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Based on observation, interview and document review, the hospital failed to ensure patient safety for 2 of 14 patients (P1, P2) when they failed to discharge a patient from the emergency department (ED) back to her memory care facility, and failed to provide re-evaluation of a patient's condition who was triaged as needing urgent intervention but was waiting in the ED waiting area for more than two hours without re-evaluation.

See A0144.

An IJ was identified on 7/30/21 at 12:00 p.m., related to patients receiving care in a safe setting. The IJ was removed 8/2/21 at 11:30 a.m. after verification of implementation of an acceptable removal plan, but the hospital remained out of compliance at the Condition of Patient Rights. See A144.

Based on observation, interview, and document review, the hospital failed to provide care in a safe setting for 1 of 14 patients (P1) when she was admitted to the emergency department (ED) from a memory care facility, was discharged to the community and became lost for over 11 hours. In addition, the facility failed to reassess P2 when she presented to the ED and was triaged as needing urgent intervention, but waited for more than four hours to be seen by ED staff without being reevaluated for her condition during the waiting period.

The IJ began on 7/18/21, when staff discharged P1 to the community instead of her memory care facility, and P1 was lost in the community for over 11 hours. The Director of Quality, Director of Risk Management, ED Director, ED manager, ED Supervisor, VP Operations, VP Nursing, VP Medical Affairs, System Director Safety,and System Risk manager were notified of the IJ finding on 7/30/21, at 12:00 p.m. The IJ was removed on 8/2/21, at 11:30 a.m. after verification of an acceptable removal plan.

Findings include:

P1's ED Visit Information in the electronic health record (EHR) dated 7/18/21, indicated P1 arrived at the ED on 7/18/21, at 7:29 p.m. by ambulance and with complaints of increased hand pain from a fall with a previously identified fracture from a "non-healthcare facility." Documentation from the ambulance run dated 7/18/21, indicated P1 came from a custodial care facility, and this documentation was provided to ED staff. P1 was evaluated by ED staff for her complaint. Discharge Information in the EHR revealed P1 was discharged "Home" with self care on 7/18/21, at 11:40 p.m..

P1's memory care Kardex dated 7/29/21, and sent with the ambulance to the hospital, listed P1's address, phone number, and information about contacts (facility, family, social worker, and medical).

During an interview on 7/29/21, at 12:20 p.m. the regional director for clinical services (RDCS) at P1's memory care facility stated P1 was sent to the ED on 7/18/21. RDCS stated P1 was sent to the ED via ambulance, and P1's information was sent to the ED with the ambulance. RDCS stated the hospital never called to let the facility know P1 was being discharged. The RDCS stated on 7/19/21, at about 11:00 a.m. law enforcement brought P1 back to the facility and stated she was found by a Good Samaritan, lost in St. Paul, crying, and unable to state where she lived.

During an interview with registered nurse (RN)-C on 7/29/21, at 3:10 p.m. she stated she discharged P1 upon the request of another staff person. RN-C stated the ED was very busy that night, and she did not know P1 was from a memory care facility. RN-C stated P1 was discharged to her own self care. RN-C stated P1 left the ED by the main door. RN-C stated she did not recall any papers from the memory care facility in P1's ED information.

During an interview with RN-D on 7/29/21, at 3:30 p.m. she stated she cared for P1 during part of her ED visit on 7/18/21. P1 told her she was from a memory care facility, but RN-D did not update that information in P1's medical record. RN-D stated P1 seemed like a good historian, so she did not think she needed to tell the next staff member that P1 came from a memory care facility.

During an interview on 7/29/21, at 3:50 p.m. RN-E (supervisor) stated there was no policy related to where the paperwork sent with a patient from a facility was stored, but the ED practice was usually to put the paperwork with the ED stickers, on the ED paper chart.

P2's ED Visit Information in the EHR indicated P2 presented to the ED for evaluation of abdominal pain on 7/29/21, at 7:11 a.m. P2's flowsheet revealed P2 was triaged at a level 3 acuity level (urgent) and P2 was not reassessed until 11:38 a.m., more than four hours later. P2's provider noted indicated P2 diagnosed with urinary tract infection and cirrhosis of the liver.

On 7/29/21, at 10:01 a.m. P2 was observed in the ED waiting room.

During an interview on 7/29/21, at 10:01 a.m. RN-P stated P2 was a patient who arrived to the ED for complaint of abdominal pain, and was still waiting in the ED lobby because the ED did not have any open beds that were staffed in the main ED. RN-P explained there were nine empty beds, but the beds were not staffed with nurses until 11:00 a.m.

During an interview on 7/29/21, at 11:24 a.m. RN-R stated the lack of staff nurses to cover ED beds led to patients having to wait in the ED lobby for seven to eight hours, with some waiting up to 10 hours. RN-R stated the facility added a provider in triage (PIT) to improve flow, but while the provider wrote orders, without nurses to implement the orders, patients remained in the lobby. RN-R reported no additional nursing staff were added to the triage and lobby area, and while the expectation is the triage or "PIVET" nurses to re-evaluate patients in the lobby, they often can not do so because they are busy triaging patients and doing "crowd control." RN-R added it was not uncommon to have 30 patients in the lobby waiting for an emergency department bed.

During an interview on 7/29/21, at 2:30 p.m. the RN-Q verified P2 arrived at 7:13 a.m. on 7/29/21, and there was no reassessment of P2 until after 11:38 a.m.

The hospital's ED Standards of Care directed if a patient was triaged at an acuity level of 3 and was waiting in the ED lobby, the patient was to be re-evaluated by the ED staff at least every 2 hours to ensure his/her condition remained stable. The standard indicated the re-evaluation should include vital signs, pain assessment, and a focused assessment.

The IJ was removed on 8/2/21, at 11:30 a.m. when the hospital submitted and implemented an acceptable removal plan that included appropriate education and training of staff and review of policy and procedures. This was verified through document review and interview.