on but did not ask her to delay the patient's discharge. When asked why Patient #1 was not placed back to a swing bed until placement was arranged, CM #1 stated the patient did not meet criteria for swi