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Based on a review of medical records, video recordings, local law enforcement reports, interviews with facility staff, an interview with the complainant, and an interview with patient's family, a review of the Governing Body Bylaws, and a review of the Medical Staff Rules and Regulations, it was determined that the facility failed to ensure that the medical staff was held accountable to the quality and care that was provided to their patients. Specifically, the facility failed to ensure that two out of five sampled patients (P) (P#1 and P#2) were appropriately discharged.

Cross-reference A0049 Medical Staff Accountability as it relates to the facility failing to ensure that the medical staff was held accountable for the quality and care that was provided to their patients.

Based on a review of medical records, video recordings, local law enforcement reports, interviews with facility staff, an interview with the complainant, and an interview with the patient's family, a review of the Governing Body Bylaws, and a review of the Medical Staff Rules and Regulations, it was determined that the facility failed to ensure that the medical staff was held accountable to the quality and care that was provided to their patients. Specifically, the facility failed to ensure that two out of five sampled patients (P) (P#1 and P#2) were appropriately discharged.

Findings:

A review of the facility's Emergency Department (ED) Log revealed that P#1 arrived at the ED on 5/31/22 at 11:44 a.m. with a chief complaint of seizures and an ED disposition of 'Admit to Inpatient or Observation.' Continued review revealed that P#1 arrived at the ED again on 6/2/22 at 10:26 p.m. with a chief complaint of Altered Mental Status and an ED disposition as 'Admit to Inpatient or Observation".

A medical record review revealed that P#1 was a 65-year-old who presented to the emergency department (ED) via emergency medical services (EMS) on 5/31/22 at 11:44 a.m. after a seizure was witnessed at home.

A review of an 'ED Provider Note" at 12:48 p.m. revealed that P#1 was only responsive to pain when EMS arrived on the scene. P#1 had a past medical history of a seizure disorder, high blood pressure, previous stroke, and alcohol abuse with withdrawal. P#1's family was unavailable in the ED, so limited history was obtained. A neurological exam indicated that P#1 was somnolent (drowsy, sleepy) and arousable to significant tactile stimulation. A further review revealed that P#1's daughter later stated that P#1 was non-compliant with medication. P#1's daughter said she did not believe P#1 was still drinking. She also voiced concerns about not being able to care for P#1 at home. The ED diagnosis was seizures, non-compliance with medication regimen, and encephalopathy (broad term used for any brain disease that alters brain function or structure). P#1 was admitted for observation and possible placement.

A review of a 'History and Physical Notes' at 4:31 p.m. revealed that P#1 was arousable to verbal commands and conversing appropriately upon evaluation. P#1 was alert and oriented x 1 (to person only). P#1 had five out of five strength in both upper and lower extremities. P#1's daughter stated that P#1 had been forgetful for the past two years and had progressively gotten worse. The 'Review of Systems' revealed that P#1's neurological exam was positive for altered mental status and seizures. P#1 had a history of dementia. Additionally, P#1's daughter thought P#1 might have been experiencing some falls because she found some blood on the floor a week or so ago. The note revealed that P#1 was taking Seroquel (antipsychotic) nightly, and he lived with his daughter. A need for discharge planning was indicated. A further review of the 'History and Physical Notes' at 4:45 p.m., written by the Attending Physician, Medical Doctor (MD) GG, revealed that P#1 was at a baseline confusion at home. MD GG suspected the seizure was due to alcohol withdrawal vs. marijuana.

A review of the 'Case Management Initial Discharge Planning,' written by Registered Nurse (RN) CC at 8:40 p.m., revealed that P#1 had been living with P#1's daughter and required assistance with daily living activities. P#1 could ambulate but had experienced some falls. P#1 had a walker at home but refused to use it. P#1 had a history of smoking and had started two fires. P#1's daughter had expressed that she was unable to provide the care and assistance that P#1 needed. P#1's anticipated discharge was to a long-term care facility, and medical transport would be needed.

A review of a Physical Therapy (PT) note dated 6/1/22 at 2:19 p.m. revealed that discharge considerations included 24/7 supervision due to safety concerns with fall risk. P#1 was oriented to person but was disoriented to situation, time, and place.

A review of the plan of care dated 6/1/22 at 6:00 p.m. revealed 'safety falls' and 'knowledge deficit' as problems for P#1.

A review of a PT note dated 6/2/22 at 11:55 a.m. revealed that P#1's overall cognitive status was impaired. P#1 had a decreased recall of biographical information and a deceased recall of recent events. P#1 was oriented to person and place. P#1 became fatigued quickly during dynamic standing balance and required seated resting breaks. Additionally, P#1 required assistance with his gait (manner of walking). General comments on the note revealed that P#1 became tearful and agitated during the PT session stating, "I don't know what the hell is wrong with me. They won't tell me. I just woke up, and I was right here. If I'm nuts, tell me dammit".

A review of a 'Nursing Note' dated 6/2/22 at 3:18 p.m., written by Charge Nurse (CN) EE, revealed that P#1 stated that he was going to call home and would call for a car service to pick him up. P#1 was alert and oriented and was adamant about leaving. A physician (did not indicate the physician's name) came to speak to P#1. After speaking to P#1, he still refused to stay.

A review of the 'Case Management Final Discharge Transition,' dated 6/2/22 at 3:33 p.m., written by RN AA, revealed that P#1's daughter could no longer care for P#1 because of work. RN AA explained to P#1 that he was medically stable, ambulatory, alert, and oriented. RN AA noted she would email resources to P#1's daughter for placement alternatives. Per Osteopathic Doctor (DO), HH and MD GG P#1 was decisional and signed the Against Medical Advice (AMA) form. RN AA offered to provide transportation for P#1, but he declined. P#1 agreed to let the Emergency Medical Technician (EMT) wheel him out to the curb, where P#1 was seen walking the parking lot toward the main road in front of the facility.

A review of a 'Nursing Note' dated 6/2/22 at 3:34 p.m. written by RN FF revealed that P#1 signed the AMA form. P#1 stated, "I don't know where I am going, but I am getting out of here." P#1 refused transport arrangement. DO HH and MD GG evaluated P#1, and P#1's daughter was contacted. P#1 was wheeled off the unit to the facility's parking lot by the discharge nurse.

A review of the 'Discharge Summary,' dated 6/2/22 at 3:55 p.m., written by DO HH and attestation signed by MD GG, revealed that P#1 was admitted for workup and management of a seizure disorder likely due to non-compliance with home seizure medication. Neurology signed off on P#1 with instructions to continue home seizure medications. On the day of discharge, P#1 was adamant about leaving AMA. The discharge summary revealed that P#1 demonstrated the capacity that if he were to leave AMA without medication, he could have another seizure, fall, or even die. P#1 was able to comprehend and repeat everything back. P#1 was alert and oriented to person, place, and time. MD GG evaluated P#1 and agreed with the discharge of P#1. P#1's daughter was notified multiple times, and it was explained that P#1 had the capacity to leave, and the facility could not keep him against his will. P#1's daughter informed the facility that she could not pick up P#1. The facility made it clear to P#1's daughter that P#1 could not stay in the facility against his will, and it was in the best interest of P#1 for his daughter to pick him up and bring him home while trying to find more assistance at home to take care of P#1. Despite multiple attempts, P#1 was discharged AMA at 3:55 p.m., with a seizure medication prescription sent to P#1's pharmacy. P#1's discharge diagnosis was seizures, and P#1's discharge condition was listed as 'stable.' P#1's 'Active Problems' included dementia.

A review of a video monitoring recording provided by the facility, dated 6/2/22 at 3:24 p.m., revealed the following:

3:24:11 P#1 was seen being escorted out of the facility in a wheelchair by an EMT
3:24:19 P#1 got out of the wheelchair under the covered vestibule and walked over to a trashcan located outside the facility (the video does not allow a view of the direction P#1 walked)
3:24:30 EMT was seen standing behind the wheelchair that P#1 had occupied
3:25:22 EMT walked away from the wheelchair and walked further outside the facility
3:25:29 EMT was seen standing outside facing out towards the parking lot
3:26:09 EMT walked further outside the facility, turned to the right, and walked out of view of the camera
3:37:44 EMT was seen coming back into view of the camera. EMT rolled the wheelchair back into the facility.

A continued review revealed additional video recordings from an alternate camera angle. It revealed the following:
3:25:32 P#1 was seen walking down the sidewalk away from the facility
3:26:02 P#1 stepped off the sidewalk and crossed the parking lot, walking towards the right, out of camera view

A continued review of the medical record revealed that P#1 arrived back at the facility's ED on 6/2/22 at 10:25 p.m. for evaluation of altered mental status. An 'ED Provider Note," written by ED BB at 12:17 a.m., revealed that P#1 was found by local law enforcement (LLE) #2 wandering around on the main road that ran along the front of the facility. P#1 was asked where he lived and replied, "I don't know." P#1 was able to confirm that he lived with his daughter. P#1 complained of mild chest pain with shortness of breath when asked. P#1's history was limited secondary to dementia. P#1's daughter reported that she was unable to care for P#1 because of her long hours at work. P#1's daughter reported that P#1 often left their home and wandered around. P#1's neurological exam revealed that P#1 was oriented to person and place. P#1 had difficulty stating the month. He was able to state the year using his fingers. P#1 could follow simple commands. P#1 was a poor historian. P#1 could not recall much of the events following the discharge earlier in the day. P#1's Troponin (type of protein found in the blood when there is heart muscle damage) levels were 587 (normal below 120). P#1 was admitted to inpatient with a stable condition. The ED's final diagnosis was chest pain: unspecified, elevated Troponin, acute kidney injury, and non-ST elevation myocardial infarction (NSTEMI) (a type of heart attack that usually happens when the heart's needs for oxygen cannot be met).

A review of a CM' Progress Note" written 6/3/22 at 1:07 a.m. revealed that P#1's daughter left work after receiving a call that P#1 was discharged AMA earlier in the day. P#1's daughter stated she arrived at the facility and immediately started searching the facility's grounds, "screaming" for her father in the parking garage and parking lots. She later moved the search to the main road that ran along the front of the facility. P#1's daughter drove around for hours and could not locate P#1. P#1's daughter reported she contacted LLE #2 and reported P#1 as a missing and endangered adult with altered mental status, dementia, and seizures. The CM met with P#1 and asked P#1 for his date of birth, but he could not verbalize it. P#1 stated he could write it and wrote "12 22 22." P#1 could not verbalize the city he resided. When CM called out three options, P#1 said "no." When CM called out the correct city P#1 lived in, he said, "That's it." P#1 stated he wanted to go to his mother's home, but when asked what city she lived in, P#1 could not verbalize it. Further review revealed that P#1 appeared to lack the ability to care for himself and make decisions regarding his care, safety, and wellbeing.

A review of the "Discharge Summary Note" dated 6/8/22 at 2:40 p.m. revealed that P#1 was discharged home with home health. Once P#1's insurance was activated, P#1's family was to reach out to P#1's primary care physician (PCP) for a referral for facility admission. P#1 and P#1's daughter agreed with the plan, and prescriptions for all home and new medications were signed and given to P#1. P#1 was to follow up with his PCP in one week. P#1's final discharge diagnosis was acute kidney injury. Active problems included: NSTEMI, seizure, history of stroke, dementia, and major neurocognitive disorder. P#1's discharge condition was "good."

A review of LLE #3 "Reporting Officer Narrative" dated 6/2/22 at 7:19 p.m. revealed that at 7:17 p.m., the officer was dispatched about a missing person's report that involved P#1, occurring at the facility's address around 3:26 p.m. per P#1's daughter. Officers canvased the area and were unable to locate P#1. As a result, a Mattie Call (a law enforcement-initiated system to locate missing elderly or disabled persons) was sent out by dispatch. At 10:24 p.m., an officer was advised by dispatch that P#1 had walked back to the facility. P#1 advised that he was just out wandering around. P#1 appeared coherent and responded to officers. P#1 was turned over to the facility and medical staff. P#1's daughter was advised of the recovery of P#1.

A telephone interview was conducted with the complainant on 6/23/22 at 2:00 p.m. in the facility's conference room. The complainant stated that P#1 had been wandering around for seven hours between when P#1 left AMA and when he was picked up by local law enforcement and taken back to the ED. She stated that P#1 had been picked up by a passerby and driven and dropped off along the expressway. Local law enforcement found him near a grocery store. P#1 had fallen at some point and scrapped his arms, which were bleeding. The complainant stated that P#1 could not recall the event other than P#1 had stopped and got a cup of coffee.

An interview was conducted with Registered Nurse (RN) AA on 6/21/22 at 4:20 p.m. in the conference room. RN AA stated that she was a Case Manager (CM) and had worked at the facility for four years. RN explained that her job as a CM consisted of discharge planning which started upon admission. This included speaking with the patient and his/her family regarding the discharge process and providing resources if needed (placement for rehabilitation facilities or home health). RN AA said that she recalled P#1. She stated that she remembered that P#1's daughter said she could not handle P#1 returning home after discharge. P#1 had a history of alcoholism. Additionally, P#1 wandered away from home. RN AA said she recalled that P#1's physicians told her that P#1 was decisional, alert, and oriented on the day of discharge. RN AA stated that she informed P#1's daughter of this, and the facility did not have a reason to keep P#1 from leaving AMA. P#1 was also medically stable per the physician report. RN AA recalled that P#1's daughter received another call from the facility during their discussion that P#1's daughter needed to come to the facility and pick up P#1. RN AA stated that P#1's daughter was upset. RN AA said that she went to the Discharge Lounge (a room where discharged patients could wait to be picked up) and found P#1 had dressed, stating he wanted to leave the facility. In addition, RN AA said that P#1 did not want the facility to call his daughter and did not want to go back home because his daughter would not want him back. RN AA said she tried to set up transportation for P#1, but he refused. She continued stating that P#1 seemed aware of his decisions and understood the danger of leaving AMA. RN AA said that P#1 had begun to get agitated. RN AA stated that the emergency medical technician (EMT) DD wheeled P#1 out the facility's front door, and P#1 walked across the parking lot to the main road in front of the facility. RN AA stated that she and EMT DD were concerned for P#1's safety, so EMT DD picked up his phone to call 911 to ask if they could pick up P#1 and take him where he needed to go. RN AA stated that she walked into the ED to look for security and ask for their assistance, but there was no one in the security office. RN AA recalled that MD GG and MD HH were in the Discharge Lounge when P#1 wanted to leave AMA. RN AA said that later that day, a Mattie Call had gone out on the news concerning P#1. RN AA said she was unaware that P#1 had a history of dementia.

An interview was conducted with Medical Doctor (MD) BB on 6/21/22 at 4:45 p.m. in the conference room. MD BB stated that she was a contracted physician and had worked in the facility's ED for seven years. MD BB said she provided care to P#1 when he returned to the ED on 6/3/22 around midnight. She recalled that local law enforcement had found P#1 wandering around the main road in front of the facility and brought P#1 back to the ED. P#1 had been without food or water for eight hours. MD BB said that she read P#1's discharge summary from 6/2/22 and recalled talking to a CM (she could not remember the name). MD BB stated that CM said P#1's daughter had said that P#1 was incompetent to make decisions, and P#1's daughter could not come to pick up P#1 from the facility. P#1 was discharged from the facility AMA. MD BB explained that P#1 complained of chest pain and shortness of breath on his second visit to the ED. MD BB said P#1 had difficulty communicating due to a prior stroke. She stated that P#1 was not as oriented at first glance but could answer some questions. MD BB said P#1 knew where he was and who he was and "kind of" knew the year. MD BB stated that she would not have let P#1 leave AMA with P#1's presentation in the ED during the second visit. She continued saying he did not have the capacity to make his own decisions at that time. MD BB stated that many dementia patients seemed okay during the day but worsened in the evenings. She said that when caring for dementia patients, she always involved the family or emergency contact in the discharge planning. CM would also be involved. MD BB explained that if she had a patient who wanted to leave AMA, she would assess their capacity to leave and try to determine why the patient wanted to leave. MD BB stated that she would explain in simple terms the patient's diagnosis and the risk involved in leaving, and then she would have the patient explain it back to her on their terms. In addition, she said that she would ensure that the patient had a safe way to go home and could manage themselves at home.

An interview was conducted with Emergency Medical Technician (EMT) DD on 6/22/21 at 10:55 a.m. in the conference room. EMT DD stated that he had been an EMT for 20 years. He had worked at the facility for three years as an ED technician. As an ED technician, EMT DD stated he helped with blood draws, vital signs, and transporting patients. EMT DD said that he recalled P#1. He explained that he had been called to assist with P#1. When EMT DD approached, P#1 was walking down the hallway, and P#1 wanted to leave the facility. He stated that P#1 was non-compliant, hostile, and difficult to reason with. In addition, he said that P#1 was combative but had not attacked anyone. EMT DD said that he was able to calm P#1 down enough that they entered the Discharge Lounge. Nurses and other technicians tried to convince P#1 to stay, but P#1 became hostile again, using profanity. He explained that P#1 was aggressive, but not to the point he felt threatened. EMT DD stated he was able to calm P#1 once more by explaining that he needed to remove P#1's intravenous (IV) if P#1 wanted to leave. EMT DD said that he stepped out of the Discharge Lounge and informed P#1's doctor (he was unsure of the name) that the situation was escalating rapidly, and that security might need to be called. EMT DD stated that P#1's doctor informed him that P#1 was signing out AMA and P#1 was free to go. EMT DD said that P#1 overheard the conversation and became irate. EMT DD stated he engaged P#1 once more and explained that he could get a wheelchair and escort him out of the facility. P#1 calmed after this. EMT DD stated that while he was getting P#1 into the wheelchair, nurses were still trying to encourage P#1 to stay at the facility. EMT DD said he wheeled P#1 to the Women's Center entrance, and P#1 was using profanity and saying that P#1 felt he was being lied to and held against his will. When they arrived at the entrance, EMT DD tried again to talk P#1 into staying at the facility. EMT DD said he explained to P#1 that it was hot outside, and EMT DD was concerned about P#1 leaving on foot and walking with P#1's medical condition. P#1 replied to him, "mind your own damn business and find something else to do." EMT DD said a nurse (RN AA) came outside after P#1 started to walk away, and she asked him to call 911 to advise them of the situation. EMT DD stated that while he had eyes on P#1, he placed a call to 911. The 911 dispatcher was given P#1's description and P#1's travel route. The dispatcher replied that they were unsure if anything could be done but would see if a patrol car was in the area to locate P#1 and offer assistance. EMT DD said that everyone involved with P#1 agreed it was a bad idea for P#1 to leave AMA. He explained that short of restraining P#1, he felt the staff did everything they could to keep P#1 from leaving the facility. EMT DD explained that P#1 was aware of person, place, and time. EMT DD said that he felt that P#1 was decisional and did not seem confused.

An interview was conducted with Charge Nurse (CN) EE on 6/22/22 at 11:30 a.m. in the conference room. CN EE stated she had been an RN for 17 years and had worked at the facility for four years. CN EE said that she recalled P#1. She explained that P#1's daughter and granddaughter had visited P#1 and told P#1 that he could not return home after discharge. About one to two hours later, P#1 dressed and told staff that he was leaving the facility. CN EE said that P#1's daughter was notified and was asked to come to the facility because P#1 wanted to leave AMA. P#1's daughter replied that she could not go and pick up P#1 but would call her brother and see if he could come. CN EE stated that P#1 started to walk down the hallway, and they redirected him to allow time for P#1's doctor (she could not recall the name) to come and talk with P#1. She explained that a total of six employees were speaking with P#1 and trying to talk him into staying at the facility. CN EE stated that P#1 said he would go where he wanted to go and get an Uber ride. P#1 was insistent on leaving the facility. CN EE said that P#1 was alert and oriented at the time of discharge. P#1 knew his name, his birth date, and where he was at the moment. She explained that P#1's doctor (could not recall the name) talked to P#1 to ensure that he could answer questions appropriately.

An interview was conducted with RN FF on 6/22/22 at 12:45 p.m. in the conference room. RN FF stated that she had been an RN for five years and had worked at the facility for a year. RN FF explained that she was P#1's nurse when he left AMA. She continued to explain that P#1's daughter and granddaughter had visited P#1 and informed P#1 that he could not return to their home after discharge and would have to go to a rehabilitation facility or another care facility. She recalled that P#1 was teary and seemed sad. She continued explaining that after P#1's family had left, Physical Therapy (PT) assisted P#1 into a chair. RN FF stated that P#1 said, "What am I doing here?". P#1 tried to remove his IV because he wanted to leave the facility. P#1 did not know where he was going but wanted to leave. She recalled that P#1 said he only had one dollar in his pocket. RN FF said that she assessed P#1 for his knowledge of person, place, and time and he was aware of all three. She explained that she then messaged P#1's doctor (she could not recall the name) to inform him of P#1's intentions to leave. RN FF said P#1 commented that he knew his rights and that the facility could not keep him against his will. She stated that staff tried to stall P#1 from leaving by redirecting him to another hallway. At one point, P#1 figured this out and started getting agitated and said he didn't know why they were trying to keep him. RN FF stated that security was on the scene and was able to calm P#1 down. RN FF said she worried P#1 would fall because he had an unsteady gait. She explained that she was not comfortable with him ambulating by himself. P#1 was offered transportation, but P#1 declined. RN FF remembered that CN EE and DO HH had both called and spoke to P#1's daughter, informing her that P#1 was trying to leave. P#1's daughter could not come and pick P#1 up because she was at work and was over an hour away.

An interview was conducted with DO HH on 6/22/22 at 2:00 p.m. in the conference room. MD HH stated that he recalled P#1. He said that P#1 wanted to leave AMA. MD HH said that P#1 was alert and oriented. MD HH explained that P#1 was knowledgeable on why he was in the facility and was aware of the risk of leaving AMA. MD HH stated that P#1 was made aware of the risk of having another seizure or even dying, and P#1 verbalized his understanding. MD HH said that he and MD GG assessed P#1 for capacity and agreed that P#1 could make decisions for himself. MD HH said that P#1's daughter was notified, and she could not come and pick up P#1. He said she was informed that P#1 was medically stable and that P#1 had the capacity to make his own decisions. Therefore, they could not keep P#1 against his will.

An interview was conducted with Medical Director of Quality and Safety (MD) LL on 6/23/22 at 10:40 a.m. in the conference room. MD LL stated he had held the position for one year and also worked as a hospitalist within the facility. MD LL said that as the Medical Director of Quality and Safety, he focused on quality improvement and patient safety. He explained that a safe discharge was one in which the physician felt the patient was medically appropriate for discharge. He further explained that medically appropriate meant that there was no longer anything that could be completed in the hospital that the patient, or outside resources, could not do at the patient's home. MD LL continued to explain that any physician could evaluate medical decision capacity, but the attending physician would make the final decision. Medical decision capacity was completed by asking the patient questions to ensure that the patient could understand his/her medical problems and conditions. The patient also needed to understand the risk and benefits of the decision he/she was making. Additionally, the physician assessed the patient's orientation of person, place, and time. He explained that even though a patient may have a history of dementia or Alzheimer's, the patient could still have medical decision-making capacity and decide to leave AMA. The physician would evaluate and determine medical decision capacity at the time the patient wanted to leave the facility. MD LL explained that if a patient were deemed not to have medical decision capacity, the patient would be put on a medical hold.

A follow-up telephone interview was conducted with DO HH on 6/23/22 at 12:07 p.m. in the conference room. DO HH stated that he reviewed P#1's medical record, including the PT notes, prior to P#1 leaving AMA. He stated he also spoke to the CM (he could not recall the name). DO HH said the mental capacity assessment was usually done at the patient's bedside, but P#1 was in the hallway wanting to leave. He explained that even if the patient had issues with mental capacity earlier in the day, he would still let the patient leave if the assessment concluded that the patient had medical decision capacity. DO HH explained, "especially in this incident because he was trying to leave quickly, and he was agitated, and security was involved." DO HH said that P#1 told him he would go to his parent's house or a friend once he was discharged. DO HH explained that a safe discharge meant the patient was medically stable and had a safe place to go after discharge.

A review of the facility's Complaint and Grievance Log dated 6/1/22 to 6/18/22 revealed there was a grievance for P#2 that was entered on 6/3/22.

A review of the grievance for P#2 revealed that P#2's family member informed ED staff that P#2 had a history of dementia on arrival at the facility. P#2 was discharged from the facility without notifying P#2's family. P#2 left the facility on foot. At some point, P#2 was driven to a family member's home in another county by local law enforcement. P#2's family member was able to contact the family member whom P#2 lived with, and she was picked up and taken to her home address.

A review of a response letter to P#2's grievance, dated 6/6/22, written by MD NN, and sent to P#2's family member, revealed that the letter stated, "I also regret to hear we did not ensure a safe discharge plan upon your release."

A review of an Emergency Medical Services (EMS) report revealed that P#2 was a 63-year-old with complaints of chest pain. EMS arrived on the scene on 5/28/22 at 5:11 a.m. and found P#2 ambulating in the driveway to the ambulance. P#2 was alert and oriented.

A medical record review revealed that P#2 arrived via EMS at the facility on 5/28/22 at 6:25 a.m. with a chief complaint of chest pain. An ED provider note at 6:38 a.m. revealed that P#2 had a past medical history of high blood pressure and Alzheimer's Disease (progressive disease that destroys memory and other important memory functions). P#2's neurological assessment was negative (normal) for confusion. P#2 was alert and oriented to person, place, and time. P#2's thought content was normal. At 8:00 a.m., a note was added that P#2 was capable of making medical decisions. P#2 was admitted for observation and stress testing since P#2's cardiac workup in the ED was negative.

A review of an 'Emergency Observation Unit Note' dated 5/28/22 at 9:26 a.m. by Family Nurse Practitioner (FNP) MM revealed that P#2 had a medical history of Alzheimer's Disease. A physical exam revealed that P#2 was alert. P#2's echocardiogram (medical test to check heart rhythm and blood flow through the heart) was normal, as well as her repeated cardiac enzymes (blood test to check stress of the heart). P#2 was asymptomatic with stable vital signs. The recommendation was to discharge P#2 with follow-up with P#2's primary care provider and return to the ED with new or worsening symptoms.

A review of a Nursing Assessment at 12:06 p.m. revealed that P#2 was oriented to person, place, time, and situation. In addition, p #2 was alert, and her speech was clear.

A review of the flowsheet from P#2's medical record revealed that at 2:50 p.m., discharge instructions were reviewed and signed by P#2. A copy was given to P#2, and she acknowledged understanding. The patient care technician (PCT) was notified that P#2 was ready for discharge. P#2 stated she was waiting for her ride.

A review of a video monitoring recording provided by the facility, dated 5/28/22 at 2:59 p.m., revealed the following:

3:14:07 P#2 walked out of the facility, escorted by an unknown staff member
3:14:13 P#2 walked to the left past the unknown staff member. The unknown staff member was seen standing outside the facility's vestibule.
3:14:17 The unknown staff member turned and walked back into the facility

A review of local law enforcement (LLE) #1 "Incident Detail Report, revealed that on 5/28/22 at 5:21 p.m., a call was received from LLE #2. A review of the 'comments' revealed that a woman came up to the post, stating she had just got released from the hospital and that she was walking to another county. The female had the hospital tag on her wrist and "seemed completely out of it." The female was given a ride to the county closest to the one she said she was walking to. The female did not know the address but could tell the police officer how to get there. The female was dropped off at a family member's residence at 6:36 p.m.

An interview was conducted with Medical Director of Emergency Medicine (MD) NN on 6/23/22 at 1:39 p.m. MD NN stated he had held the position for three and a half years. He explained that he reviewed the medical record for P#2 and wrote the response letter to P#2's family from their filed grievance. When asked about the sentence in the letter that stated, "I also regret to hear we did not ensure a safe discharge plan upon your release," MD NN said it was a wording error on his part. He explained that he should have written instead what the complainant/patient felt was considered a safe discharge. MD NN explained that patients with dementia could function normally. If the patient were alert to person, place, and time and was of sound decision making at the time of discharge, he would allow the patient to leave the facility. He continued to say that a safe discharge was considered when the emergent medical condition had been stab

Based on a review of medical records, video recordings, local law enforcement reports, interviews with facility staff, an interview with the complainant, an interview with the patient's family, and a review of policies and procedures, it was determined that the facility failed to promote and protect the rights of two out of five sampled patients (P) (P#1 and P#2).

Cross-reference A0144 Patient Rights: Care in a Safe Setting, as it relates to the facility failing to ensure P#1 and P#2 received care in a safe setting when both were inappropriately discharged. P#1 was returned to the facility ED by local law enforcment after being found wandering the community. P#2 was provided transportation home by local law enforcement after presenting to a local post seeking assistance.

Based on a review of medical records, video recordings, local law enforcement reports, interviews with facility staff, an interview with the complainant, and an interview with the patient's family, a review of policies and procedures, it was determined that the facility failed to ensure that two out of five sampled patients (P) (P#1 and P#2) received care in a safe setting. Specifically, the facility failed to ensure that P#1 and P#2 were appropriately discharged.

Findings:

A review of the facility's Emergency Department (ED) Log revealed that P#1 arrived at the ED on 5/31/22 at 11:44 a.m. with a chief complaint of seizures and an ED disposition of 'Admit to Inpatient or Observation.' Continued review revealed that P#1 arrived at the ED again on 6/2/22 at 10:26 p.m. with a chief complaint of Altered Mental Status and an ED disposition as 'Admit to Inpatient or Observation".

A medical record review revealed that P#1 was a 65-year-old who presented to the emergency department (ED) via emergency medical services (EMS) on 5/31/22 at 11:44 a.m. after a seizure was witnessed at home.

A review of an 'ED Provider Note" at 12:48 p.m. revealed that P#1 was only responsive to pain when EMS arrived on the scene. P#1 had a past medical history of a seizure disorder, high blood pressure, previous stroke, and alcohol abuse with withdrawal. P#1's family was unavailable in the ED, so limited history was obtained. A neurological exam indicated that P#1 was somnolent (drowsy, sleepy) and arousable to significant tactile stimulation. A further review revealed that P#1's daughter later stated that P#1 was non-compliant with medication. P#1's daughter said she did not believe P#1 was still drinking. She also voiced concerns about not being able to care for P#1 at home. The ED diagnosis was seizures, non-compliance with medication regimen, and encephalopathy (broad term used for any brain disease that alters brain function or structure). P#1 was admitted for observation and possible placement.

A review of a 'History and Physical Notes' at 4:31 p.m. revealed that P#1 was arousable to verbal commands and conversing appropriately upon evaluation. P#1 was alert and oriented x 1 (to person only). P#1 had five out of five strength in both upper and lower extremities. P#1's daughter stated that P#1 had been forgetful for the past two years and had progressively gotten worse. The 'Review of Systems' revealed that P#1's neurological exam was positive for altered mental status and seizures. P#1 had a history of dementia. Additionally, P#1's daughter thought P#1 might have been experiencing some falls because she found some blood on the floor a week or so ago. The note revealed that P#1 was taking Seroquel (antipsychotic) nightly, and he lived with his daughter. A need for discharge planning was indicated. A further review of the 'History and Physical Notes' at 4:45 p.m., written by the Attending Physician, Medical Doctor (MD) GG, revealed that P#1 was at a baseline confusion at home. MD GG suspected the seizure was due to alcohol withdrawal vs. marijuana.

A review of the 'Case Management Initial Discharge Planning,' written by Registered Nurse (RN) CC at 8:40 p.m., revealed that P#1 had been living with P#1's daughter and required assistance with daily living activities. P#1 could ambulate but had experienced some falls. P#1 had a walker at home but refused to use it. P#1 had a history of smoking and had started two fires. P#1's daughter had expressed that she was unable to provide the care and assistance that P#1 needed. P#1's anticipated discharge was to a long-term care facility, and medical transport would be needed.

A review of a Physical Therapy (PT) note dated 6/1/22 at 2:19 p.m. revealed that discharge considerations included 24/7 supervision due to safety concerns with fall risk. P#1 was oriented to person but was disoriented to situation, time, and place.

A review of the plan of care dated 6/1/22 at 6:00 p.m. revealed 'safety falls' and 'knowledge deficit' as problems for P#1.

A review of a PT note dated 6/2/22 at 11:55 a.m. revealed that P#1's overall cognitive status was impaired. P#1 had a decreased recall of biographical information and a deceased recall of recent events. P#1 was oriented to person and place. P#1 became fatigued quickly during dynamic standing balance and required seated resting breaks. Additionally, P#1 required assistance with his gait (manner of walking). General comments on the note revealed that P#1 became tearful and agitated during the PT session stating, "I don't know what the hell is wrong with me. They won't tell me. I just woke up, and I was right here. If I'm nuts, tell me dammit".

A review of a 'Nursing Note' dated 6/2/22 at 3:18 p.m., written by Charge Nurse (CN) EE, revealed that P#1 stated that he was going to call home and would call for a car service to pick him up. P#1 was alert and oriented and was adamant about leaving. A physician (did not indicate the physician's name) came to speak to P#1. After speaking to P#1, he still refused to stay.

A review of the 'Case Management Final Discharge Transition,' dated 6/2/22 at 3:33 p.m., written by RN AA, revealed that P#1's daughter could no longer care for P#1 because of work. RN AA explained to P#1 that he was medically stable, ambulatory, alert, and oriented. RN AA noted she would email resources to P#1's daughter for placement alternatives. Per Osteopathic Doctor (DO), HH and MD GG P#1 was decisional and signed the Against Medical Advice (AMA) form. RN AA offered to provide transportation for P#1, but he declined. P#1 agreed to let the Emergency Medical Technician (EMT) wheel him out to the curb, where P#1 was seen walking the parking lot toward the main road in front of the facility.

A review of a 'Nursing Note' dated 6/2/22 at 3:34 p.m. written by RN FF revealed that P#1 signed the AMA form. P#1 stated, "I don't know where I am going, but I am getting out of here." P#1 refused transport arrangement. DO HH and MD GG evaluated P#1, and P#1's daughter was contacted. P#1 was wheeled off the unit to the facility's parking lot by the discharge nurse.

A review of the 'Discharge Summary,' dated 6/2/22 at 3:55 p.m., written by DO HH and attestation signed by MD GG, revealed that P#1 was admitted for workup and management of a seizure disorder likely due to non-compliance with home seizure medication. Neurology signed off on P#1 with instructions to continue home seizure medications. On the day of discharge, P#1 was adamant about leaving AMA. The discharge summary revealed that P#1 demonstrated the capacity that if he were to leave AMA without medication, he could have another seizure, fall, or even die. P#1 was able to comprehend and repeat everything back. P#1 was alert and oriented to person, place, and time. MD GG evaluated P#1 and agreed with the discharge of P#1. P#1's daughter was notified multiple times, and it was explained that P#1 had the capacity to leave, and the facility could not keep him against his will. P#1's daughter informed the facility that she could not pick up P#1. The facility made it clear to P#1's daughter that P#1 could not stay in the facility against his will, and it was in the best interest of P#1 for his daughter to pick him up and bring him home while trying to find more assistance at home to take care of P#1. Despite multiple attempts, P#1 was discharged AMA at 3:55 p.m., with a seizure medication prescription sent to P#1's pharmacy. P#1's discharge diagnosis was seizures, and P#1's discharge condition was listed as 'stable.' P#1's 'Active Problems' included dementia.

A review of a video monitoring recording provided by the facility, dated 6/2/22 at 3:24 p.m., revealed the following:

3:24:11 P#1 was seen being escorted out of the facility in a wheelchair by an EMT
3:24:19 P#1 got out of the wheelchair under the covered vestibule and walked over to a trashcan located outside the facility (the video does not allow a view of the direction P#1 walked)
3:24:30 EMT was seen standing behind the wheelchair that P#1 had occupied
3:25:22 EMT walked away from the wheelchair and walked further outside the facility
3:25:29 EMT was seen standing outside facing out towards the parking lot
3:26:09 EMT walked further outside the facility, turned to the right, and walked out of view of the camera
3:37:44 EMT was seen coming back into view of the camera. EMT rolled the wheelchair back into the facility.

A continued review revealed additional video recordings from an alternate camera angle. It revealed the following:
3:25:32 P#1 was seen walking down the sidewalk away from the facility
3:26:02 P#1 stepped off the sidewalk and crossed the parking lot, walking towards the right, out of camera view

A continued review of the medical record revealed that P#1 arrived back at the facility's ED on 6/2/22 at 10:25 p.m. for evaluation of altered mental status. An 'ED Provider Note," written by ED BB at 12:17 a.m., revealed that P#1 was found by local law enforcement (LLE) #2 wandering around on the main road that ran along the front of the facility. P#1 was asked where he lived and replied, "I don't know." P#1 was able to confirm that he lived with his daughter. P#1 complained of mild chest pain with shortness of breath when asked. P#1's history was limited secondary to dementia. P#1's daughter reported that she was unable to care for P#1 because of her long hours at work. P#1's daughter reported that P#1 often left their home and wandered around. P#1's neurological exam revealed that P#1 was oriented to person and place. P#1 had difficulty stating the month. He was able to state the year using his fingers. P#1 could follow simple commands. P#1 was a poor historian. P#1 could not recall much of the events following the discharge earlier in the day. P#1's Troponin (type of protein found in the blood when there is heart muscle damage) levels were 587 (normal below 120). P#1 was admitted to inpatient with a stable condition. The ED's final diagnosis was chest pain: unspecified, elevated Troponin, acute kidney injury, and non-ST elevation myocardial infarction (NSTEMI) (a type of heart attack that usually happens when the heart's needs for oxygen cannot be met).

A review of a CM' Progress Note" written 6/3/22 at 1:07 a.m. revealed that P#1's daughter left work after receiving a call that P#1 was discharged AMA earlier in the day. P#1's daughter stated she arrived at the facility and immediately started searching the facility's grounds, "screaming" for her father in the parking garage and parking lots. She later moved the search to the main road that ran along the front of the facility. P#1's daughter drove around for hours and could not locate P#1. P#1's daughter reported she contacted LLE #2 and reported P#1 as a missing and endangered adult with altered mental status, dementia, and seizures. The CM met with P#1 and asked P#1 for his date of birth, but he could not verbalize it. P#1 stated he could write it and wrote "12 22 22." P#1 could not verbalize the city he resided. When CM called out three options, P#1 said "no." When CM called out the correct city P#1 lived in, he said, "That's it." P#1 stated he wanted to go to his mother's home, but when asked what city she lived in, P#1 could not verbalize it. Further review revealed that P#1 appeared to lack the ability to care for himself and make decisions regarding his care, safety, and wellbeing.

A review of the "Discharge Summary Note" dated 6/8/22 at 2:40 p.m. revealed that P#1 was discharged home with home health. Once P#1's insurance was activated, P#1's family was to reach out to P#1's primary care physician (PCP) for a referral for facility admission. P#1 and P#1's daughter agreed with the plan, and prescriptions for all home and new medications were signed and given to P#1. P#1 was to follow up with his PCP in one week. P#1's final discharge diagnosis was acute kidney injury. Active problems included: NSTEMI, seizure, history of stroke, dementia, and major neurocognitive disorder. P#1's discharge condition was "good."

A review of LLE #3 "Reporting Officer Narrative" dated 6/2/22 at 7:19 p.m. revealed that at 7:17 p.m., the officer was dispatched about a missing person's report that involved P#1, occurring at the facility's address around 3:26 p.m. per P#1's daughter. Officers canvased the area and were unable to locate P#1. As a result, a Mattie Call (a law enforcement-initiated system to locate missing elderly or disabled persons) was sent out by dispatch. At 10:24 p.m., an officer was advised by dispatch that P#1 had walked back to the facility. P#1 advised that he was just out wandering around. P#1 appeared coherent and responded to officers. P#1 was turned over to the facility and medical staff. P#1's daughter was advised of the recovery of P#1.

A telephone interview was conducted with the complainant on 6/23/22 at 2:00 p.m. in the facility's conference room. The complainant stated that P#1 had been wandering around for seven hours between when P#1 left AMA and when he was picked up by local law enforcement and taken back to the ED. She stated that P#1 had been picked up by a passerby and driven and dropped off along the expressway. Local law enforcement found him near a grocery store. P#1 had fallen at some point and scrapped his arms, which were bleeding. The complainant stated that P#1 could not recall the event other than P#1 had stopped and got a cup of coffee.

An interview was conducted with Registered Nurse (RN) AA on 6/21/22 at 4:20 p.m. in the conference room. RN AA stated that she was a Case Manager (CM) and had worked at the facility for four years. RN explained that her job as a CM consisted of discharge planning which started upon admission. This included speaking with the patient and his/her family regarding the discharge process and providing resources if needed (placement for rehabilitation facilities or home health). RN AA said that she recalled P#1. She stated that she remembered that P#1's daughter said she could not handle P#1 returning home after discharge. P#1 had a history of alcoholism. Additionally, P#1 wandered away from home. RN AA said she recalled that P#1's physicians told her that P#1 was decisional, alert, and oriented on the day of discharge. RN AA stated that she informed P#1's daughter of this, and the facility did not have a reason to keep P#1 from leaving AMA. P#1 was also medically stable per the physician report. RN AA recalled that P#1's daughter received another call from the facility during their discussion that P#1's daughter needed to come to the facility and pick up P#1. RN AA stated that P#1's daughter was upset. RN AA said that she went to the Discharge Lounge (a room where discharged patients could wait to be picked up) and found P#1 had dressed, stating he wanted to leave the facility. In addition, RN AA said that P#1 did not want the facility to call his daughter and did not want to go back home because his daughter would not want him back. RN AA said she tried to set up transportation for P#1, but he refused. She continued stating that P#1 seemed aware of his decisions and understood the danger of leaving AMA. RN AA said that P#1 had begun to get agitated. RN AA stated that the emergency medical technician (EMT) DD wheeled P#1 out the facility's front door, and P#1 walked across the parking lot to the main road in front of the facility. RN AA stated that she and EMT DD were concerned for P#1's safety, so EMT DD picked up his phone to call 911 to ask if they could pick up P#1 and take him where he needed to go. RN AA stated that she walked into the ED to look for security and ask for their assistance, but there was no one in the security office. RN AA recalled that MD GG and MD HH were in the Discharge Lounge when P#1 wanted to leave AMA. RN AA said that later that day, a Mattie Call had gone out on the news concerning P#1. RN AA said she was unaware that P#1 had a history of dementia.

An interview was conducted with Medical Doctor (MD) BB on 6/21/22 at 4:45 p.m. in the conference room. MD BB stated that she was a contracted physician and had worked in the facility's ED for seven years. MD BB said she provided care to P#1 when he returned to the ED on 6/3/22 around midnight. She recalled that local law enforcement had found P#1 wandering around the main road in front of the facility and brought P#1 back to the ED. P#1 had been without food or water for eight hours. MD BB said that she read P#1's discharge summary from 6/2/22 and recalled talking to a CM (she could not remember the name). MD BB stated that CM said P#1's daughter had said that P#1 was incompetent to make decisions, and P#1's daughter could not come to pick up P#1 from the facility. P#1 was discharged from the facility AMA. MD BB explained that P#1 complained of chest pain and shortness of breath on his second visit to the ED. MD BB said P#1 had difficulty communicating due to a prior stroke. She stated that P#1 was not as oriented at first glance but could answer some questions. MD BB said P#1 knew where he was and who he was and "kind of" knew the year. MD BB stated that she would not have let P#1 leave AMA with P#1's presentation in the ED during the second visit. She continued saying he did not have the capacity to make his own decisions at that time. MD BB stated that many dementia patients seemed okay during the day but worsened in the evenings. She said that when caring for dementia patients, she always involved the family or emergency contact in the discharge planning. CM would also be involved. MD BB explained that if she had a patient who wanted to leave AMA, she would assess their capacity to leave and try to determine why the patient wanted to leave. MD BB stated that she would explain in simple terms the patient's diagnosis and the risk involved in leaving, and then she would have the patient explain it back to her on their terms. In addition, she said that she would ensure that the patient had a safe way to go home and could manage themselves at home.

An interview was conducted with Emergency Medical Technician (EMT) DD on 6/22/21 at 10:55 a.m. in the conference room. EMT DD stated that he had been an EMT for 20 years. He had worked at the facility for three years as an ED technician. As an ED technician, EMT DD stated he helped with blood draws, vital signs, and transporting patients. EMT DD said that he recalled P#1. He explained that he had been called to assist with P#1. When EMT DD approached, P#1 was walking down the hallway, and P#1 wanted to leave the facility. He stated that P#1 was non-compliant, hostile, and difficult to reason with. In addition, he said that P#1 was combative but had not attacked anyone. EMT DD said that he was able to calm P#1 down enough that they entered the Discharge Lounge. Nurses and other technicians tried to convince P#1 to stay, but P#1 became hostile again, using profanity. He explained that P#1 was aggressive, but not to the point he felt threatened. EMT DD stated he was able to calm P#1 once more by explaining that he needed to remove P#1's intravenous (IV) if P#1 wanted to leave. EMT DD said that he stepped out of the Discharge Lounge and informed P#1's doctor (he was unsure of the name) that the situation was escalating rapidly, and that security might need to be called. EMT DD stated that P#1's doctor informed him that P#1 was signing out AMA and P#1 was free to go. EMT DD said that P#1 overheard the conversation and became irate. EMT DD stated he engaged P#1 once more and explained that he could get a wheelchair and escort him out of the facility. P#1 calmed after this. EMT DD stated that while he was getting P#1 into the wheelchair, nurses were still trying to encourage P#1 to stay at the facility. EMT DD said he wheeled P#1 to the Women's Center entrance, and P#1 was using profanity and saying that P#1 felt he was being lied to and held against his will. When they arrived at the entrance, EMT DD tried again to talk P#1 into staying at the facility. EMT DD said he explained to P#1 that it was hot outside, and EMT DD was concerned about P#1 leaving on foot and walking with P#1's medical condition. P#1 replied to him, "mind your own damn business and find something else to do." EMT DD said a nurse (RN AA) came outside after P#1 started to walk away, and she asked him to call 911 to advise them of the situation. EMT DD stated that while he had eyes on P#1, he placed a call to 911. The 911 dispatcher was given P#1's description and P#1's travel route. The dispatcher replied that they were unsure if anything could be done but would see if a patrol car was in the area to locate P#1 and offer assistance. EMT DD said that everyone involved with P#1 agreed it was a bad idea for P#1 to leave AMA. He explained that short of restraining P#1, he felt the staff did everything they could to keep P#1 from leaving the facility. EMT DD explained that P#1 was aware of person, place, and time. EMT DD said that he felt that P#1 was decisional and did not seem confused.

An interview was conducted with Charge Nurse (CN) EE on 6/22/22 at 11:30 a.m. in the conference room. CN EE stated she had been an RN for 17 years and had worked at the facility for four years. CN EE said that she recalled P#1. She explained that P#1's daughter and granddaughter had visited P#1 and told P#1 that he could not return home after discharge. About one to two hours later, P#1 dressed and told staff that he was leaving the facility. CN EE said that P#1's daughter was notified and was asked to come to the facility because P#1 wanted to leave AMA. P#1's daughter replied that she could not go and pick up P#1 but would call her brother and see if he could come. CN EE stated that P#1 started to walk down the hallway, and they redirected him to allow time for P#1's doctor (she could not recall the name) to come and talk with P#1. She explained that a total of six employees were speaking with P#1 and trying to talk him into staying at the facility. CN EE stated that P#1 said he would go where he wanted to go and get an Uber ride. P#1 was insistent on leaving the facility. CN EE said that P#1 was alert and oriented at the time of discharge. P#1 knew his name, his birth date, and where he was at the moment. She explained that P#1's doctor (could not recall the name) talked to P#1 to ensure that he could answer questions appropriately.

An interview was conducted with RN FF on 6/22/22 at 12:45 p.m. in the conference room. RN FF stated that she had been an RN for five years and had worked at the facility for a year. RN FF explained that she was P#1's nurse when he left AMA. She continued to explain that P#1's daughter and granddaughter had visited P#1 and informed P#1 that he could not return to their home after discharge and would have to go to a rehabilitation facility or another care facility. She recalled that P#1 was teary and seemed sad. She continued explaining that after P#1's family had left, Physical Therapy (PT) assisted P#1 into a chair. RN FF stated that P#1 said, "What am I doing here?". P#1 tried to remove his IV because he wanted to leave the facility. P#1 did not know where he was going but wanted to leave. She recalled that P#1 said he only had one dollar in his pocket. RN FF said that she assessed P#1 for his knowledge of person, place, and time and he was aware of all three. She explained that she then messaged P#1's doctor (she could not recall the name) to inform him of P#1's intentions to leave. RN FF said P#1 commented that he knew his rights and that the facility could not keep him against his will. She stated that staff tried to stall P#1 from leaving by redirecting him to another hallway. At one point, P#1 figured this out and started getting agitated and said he didn't know why they were trying to keep him. RN FF stated that security was on the scene and was able to calm P#1 down. RN FF said she worried P#1 would fall because he had an unsteady gait. She explained that she was not comfortable with him ambulating by himself. P#1 was offered transportation, but P#1 declined. RN FF remembered that CN EE and DO HH had both called and spoke to P#1's daughter, informing her that P#1 was trying to leave. P#1's daughter could not come and pick P#1 up because she was at work and was over an hour away.

An interview was conducted with DO HH on 6/22/22 at 2:00 p.m. in the conference room. MD HH stated that he recalled P#1. He said that P#1 wanted to leave AMA. MD HH said that P#1 was alert and oriented. MD HH explained that P#1 was knowledgeable on why he was in the facility and was aware of the risk of leaving AMA. MD HH stated that P#1 was made aware of the risk of having another seizure or even dying, and P#1 verbalized his understanding. MD HH said that he and MD GG assessed P#1 for capacity and agreed that P#1 could make decisions for himself. MD HH said that P#1's daughter was notified, and she could not come and pick up P#1. He said she was informed that P#1 was medically stable, and that P#1 had the capacity to make his own decisions. Therefore, they could not keep P#1 against his will.

An interview was conducted with Medical Director of Quality and Safety (MD) LL on 6/23/22 at 10:40 a.m. in the conference room. MD LL stated he had held the position for one year and also worked as a hospitalist within the facility. MD LL said that as the Medical Director of Quality and Safety, he focused on quality improvement and patient safety. He explained that a safe discharge was one in which the physician felt the patient was medically appropriate for discharge. He further explained that medically appropriate meant that there was no longer anything that could be completed in the hospital that the patient, or outside resources, could not do at the patient's home. MD LL continued to explain that any physician could evaluate medical decision capacity, but the attending physician would make the final decision. Medical decision capacity was completed by asking the patient questions to ensure that the patient could understand his/her medical problems and conditions. The patient also needed to understand the risk and benefits of the decision he/she was making. Additionally, the physician assessed the patient's orientation of person, place, and time. He explained that even though a patient may have a history of dementia or Alzheimer's, the patient could still have medical decision-making capacity and decide to leave AMA. The physician would evaluate and determine medical decision capacity at the time the patient wanted to leave the facility. MD LL explained that if a patient were deemed not to have medical decision capacity, the patient would be put on a medical hold.

A follow-up telephone interview was conducted with DO HH on 6/23/22 at 12:07 p.m. in the conference room. DO HH stated that he reviewed P#1's medical record, including the PT notes, prior to P#1 leaving AMA. He stated he also spoke to the CM (he could not recall the name). DO HH said the mental capacity assessment was usually done at the patient's bedside, but P#1 was in the hallway wanting to leave. He explained that even if the patient had issues with mental capacity earlier in the day, he would still let the patient leave if the assessment concluded that the patient had medical decision capacity. DO HH explained, "especially in this incident because he was trying to leave quickly, and he was agitated, and security was involved." DO HH said that P#1 told him he would go to his parent's house or a friend once he was discharged. DO HH explained that a safe discharge meant the patient was medically stable and had a safe place to go after discharge.

A review of the facility's Complaint and Grievance Log dated 6/1/22 to 6/18/22 revealed there was a grievance for P#2 that was entered on 6/3/22.

A review of the grievance for P#2 revealed that P#2's family member informed ED staff that P#2 had a history of dementia on arrival at the facility. P#2 was discharged from the facility without notifying P#2's family. P#2 left the facility on foot. At some point, P#2 was driven to a family member's home in another county by local law enforcement. P#2's family member was able to contact the family member whom P#2 lived with, and she was picked up and taken to her home address.

A review of a response letter to P#2's grievance, dated 6/6/22, written by MD NN, and sent to P#2's family member, revealed that the letter stated, "I also regret to hear we did not ensure a safe discharge plan upon your release."

A review of an Emergency Medical Services (EMS) report revealed that P#2 was a 63-year-old with complaints of chest pain. EMS arrived on the scene on 5/28/22 at 5:11 a.m. and found P#2 ambulating in the driveway to the ambulance. P#2 was alert and oriented.

A medical record review revealed that P#2 arrived via EMS at the facility on 5/28/22 at 6:25 a.m. with a chief complaint of chest pain. An ED provider note at 6:38 a.m. revealed that P#2 had a past medical history of high blood pressure and Alzheimer's Disease (progressive disease that destroys memory and other important memory functions). P#2's neurological assessment was negative (normal) for confusion. P#2 was alert and oriented to person, place, and time. P#2's thought content was normal. At 8:00 a.m., a note was added that P#2 was capable of making medical decisions. P#2 was admitted for observation and stress testing since P#2's cardiac workup in the ED was negative.

A review of an 'Emergency Observation Unit Note' dated 5/28/22 at 9:26 a.m. by Family Nurse Practitioner (FNP) MM revealed that P#2 had a medical history of Alzheimer's Disease. A physical exam revealed that P#2 was alert. P#2's echocardiogram (medical test to check heart rhythm and blood flow through the heart) was normal, as well as her repeated cardiac enzymes (blood test to check stress of the heart). P#2 was asymptomatic with stable vital signs. The recommendation was to discharge P#2 with follow-up with P#2's primary care provider and return to the ED with new or worsening symptoms.

A review of the flowsheet from P#2's medical record revealed that at 2:50 p.m., discharge instructions were reviewed and signed by P#2. A copy was given to P#2, and she acknowledged understanding. The patient care technician (PCT) was notified that P#2 was ready for discharge. P#2 stated she was waiting for her ride.

A review of a video monitoring recording provided by the facility, dated 5/28/22 at 2:59 p.m., revealed the following:

3:14:07 P#2 walked out of the facility, escorted by an unknown staff member
3:14:13 P#2 walked to the left past the unknown staff member. The unknown staff member was seen standing outside the facility's vestibule.
3:14:17 The unknown staff member turned and walked back into the facility

A review of local law enforcement (LLE) #1 "Incident Detail Report, revealed that on 5/28/22 at 5:21 p.m., a call was received from LLE #2. A review of the 'comments' revealed that a woman came up to the post, stating she had just got released from the hospital and that she was walking to another county. The female had the hospital tag on her wrist and "seemed completely out of it." The female was given a ride to the county closest to the one she said she was walking to. The female did not know the address but could tell the police officer how to get there. The female was dropped off at a family member's residence at 6:36 p.m.

An interview was conducted with Medical Director of Emergency Medicine (MD) NN on 6/23/22 at 1:39 p.m. MD NN stated he had held the position for three and a half years. He explained that he reviewed the medical record for P#2 and wrote the response letter to P#2's family from their filed grievance. When asked about the sentence in the letter that stated, "I also regret to hear we did not ensure a safe discharge plan upon your release," MD NN said it was a wording error on his part. He explained that he should have written instead what the complainant/patient felt was considered a safe discharge. MD NN explained that patients with dementia could function normally. If the patient were alert to person, place, and time and was of sound decision making at the time of discharge, he would allow the patient to leave the facility. He continued to say that a safe discharge was considered when the emergent medical condition had been stabilized, the patient had decision-making capacity, the patient was aware of the risk and benefits of leaving, transportation had been arranged for the patient, and medications or outside therapies had been arranged.

A telephone interview was conducted with RN OO on 6/23/22 at 3:30 p.m.

Based on a review of medical records, video recordings, local law enforcement reports, interviews with facility staff, an interview with the complainant, an interview with the patient's family, and a review of policies and procedures, it was determined that the facility failed to ensure an effective transition for two out of five sampled patients (P) (P#1 and P#2) from the hospital to post-discharge care and to reduce the factors leading to preventable hospital readmission.

Cross-reference A0802 Discharge Planning: Patient Re-evaluation, as it relates to the facility failing to ensure that P#1 and P#2 were appropriately discharged. P#1 was returned to the facility ED by local law enforcment after being found wandering the community. P#2 was provided transportation home by local law enforcement after presenting to a local post seeking assistance.

Based on a review of medical records, video recordings, local law enforcement reports, interviews with facility staff, an interview with the complainant, an interview with the patient's family, and a review of policies and procedures, it was determined that the facility failed to ensure an effective transition for two out of five sampled patients (P) (P#1 and P#2) from the hospital to post-discharge care and to reduce the factors leading to preventable hospital readmission.

Findings:

A review of the facility's Emergency Department (ED) Log revealed that P#1 arrived at the ED on 5/31/22 at 11:44 a.m. with a chief complaint of seizures and an ED disposition of 'Admit to Inpatient or Observation.' Continued review revealed that P#1 arrived at the ED again on 6/2/22 at 10:26 p.m. with a chief complaint of Altered Mental Status and an ED disposition as 'Admit to Inpatient or Observation".

A medical record review revealed that P#1 was a 65-year-old who presented to the emergency department (ED) via emergency medical services (EMS) on 5/31/22 at 11:44 a.m. after a seizure was witnessed at home.

A review of an 'ED Provider Note" at 12:48 p.m. revealed that P#1 was only responsive to pain when EMS arrived on the scene. P#1 had a past medical history of a seizure disorder, high blood pressure, previous stroke, and alcohol abuse with withdrawal. P#1's family was unavailable in the ED, so limited history was obtained. A neurological exam indicated that P#1 was somnolent (drowsy, sleepy) and arousable to significant tactile stimulation. A further review revealed that P#1's daughter later stated that P#1 was non-compliant with medication. P#1's daughter said she did not believe P#1 was still drinking. She also voiced concerns about not being able to care for P#1 at home. The ED diagnosis was seizures, non-compliance with medication regimen, and encephalopathy (broad term used for any brain disease that alters brain function or structure). P#1 was admitted for observation and possible placement.

An electronic medical record review revealed that the ED Disposition was set to admit to Inpatient or Observation at 3:01 p.m.

A review of a 'History and Physical Notes' at 4:31 p.m. revealed that P#1 was arousable to verbal commands and conversing appropriately upon evaluation. P#1 was alert and oriented x 1. P#1 had five out of five strength in both upper and lower extremities. P#1's daughter stated that P#1 had been forgetful for the past two years and had progressively gotten worse. The 'Review of Systems' revealed that P#1's neurological exam was positive for altered mental status and seizures. P#1 had a history of dementia. Additionally, P#1'd daughter thought P#1 might have been experiencing some falls because she found some blood on the floor a week or so ago. The note revealed that P#1 was taking Seroquel (antipsychotic) nightly, and he lived with his daughter. A need for discharge planning was indicated. A further review of the 'History and Physical Notes' at 4:45 p.m., written by the Attending Physician, Medical Doctor (MD) GG, revealed that P#1 was at a baseline confusion at home. MD GG suspected the seizure was due to alcohol withdrawal vs. marijuana.

A review of the 'Case Management Initial Discharge Planning,' written by Registered Nurse (RN) CC at 8:40 p.m., revealed that P#1 had been living with P#1's daughter and required assistance with daily living activities. P#1 could ambulate but had experienced some falls. P#1 had a walker at home but refused to use it. P#1 had a history of smoking and had started two fires. P#1's daughter had expressed that she was unable to provide the care and assistance that P#1 needed. P#1's anticipated discharge was to a long-term care facility, and medical transport would be needed.

A review of a Physical Therapy (PT) note dated 6/1/22 at 2:19 p.m. revealed that discharge considerations included 24/7 supervision due to safety concerns with fall risk. P#1 was oriented to person but was disoriented to situation, time, and place.

A review of the plan of care dated 6/1/22 at 6:00 p.m. revealed 'safety falls' and 'knowledge deficit' as problems for P#1.

A review of a PT note dated 6/2/22 at 11:55 a.m. revealed that P#1's overall cognitive status was impaired. P#1 had a decreased recall of biographical information and a deceased recall of recent events. P#1 was oriented to person and place. P#1 became fatigued quickly during dynamic standing balance and required seated resting breaks. Additionally, P#1 required assistance with his gait (manner of walking). General comments on the note revealed that P#1 became tearful and agitated during the PT session stating, "I don't know what the hell is wrong with me. They won't tell me. I just woke up, and I was right here. If I'm nuts, tell me dammit".

A review of a 'Nursing Note' dated 6/2/22 at 3:18 p.m., written by Charge Nurse (CN) EE, revealed that P#1 stated that he was going to call home and would call for a car service to pick him up. P#1 was alert and oriented and was adamant about leaving. A physician (did not indicate the physician's name) came to speak to P#1. After speaking to P#1, he still refused to stay.

A review of the 'Case Management Final Discharge Transition,' dated 6/2/22 at 3:33 p.m., written by RN AA, revealed that P#1's daughter could no longer care for P#1 because of work. RN AA explained to P#1 that he was medically stable, ambulatory, alert, and oriented. RN AA noted she would email resources to P#1's daughter for placement alternatives. Per Osteopathic Doctor (DO), HH and MD GG P#1 was decisional and signed the Against Medical Advice (AMA) form. RN AA offered to provide transportation for P#1, but he declined. P#1 agreed to let the Emergency Medical Technician (EMT) wheel him out to the curb, where P#1 was seen walking the parking lot toward the main road in front of the facility.

A review of a 'Nursing Note' dated 6/2/22 at 3:34 p.m. written by RN FF revealed that P#1 signed the AMA form. P#1 stated, "I don't know where I am going, but I am getting out of here." P#1 refused transport arrangement. DO HH and MD GG evaluated P#1, and P#1's daughter was contacted. P#1 was wheeled off the unit to the facility's parking lot by the discharge nurse.

A review of the 'Discharge Summary,' dated 6/2/22 at 3:55 p.m., written by DO HH and attestation signed by MD GG, revealed that P#1 was admitted for workup and management of a seizure disorder likely due to non-compliance with home seizure medication. Neurology signed off on P#1 with instructions to continue home seizure medications. On the day of discharge, P#1 was adamant about leaving AMA. The discharge summary revealed that P#1 demonstrated the capacity that if he were to leave AMA without medication, he could have another seizure, fall, or even die. P#1 was able to comprehend and repeat everything back. P#1 was alert and oriented to person, place, and time. MD GG evaluated P#1 and agreed with the discharge of P#1. P#1's daughter was notified multiple times, and it was explained that P#1 had the capacity to leave, and the facility could not keep him against his will. P#1's daughter informed the facility that she could not pick up P#1. The facility made it clear to P#1's daughter that P#1 could not stay in the facility against his will, and it was in the best interest of P#1 for his daughter to pick him up and bring him home while trying to find more assistance at home to take care of P#1. Despite multiple attempts, P#1 was discharged AMA at 3:55 p.m., with a seizure medication prescription sent to P#1's pharmacy. P#1's discharge diagnosis was seizures, and P#1's discharge condition was listed as 'stable.' P#1's 'Active Problems' included dementia.

A review of a video monitoring recording provided by the facility, dated 6/2/22 at 3:24 p.m., revealed the following:
3:24:11 P#1 was seen being escorted out of the facility in a wheelchair by an EMT
3:24:19 P#1 got out of the wheelchair under the covered vestibule and walked over to a trashcan located outside the facility (the video does not allow a view of the direction P#1 walked)
3:24:30 EMT was seen standing behind the wheelchair that P#1 had occupied
3:25:22 EMT walked away from the wheelchair and walked further outside the facility
3:25:29 EMT was seen standing outside facing out towards the parking lot
3:26:09 EMT walked further outside the facility, turned to the right, and walked out of view of the camera
3:37:44 EMT was seen coming back into view of the camera. EMT rolled the wheelchair back into the facility.

A continued review revealed additional video recordings from an alternate camera angle. It revealed the following:
3:25:32 P#1 was seen walking down the sidewalk away from the facility
3:26:02 P#1 stepped off the sidewalk and crossed the parking lot, walking towards the right, out of camera view

A continued review of the medical record revealed that P#1 arrived back at the facility's ED on 6/2/22 at 10:25 p.m. for evaluation of altered mental status. An 'ED Provider Note," written by ED BB at 12:17 a.m., revealed that P#1 was found by local law enforcement (LLE) #2 wandering around on the main road that ran along the front of the facility. P#1 was asked where he lived and replied, "I don't know." P#1 was able to confirm that he lived with his daughter. P#1 complained of mild chest pain with shortness of breath when asked. P#1's history was limited secondary to dementia. P#1's daughter reported that she was unable to care for P#1 because of her long hours at work. P#1's daughter reported that P#1 often left their home and wandered around. P#1's neurological exam revealed that P#1 was oriented to person and place. P#1 had difficulty stating the month. He was able to state the year using his fingers. P#1 could follow simple commands. P#1 was a poor historian. P#1 could not recall much of the events following the discharge earlier in the day. P#1's vital signs on triage were: blood pressure 136/80 (normal 120/80), temperature 98 degrees Fahrenheit (normal), pulse 98 (normal 60-100), respirations 18 (normal 12-16), and pulse oxygenation of 96 percent (%) (normal). P#1's Troponin (type of protein found in the blood when there is heart muscle damage) levels were 587 (normal below 120). P#1 was admitted to inpatient with a stable condition. The ED's final diagnosis was chest pain: unspecified, elevated Troponin, acute kidney injury, and non-ST elevation myocardial infarction (NSTEMI) (a type of heart attack that usually happens when the heart's needs for oxygen cannot be met).

A review of a CM' Progress Note" written 6/3/22 at 1:07 a.m. revealed that P#1's daughter left work after receiving a call that P#1 was discharged AMA earlier in the day. P#1's daughter stated she arrived at the facility and immediately started searching the facility's grounds, "screaming" for her father in the parking garage and parking lots. She later moved the search to the main road that ran along the front of the facility. P#1's daughter drove around for hours and could not locate P#1. P#1's daughter reported she contacted LLE #2 and reported P#1 as a missing and endangered adult with altered mental status, dementia, and seizures. The CM met with P#1 and asked P#1 for his date of birth, but he could not verbalize it. P#1 stated he could write it and wrote "12 22 22." P#1 could not verbalize the city he resided. When CM called out three options, P#1 said "no." When CM called out the correct city P#1 lived in, he said, "That's it." P#1 stated he wanted to go to his mother's home, but when asked what city she lived in, P#1 could not verbalize it. Further review revealed that P#1 appeared to lack the ability to care for himself and make decisions regarding his care, safety, and wellbeing.

A review of the "Discharge Summary Note" dated 6/8/22 at 2:40 p.m. revealed that P#1 was discharged home with home health. Once P#1's insurance was activated, P#1's family was to reach out to P#1's primary care physician (PCP) for a referral for facility admission. P#1 and P#1's daughter agreed with the plan, and prescriptions for all home and new medications were signed and given to P#1. P#1 was to follow up with his PCP in one week. P#1's final discharge diagnosis was acute kidney injury. Active problems included: NSTEMI, seizure, history of stroke, dementia, and major neurocognitive disorder. P#1's discharge condition was "good."

A review of LLE #3 "Reporting Officer Narrative" dated 6/2/22 at 7:19 p.m. revealed that at 7:17 p.m., the officer was dispatched about a missing person's report that involved P#1, occurring at the facility's address around 3:26 p.m. per P#1's daughter. Officers canvased the area and were unable to locate P#1. As a result, a Mattie Call (a law enforcement-initiated system to locate missing elderly or disabled persons) was sent out by dispatch. At 10:24 p.m., an officer was advised by dispatch that P#1 had walked back to the facility. P#1 advised that he was just out wandering around. P#1 appeared coherent and responded to officers. P#1 was turned over to the facility and medical staff. P#1's daughter was advised of the recovery of P#1.

A telephone interview was conducted with the complainant on 6/23/22 at 2:00 p.m. in the facility's conference room. The complainant stated that P#1 had been wandering around for seven hours between when P#1 left AMA and when he was picked up by local law enforcement and taken back to the ED. She stated that P#1 had been picked up by a passerby and driven and dropped off along the expressway. Local law enforcement found him near a grocery store. P#1 had fallen at some point and scrapped his arms, which were bleeding. The complainant stated that P#1 could not recall the event other than P#1 had stopped and got a cup of coffee.

An interview was conducted with Registered Nurse (RN) AA on 6/21/22 at 4:20 p.m. in the conference room. RN AA stated that she was a Case Manager (CM) and had worked at the facility for four years. RN explained that her job as a CM consisted of discharge planning which started upon admission. This included speaking with the patient and his/her family regarding the discharge process and providing resources if needed (placement for rehabilitation facilities or home health). RN AA said that she recalled P#1. She stated that she remembered that P#1's daughter said she could not handle P#1 returning home after discharge. P#1 had a history of alcoholism. Additionally, P#1 wandered away from home. RN AA said she recalled that P#1's physicians told her that P#1 was decisional, alert, and oriented on the day of discharge. RN AA stated that she informed P#1's daughter of this, and the facility did not have a reason to keep P#1 from leaving AMA. P#1 was also medically stable per the physician report. RN AA recalled that P#1's daughter received another call from the facility during their discussion that P#1's daughter needed to come to the facility and pick up P#1. RN AA stated that P#1's daughter was upset. RN AA said that she went to the Discharge Lounge (a room where discharged patients could wait to be picked up) and found P#1 had dressed, stating he wanted to leave the facility. In addition, RN AA said that P#1 did not want the facility to call his daughter and did not want to go back home because his daughter would not want him back. RN AA said she tried to set up transportation for P#1, but he refused. She continued stating that P#1 seemed aware of his decisions and understood the danger of leaving AMA. RN AA said that P#1 had begun to get agitated. RN AA stated that the emergency medical technician (EMT) DD wheeled P#1 out the facility's front door, and P#1 walked across the parking lot to the main road in front of the facility. RN AA stated that she and EMT DD were concerned for P#1's safety, so EMT DD picked up his phone to call 911 to ask if they could pick up P#1 and take him where he needed to go. RN AA stated that she walked into the ED to look for security and ask for their assistance, but there was no one in the security office. RN AA recalled that MD GG and MD HH were in the Discharge Lounge when P#1 wanted to leave AMA. RN AA said that later that day, a Mattie Call had gone out on the news concerning P#1. RN AA said she was unaware that P#1 had a history of dementia.

An interview was conducted with Medical Doctor (MD) BB on 6/21/22 at 4:45 p.m. in the conference room. MD BB stated that she was a contracted physician and had worked in the facility's ED for seven years. MD BB said she provided care to P#1 when he returned to the ED on 6/3/22 around midnight. She recalled that local law enforcement had found P#1 wandering around the main road in front of the facility and brought P#1 back to the ED. P#1 had been without food or water for eight hours. MD BB said that she read P#1's discharge summary from 6/2/22 and recalled talking to a CM (she could not remember the name). MD BB stated that CM said P#1's daughter had said that P#1 was incompetent to make decisions, and P#1's daughter could not come to pick up P#1 from the facility. P#1 was discharged from the facility AMA. MD BB explained that P#1 complained of chest pain and shortness of breath on his second visit to the ED. MD BB said P#1 had difficulty communicating due to a prior stroke. She stated that P#1 was not as oriented at first glance but could answer some questions. MD BB said P#1 knew where he was and who he was and "kind of" knew the year. MD BB stated that she would not have let P#1 leave AMA with P#1's presentation in the ED during the second visit. She continued saying he did not have the capacity to make his own decisions at that time. MD BB stated that many dementia patients seemed okay during the day but worsened in the evenings. She said that when caring for dementia patients, she always involved the family or emergency contact in the discharge planning. CM would also be involved. MD BB explained that if she had a patient who wanted to leave AMA, she would assess their capacity to leave and try to determine why the patient wanted to leave. MD BB stated that she would explain in simple terms the patient's diagnosis and the risk involved in leaving, and then she would have the patient explain it back to her on their terms. In addition, she said that she would ensure that the patient had a safe way to go home and could manage themselves at home.

An interview was conducted with Emergency Medical Technician (EMT) DD on 6/22/21 at 10:55 a.m. in the conference room. EMT DD stated that he had been an EMT for 20 years. He had worked at the facility for three years as an ED technician. As an ED technician, EMT DD stated he helped with blood draws, vital signs, and transporting patients. EMT DD said that he recalled P#1. He explained that he had been called to assist with P#1. When EMT DD approached, P#1 was walking down the hallway, and P#1 wanted to leave the facility. He stated that P#1 was non-compliant, hostile, and difficult to reason with. In addition, he said that P#1 was combative but had not striked anyone. EMT DD said that he was able to calm P#1 down enough that they entered the Discharge Lounge. Nurses and other technicians tried to convince P#1 to stay, but P#1 became hostile again, using profanity. He explained that P#1 was aggressive, but not to the point he felt threatened. EMT DD stated he was able to calm P#1 once more by explaining that he needed to remove P#1's intravenous (IV) if P#1 wanted to leave. EMT DD said that he stepped out of the Discharge Lounge and informed P#1's doctor (he was unsure of the name) that the situation was escalating rapidly, and that security might need to be called. EMT DD stated that P#1's doctor informed him that P#1 was signing out AMA and P#1 was free to go. EMT DD said that P#1 overheard the conversation and became irate. EMT DD stated he engaged P#1 once more and explained that he could get a wheelchair and escort him out of the facility. P#1 calmed after this. EMT DD stated that while he was getting P#1 into the wheelchair, nurses were still trying to encourage P#1 to stay at the facility. EMT DD said he wheeled P#1 to the Women's Center entrance, and P#1 was using profanity and saying that P#1 felt he was being lied to and held against his will. When they arrived at the entrance, EMT DD tried again to talk P#1 into staying at the facility. EMT DD said he explained to P#1 that it was hot outside, and EMT DD was concerned about P#1 leaving on foot and walking with P#1's medical condition. P#1 replied to him, "mind your own damn business and find something else to do." EMT DD said a nurse (RN AA) came outside after P#1 started to walk away, and she asked him to call 911 to advise them of the situation. EMT DD stated that while he had eyes on P#1, he placed a call to 911. The 911 dispatcher was given P#1's description and P#1's travel route. The dispatcher replied that they were unsure if anything could be done but would see if a patrol car was in the area to locate P#1 and offer assistance. EMT DD said that everyone involved with P#1 agreed it was a bad idea for P#1 to leave AMA. He explained that short of restraining P#1, he felt the staff did everything they could to keep P#1 from leaving the facility. EMT DD explained that P#1 was aware of person, place, and time. EMT DD said that he felt that P#1 was decisional and did not seem confused.

An interview was conducted with Charge Nurse (CN) EE on 6/22/22 at 11:30 a.m. in the conference room. CN EE stated she had been an RN for 17 years and had worked at the facility for four years. CN EE said that she recalled P#1. She explained that P#1's daughter and granddaughter had visited P#1 and told P#1 that he could not return home after discharge. About one to two hours later, P#1 dressed and told staff that he was leaving the facility. CN EE said that P#1's daughter was notified and was asked to come to the facility because P#1 wanted to leave AMA. P#1's daughter replied that she could not go and pick up P#1 but would call her brother and see if he could come. CN EE stated that P#1 started to walk down the hallway, and they redirected him to allow time for P#1's doctor (she could not recall the name) to come and talk with P#1. She explained that a total of six employees were speaking with P#1 and trying to talk him into staying at the facility. CN EE stated that P#1 said he would go where he wanted to go and get an Uber ride. P#1 was insistent on leaving the facility. CN EE said that P#1 was alert and oriented at the time of discharge. P#1 knew his name, his birth date, and where he was at the moment. She explained that P#1's doctor (could not recall the name) talked to P#1 to ensure that he could answer questions appropriately.

An interview was conducted with RN FF on 6/22/22 at 12:45 p.m. in the conference room. RN FF stated that she had been an RN for five years and had worked at the facility for a year. RN FF explained that she was P#1's nurse when he left AMA. She continued to explain that P#1's daughter and granddaughter had visited P#1 and informed P#1 that he could not return to their home after discharge and would have to go to a rehabilitation facility or another care facility. She recalled that P#1 was teary and seemed sad. She continued explaining that after P#1's family had left, Physical Therapy (PT) assisted P#1 into a chair. RN FF stated that P#1 said, "What am I doing here?". P#1 tried to remove his IV because he wanted to leave the facility. P#1 did not know where he was going but wanted to leave. She recalled that P#1 said he only had one dollar in his pocket. RN FF said that she assessed P#1 for his knowledge of person, place, and time and he was aware of all three. She explained that she then messaged P#1's doctor (she could not recall the name) to inform him of P#1's intentions to leave. RN FF said P#1 commented that he knew his rights and that the facility could not keep him against his will. She stated that staff tried to stall P#1 from leaving by redirecting him to another hallway. At one point, P#1 figured this out and started getting agitated and said he didn't know why they were trying to keep him. RN FF stated that security was on the scene and was able to calm P#1 down. RN FF said she worried P#1 would fall because he had an unsteady gait. She explained that she was not comfortable with him ambulating by himself. P#1 was offered transportation, but P#1 declined. RN FF remembered that CN EE and DO HH had both called and spoke to P#1's daughter, informing her that P#1 was trying to leave. P#1's daughter could not come and pick P#1 up because she was at work and was over an hour away.
An interview was conducted with DO HH on 6/22/22 at 2:00 p.m. in the conference room. MD HH stated that he recalled P#1. He said that P#1 wanted to leave AMA. MD HH said that P#1 was alert and oriented. MD HH explained that P#1 was knowledgeable on why he was in the facility and was aware of the risk of leaving AMA. MD HH stated that P#1 was made aware of the risk of having another seizure or even dying, and P#1 verbalized his understanding. MD HH said that he and MD GG assessed P#1 for capacity and agreed that P#1 could make decisions for himself. MD HH said that P#1's daughter was notified, and she could not come and pick up P#1. He said she was informed that P#1 was medically stable, and that P#1 had the capacity to make his own decisions. Therefore, they could not keep P#1 against his will.

An interview was conducted with Medical Director of Quality and Safety (MD) LL on 6/23/22 at 10:40 a.m. in the conference room. MD LL stated he had held the position for one year and also worked as a hospitalist within the facility. MD LL said that as the Medical Director of Quality and Safety, he focused on quality improvement and patient safety. He explained that a safe discharge was one in which the physician felt the patient was medically appropriate for discharge. He further explained that medically appropriate meant that there was no longer anything that could be completed in the hospital that the patient, or outside resources, could not do at the patient's home. MD LL continued to explain that any physician could evaluate medical decision capacity, but the attending physician would make the final decision. Medical decision capacity was completed by asking the patient questions to ensure that the patient could understand his/her medical problems and conditions. The patient also needed to understand the risk and benefits of the decision he/she was making. Additionally, the physician assessed the patient's orientation of person, place, and time. He explained that even though a patient may have a history of dementia or Alzheimer's, the patient could still have medical decision-making capacity and decide to leave AMA. The physician would evaluate and determine for medical decision capacity at the time the patient wanted to leave the facility AMA. MD LL explained that if a patient were deemed not to have medical decision capacity, the patient would be put on a medical hold.

A follow-up telephone interview was conducted with DO HH on 6/23/22 at 12:07 p.m. in the conference room. DO HH stated that he reviewed P#1's medical record, including the PT notes, prior to P#1 leaving AMA. He stated he also spoke to the CM (he could not recall the name). DO HH said the mental capacity assessment was usually done at the patient's bedside, but P#1 was in the hallway wanting to leave. He explained that even if the patient had issues with mental capacity earlier in the day, he would still let the patient leave if the assessment concluded that the patient had medical decision capacity. DO HH explained, "especially in this incident because he was trying to leave quickly, and he was agitated, and security was involved." DO HH said that P#1 told him he would go to his parent's house or a friend once he was discharged. DO HH explained that a safe discharge meant the patient was medically stable and had a safe place to go after discharge

A review of the facility's Complaint and Grievance Log dated 6/1/22 to 6/18/22 revealed there was a grievance for P#2 that was entered on 6/3/22.

A review of the grievance for P#2 revealed that P#2's family member informed ED staff that P#2 had a history of dementia on arrival at the facility. P#2 was discharged from the facility without notifying P#2's family. P#2 left the facility on foot. At some point, P#2 was driven to a family member's home in another county by local law enforcement. P#2's family member was able to contact the family member whom P#2 lived with, and she was picked up and taken to her home address.

A review of a response letter to P#2's grievance, dated 6/6/22, written by MD NN, and sent to P#2's family member, revealed that the letter stated, "I also regret to hear we did not ensure a safe discharge plan upon your release."
A review of an Emergency Medical Services (EMS) report revealed that P#2 was a 63-year-old with complaints of chest pain. EMS arrived on the scene on 5/28/22 at 5:11 a.m. and found P#2 ambulating in the driveway to the ambulance. P#2 was alert and oriented.

A medical record review revealed that P#2 arrived via EMS at the facility on 5/28/22 at 6:25 a.m. with a chief complaint of chest pain. An ED provider note at 6:38 a.m. revealed that P#2 had a past medical history of high blood pressure and Alzheimer's Disease (progressive disease that destroys memory and other important memory functions). P#2's neurological assessment was negative (normal) for confusion. P#2 was alert and oriented to person, place, and time. P#2's thought content was normal. At 8:00 a.m., a note was added that P#2 was capable of making medical decisions. P#2 was admitted for observation and stress testing since P#2's cardiac workup in the ED was negative.

A review of an 'Emergency Observation Unit Note' dated 5/28/22 at 9:26 a.m. by Family Nurse Practitioner (FNP) MM revealed that P#2 had a medical history of Alzheimer's Disease. A physical exam revealed that P#2 was alert. P#2's echocardiogram (medical test to check heart rhythm and blood flow through the heart) was normal, as well as her repeated cardiac enzymes (blood test to check stress of the heart). P#2 was asymptomatic with stable vital signs. The recommendation was to discharge P#2 with follow-up with P#2's primary care provider and return to the ED with new or worsening symptoms.

A review of a Nursing Assessment at 12:06 p.m. revealed that P#2 was oriented to person, place, time, and situation. In addition, p #2 was alert, and her speech was clear.

A review of the flowsheet from P#2's medical record revealed that at 2:50 p.m., discharge instructions were reviewed and signed by P#2. A copy was given to P#2, and she acknowledged understanding. The patient care technician (PCT) was notified that P#2 was ready for discharge. P#2 stated she was waiting for her ride.

A review of a video monitoring recording provided by the facility, dated 5/28/22 at 2:59 p.m., revealed the following:
3:14:07 P#2 walked out of the facility, escorted by an unknown staff member
3:14:13 P#2 walked to the left past the unknown staff member. The unknown staff member was seen standing outside the facility's vestibule.
3:14:17 The unknown staff member turned and walked back into the facility

A review of local law enforcement (LLE) #1 "Incident Detail Report, revealed that on 5/28/22 at 5:21 p.m., a call was received from LLE #2. A review of the 'comments' revealed that a woman came up to the post, stating she had just got released from the hospital and that she was walking to another county. The female had the hospital tag on her wrist and "seemed completely out of it." The female was given a ride to the county closest to the one she said she was walking to. The female did not know the address but could tell the police officer how to get there. The female was dropped off at a family member's residence at 6:36 p.m.

An interview was conducted with Medical Director of Emergency Medicine (MD) NN on 6/23/22 at 1:39 p.m. MD NN stated he had held the position for three and a half years. He explained that he reviewed the medical record for P#2 and wrote the response letter to P#2's family from their filed grievance. When asked about the sentence in the letter that stated, "I also regret to hear we did not ensure a safe discharge plan upon your release," MD NN said it was a wording error on his part. He explained that he should have written instead what the complainant/patient felt was considered a safe discharge. MD NN explained that patients with dementia could function normally. If the patient were alert to perso