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Based on record review (RR) and interviews the facility failed to ensure that one patient's (P)1 Emergency Room (ER) records were complete and accurate. As a result of this deficiency the medical team did not always have access to accurate medical record for P.

Findings include:

1) P1 is a 72-year-old male with past history of hypertension, bipolar, anxiety, depression, and schizophrenia who had seven ER visits from 08/07/21 through 08/14/21.

2) Reviewed P1's medical records on 10/08/21 which revealed the following:
08/07/21 01:52 PM, ER Physician (ERMD)1 documented "Patient presents to the ED (ER) via EMS (emergency medical services/ambulance) for complaints of AMS (altered mental status) by bystander... This is 3rd visit to the ED today. He was seen last night where he left AMA (against medical advice)." There is no documentation in P1's previous visits that he left AMA.

3) There was incomplete nursing documentation on P1's ER visit on 08/14/21. The Registered Nurse (RN)4 did not complete a discharge checklist with P1 at the time of discharge.

4) The ERMD's documentation on P1's visits to the ER on 08/13/21 and 08/14/21 documented P1 was seen by a psychiatrist on a previous visit. This is inaccurate documentation. On 08/08/21, a social worker (SW)1 spoke with the psychiatrist on the phone and communicated the psychiatrist's recommendation to stop one of P1's medications which the SW communicated to the ERMD. The psychiatrist did not do a telehealth visit or come to the ER to examine P1.

5) 08/13/21 05:53 PM, RN6's Disposition note: "taxi here to pick up patient, patient has his own funds. SW2 assisted patient with discharge reinforcement." RN6 was unavailable for interview. This documentation leads one to believe the taxi was present at the time P1 was discharged and he safely got into the taxi.

On 10/08/21 at 01:00 PM. reviewed a video tape provided by security with the Risk Manager (RM). The video revealed P1 was taken out of the ER in a wheelchair to a bench to sit and wait for the taxi. Shortly after, P1 is seen to leave the area prior to the taxi's arrival. P1 was later reported to the police as a missing person because he did not return home.

Based on observations, interviews, and record review (RR) the facility failed to follow current Standards of Care in the Emergency Department (ER) when they did not have policies for a safe discharge from the ER and did not make reasonable efforts to develop a safe discharge plan for one patient (P)1 who had moderate cognitive impairment.

Findings include:

1) Emergency Nurses Association Position Statement "Safe Discharge from the Emergency Department" revised September 2019 included "The discharge process is complex, involving nursing judgement, critical thinking, and decision making. ...Each patient is unique with needs that are equally unique. Discharge policies and procedures vary by institution, but each is designed with patient safety in mind. Everyone discharged from the ED deserves a well-planned discharge process that includes an assessment of clinical stability, assures understanding of instructions, and ensures safe transportation to their home or to the care of a capable caregiver."

2) Cross Reference Tag A 1104 Emergency Services Policies
P1 was seen in the ER and discharged seven times between 08/07/21 and 08/14/21. Was seen three times on 08/07/21. Visit one (08/07/21)-After discharge found wandering/lost with altered mental status (AMS), fell receiving cuts. Returned to ER via EMS.
Visit two (08/07/21)-After discharge found wandering/lost with AMS. Returned to the ER via EMS.
Visit three (08/07/21)-After discharge, fell receiving abrasions.
Visit four (08/08/21)-AMS during visit
Visit six (08/13/21)-Arrived with AMS status, after discharge did not return home safely and missing person filed with police

A Social Worker (SW) did a Mini-Mental State Assessment on P1's fourth visit (08/08/21) which indicated he had moderate cognitive impairment. On P1's sixth visit (08/13/21) the diagnosis was "Wandering Behavior," yet when he was discharged from the ER P1 was placed on a bench to wait for a taxi with no one to monitor him. P1 wandered off and left before the taxi arrived. When P1 did not return home safely a missing person report was filed with the police.

P1 had an order for a psychiatric (psych) consult on his fourth visit. P1 was on two antidepressants and two antipsychotic for his diagnoses of bipolar, anxiety, depression and schizophrenia. P1 was falling frequently with documented altered mental status. The psychiatrist did not examine P1. The consult was an unlicensed Social Worker (SW)1 who had a telephone conversation with psych at which time he recommended a change in P1's medication. SW1 relayed this recommendation to the ER physician. This practice was outside the scope of SW1's job description.

Based on observations, interviews, and record review (RR) the facility failed to follow current Standards of Care in the Emergency Department (ER) when they did not have policies for a safe discharge from the ER and did not make reasonable efforts to ensure one patient (P)1 who had cognitive impairment had a safe discharge plan. As a result of this deficiency P1 was discharged from the ER on 08/13/21 and did not arrive home safely. P1 became a missing person with the Honolulu Police Department. There was the potential this could have resulted in serious harm or death. In addition, P1's psychiatric consult was the psychiatrist (psych) discussing P1's case with an unlicensed Social Worker (SW)1 who communicated a medication change recommendation to the ERMD. This was outside the scope of her job description and does not meet the standard of care definition of a psychiatric consultation. This deficient practice could result in miscommunication from a nonmedical SW and P1 did not get the evaluation he needed which could potentially result in harm.

Findings include:

1) P1 is a 72-year-old male with history of hypertension, bipolar, anxiety, depression, schizophrenia that had seven ER visits from 08/07/21 through 08/14/21. He was independent and lived at home with a girlfriend and one other adult. P1 was on multiple medications which included Desvenlafaxine (antidepressant for major depressive disorder), Bupropion HCL (antidepressant for depression), Zyprexa (antipsychotic for agitation associated with Schizophrenia) and Seroquel (antipsychotic) agitation and insomnia). P1 had been followed by an outside case worker. It is unknown the last time P1 saw his primary physician or a psychiatrist.

2) Reviewed P1's records on 10/07/21 which revealed the following:
Visit one: 08/07/21 Arrival 01:45 AM. Discharge 04:21 AM. To ER via EMS (Emergency Medical Services) with complaint of twitches to upper body. P1 was given a prescription and discharged." Registered Nurse (RN) notes documented "abrasions to bilateral feet, bilateral knees, R (right) ankle, L (left) elbow, and forehead, most with pink wound bed (appear fresh)."

Visit two: 08/07/21 Arrival 06:59 AM. Discharge 10:23 AM. To ER via EMS. The EMS report read: " ...Found wandering around after being discharged from the hospital by Fire personnel. Pt. (P1) was discharged from the hospital earlier this morning and attempted to walk to his house from the hospital. Pt relates he was "pushed from behind, but nobody was there." Pt states he fell approximately 3-4 times to the ground causing multiple abrasions and wounds to his upper and lower extremities and forehead. ...the only pain he was feeling was "trying to get to my son." The location EMS picked up P1 was approximately 1.2 miles from the facility. 08/07/21 06:59 AM RN1 note "...pt. arrives with cuts to his feet and forehead ...per previous shift pt. did not have any cuts. ...is talking about external forces on arrival." On arrival, the fall risk assessment question "Are you currently steady on your feet?" was answered "No," and the question "Do you ambulate w(with)/assist?" was answered "Yes." At 10:00 AM RN1 note: "Pt arrived via EMS with no way to get home. Pt fell numerous times attempting to walk home earlier (distance from facility to home address is 2.0 miles). Patient's significant other (friend) was contacted and stated that they don't know anyone who has a car and that no one could pick him up. Pt did not qualify for medical taxi. ...Pt was provided with info on bus schedule and was walked to the bus station for safety."

Visit three: 08/07/21 Arrival 01:39 PM. Discharged 08/08/21 07:40 AM. EMS report documented "Found ...oriented to name only. ...School staff states that the patient was wandering around the campus aimlessly. Staff (school) states that the patient could not tell them where he was at..." 08/07/21 02:10 PM ERMD1: "Patient presents to the ED (ER) via EMS for complaints of AMS (altered mental status) by bystander...Patient found wandering the Hilo High School grounds (1.2 miles from facility)." 08/07/21 10:28 PM, ERMD1: "...patient appears safe for discharge but unfortunately does not have a safe place to go or means of getting there. For example, following discharge this morning patient was given resources to take the bus but was unable to do so ultimately. I have significant concern that patient will bounce back if discharged this time. As a result, social work was consulted...Plan is to allow patient to sleep overnight and discharge to a safe place in the morning." EDMD1 documented "ED disposition" date as 08/07/21 at 05:00 PM. 08/07/21 06:16 PM RN1: "This RN consulted with social work and MD to attempt to make a safe plan for patients discharge. As this patient has attempted to get home safely multiple times today and been unsuccessful a new plan needed to be made. ...Due to patient still feeling "slightly off balance," it was decided that the patient would spend the night in the ER...and then re-assess the situation in the morning. ...Pt will require a unique solution to get transportation home." 08/08/21 08:28 AM RN2 documented "I discussed the PTs previous admissions and returns to the ER following falls with MD2. I expressed my opinion that the PT (P1) could be considered a danger to himself if he keeps falling. I was instructed to conduct a road test (slang phrase referring to assessment of discharge suitability i.e., gait, ambulation) that both myself and MD2 observed the PT walk...Per MD2 the PT is alert/oriented and demonstrates an ability to walk without falling. There is no medical reason to admit the PT to the Hospital at this time. MD2 also declined to admit the PT as an MH (Mental Health) hold. I was instructed to Discharge the PT following the PT's successful completion of the road test. I requested the assistance of security. Security escorted the PT off the property to a safe location." The place of the "safe location" was not documented. ERMD1's last note was 08/07/21 at 05:00 PM. P1 slept in the ER overnight and left at 07:40 AM. There were no SW notes documented on this visit, and no notes from MD2 prior to P1 leaving the ER.

Visit four 08/08/21 Admit 01:18 PM. Discharge 07:03 PM. 08/08/21 01:33 PM Nursing Triage note: "Pt was walking home from ED where he had a mechanical fall, so started walking back to the ED. Abrasion noted to R hand, and bilateral knees. ...Dirt to face mask, shirt, pants, and socks." On arrival P1 was assessed to be a fall risk and his pulse was 115 (normal 60-100). 08/08/21 05:29 PM. SW1: "Pt. received a score of 22 out of a maximum score of 33 on the Mini-Mental State Examination (test used to measure cognitive impairment/often used to screen for dementia) conducted by SW." A score of 22 indicates moderate cognitive impairment. "...arrived by private vehicle the second time today after having another mechanical fall. Pt. stated he has been having trouble slowing down and finds himself falling. SW called CM (P1's case manager) who "stated pt. has been declining since January and has observed pt. to be disoriented and having increased falls. SW spoke with Pt girlfriend who stated pt. returned home yesterday and today, pt did not bring back his meds from the hospital. Pt forgets to drink water and is not sleeping, is restless and up cleaning house all night. Pt. stated he tries to get six (6) hours of sleep per night but then confirmed he is not sleeping, "I can't sleep" then rambled about checking on cars. SW spoke with Psychiatrist (Psych) who reviewed pt. medications and made the following recommendations. "Stop Desvenlafaxine [Desvenlafaxine ER] 100 mg. PO DAILY..." 8/08/21 06:33 PM. RN3 note: "Patient intermittently confused. Originally new [sic] where he was and was A&O (alert and oriented) to name, DOB (date of birth), month, year, and place upon arrival. Patient currently confused, knowing that he's in Hilo, but believed he was in the "psych unit." Patient also asked if I was sending him "back to Tulsa" Patient is known to be intermittently confused, during the past 4x ED visit ..." 08/08/21 07:03 PM. RN3: "ambulated out to ...Taxi in the round about." 08/08/21 07:40 PM Physician's Assistant (PA)1: P1 had Intravenous (IV) fluids for hydration. "Social work was involved with this patient. They contacted his caseworker, was unavailable to come meet with the patient in the ER today. ...The social worker kindly spoke with our on-call psychiatrist, who recommended discontinuing desvenlafaxine. ...Patient's girlfriend is able to help take care of him at home. His is discharged with refills for his prescriptions." PA1 discontinued P1's desvenlafaxine.

Visit five 08/10/21 Arrive 04:05 AM. Discharge 08:58 AM.
To ER via EMS. Chief complaint abdominal pain. Medical work up was completed and P1 was given pain medication and IV fluids for hydration. 08/10/21 06:58 AM RN disposition note "RN spoke with Pt emergency contact, friend to pick pt. up. Friend reported she has money to pay for pt taxi. RN called ...Taxi who confirmed pick up.

Visit six 08/13/21 Arrive 12:39 PM Discharge 05:53 PM 08/13/21 12:39 PM RN6 triage note: "patient arrives via EMS, with altered mental status ...able to stand upon arrival, gazed look." P1 was assessed to be a fall risk. 08/13/21 01:13 PM ERMD3: "...During his (P1) last visit he was evaluated by social work and psychiatry. ...appears dazed. ...Social worker was consulted to assist with discharge planning and attempted to contact case worker (P1's CM)." The diagnosis for the visit was "Wandering Behavior." 08/13/21 05:53 PM RN4: taxi here to pick up patient, patient has his own funds. SW2 assisted patient with discharge reinforcement." 08/13/21 09:06 PM SW2 late note: "Pt. was discharged home. I contacted brother [error, friend], who set up taxi transportation with ...Taxi. Pt. made aware taxi will be arriving in 15 min. Taxi driver called nurse station and was unable to find pt. I received a call from HPD (Honolulu Police Department) dispatch @ 20:47. Pt is reported as a missing person. I informed dispatch that ...taxi arrived and was asking about his whereabouts. I informed dispatch that pt. has a hx of walking home since he lives nearby."

Visit seven 08/14/21 Arrived 04:36 AM. Discharged 12:20 PM. 08/14/21 04:36 AM RN5 Triage Assessment: " ...911 activation by Pts Case Manager, who was concerned pt was having a stroke." RN5 identified P1 as a fall risk. 08/14/21 04:35 AM. ERMD4: "Per report the person who lives with him [P1], called the crisis line this morning trying to get the patient in LCRS (licensed crisis bed shelter) bed. States that he needed to be evaluated because of his frequent falls and worsening confusion. A crisis social worker came to the house and evaluated the situation. She states that he had multiple falls even while she was there. ...Per report patient was seen here yesterday for confusion initially concern for stroke. ...A taxi was called for the patient however the patient wandered off ...He was then found by police. ...During his last visit he was evaluated by social work and psych...who recommended discontinuing his desvenlafaxine. ... On exam, he is alert oriented x3 though he does not know the circumstances why he is here and starts to talk about his pancreas. ...With multiple unrevealing workups, mostly likely this is a combination of his psychiatric disease, his age and some dementia. ...Will need to be reevaluated given [sic] by social work in a more long-term placement need to be sought. 08/14/21 12:11 PM ERMD4: "No indication for acute admission at this time. Patient wishes to be discharged. Cannot be held at this time. I do believe we will have patient return [sic]the emergency department as he has no appropriate long-term plan established. ...Dx: frequent falls, wandering behavior." 08/14/21 12:02 PM RN4's disposition note at 12:20 PM identified P1's cognition was a barrier to learning. There were no SW notes on this visit.

3) On 10/08/2021 at 09:00 AM during an interview with RN1, she said she was familiar with P1. She said she knew "he came in frequently over a couple day period with potential altered mental status, a couple of times in the same shift and there were issues with discharge." RN1 said P1 is usually insistent on walking home and remembered he was walked to the bus stop one time and he didn't wait for the bus. RN1 went on to say the "SW was consulted, and we were attempting to find safe way home." RN1 said P1 didn't qualify for a "Medical taxi" based on insurance coverage and the facility does not have any other transportation vouchers. She said the staff sometimes put money together to pay for rides. RN1 said "Typically, if a taxi is coming, we will wait outside with them [patients]." She went on to say when she was assigned to P1 on 08/07/21, she was concerned about sending him home. He had a "bewildered appearance" that day so we kept him overnight. The next day I was assigned to another section but remember "there were questions as to why he was still here." Quiered what the facility standards and policy was for nursing documenting assessments and vital signs. RN1 said they didn't have a policy and depends on acuity. RN1 confirmed the ER has access to psychiatrists and can do "tele consults."

4) On 08/10/21 at 10:00 AM during an interview with SW3, she confirmed P2 did not qualify for a taxi voucher and the staff sometimes put money together for rides. SW2 said some of the difficult discharges don't go home, get admitted and then it becomes difficult to find placement for discharge. Inquired if SW3 or anyone had discussed P1's unique transportation needs with her supervisor (ER Manager) or Medical Director to develop a safe plan and she said no.

5) On 10/08/21 at 10:37 AM during an interview with RN3, he said he was very concerned regarding P1's safety at the time of discharge on visit four, so "I kept him inside so he wouldn't fall on me." RN3 went on to say when the taxi got there, "I wheeled him out so he wouldn't fall and when he got into the taxi, I buckled his seat belt ...I told the taxi driver to not stop anywhere and make sure he got home safe."

6) On 10/08/21 at 11:14 AM during a phone interview with SW1, she said she recalled P1 had been in earlier and discharged. "P1 was very tall and he said he would get going and get momentum and fall." SW1 confirmed she had a phone conversation on 08/08/21 with the psychiatrist to discuss P1's case. SW1 said "he (psych) didn't seem overly concerned." SW1 said she was not aware of psych seeing or examining P1. She went on to say the Psychiatrists are in the behavioral health unit and sometimes come to the ER to see patients, and can also set up a teleconference visit. SW1 said she believed the medication change was recommended based on the behaviors she reviewed with him. SW1 said the usual process is "the ERMD orders a Social Work and psych consult. After the SW reviews everything, we contact the on-call psych and provide them with all the background, current medications, and stuff. Then we usually talk to the ERMD and let them know what psych said and they [ERMD] decide what to do based on the situation." SW said to her knowledge, the ERMD did not discuss the case with psych."

7) On 10/08/21 at 08:00 AM observed the entrance/exit to the ER. There was a podium just outside the doors with security present. Observed the security officer greet, screen, and interact with a constant stream of people. There were wood benches against the wall outside the ER next to the podium where people were sitting.
On 10/08/21 at 08:40 AM during an interview with the Security Manager (contract agency) and the facility Administrative Services Officer (ASO), they said the ER has an officer at the ER entrance/exit 24/7. The ASO said the security staff will assist with helping patients get in and out of vehicles but are not responsible to monitor anyone while they wait. He said If a taxi pulls up looking for someone, they will go inside to let the ER staff know.

8) Requested the ER policy/procedure for discharge and the Risk Manager (RM) provided the facility policy titled "Discharge of Patients" revised April 2021. Review of this policy revealed it included a statement for guidance when a patient wanted to leave against medical advice, but nonspecific information related to an ER discharge. When queried the RM if there was a policy with more content specific to ER, she said no.

9) Reviewed the facility "Event Reporting" policy revised June 2020. The purpose statement included: "To provide a systematic process of collecting event data for improving patient outcomes, patient safety and staff performance." The definition of an event "is an occurrence that is not consistent with routine ..."

On 10/08/21 during an interview with the RM, she said she was not aware of safety issues with P1's discharges from the ER and would have expected an event report to be completed when the ER was notified by police P1's was a missing person report after discharge from the ER.

10) The ER SW staff are employees of the ER, report to the ER Manager and have ER specific job descriptions. Review of documents revealed there were three different job descriptions, SW1, SW11 and SW111. SW1 is a trainee, and SW111 included "privileged and credentialed as an advanced practice professional." The function of the positions is to provide social services and complex care coordination and transition of care services to the patients/resident of ..., Emergency Department and ..." One of the major duties/responsibilities is ..." Ensure safe and appropriate discharge with respect to social determinates for the patient." Discharge planning duties included "Performs all aspects of patient care and services with attention to maximizing patient safety and performance improvement." One of the responsibilities of the SW is to "Assist with identifying concerns and issues related to the transitional care services ...and other social determinates of health to the... Director/Supervisor, Medical Director, professional staff and external stakeholders and assist in problem solving and follow through."The ER SW job descriptions do not include relaying a patients physical and mental condition with a physician consultant, obtaining a telephone recommendation of medication changes and communicating those recommendations to the ERMD. This is outside the scope of the job description for SW1 and SW 11 who are unlicensed and not certified. In addition, this practice does not adhere to standards of practice.
The ER SW staff did not bring this complex discharge issue to the ER leadership to problem solve and develop a plan.