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Based on observation, interview, and document review, the facility failed to identify and implement discharge plans for transportation arrangements for 1 of 10 residents (P1) reviewed for discharge planning. P1, who had a documented mental health diagnosis including hallucinations and delusions resulting in cognitive impairment, was discharged without transportation to their assisted living residence. As a result, P1 went missing for approximately 24 hours before being located by law enforcement and returned to the facility.

Findings include:

P1's admission Record dated 7/7/25, indicated P1's diagnoses included schizophrenia (mental health conditions with hallucinations, delusions, eccentric speech and behavior, and diminished emotional expression and purposeful activity), suicidal ideation, and auditory hallucinations (hearing things that are not there).

On 7/7/25 at 7:34 p.m., P1's medical record indicted P1 arrived at the emergency department (ED) via emergency medical services (EMS) experiencing suicidal ideation and auditory hallucinations. P1 was a patient at an assisted living.

On 7/7/25 at 7:41 p.m., P1's medical record indicated it was appropriate for P1 to be discharged, return to the assisted living facility, and follow up with community providers for treatment, safety and medication management.

On 7/7/25 at 10:38 p.m. P1's medical record indicated nursing staff gave P1 the discharge paperwork, and he left the hospital before transportation could be arranged back to his assisted living facility (ALF), and his whereabouts were unknown.

On 7/8/25 at 11:12 a.m. a medical doctor (MD)-A note indicated P1 lives in assisted living facility and recommended him to be discharged back to his group home (ALF).

On 7/14/25 at 11:45 a.m., a review of the video footage outlined a registered nurse (RN)-A gave P1 discharge paperwork and his belongings, and then P1 was escorted by security officer (SO)-B who opened the exit door for him, and P1 left the ED on foot.

On 7/14/25 at 3:12 p.m., Security Officer (SO)-B stated when patients get discharged, they had to show at the exit door their discharge documents with a "green sticker" marker. The SO would then open the door for them to leave. SO-B stated it is not a requirement in the ED department to ask about a transportation arrangement prior to opening the door for a discharged patient with a "green sticker". SO-B stated he did not check with the nursing staff if P1 was ready to be discharged but assumed it was fine since he had the "green sticker".

On 7/14/25 at 3:40 p.m., RN-A stated he was P1's nurse during his hospitalization. RN-A stated he gave the discharge instructions document to P1 with his belonging upon request. RN-A stated he called the ALF and got confirmation P1 was in their system. RN-A stated the assessor social worker (SW)-A asked him to set up a ride for P1. RN-A stated P1 left ED before he could arrange a transportation back to his assisted living facility for him. RN-A stated he did not receive education about safe discharge planning recently.

On 7/15/25 at 10:20 a.m. the nurse manager at the ALF, RN-F stated P1 called the police after 24 hours of being missing on 7/8/25 and was located at a McDonald's on Hennepin and Lake Street which was about 2.1 miles from the hospital. He was picked up from the McDonald's and brought to Waconia and Ridgeview Hospital. RN-F stated P1 did have delusions, paranoia, and was at a high risk for personal safety when alone. RN-F stated she was afraid something could have happened to P1 when they were alone. RN-F stated P1 thought he had to walk back to the facility from the hospital. The ALF staff picked him up from the Waconia and Ridgeview Hospital and brought him back to the assisted living facility on 7/8/25 at 10:35 p.m. P1 had not sustained any physical injuries.

On 7/15/25 at 11:07 a.m., SW-A stated she did the diagnostic evaluation center (DEC) assessment on P1 and called the assisted living facility to verify the address. SW-A stated she sent a message and provided an address for RN-A to set up a transport for P1. SW-A stated when she asked RN-A where he sent P1, RN-A replied P1 was gone. SW-A stated she called the attending physician (MD)-A who informed the charge nurse about a missing vulnerable adult situation. SW-A stated missing adult alert was initiated at that time and she heard overhead speaker with P1 description in the alert.

On 7/15/25 at 12:06 p.m. SW-B stated SW-A sent her a message referring to a miscommunication within the ED which had let the security officer to walk out P1 to the exit door. SW-B stated there was a lack of clarity if the ED had arranged the transportation or not. SW-B stated transportation should always be arranged for patients discharging back to group homes (AL) which did not occur.

On 7/15/25 at 12:21 p.m., RN-B stated when he got a call from MD-A he went to talk to RN-A who said he gave P1 his discharge paperwork and his belongings and P1 was gone when he came back. RN-B stated RN-A did not arrange transportation for P1 and should have done this--along with not giving P1 a green sticker to be released from the ED. RN-B stated if someone needs to wait for transportation they wait until transport shows up before giving to the patient the discharge document with the green sticker. RN-B stated he called SO-C to initiate a missing vulnerable adult alert and called the police who showed up at the ED to get P1's description. RN-B stated he directed RN-A to notify the ALF and to file an incident report. RN-B stated for any patients from a group home (ALF), nursing staff must arrange the transportation for them and notify the group home about their discharges and arrival time. RN-B stated RN-A was a pool nurse and did not know the process for group home patients. RN-B stated patients from (ALF) should remained at the ED pending their transport arrangement.

On 7/16/25 at 1:06 p.m., MD-A stated he spoke to the charge nurse, RN-B about P1 missing and he initiated a vulnerable adult missing alert. MD-A stated he ordered DEC assessment for P1, and a final disposition ordered for his discharge with a transportation arrangement back to his group home. MD-A stated the normal process would be to set up a ride for patients regardless of their legal guardian status from a group home (AL) so they would return safely.

On 7/16/25 at 2:09 p.m. SO-C stated when he became aware of P1's missing, he asked dispatch to initiate a missing adult alert and then reviewed the video, which showed P1 had his discharge paperwork with a green sticker, and he was let out by one of the security officers. SO-C stated the clinical staff should have communicated with the security department about P1's need for transport back to his ALF. SO-C stated nurses should not give the discharge document with a green sticker to patients from ALF if they did not make any transportation arrangement yet.

On 7/16/25 at 9:42 a.m., RN-C stated after the provider gave the discharge instructions to the patient from a group home, nursing staff should communicate with the security department for P1's need of transportation back to the facility. RN-C stated nurses must wait for the transportation before giving the discharge document with a green sticker to the patient from (ALF).

7/16/25 at 4:02 p.m., the ED nurse manager, RN-E stated if the nursing staff were aware that P1 came from ALF, they should have set up transportation for his return to his facility. RN-E stated he did not know if RN-A was told to set up a ride for P1. RN-E stated he did not do anything to address the issue with P1's discharge planning. RN-E stated he had not been provided any discharge planning review education when the ED staff discharge patients back to the nursing facilities.

The facility Discharge Planning Policy dated 1/8/24 indicated the discharge planning is a coordinated interdisciplinary process that begins as early as possible in the patient's treatment and results in the identification of discharge needs, development, implementation, and coordination of a discharge care plan that meets the patient needs included when needed, transportation arrangement in a timely manner.

Based on document review, the hospital failed to ensure a system for informing patients of their right to formulate an advanced directive at emergency department during admission for 5 of 10 patients reviewed for advanced directives.

Findings include:

P3's Admission Default Flowsheet Data dated 7/7/25, indicated P3 did not have an advanced directive. P3's flowsheet lacked evidence advance directive information was provided.

P4's Admission Default Flowsheet Data dated 7/7/25, indicated P4 did not have an advanced directive. P4's flowsheet lacked evidence advance directive information was provided.

P5's Admission Default Flowsheet Data dated 7/7/25, indicated P5 did not have an advanced directive. P5's flowsheet lacked evidence advance directive information was provided.

P7's Admission Default Flowsheet Data dated 7/8/25, indicated P7 did not have an advanced directive. P7's flowsheet lacked evidence advance directive information was provided.

P8's Admission Default Flowsheet Data dated 7/10/25, indicated P7 did not have an advanced directive. P8's flowsheet lacked evidence advance directive information was provided.

On 7/14/25 at 11:45 a.m., a registered nurse (RN)-D stated admission nurses provided the advance directive notice to the patients during an admission and documented in the admission navigator but was not a requirement at the emergency department.

On 7/14/25 at 11:45 a.m., RN-E (emergency department [ED] manager) stated he was unable to verify whether P3, P4, P5, P7, and/or P8 had received the required advanced directive information at the time of admission. RN-E stated advanced directives spot was in the admission tool but was not a requirement in the emergency department to offer an advanced directive information at the time of admission.

On 7/14/25 at 3:20 p.m., a system program manager (SPM)-D stated there were workgroup and plan in motion to update their Advance Care Planning (ACP) and Advance Directive policy and the corresponding practice to match the regulation which required Advance Directive information should be offered to all patients presented to the emergency department but were not finalized yet.

The hospital Advance Care Planning (ACP) and Advance Directives policy dated 1/20/22 and reviewed on 11/05/24 directed admission nurses to review the medical record and document the presence of an Advance Directives in the admission navigator. The policy further directed nurses to provide a health care directive information at the time of any inpatient admission and documented in the admission navigator.

State Operations Manual (SOM) states Advanced Directive information should also be given to all patients presenting to the ED and must be documented in the patient's medical record.

Based on observation, interview, and document review, the facility failed to implement discharge need for transportation arrangements for 1 of 10 residents (P1) reviewed for discharge planning. As a result, P1 went missing for approximately 24 hours before being located by law enforcement and returned to the facility.

Findings include:

P1's admission Record dated 7/7/25, indicated P1's diagnoses included schizophrenia (mental health conditions with hallucinations, delusions, eccentric speech and behavior, and diminished emotional expression and purposeful activity), suicidal ideation, and auditory hallucinations (hearing things that are not there).

On 7/7/25 at 7:34 p.m., P1's medical record indicted P1 arrived at the emergency department (ED) via emergency medical services (EMS) experiencing suicidal ideation and auditory hallucinations. P1 was a patient at an assisted living.

On 7/7/25 at 7:41 p.m., P1's medical record indicated it was appropriate for P1 to be discharged, return to the assisted living facility, and follow up with community providers for treatment, safety and medication management.

On 7/14/25 at 11:45 a.m., a review of the video footage outlined a registered nurse (RN)-A gave P1 discharge paperwork and his belongings, and then P1 was escorted by security officer (SO)-B who opened the exit door for him, and P1 left the ED on foot.

On 7/14/25 at 3:40 p.m., RN-A stated he was P1's nurse during his hospitalization. RN-A stated he gave the discharge instructions document to P1 with his belonging upon request. RN-A stated he called the ALF and got confirmation P1 was in their system. RN-A stated the assessor social worker (SW)-A asked him to set up a ride for P1. RN-A stated P1 left ED before he could arrange a transportation back to his assisted living facility for him. RN-A stated he did not receive education about safe discharge planning recently.

On 7/15/25 at 10:20 a.m. the nurse manager at the ALF, RN-F stated P1 called the police after 24 hours of being missing on 7/8/25 and was located at a McDonald's on Hennepin and Lake Street which was about 2.1 miles from the hospital. He was picked up from the McDonald's and brought to Waconia and Ridgeview Hospital. RN-F stated P1 did have delusions, paranoia, and was at a high risk for personal safety when alone. She was afraid something could have happened to P1 when they were alone. RN-F stated P1 thought he had to walk back to the facility from the hospital. The ALF staff picked him up from the Waconia and Ridgeview Hospital and brought him back to the assisted living facility on 7/8/25 at 10:35 p.m. P1 had not sustained any physical injuries.

On 7/15/25 at 11:07 a.m., SW-A stated she did the diagnostic evaluation center (DEC) assessment on P1 and called the assisted living facility to verify the address. SW-A stated she sent a message and provided an address for RN-A to set up a transport for P1. SW-A stated when she asked RN-A where he sent P1, RN-A replied P1 was gone. SW-A stated she called the attending physician and a missing vulnerable adult alert was initiated.

On 7/15/25 at 12:06 p.m. SW-B stated SW-A sent her a message referring to a miscommunication within the ED which had let the security officer to walk out P1 to the exit door. SW-B stated there was a lack of clarity if the ED had arranged the transportation or not. SW-B stated transportation should always be arranged for patients discharging back to group homes (AL) which did not occur.

On 7/15/25 at 12:21 p.m., RN-B stated RN-A did not arrange transportation for P1 and should have done this--along with not giving P1 a green sticker to be released from the ED. RN-B stated if someone needs to wait for transportation they wait until transport shows up before giving to the patient the discharge document with the green sticker.

RN-B stated any patients from a group home (ALF), nursing staff must arrange the transportation for them and notify the group home about their discharges and arrival time. RN-B stated RN-A was a pool nurse and did not know the process for group home patients. RN-B stated patients from (ALF) should remained at the ED pending their transport arrangement.

On 7/16/25 at 1:06 p.m., MD-A stated he spoke to the charge nurse, RN-B about P1 missing and he initiated a vulnerable adult missing alert. MD-A stated he ordered DEC assessment for P1, and a final disposition ordered for his discharge with a transportation arrangement back to his group home. MD-A stated the normal process would be to set up a ride for patients regardless of their legal guardian status from a group home (AL) so they would return safely.

The facility Discharge Planning Policy dated 1/8/24 indicated the discharge planning is a coordinated interdisciplinary process that begins as early as possible in the patient's treatment and results in the identification of discharge needs, development, implementation, and coordination of a discharge care plan that meets the patient needs included when needed, transportation arrangement in a timely manner.