Inadequate Discharge Coordination for a Vulnerable Patient at the Portland VA Medical Center in Oregon

The VA Office of Inspector General (OIG) evaluated allegations that Portland VA Medical Center (facility) staff “inappropriately discharged” a patient with “severe cognitive impairment,” then “turned away” the patient, and failed to provide the patient’s records to Adult Protective Services (APS). The OIG identified a concern regarding discharge coordination with family. In 2021, the patient, with a history of alcohol use and cognitive impairment, presented to the facility’s Emergency Department with gangrene and homelessness. Throughout the patient’s 33-day admission, staff evaluated the patient’s cognitive functioning, communicated with the patient’s family and APS staff, and pursued placements. Approximately an hour after discharge, the patient presented to the facility’s Emergency Department. A social worker provided the patient with a bus ticket “to return to the shelter.” Within an hour, the patient returned and the social worker reprinted the instructions and advised the patient to board the bus. The OIG substantiated that the patient was discharged to a non-VA homeless shelter by cab but did not substantiate the patient was “inappropriately discharged.” Staff determined that direct transport was preferable to the more complicated bus route. The OIG was unable to determine whether staff discussed the patient’s final discharge plan with family due to an absence of documentation and conflicting reports. The OIG substantiated that staff did not establish a safe transportation plan after the patient returned to the Emergency Department after discharge. The OIG did not substantiate that staff failed to provide the patient’s records to APS. However, staff returned requests without providing information regarding specific missing elements. The OIG made three recommendations related to consideration of requiring staff to document family contacts, a review of the Emergency Department social worker’s care coordination of the patient, and consideration of Privacy Office staff communicating the missing element(s) when returning a release of information request.