HospitalInspections.org

Based on interview and record review, the hospital failed to ensure an emergency medical condition was stabilized prior to discharge for two of 20 sampled patients, Patient 3 and Patient 4 when:

1. Patient (Pt) 3 came to the Emergency Department (ED) on 3/10/24, with a chief complaint of "Alcohol Withdrawal, had tachycardia (high heart rate) and received Chlordiazepoxide (a medication used to treat anxiety, insomnia and symptoms of withdrawal from alcohol and Lorazepam (medication to treat anxiety and sleeping problems that are related to anxiety) when her blood alcohol level was 212.50 mg/dL., and was prescribed Chlordiazepoxide for home use. Pt 3 was discharged two hours later by herself still tachycardic and without being evaluated to ensure she was functionally stable prior to discharge.

This failure resulted in worsening of Pt 3's condition and Pt 3 returned to the ED on 3/12/24 by ambulance after Pt 3 was found walking around not acting normal, had been drinking alcohol, mixing [name of mouthwash] shots, and taking Chlordiazepoxide. Pt 3 was placed on a 1799 hold (a 24-hour involuntary medical hold that can be placed on a patient in California by certain licensed staff and healthcare providers) and transferred to an inpatient psychiatric treatment center.

2. Patient (Pt) 4, a homeless patient, was brought in by the ambulance to the ED on 8/9/24 for a chief complaint of increased blood glucose of 450 mg/dl (a blood sugar reading of 300 mg/dL or higher is considered dangerous and can lead to serious complications). Pt 4 was given a bolus (administration of a concentrated dose of a substance for immediate effect) of normal saline solution by the paramedics. In the ED, Pt 4 was placed in the lobby, labs were drawn, and no other interventions were done. Pt 4's abnormal lab results were not addressed and Pt 4's Blood Glucose was not checked prior to discharge. Pt 4's discharge was not completed in accordance with the facility's policy and procedure (P&P) titled, "AD 3.08 California Hospital Discharge Planning for Homeless Patient," and Pt 4 was not offered a ride to the shelter or weather appropriate clothing, and access to prescribed medication was not arranged.

These failures resulted in Pt 4 experiencing worsening hyperglycemia and being brought back to the ED by ambulance after being found outside a convenience store with a blood sugar of 347 mg/dL, 11 hours after being discharged from the ED.

Findings:

1.During a review of the hospital's report of returns to Emergency Department (ED) within 48 hours (of a previous ED visit) for March 2024, the report indicated Pt 3 was a 29-year-old female who came to the ED at 3:49 p.m. on 3/10/24 with a chief complaint of "Alcohol withdrawal; STATES NEEDS TO DETOX" and was discharged on 3/10/24 at 8:59 p.m. The report indicated that Pt 3 was brought back to ED via ambulance on 3/12/24 at 8:48 p.m. with a chief complaint of "[Brought in by ambulance] from home for [ethanol alcohol] use.; [Emergency Medical Services - EMS] mentions pt reported physical abuse from live in [boyfriend] and [name of city] police were present."

During a concurrent interview and record review on 08/16/24 at 10:30 a.m. with the Emergency Room Manager (EDM) 1 and Quality Registered Nurse (RNQ) 1, Pt 3's medical records for ED visits for dated 3/10/24 and 3/12/24 were reviewed. The "ED Note - Physician" dated 3/10/24, indicated, " ... 29 [year old female] presents herself to the ED for alcohol withdrawals. Patient reports that she normally drinks 3 bottles of wine a night. However, her most recent intake was a tall can of beer about 2 days ago since she is trying to detox from it. Since then, she states she has been feeling shaky and feels as if she had a seizure the night prior. No other symptoms reported. She reports that she did try [Chlordiazepoxide (medication used to treat anxiety, insomnia, and symptoms of withdrawal from alcohol)] for her symptoms but states that it brought no relief. No other medical history ...Home medications ...acamprosate (This medication is used along with counseling and support to help people who are alcohol dependent not drink alcohol. Acamprosate works by restoring the natural balance of chemicals in the brain), sertraline (antidepressant) and trazodone (antidepressant) ...ED Course: Patient presents for the above reasons. Based on the patient's ED work - up today, I believe discharge is the appropriate course of action. Patient was educated on their results and instructed to follow-up with the listed physician/clinic below in their discharge paperwork, and given return precautions if their symptoms continue or worsen ...Follow up... Follow with primary care physician ...within 3-5 days ... PCP NO KNOWN ..."

The "Patient Summary Report" indicated Pt 3 arrived in the ED on 3/10/24 at 3:49 p.m. The patient was triaged at 3:52 p.m. and was assigned an emergency severity index (ESI) level 3 (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed, ESI 1 being the most serious). Patient received Lorazepam (medication to treat anxiety and sleeping problems that are related to anxiety) and Chlordiazepoxide at 6:05 p.m. The review of "ED triage form" indicated initial vital signs on 3/10/24 at 3:52 p.m. Heart Rate (HR) 150 beats per minute (bpm-normal values 60-100 bpm), Blood Pressure (BP) 141/99 millimeters of mercury (mm/Hg - Unit of pressure that is used to measure blood pressure; normal 120/80 mmHg). The review of "lab results" indicated complete blood count with differential (CBC- blood test that measures many different parts often used to help screen overall health and measures the number of types of blood cells), ethanol level and Comprehensive Metabolic Panel (CMP - a routine blood test that measures 14 substances in the blood to provide information about the body's chemical balance and metabolism) were completed on 3/10/24 at 6:49 p.m. The lab results showed Ethanol level (measure the amount of alcohol in a person's blood) 212.50 and Ethanol Percentage 0.21 at 6:49 p.m. The flow sheet titled "Vitals" indicated on 3/10/24 at 8:11 p.m. HR was 132, BP 135/89, oxygen saturation 96%. Review of the document titled "ED Discharge form-Text" dated 3/10/24 indicated " ...Discharged from ED, Mode of discharge: Ambulatory; Mode of transportation: Private vehicle ...ED Discharged: Home ...ED Condition: Stable ... ED accompanied by: Self ...Discharge comments: See provider documentation for full assessment details, plan of care and discharge plan ...". The "ED Note- Physician" dated 3/10/24 indicated Pt 3 was prescribed chlordiazepoxide to take at home and the record indicated patient was discharged at 8:59 p.m. on 3/10/24. The review of "Nursing note" dated 3/10/24 at 3:59 p.m. indicated " ...Pt's roommate came up to this [Registered Nurse] and stated pt told him she needs to be on a hold but "they [would not] put her on a hold because she [would not] get out of the car and walk in the building, then she got arrested but they didn't press charges so now she is going to tell you she is coming in asking for alcohol pills but she needs to be on a hold." Pt denies [suicidal ideation/homicidal ideation] to this [Registered Nurse] at this time. EDM 1 stated she was not able to find any documentation that physician was notified about the concerned shared by roommate with nurse regarding need for hold. EDM 1 stated discharge instructions indicate patient was discharged to self, left by herself in a private vehicle at 8:59 p.m. The EDM 1 stated the discharge instructions lists the patient's condition as stable and no other documentation existed regarding patient's mental capacity or ability to take care of herself. EDM 1 validated Pt 3 received Lorazepam and Chlordiazepoxide at 6:05 p.m., and Pt 3's blood ethanol level was 212.50 at 6:49 p.m., three hours after arrival to ED. EDM 1 validated the discharge instructions to "follow up with NO Physician" in 3-4 days. EDM 1 stated ideally, they would discharge the patient with family or someone responsible to take care of the patient if they are not able to provide for themselves. EDM 1 stated the discharge instructions do not provide clear follow up instructions and needs to be worked on. EDM 1 stated the ED nurse does the assessment before discharge and would not have discharged the patient if they had any concerns. EDM 1 stated she cannot validate if the patient was functionally stable and ok to drive without having any documentation, however, they normally do not document the assessment before discharge and stated most likely the documentation is incorrect or missing regarding self-discharge in a private vehicle. EDM 1 stated HR greater than 130 prior to discharge was not concerning.

During a concurrent interview and record review on 08/19/24 at 2:30 p.m. with the Emergency Room Medical Director (EDMD), EDM 1 and RNQ 1, Pt 3's medical records dated 3/10/24 and 3/12/24 were reviewed. EDMD stated he has reviewed patient record for both ED visits. EDMD stated he was not sure why the discharge information lists "NO physician". EDMD stated they do not update this information and this information gets pulled automatically. The EDMD stated he was not too concerned with "HR of 132 in otherwise healthy individual." The EDMD stated before discharge they look at the patient to ensure that patient is functionally stable. The EDMD stated RN will assess and communicate with assigned provider as needed. The EDMD stated providers do not document functional stability of the patient but always assess before the discharge disposition. The EDMD stated the blood alcohol level of 212.50 could be where the patient normally lives. The EDMD stated that patient most likely did not drive herself upon discharge and stated the documentation was missing.

During a review of Pt 3's "EMS Patient Care Record (PCR)" dated 3/12/24, the PCR indicated, " ... Pt is a 29-year-old female not acting right. Boyfriend called 911. On arrival found Pt in a trailer walking around not acting normal. Per boyfriend he called for possible overdose. Pt has been drinking alcohol today and taking shots of Listerine during the day. Pt states she is being mental abused by her boyfriend and he slapped her around about 3 weeks ago. Ceres PD was called, and they came out and did a report. Pt is not on 5150 hold, pt does not want to harm herself. Pt has no complaints during transport ..."

During a concurrent interview and record review on 08/19/24 at 2:35 p.m. with EDM 1 and RNQ 1, Pt 3's medical record dated 3/12/24 was reviewed. The document titled "Patient Summary Report" dated 3/12/24 indicated, Pt 3's returned to ED by ambulance with diagnoses which included: Alcohol use, Poly pharmacy and Altered Mental Status on 3/12/24 at 8:48 p.m., and was triaged at 9:00 p.m. Review of "ED Note-Physician" dated 3/12/24 indicated, " ...HISTORY OF PRESENT ILLNESS: 29-year-old female history of alcohol abuse recently evaluated on 3/10 for alcohol withdrawal presents to the ED for intoxication, brought in by initially called for domestic violence, reportedly had been slapped by the boyfriend, patient however denies this, denies any pain, patient had [Chlordiazepoxide] medication bottle next to her bedside, appears intoxicated able to provide city where she lives slurring speech ...no external sings of trauma concerning for ICH or fracture ...I was worried for the patient safety, so I have placed them under 1799 hold with plans for further evaluation ...Patient was seen taking unknown number of the [Chlordiazepoxide] medications despite medications ordered to be taken away from patient. Patient was monitored for period of time in the emergency department ..." Review of "Nursing Note" dated 3/12/24 at 11:39 p.m., indicated, " ...Pt found with empty [Chlordiazepoxide] bottle states "It's not a big deal I just took a couple...". The record indicated after this, Pt 3 was placed on a 1799 hold on 3/12/24 at 11:57 p.m. and transferred to an inpatient psychiatric treatment center on 3/13/24 at 4:57 a.m. The EDM 1 stated she does not know how the patient was able to take [Chlordiazepoxide] in ED. EDM 1 stated medication should have been taken away from the patient.

During a review of the facility's P&P titled, "MOD COMP-RCC 5.16 EMTALA POLICY," dated 4/24/24, indicated, "..To ensure individuals presenting to [hospital name]emergency department receive an appropriate Medical Screening Examination (MSE) and stabilizing treatment of appropriate transfer in accordance with Emergency Medical Treatment and Labor Act of 1986 (EMTALA) ...[hospital name] will provide an individual who is determined to have an Emergency Medical Condition further medical examination and treatment as is required to stabilize the Emergency Medical Condition, including admission for inpatient care, or arrange an appropriate transfer of the individual to another medical facility with the Capability to provide the stabilizing care ..."

During a professional reference review retrieved from (https://www.ncbi.nlm.nih.gov/books/NBK547659/) titled, "Chlordiazepoxide", dated 1/30/20, the reference indicated, " ...Contraindications ... The use of benzodiazepines, including chlordiazepoxide, exposes individuals to the risk of misuse, abuse, and potential addiction, resulting in overdose or death. Benzodiazepine abuse and misuse often involve concurrent alcohol and illicit substances, contributing to a higher incidence of severe adverse outcomes. Before prescribing chlordiazepoxide and throughout treatment, evaluate each patient's susceptibility to abuse, misuse, and addiction ... Patients should be informed about life-threatening adverse effects if combined with opiates, alcohol, and other CNS-depressant medications ..."

2. During a review of the hospital's report of patients who returned to the ED within 48 hours of a previous ED visit for August 2024, the report indicated Pt 4 was a 32-year-old male who came to the ED at 4:41 p.m. on 8/9/24 with a chief complaint of "Increased blood sugar" and was discharged on 8/9/24 at 7:49 p.m., three hours and nine minutes later. The report indicated that Pt 4 returned to the ED on 8/10/24 at 6:44 a.m. with a chief complaint of "Increased Blood Sugar; DIABETIC".

During a review of Pt 4, "[Emergency Medical Services (EMS)] Patient Care Record (PCR)" dated 8/9/24, the PCR indicated, " .... Address: Homeless ...dispatched code 3 ...male siting up talking to fire [department]... [Glasgow Coma Scale (GCS) is a system to "score" or measure how conscious you are. The score ranges from 3-15. Patients with scores of 3 to 8 are usually considered to be in a coma and 15 is the best you can get] GCS of 15. Pt stated he smoked meth and now his sugar is high [Blood glucose level (BGL)] 414 and pt stated his mouth is dry.... [arrival on site-Hospital name], charge [nurse] advised to take pt to triage. Report given to triage nurse ...Medication administration ...Normal Saline (mixture of sodium chloride and water) ...Intravenous (IV - Into or within a vein) ...500 milliliters (ml-unit of measurement) ..."

During a concurrent interview and record review on 08/20/24 at 10:30 a.m. with the EDM 1 and RNQ 1, Pt 4's record dated 8/9/24 was reviewed. The document titled "Patient Summary Report," dated 8/9/24 indicated, Pt 4 arrived in the ED on 8/9/24 at 4:41 p.m., was triaged at 4:57 p.m. and emergency severity index (ESI) level 3 (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed, ESI 1 being the most serious) was assigned. The order was placed for Complete Blood Count with auto differential (CBC- blood test that measures many different parts often used to help screen overall health and measures the number of types of blood cells), Hemoglobin A1C (blood test that measures the average blood sugar level over the past three months), Basic Metabolic Panel (BMP- blood test that measures eight substances in the blood to evaluate various body functions and processes), and Beta Hydroxybutyrate (test used to detect ketones in blood or urine and monitor ketosis, metabolic state that occurs when your body burns fat for energy instead of glucose.) on 8/9/24 at 6:02 p.m. The patient was discharged on 8/9/24 at 7:49 p.m. Pt 4's vital signs at 4:57 p.m. were normal. The review of "ED Note-Physician" dated 8/9/24 indicated, Pt 4 arrived with chief complaint "High blood sugar, 450. EMS administered 500 ml, [normal saline -(NS)], [blood glucose] after 350. Used meth today per patient. EMS IV pulled before coming out to ED lobby". The document indicated " ...Pt states that he has no current [Diabetes mellitus (DM - condition when body does not produce enough insulin, or the body's cells do not respond to insulin)] medications, but used to be on Metformin and insulin. Unable to obtain further information and medical [history] due to pt's medical status ...Physical exam...General: Patient is thin-appearing, cachectic, looking around, and not following instructions ...lab summary statements ...normal white blood cells (WBCs- are part of the body's immune system. They help the body fight infection and other diseases) count 9.0, hemoglobin (Hb- is the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues) is low at 8.6 with low [Mean corpuscula volume (MCV- measures the average size of your red blood cell, help identify anemia and other conditions) of 61.1 Platelets (are a blood component whose function is to react to bleeding from blood vessel injury by clumping, thereby initiating a blood clot) adequate at 338. Patient's electrolytes show a low sodium (blood test measures the amount of sodium in your blood) of 129 but I believe this is due to elevated blood sugar of 314. Creatine (a lab test to assess kidney functions) is normal at 0.8 although [Blood Urea Nitrogen (BUN -test measures how much urea nitrogen is in your blood. It helps to determine if kidneys are working as they should is slightly up at 37 which may go along with some mild dehydration. Hemoglobin A1c is 9.1 showing poor control ...He is not willing to give much information and appears to be under the influence of methamphetamine. Physical exam shows him to be cachectic and somewhat pale appearing. His vitals sings were unremarkable ...He is microcytic anemic. His blood sugar is elevated at 314 consistent with his poor control. His BUN is elevated at 37 and EMS did give him a bolus ...I will be discharging him with prescription of metformin. He needs to work with his doctor at his clinic to control his anemia but more importantly he needs to be in a treatment program for his methamphetamine use and I have given him referrals ..." The review of "lab results for Beta Hydroxybutyrate" dated 8/9/24 at 6:02 p.m. also indicated 1.06 millimoles per liter (mmol/L) (normal 0.02 -0.27). EDM 1 stated she was unable to find any interventions done in ER besides lab draws. EDM 1 also validated no documentation regarding plan or rationale for high Beta Hydroxybutyrate level on provider note. EDM 1 also validated no blood glucose check was done during the entire ED stay and only documented glucose level in patient record is 314 from BMP that was done on 3/9/24 at 6:02 p.m. EDM 1 stated patient was treated by paramedics with fluid bolus and blood glucose check was completed by EMS, no other medications were administered in ED. The EDM 1 stated BG level of 314 is high and she could not provide an explanation as to why no other interventions were completed in ED to address blood glucose, to recheck the blood glucose level or to address the high Beta Hydroxybutyrate level in ED prior to discharge on 8/9/24 at 7:49 p.m.

During a concurrent interview and record review on 08/20/24 at 10:40 a.m. with the Emergency Room Manager (EDM) 1 and Quality Registered Nurse (RNQ) 1, Pt 4's record dated 8/9/24 was reviewed. The document titled "ED Discharge Form-Text" indicated, Pt 4 was discharged on 8/9/24, a Friday at 7:49 p.m., ED Disposition: discharge, ED discharged: home (although homeless). The EDM 1 stated although a shelter list was provided, the document does not reflect if the patient was offered or given taxi voucher or ride as needed to a shelter along with weather appropriate clothing. The EDM 1 stated the missing elements are required prior to discharge in accordance with hospital policy and state law concerning homeless patient discharge. The EDM 1 validated 8/9/24 was Friday, and stated she did not know what resources would be open/available to a patient upon discharge to pick up his medication or if the shelter accepts patients at nighttime.

During a review of Pt 4's "[Emergency Medical Services (EMS)] Patient Care Record (PCR) " dated 8/10/24, the PCR indicated, " ...32-year-old male outside of seven eleven shop with fire department crew by his side. Patient stated that he has been having diabetic issues, has been going in and out of [hospital name] for past few days. Patient reported he has not been able to take his medications. Patient also complaint of some left ankle pain, no obvious sign of trauma noted. Patient denies falls, stated he has been doing lot of walking. Patient admitted to weed and meth usage. Patient able to ambulate to gurney ..."

During a concurrent interview and record review on 08/20/24 at 10:45 a.m. with the Emergency Room manager (EDM) 1 and Quality Registered Nurse (RNQ) 1, Pt 4's record dated 8/10/24 was reviewed. The document titled, "Patient Summary Report" indicated patient returned to the ED on 8/10/24 at 6:44 a.m. Pt was triaged at 6:49 a.m. and ESI of 3 was assigned. The order was placed for chest X-ray (use to create picture of inside the body), Electrocardiogram (EKG - a test to record the electrical signals in the heart), X-ray ankle, Urinalysis (test that examines urine for physical properties, cells, organisms, and other substances), Troponin1(blood test to detect heart damage and diagnose heart conditions), CBC, and CMP were ordered. Pt 4 was also given Insulin Regular and Sodium Chloride IV and blood glucose levels. Review of document titled "ED Note- Physician" dated 8/10/24 indicated, " ...Chief Complaint: [brought in by ambulance (BIBA)] for elevated blood sugar. Has [left] ankle pain, feels like a burning sensation. [fingerstick blood sugar (FSBS)] 345 ...Radiology/Diagnostic Results ...XR Ankle ..findings ...Impression: Negative Ankle/Foot ...Degenerative arthritic changes ...No fracture ...XR Chest ...Impression: Negative ...EKG ...Sinus, No PVCs, No obvious ST changes, No [bundle branch block (BBB - condition that occurs when the electrical signal that causes the heart to beat is blocked or delayed in one or both of the heart's bundle branches )] " The "lab results" dated 8/10/24 indicated glucose level at 6:59 a.m. 347, at 8:22 a.m. 382, at 10:36 a.m. 317, at 11:21a.m. 181. The "Medication Administration Record (MAR)" dated 8/10/24 indicated, Pt 4 received 5 units of insulin (medication used in the treatment and management of high blood sugar) at 10:41 a.m. and sodium chloride (used for replenishing fluid and for restoring and maintaining the concentrations of sodium and chloride) 0.9% 1000 ml at 10:29 a.m. Review of document titled "ED Discharged Form" dated 8/10/24 indicated, " ED Disposition: Discharge Mode of discharge: Ambulatory ... Mode of transportation: Other: bus pass ...ED Discharged: Shelter ...ED condition: Stable ...ED Accompanied by: Self ...Discharge Comments: Clothes weather appropriate, gave sandwich and bus pass. The EDM 1 stated patient was discharged appropriately on 8/10/24 at 11:35 a.m.

During a concurrent interview and record review on 08/20/24 at 11:00 a.m. with the Emergency Room manger (EDM) 1 and Quality Registered Nurse (RNQ), the P&P titled, " AD 3.08 California Hospital Discharge Planning for Homeless Patient," dated 6/22/22 was reviewed. The EDM 1 stated regarding Pt 4, she was not able to locate any documentation regarding referral or consult by a social worker. The EDM1 stated it was not the facility process to get a social worker consult for homeless discharges. The EDM 1 stated she was not able to find documentation of a full cognitive assessment as outlined in the policy.


During a review of the facility's policy and procedure (P&P) titled, "MOD COMP-RCC 5.16 EMTALA POLICY," dated 4/24/24, the P&P indicated, "..To ensure individuals presenting to [hospital name] emergency department receive an appropriate Medical Screening Examination (MSE) and stabilizing treatment of appropriate transfer in accordance with Emergency Medical Treatment and Labor Act of 1986 (EMTALA) ...[hospital name] will provide an individual who is determined to have an Emergency Medical Condition further medical examination and treatment as is required to stabilize the Emergency Medical Condition, including admission for inpatient care, or arrange an appropriate transfer of the individual to another medical facility with the Capability to provide the stabilizing care ..."

During a review of the facility's P&P titled, " AD 3.08 California Hospital Discharge Planning for Homeless Patient," dated 6/22/22, the P&P indicated, " ...Purpose of this policy is to ensure transition management and discharge planning for the homeless patient is conducted with dignity, respect and compassion, in accordance with regulatory requirements and accreditation standards to improve continuity of care and follow a process for discharge planning that will address health care needs of the homeless patient population in the State of California (State) ...This policy applies to Homeless Individual presenting to Hospitals in California and includes in patients, observation admissions and certain types of outpatients, including, outpatients in a bed and Emergency Department patients ...The discharge planning process will be individualized and will begin as soon as possible, in the Emergency Department once the homeless patient is medically stable, or upon direct admission as an Inpatient or Outpatient. If there are complex discharge needs, Hospital Case Management assistance must be requested. The Discharge Planning Checklist for homeless patient will be initiated at this to develop an initial discharge plan for homeless patients presenting to the Hospital with the goal of balancing available community resources with patient choice and continuity of care. Prior to discharge, an appropriate discharge plan for the post-hospital medical care will be completed and documented in the medical record ...the hospital will offer weather-appropriate clothing and/or shoes to the patient as provided in this policy ...Social services/designated trained staff will assess homeless patient's ability to maintain mental cognition and stability post-hospitalization. The following are factors to be considered: history of frequent admissions, incarceration, interactions with law enforcement, associations with family or friends, frequents housing transitions, inconsistent locations for sleeping or food, ability to maintain/access public benefits and ability to maintain a treatment regimen ... Cognitive Assessment. When developing discharge plans, treating physicians, nurses, discharge planners and/or social workers will evaluate and document the patient's mental status during their clinical examination or assessments over the course of the patient's hospital stay to determine whether the patient is cognitively intact. The cognitive assessment will consider the homeless patient's individual circumstances (i.e. the patient's living arrangements and available support system post post-hospitalization) and details of the discharge plan what is to be implemented for the patients. The cognitive assessment will include the patient's orientation to person, place, circumstances and time, ability to provider self-care, his or her ability carry out usual activities or to protect his or her rights, the ability to obtain follow-up medical/mental health care, food and shelter, and ability to negotiate the environment being discharge to. The assessment will be documented in the patient's medical record ...Services offered to Homeless Patients Before Discharge ...Clothing...if the patient does not arrive with weather appropriate clothing, the hospital will offer weather appropriate clothing and encourage the patient to change in to weather-appropriate clothing before leaving the hospital ..."