For historical purposes this articles has been mirrored from:http://www.sacbee.com/topstories/story/2146926.html


Probe faults Kaiser for leaving brain-injured man on Sacramento streets
cpeytondahlberg@sacbee.com
Published Saturday, Aug. 29, 2009

The Kaiser hospital in south Sacramento failed to follow state law when it discharged a brain-injured young man to the streets outside a closed homeless services program, a state investigation has concluded.

The "deficiency" finding does not carry a fine, but Kaiser will be required to file a correction plan with the state, according to Ralph Montano, a spokesman with the California Department of Public Health.

In an e-mailed statement Friday, Kaiser said the state's conclusion matches what the hospital said soon after the May 23 incident: "In this matter we unfortunately did not fully follow our discharge policy."

The man involved, Jason Adams, suffered a traumatic brain injury in a 2005 car crash, leaving him with virtually no short-term memory, according to his father, Ken Adams. He was unable to function on his own and had recently walked onto a freeway and been struck by a car, his father said.

With his parents unable to manage him, Jason Adams had been placed in various care facilities by Kaiser, which provided his health insurance. The state investigation noted he had bounced among different facilities and Kaiser's emergency room on May 22, the Friday before Memorial Day weekend.

Kaiser then decided to call a taxi and arrange for him to be taken to an area where he could line up for a shelter shuttle bus between 2 and 3 p.m. on Saturday, the state report says.

Jason Adams was unable to follow such instructions, his father said. He was alerted to his son's problem when the cab driver phoned him, saying he was worried about leaving the disoriented young man on the streets outside Loaves & Fishes, a homeless services program that was closed for the weekend.

Ken Adams said he complained vigorously to the hospital, which then alerted police. At one point, three patrol cars were involved in the search for Jason Adams. Officers found him within a few hours and returned him safely to Kaiser.

Kaiser has rigorous discharge policies, which require it to contact the receiving institution and make sure someone is expecting the patient, the health system said in its Friday statement.

"We have apologized to our patient and his family for this error," said the e-mail, which a spokeswoman said represented the views of Max Villalobos, a Kaiser senior vice president.

"This was a rare event among our 650,000 discharges, but even one mistake is too many and we have taken steps to reinforce our policy," it said.