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Based on interview and record review, the facility failed to assess discharge needs and ensure discharge to a safe environment for one (P-1) of 10 vulnerable Emergency Department patients reviewed for discharge planning, resulting in a poor outcome for P-1 and the potential for poor outcomes for all patients discharged from the emergency department. Findings include:

A - 0800 Failure to follow discharge process.

Based on interview and record review, the facility failed to accurately assess discharge needs for one (P-1) vulnerable Emergency Department (ED) patient out of total sample of 10 patients reviewed for discharge planning, resulting in the facility's failure to identify the correct discharge location for P-1 and the potential for harm. Findings include:

On 07/18/2024 at 1200, review of medical record for P-1 revealed she was a 71-year-old female who presented to the emergency department via ambulance at 1529 on 05/28/2024. Her chief complaint is documented as black or bloody stool. Providers note documented active problem list to include altered mental status, superficial thrombophlebitis (inflammation in a vein caused by a blood clot) left upper extremity, chronic hypoxic respiratory failure, spinal stenosis of lumbar region with neurogenic claudication (narrowing of space around lower spine, putting pressure on spinal cord and can compress blood vessels around spine causing weakness, numbness, tingling in feet and legs and loss of bowel/bladder control), vulvar ulceration, paresthesia (numbness) both feet, wound left buttock, rectal bleeding, urinary incontinence, and cognitive impairment. P-1 resided at a skilled nursing facility, used a Hoyer lift and was unable to stand at all. P-1's baseline oxygen of 2 liters (L), alert and oriented x2, not to situation or place. Physical exam documented P-1 to be chronically ill in appearance, irregularly irregular heart rate, 2-3+ significant pitting edema to bilateral lower extremities, alert and oriented to self only. P-1 received treatment for a urinary tract infection. She continued to complain of rectal pain which the provider documented was due to chronic wounds and skin breakdown she had from laying and wearing a diaper. The note indicated P-1 lived in a skilled nursing facility and was stable to be discharged back to home. Supervising physician note dated 05/28/2024 indicated P-1 was stable and to be discharged back to the nursing home with a prescription for Macrobid.

Review of nursing note for ED visit #1 dated 05/29/2024 at 0159 indicated report called to RN (name listed) at the skilled nursing facility. The note documented that P-1 did not live at her previous apartment.

Emergency Department (ED) visit #2 05/29/2024:

Provider note dated 05/29/2024 at 1525 indicated P-1 is a 71-year-old female who was a poor historian and does not appear to have capacity to make her own decisions. P-1 was currently residing at a subacute rehab (SAR) and on 05/28/2024 had an appointment with a physician where there was concern for possible GI bleed and was sent to the ED. P-1 was evaluated, found to have a UTI and was discharged back to the SAR. The provider note documented that P-1 was taken back to her apartment and placed on an air mattress which was on the floor. Provider note indicated P-1 had a signed document as of 5/22/2024 by a physician and psychologist that stated that she did not have capacity to make her own decisions. On 05/29/2024 there was concern when the P-1 did not return to the subacute rehab so the police, Emergency Medical Services (EMS) and fire department were contacted to do a well check. They did find her where EMS left her last night (05/28/2024) on her air mattress. They brought her to the emergency department for evaluation. Providers note at 1652 revealed provider was made aware of this patient by social work, who received a phone call from P-1's power of attorney discussing the concerns with admitting labs and the mix up with transporting the patient back to her apartment instead of the subacute rehab last night.

RN triage note for ED visit #2 dated 05/29/2024 at 1541 revealed P-1 arrived via EMS from home after being found on the ground, "presumably there all night". P-1 was seen in this ED yesterday and diagnosed with urinary tract infection. P-1 was discharged home to her apartment when pt had been living at a subacute rehab facility. After EMS dropped P-1 off "last night" pt slid on to the ground from her bed to pick something up and was unable to get up. Family friend called 911 to go check on P-1. Reports back/butt pain from being on the ground throughout the night.

Patient demographic information and certification of medical necessity for transport for the ED visit of 05/28/2024 for P-1 was provided to the surveyor by Staff A on 07/18/2024 at 1340. Review of the patient demographic information for P-1 revealed her address to be her previous apartment and not the skilled nursing facility where she was currently living. Review of the certificate of medical necessity form revealed "destination" was documented as the address of her previous apartment and not the skilled nursing facility.

In an interview on 07/18/2024 at 1230, Staff J (Experience of Care) stated a grievance was received on 05/29/2024 from the friend of P-1. She was concerned about how P-1 was taken to her old apartment instead of back to the subacute nursing home where she was living when she was discharged from the emergency department. Staff J stated the ambulance service is owned by the hospital, so she reached out to the manager of the EMS service, who told her they take the patients where they are told to take them. Staff J stated the ED Manager investigated and found the hospital had P-1's old address in their system and had not updated her information with her new subacute facility address as her new address. Because the ambulance service is owned by the hospital, the information on their transfer forms comes directly from P-1's medical records, which was her old address. Staff J stated they determined the mix up happened due to P-1's address not being updated in their system, and when P-1 was returned to her apartment, she wanted to stay there and not return to the subacute rehab. Staff J said P-1 was her own decision maker, so she was allowed to stay in her apartment.

In an interview on 07/18/2024 at 1430, Staff K (Director of EMS (Emergency Medical Services) stated the ambulance staff took P-1 back to her apartment, which is where P-1 requested to go and where the transfer paperwork listed as the destination. When queried as to whether his expectation for leaving P-1 on an air mattress on the floor of her apartment, when she was not able to stand or move was a safe situation, Staff J stated no, that was not a safe way to leave P-1.

In an interview on 07/18/2024 at 1350, Staff F stated she did not have any involvement with P-1 until her second visit to the emergency department on 05/29/2024 when her advocate/power of attorney called with concerns about how P-1 ended up at her apartment instead of the subacute rehab facility where she had been for quite some time. Staff F said she did not know how that happened, and the hospital did not obtain the documents that P-1 wasn't her own decision maker until her second ED visit on 05/29/2024.

Review of facility Utilization Management Process, Annual Plan dated "2023", revealed V. Discharge Planning (42 CFR 482.43) The purpose of Discharge Planning is to ensure the gains achieve from hospitalization can be maintained following hospital transition thus promoting optimal patient outcomes. The inter professional team that includes the physician, registered nurse, care manager, and social worker, together with other members of the health care team shall assess each patient ' s unique actual and potential transition planning needs, collaborate with the patient/pt. Representative create transition planning goals and develop a plan to meet identified needs/goals.