The trusted source for
healthcare information and
Los Angeles hospital settles homeless 'dumping' case and avoids charges
New protocol makes Skid Row drop-off the last possible option
More than a year after an elderly hospital patient was found wandering a crime-ridden area in a hospital gown and slippers, the nation's largest HMO agreed in a settlement with the city to changes aimed at ending the dumping of homeless patients on streets. A civil lawsuit filed by the city also will be dismissed.
Kaiser Permanente, based in Oakland, CA, will create new protocols for discharging homeless patients in its chain of hospitals, train staff, and allow a retired U.S. district judge to monitor its progress, says Kaiser spokesman Jim Anderson in Los Angeles.
Carol Ann Reyes, 64, was discharged from Kaiser's Bellflower hospital in March 2006 and dropped off by a taxi outside the Union Rescue Mission in the city's notorious Skid Row area. She wandered around, apparently confused, for several minutes until mission staff took her in.
City Attorney Rocky Delgadillo, JD, filed charges of misdemeanor false imprisonment in November against Kaiser and said he wanted to send a message to hospitals nationwide that engage in patient dumping. Los Angeles authorities are investigating allegations that a dozen area hospitals have dumped more than 50 homeless patients downtown. Kaiser also faced civil claims related to the mistreatment of Reyes.
As part of the settlement, Kaiser will pay $5,000 in civil penalties, $50,000 in investigative costs to the city attorney's office, and $500,000 to a charitable foundation benefiting local homeless programs. (See box below for details of the agreement.)
These are the details of the agreement reached between the Los Angeles City Attorney and Kaiser Permanente that will result in the dismissal of criminal charges brought in the case of Carol Ann Reyes, a homeless woman shown on videotape on Skid Row in Los Angeles in March 2006:
A court-appointed referee will oversee the agreement for the next three years.
Kaiser previously denied wrongdoing. Kaiser spokeswoman Diana Bonta said in November that hospital staff had called a taxi to take Reyes to Skid Row, but called ahead to the mission to let staff know she was on her way. Benjamin Chu, MD, president of Kaiser Permanente's Southern California region, released a statement saying the release of Reyes was a breakdown in hospital protocol and an aberration. "I don't think the policies and procedures were wrong," he said. "They just weren't as tight as we'd like them to be."
Other hospitals expected to follow
Other hospitals in the area have been accused of similar mistreatment of homeless patients, and risk managers across the country report that hospitals can find themselves in a no-win situation when discharged patients have nowhere to go. Many homeless patients resist attempts to discharge them in a more humane manner, risk managers report.
The agreement is binding only for Kaiser facilities, but most California hospitals with emergency departments plan to follow the Kaiser protocol, says Jim Lott, executive vice president of policy development and communications for the Hospital Association of Southern California. Delgadillo says his office has received 55 reports of homeless patient dumping on Skid Row over the last year, with one of the most notorious involving Hollywood Presbyterian Medical Center. In that February 2007 incident, hospital staff twice tried to deliver the paraplegic man to the Midnight Mission, which he had listed as his home address on hospital paperwork. On the first attempt security guards objected when the patient was brought into the mission courtyard on a gurney. Witnesses reported that a van returned later with the paraplegic man in a soiled hospital gown, a broken colostomy bag, and with no wheelchair or walker. The man hurled himself from the vehicle, crawled on the street, and dragged a bag of his belongings in his clenched teeth until the witnesses helped him.
According to the witnesses, the van driver ignored their cries for help and instead applied makeup and perfume before speeding off. Hospital spokesman Dan Springer issued a statement saying the hospital found the incident "extremely troubling and regrettable. The fact is, we would never condone leaving an individual at a location without his consent." He admitted that the hospital's procedures for discharging homeless and disabled patients were not followed.
After the Kaiser settlement, Hollywood Presbyterian Medical Center announced that it would adopt the new guidelines and better train its staff, but Delgadillo responded by saying, "This announcement by itself doesn't impact our investigation."
Settlement terms called reasonable
The Kaiser settlement was a good resolution of the dispute, says Linda Stimmel, JD, partner and co-founder of Stewart & Stimmel in Dallas, and Mary Jean Geroulo, JD, an attorney with the firm who previously was a hospital administrator for 10 years. The hospital was suffering extremely bad publicity from the controversy and did not handle the initial accusations well, they say.
The terms of the settlement essentially require the hospital to discharge homeless patients in a dignified manner, using a specific protocol that ensures the health provider has taken reasonable steps to find a safe way for the patient to re-enter the community, Geroulo says. The controversy in California involves accusations that hospital staff acted callously and treated patients with disrespect just because they were homeless, and Geroulo says the settlement provides a structured process to ensure that does not happen.
"These are processes that should be standard operating procedures for hospitals," she says. "This does not create any heightened level of responsibility, but rather it ensures that the hospital follows procedures it should have been following all along."
More allegations will come
The media attention to this issue increases the risk for all hospitals treating a high percentage of homeless patients, Stimmel cautions.
"We've seen this through the years. Once a case or an issue gets in the headlines, there are plaintiffs' attorneys who are looking for new avenues in which to pursue hospitals," Stimmel says. "We would be naive to think that plaintiffs' attorneys won't be on the lookout for this now, perhaps even having people stationed around hospitals looking for cases like this. Risk managers should be operating with an increased awareness of this issue, because we know the attorneys will be."
The counter to those charges will be a discharge process, carefully documented, that shows you did the best you could for a homeless patient, they say.
However, Geroulo and Stimmel emphasize that the Kaiser settlement does not impose any obligations on other facilities. Plaintiff's attorneys still will try to use the Kaiser settlement as a standard for other hospitals, they say, but standards of care are local rather than national.
"Will they try to use it against you? They absolutely will," Stimmel says. "But just because one hospital settled with these terms, that doesn't make it a rule. But plaintiffs' attorneys definitely will bring it up and use it as something to talk about."
Do what is reasonable
Even if you want to abide by the same terms as Kaiser, that does not mean you have to do anything beyond what is reasonable. Discharging homeless patients can be extremely difficult because ultimately the patient still will be homeless no matter how carefully you discharge him or her, they say. They caution against misinterpreting the Kaiser settlement to mean that hospitals are expected to find a perfect solution or just not discharge the patient. (See box below for more on why risk managers should not overreact to the Kaiser settlement.)
Discharging homeless patients can be tricky, but the recent controversy in California should not make risk managers so cautious that every homeless patient ready for discharge becomes a crisis, say Linda Stimmel, JD, partner and co-founder of Stewart & Stimmel in Dallas, and Mary Jean Geroulo, JD, an attorney with the firm.
Use the Kaiser settlement as a reason to review your discharge processes and meet with discharge planners to review how these difficult cases are handled, Stimmel and Geroulo advise. The purpose of the meeting should be twofold: to make sure that homeless patients are being discharged in a proper way, but also to make sure that discharge planners are not erring too far in the other way by "freezing up" when it seems a homeless shelter is the only option, they suggest.
"They need to understand that it can be reasonable, and they can't just hang on to those patients until something else comes up," Stimmel says. "This settlement does not require anything other than reasonable care in discharging the homeless, and we can't let people think it demands they perform miracles. When they think that, the whole system just comes to a stop."
Geroulo and Stimmel also urge risk managers not to become overly sensitive to the issue and create an atmosphere in which staff are afraid to discharge homeless patients. Even though Los Angeles hospitals are suffering from bad publicity related to the incidents, they say risk managers should strive for doing the right thing rather than pandering to critics.
"If you start trying to structure policies and procedures to avoid lawsuits and bad publicity, you're doing yourself a disservice," Stimmel says. "Sometimes you're going to get publicity, and sometimes you're going to get lawsuits you have to defend, but in the long run you're better off doing what you know is right and reasonable."
"Do not be afraid, risk managers, to send patients to a shelter. Do not let this settlement make you afraid," Stimmel says. "If you have to send the patient to a shelter because you've determined that is the best discharge option, then go ahead and do that. You only have to be reasonable. You don't have to solve the homeless problem."
For more information on appropriate discharge of homeless patients, contact: