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FROEDTERT MEMORIAL LUTHERAN HOSPITAL 9200 W WISCONSIN AVE MILWAUKEE, WI 53226 April 6, 2017
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on record review and interview, staff failed to ensure that all patients have a discharge plan that provides for a safe and appropriate discharge destination and meets the needs of the patient in 1 of 10 medical records reviewed (Patient 1).

Findings include:

Staff failed to provide referrals to pertinent communty resources to assist with post discharge needs and develop a discharge plan in coordination with family/support persons to ensure a safe and appropriate discharge plan and destination. See tag A820.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, staff failed to ensure all patients have a discharge plan that provides for a safe and appropriate discharge destination and meets the needs of the patient in 1 of 10 medical records reviewed (Patient #1). This could potentially impact all 589 patients currently on census at this hospital.

Findings include:

Review of Policy titled, "Discharge Planning, Homeless Shelter Referrals" last reviewed 7/19/2016 states the following:
-The Social Worker will provide education about community resources available to the homeless. Written list of emergency housing resources will be provided upon request.
-Options with family, friends, or other informal supports will be identified.
-Patient will be assessed for appropriateness of shelter care based on medical diagnosis
-Resources will be provided to patients who are in need of contacts for transitional or permanent housing assistance
-The Social Worker will initiate contact with community homeless shelters, if there are medical needs, directly to identify bed availability
-If no medical needs are identified, Social Worker will assist patient with contacting 211 for available housing resources.
-Once a discharge plan has been formulated, the social worker will assist to coordinate appropriate transportation to the identified address

Review of Policy titled, "Discharge Planning in the Inpatient and Emergency Environments" last reviewed 7/22/2016 states the following,
-A discharge plan is developed in collaboration with the patient and/or advocate, the multidisciplinary team and appropriate community agencies. As part of the planning process, options for post-hospital care are presented to the patient and/or advocate by providing a choice letter. These options may include community agency services. Once an option is selected by the patient, a minimum of 2 to 3 facilities/providers is presented. The discharge plan is communicated to the members of the multidisciplinary team and the patient. The discharge plan is documented in the patient's medical record. Supportive counseling is provided by the Social Worker/case manager to facilitate patient adjustment to the discharge plan.

Record Review 4/6/2017:

Review at 11:25 am of Patient 1's medical records showed Patient 1 arrived in the Emergency Department on 3/4/2017 after being hit by a car while walking across the street. Patient 1 was admitted to an inpatient floor of the hospital on [DATE] at 10:30 am and discharged on [DATE] at approximately 4:20 PM. Per Patient 1's Orthopaedic Surgery Discharge Summary signed by Physician "I" on 3/9/2017, the "Discharge Diagnosis" is listed as right calcaneus fracture and left tibial plateau fracture. According to the Discharge Summary Medical Updates, "no acute surgical intervention warranted for these injuries. Patient will follow up as an outpatient to further determine surgical date for fixation".

Per review at 11:45 am of Patient 1's care plan notes from Occupational Therapy dated 3/6/17 and 3/7/17, Patient 1 is nonweight-bearing on bilateral lower extremities. "Anticipated D/C (discharge) disposition" is listed as "Home with assist". Functional effects of deficits/limitations is listed as "Decreased independence with ADL (activities of daily living) tasks/transfers, activity tolerance/strength, ROM (range of motion), increased pain." Anticipated equipment needs at discharge is listed as "bedside commode, transfer board, tub bench, wheelchair, wheelchair seat cushion". Occupational Therapy notes state, "(Patient 1) is homeless. Prior to admission (Patient 1) was independent with ADL. (Patient 1) Reports prior level of mobility was independent in community without assistive device".

Review at 12:00 pm of Case Manager "F" Discharge Planning notes reveal the following:

3/7/17 12:20 pm: Case Manager "F" met with patient 1 to discuss potential for SAR (subacute rehabilitation facility) or respite care. Patient 1 was made aware that Patient 1 is functioning independently at wheelchair level and will be at this level for sometime as Patient 1 will be nonweight bearing on bilateral lower extremities for "several months". Per "F's" notes, Patient 1 understands that Patient 1 could contact Salvation Army Respite, Patient 1 reports that Patient 1 chooses not to because of the work Patient 1 does with the homeless.

3/7/17 2:45 pm: "F's" case manager notes state Patient 1 understands not being able to discharge to subacute rehab facility as Patient 1 is functioning independently at wheelchair level of care. Per "F's" case manager notes, Patient 1 reports making phone calls to several Extended Stay hotels in the area. Patient 1 reports planning to call daughter in California in effort to obtain credit card information to pay for room.

3/8/17 8:03 am: "F's" case manager notes state "F" reiterated to Patient 1 that discharge orders were in place yesterday. Per notes, Patient 1 reports daughter in California never contacted Patient 1 and a group of friends are collecting donations to assist Patient 1 in finding a place to stay. Patient 1 suggests that friends are making it sound like Patient 1 is being "thrown out". Per "F's" notes, Patient 1 would like to consider transfer to a different acute hospital facility as it would be in network for Patient 1. Per "F's" addendum note, "F" made phone call to Patient 1's insurance companies utilization review nurse requesting additional information with regard to the discharge process, utilization review nurse reported contacting supervisor about this situation and will follow up with "F" later in the morning.

3/8/17 3:54 pm: "F's" case manager notes state "F" contacted Patient 1's insurance company and was informed Patient 1 has no Custodial Care benefits available and Patient could disenroll in current insurance plan and then enroll in different plan that may get Patient 1 approval for a skilled nursing facility. "F" attempted to contact Ombudsman and was unable to speak to representative. "F" then contacted the Salvation Army Respite and was told the Salvation Army was at capacity and Patient 1 would have to call #211 for referral.

No other case manager discharge planning notes documented in regards to finding Patient 1 placement after discharge.

On 3/8/17 at 4:43 pm, Registered Nurse "J's" Discharge Note states, "(Patient 1) discharged to front of hospital lobby accompanied by security." "Patient was escorted out by security with all belongings."

Review at 12:30 pm of "Safety/Security, Refusal to Leave" security incident report dated 3/8/2017 at 4:17 pm states the following, "This report concerns an eviction on (floor #) in which the patient (Patient 1) refused to leave (acute care hospital) event though (Patient 1) had been discharged yesterday". Per security incident report, officers informed Patient 1 "(Patient 1) was going to be evicted from (Patient 1's) room today."; "(Patient 1) began telling us that (Patient 1) had nowhere to go..."

Interview on 4/6/17 at 2:45 pm with Director of Security "H" revealed 3 officers escorted Patient 1 out of hospital room because Patient 1 refused to leave room after being medically discharged by staff. "H" asked why Patient 1 refused to leave hospital and "H" responded Patient 1 stated he had "no place to go." Per "H" Patient 1 was being cooperative.

Per interview on 4/6/17 beginning at 1:50 pm with Case Manager "F", when asked what Patient 1's plan was for discharge, "F" responded, "I did not know what (Patient 1's) plans were, (Patient 1) had plenty of time to make arrangements." When "F" was asked where Patient 1 was going and who was going to assist Patient 1 at home, "F" responded "I don't know, (Patient 1) had no address to give". Per "F" Patient was given "many options" for discharge but refused all of them. When "F" was asked what options were given to Patient 1 for homeless shelters, "F" stated that with Patient 1's injuries there was only 1 option for homeless shelters which was the Salvation Army Respite. Per "F" patient refused this option, however "F's" case manager notes on 3/8/17 at 3:54 pm state that Salvation Army was full to capacity ("F" confirmed this during interview). Per "F" the other options for Patient 1 was the Extended Stay hotel and family and friends. Per "F" no other options for living arrangements and assistance at home were provided to Patient 1. When asked why Patient 1 was removed by security, "F" responded "I don't know, once security is involved I am out of it". "F" was asked had "F" ever attempted to contact any family and/or friends to establish a plan for discharge, and "F" responded "no". When asked had "F" assisted Patient 1 in contacting #211 to identify any other potential community resources available to Patient 1, "F" responded "no". When "F" was asked if transportation was arranged for Patient 1, "F" responded "No, there was no address given."

"F" was unable to provide any documentation or evidence that staff assisted Patient 1 in finding a safe discharge destination and home with assistance based on injuries sustained.