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Based on interview and documentation review it was determined the Hospital failed to ensure all patients received care in a safe setting related to arranging appropriate transportation at discharge in one (Patient #1) of thirteen ED patients medical records reviewed.

Findings included:

Review of documentation indicated Patient #1, was brought to the Hospital's ED from the nursing home where he/she was a resident, for evaluation of a cellulitis of the right lower extremity that had not improved after a 7 day course of oral antibiotics. It was noted during triage Patient #1's past medical history included psychosis, schizophrenia, senile dementia, paranoia and obsessive compulsive disorder.

Review of the Physician Assistant's documentation indicated the Patient was assessed as needing hospitalization for administration of IV antibiotics to treat the cellulitis. Patient #1 refused admission, reporting he/she would rather return to the nursing home and take oral antibiotics. The risk of not receiving IV antibiotics was discussed with Patient #1 who signed out against medical advice.

Review of nursing documentation indicated Patient #1 was discharged back to the nursing home. Patient #1 was brought out to the ED lobby and a taxi cab was called. Documentation did not indicate the nursing home was called to report Patient #1 was returning and had taken a taxi back to the facility.

The Physician Assistant was interviewed in person on 11/24/10. The Physician Assistant said he/she had told the nurse Patient #1 was ready to go back to the nursing home. He/she said the nurse made the arrangements for Patient #1's transportation, which was standard procedure. The Physician Assistant said the nurse had not checked with him/her regarding how to send Patient #1 back and he/she had not realized Patient #1 had been sent back to the nursing home by taxi until the nursing home had called later that same day.

The ED Registered Nurse (RN#2) who had discharge Patient #2 was interviewed by telephone on 11/30/10. RN #2 said he/she had assumed the care of Patient #1 at 3:00 PM and had received a status report, on Patient #1, from RN#1. RN #1 had reported the Physician Assistant wanted to admit Patient #1 however Patient #1 wanted to return to the nursing home and take oral antibiotics. RN #2 said Patient #1 kept asking when he/she could leave and once he/she reviewed Patient #1's discharge documents from the Physician Assistant he/she had gone to the desk and asked the Health Care Coordinator to make arrangements for Patient #1 discharge. RN #2 said he/she did not recall why but the Health Care Coordinator reported, after checking the computer, Patient #1 was not eligible to return to the nursing home by ambulance. Patient #1 was standing at the desk during this interchange and reported he/she had money for a taxi. RN #2 said he/she walked Patient #1 out to the lobby and asked the security officer, seated in the lobby, to call a taxi for Patient #1. RN #2 said he/she did not realize Patient #1's diagnosis included psychosis, schizophrenia, senile dementia, paranoia and obsessive compulsive disorder. RN #2 said he/she had called the nursing home with to inform them of Patient #1's return however he/she could not recall who he/she had spoken to or why it had not been documented.

The Health Care Coordinator was interviewed by telephone on 12/7/10. The Health Care Coordinator said a nurse would make the final decision if there was some reason or problem with sending a patient who arrived by ambulance back by ambulance when discharged.

The ED Nurse Manager (Nurse Manager) was interviewed by telephone on 12/7/10. The Nursing Manager said the ED nurse would make the final decision as to how to send a patient back to a nursing home and would direct a health care coordinator as to what type of transportation to arrange.

Based on documentation review it was determined the Hospital failed to have adequate numbers of registered nurses on duty in the ED.

Findings included:

The Hospital's ED staffing plan was reviewed. The staffing plan identified staffing between 7:00 AM and 9:00 AM would include 11 registered nurses (RN's); between 9:00 AM and 11:00 AM would include 14 RN's; between 11:00 AM and 3:00 PM would include 16 RN's; between 3:00 PM and 7:00 PM would include 16 RN's; 7:00 PM and 11:00 PM would include 16 RN's: between 11:00 PM and 3:00 AM would included 12 RN's and between 3:00 AM and 7:00 AM would included 9 RN's.

Review of ED Nursing November 7-20, 2010 staffing work sheets indicated staffing levels were not met as specified in the ED staffing plan on: November 7, 8,13,14, 19 between 7:00 AM and 9:00 AM and between 9:00 AM and 11:00 AM; November 9 between 7:00 AM and 9:00 AM, 9:00 AM and 11:00 AM and 11:00 AM and 3:00 PM; November 16 between 7:00 AM and 9:00 AM; November 18 between 9:00 AM and 11:00 AM.