HospitalInspections.org

Based on interviews and record review, the facility staff failed to ensure the safety of 1 of 7 discharged minor patients (Patient #1) out of a total of 10 patient records reviewed.

Findings include:

The facility failed to ensure patients were receiving care in a safe setting. (See tag A-0144)

Based on record review and interviews, the facility staff failed to ensure the safety of 1 of 7 discharged minor patients out of a total of 10 patient records reviewed. (Patient #1)

Findings include:

The policy titled "Discharge" last revised 10/2020 revealed in part "F. Documentation a. Patient release record will be signed in Admission Office. i. To be completed by person transporting patient at discharge. b. Verify the identification (ID) of the transport person is the person identified by Social Worker as providing transport. a. A Transport Agency should provide a trip manifest to verify the transport if they do not have a company ID."

The policy titled "203.04 Discharge Planning" last revised 12/2018 revealed in part "9. Social worker will coordinate transportation arrangements with family members, contracted transportation providers, community agency staff, or patient transportation office. 10. The social worker will let the Registrar's Office and other appropriate areas of the hospital know of the scheduled discharge date via an email to the 'the discharge group'."

Record review of Patient #1's medical record revealed Patient #1 is a 15 year old with a history of autism was admitted on 10/3/2020 under a Emergency Detention: 51.15 through Kenosha County for concerns of aggressive behavior towards family and a danger to self and others. Patient #1 was discharged on 10/7/2020 to home with the Emergency Detention dismissed. The patient release record revealed in part "Name--Individual transporting patient with an illegible signature and the time discharged at 11:30 (sic)." The address and telephone number for individual transporting patient were blank.

Review of the social worker discharge email dated 10/6/2020 at 6:40 PM revealed "Patient #1, Youth Services Unit (YSU), will discharge 10/07/2020 at 1200. She will be picked up by her mother and going home with her."

Review of the root cause analysis (RCA) conducted on 10/9/2020 revealed in part "Analysis Question 2. Were there any steps in the process that did not occur as intended? RCA Findings: ID was not checked; Signature of person transporting patient was not legible: Person transporting was not referenced with the discharge email; Patient was not discharged to mother as indicated in email. Organization Plan of Action: Action Item #1. The Registered Nurse (RN) discharge procedure will be updated to include process for ID check. Method: Policy education will be provided to RN's with implementation by 11/2/2020. Action Item #2. Discharge Planning Policy 203.04 will be updated to outline required elements in the social worker (SW) discharge email. Elements to include the full name and address of transporting person. Method: Policy education will be provided with implementation by 11/2/2020."

During an interview with Director of Nursing (DON) B on 10/27/2020 at 12:18 PM B stated "The incident was addressed the same day at our 1:00 PM supervisor meeting."

During an interview with Youth Services Unit (YSU) manager C on 10/27/2020 at 12:40 PM C stated "There was education done at change of shift report and I also sent an email to all my nurses."

During an interview with registered nurse (RN) E on 10/26/2020 1:30 PM. When asked E what is the discharge process, E stated "We get an email from the social worker (SW) with the discharge plan and arrangements for who is picking up the patient and at what time. When family or transport arrives at Admissions the staff there get the patient's release form signed and check their ID. Admissions then calls the nursing unit to let us know that the patient's ride is here. Staff brings the patient down, there are 2 ID checks done, by admissions and the nurse. I received a call from admissions that Patient #1's ride was here so I brought the patient down. Patient #1 said hi to the driver as if he/she knew him/her. I did not check the drivers ID as I usually do."

During an interview with admissions desk staff J on 10/27/2020 at 9:15 AM when asked what the discharge process is, J stated "We check the person's ID, get a signature on the paper (patient release form), then we call the nursing unit. A copy of the paper goes to the nurse. The SW sends an email with the discharge information which we (admissions staff) enter on the patient release form."

During an interview with Admissions Coordinator G on 10/27/2020 at 9:20 AM, G stated "I checked out Patient #1 on 10/07/2020 when the Midwest Transportation Management (MTM) driver arrived. I checked the trip ticket on their phone and got a signature. Then I called the nursing unit. The nurse brought the patient down and was discharged with the MTM driver. Complainant A arrived shortly after patient #1 left and was very upset. Complainant A had made the transportation arrangements with MTM and apparently two tickets were made. We immediately called MTM but were not able to get through for 20-30 minutes. When we connected with MTM complainant A requested that Patient #1 return back to the facility. The switch was made in front of the admissions building, so Patient #1 could ride with complainant A to home. It is not uncommon for minors to be picked up by MTM drivers when discharged."

During an interview with Social Worker (SW) D on 10/27/2020 at 9:50 AM, D stated "I communicate the discharge plan via email which goes out to multiple people including the nursing unit and admissions. The email identifies who is picking up the patient, what time and discharge follow up. Complainant A told me that the county promised that they will coordinate and approve the MTM transport for both. It is very rare that a patient or parent arranges a ride with MTM, I usually do those arrangements."

During an interview with Director of Nursing (DON) B on 10/27/2020 at 12:55 PM, B stated "The nurse has a discharge folder for each patient which has a copy of the social workers discharge email which states who is picking up the patient, when (date and time) and any other needs. Staff should reference this email when discharging a patient, both admissions staff and nurse did not verify that the person picking up Patient #1 was the person named in the social workers discharge email. The email is not part of the patient medical record. It is a communication tool." DON B confirmed "Registered Nurse (RN) E did not follow policy and procedure on 10/7/2020 when discharging Patient #1."