HospitalInspections.org

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Based on record review and interview, the facility failed to ensure that arrangements from a discharge plan evaluation were made for 1 patient (#1), out of 10 patients reviewed. Specifically, the primary nurse failed to inform the Assisted Living facility (ALF) before the patient was discharged out of the facility through a public transportation (taxi). This failed practice placed the patient at risk for inability to care for himself/herself and exposure to cold weather which may have resulted in cold-related injuries, hypothermia, and/or death. Findings:

Record review on 1/22-23/24 revealed Patient #1 was admitted to the facility with diagnoses that included acute COVID (coronavirus) infection without pulmonary involvement, generalized weakness, and dementia (loss of cognitive functioning).

Review of Patient #1's "Discharge Summary," dated 12/17/23 at 12:04 PM, revealed: " ... [Patient #1] 84-year-old ...with dementia, normally resides at assisted living facility, was brought to the emergency room for evaluation for generalized weakness. Found to have COVID infection ...Patient was admitted to the hospital for care as there was concern that the assisted living facility cannot take him/her back at his present level of functioning ...Discussion with assisted living facility, they are able to accept patient on Sunday at discharge, even with active COVID precautions ...Discharge Instructions [:] 1. Patient discharged back to assisted living facility ..."

Patient Transportation

Review of Patient #1's "Plan of Care," dated 12/17/23 at 1:34 PM, revealed: "Case Manager [CM #1] requested Navigator's assistance to provide wheelchair transportation for Patient ['] s discharge to ...[ALF]." The plan of care also revealed the Navigator called "BAC" and "Waymakers" [both are transportation companies]" but there was no opening for "BAC" that day and "Waymakers" was closed.

Further review of the plan of care revealed: " ...Navigator consulted ... [CM #1], who stated Patient [#1] is able to take a Yellow Taxi."

During an interview on 1/22/24 at 2:00 PM, Licensed Nurse (LN) #1 explained the hospital's discharge process. He/she stated after confirming the availability of the transportation service to be used for patient's discharge, the discharge nurse would call the receiving facility to verify if they were ready to accept the patient. If the ALF confirmed that they would accept the patient, the discharge nurse would start the discharge paperwork and patient education. Then, the patient would be transferred to the Discharge Lobby (where patient's wait for their transportation) or to patient's preferred transportation.

During an interview on 1/22/24 at 2:37 PM, CM #2 stated transportation arrangements could have been by private car, van, ground transportation such as taxi, or Lyft [another type of ground transportation utilized by the hospital]. He/she stated he/she would be reluctant to use taxi or Lyft for patient who will go to an ALF.

Review of the Discharge Lobby camera video recording, dated 12/17/23 between 2:17 PM to 2:22 PM, revealed Patient #1 was in a wheelchair, wearing a long white sleeve shirt, gray sweatpants, yellow socks, and black shoes. Patient #1 was wheeled out of the facility by 2 hospital staff (unidentified) and transferred to a yellow taxi. Further review of the video recording revealed the yellow taxi left at 2:22 PM.

Review of the Patient #1's "Plan of Care," dated 12/17/23 at 1:05 PM, revealed: " ...Patient discharged safely to care facility [,] transportation mode: wheelchair to taxi ...Care timeline ...12/17[/23] Discharged 1422[.]"

Hospital's discharge communication process to receiving care facility

During a joint interview on 1/22/24 at 2:37 PM with CM #2 and Social Services Staff, when asked about the communication process between the hospital and the receiving facility, CM #2 stated for a Skilled Nursing facility (SNF), the nurse would have called the SNF nurse before discharge. The CM added it would have been the same process for a patient who would be returning to an ALF. The nurse would have communicated the patient's discharge information including the date and time of discharge to the ALF. The CM stated the ALF would not call back the hospital unless there was a problem or issue.

CM #2 further stated it was not the CM's role to follow-up with the nurse whether the nurse called the ALF or not. After the discharge process, the CM would have completed a discharge narrative report and his/her role with that patient's discharge was completed.

Review of "Case Management Discharge Summary," dated 12/17/23 at 9:29 AM, revealed: " ...Steps taken Towards Discharge: 1130-CM [#1] called ...ALF again and spoke with admin [administrator] who states that it is fine for ...[Patient #1] to return today ... requests that bedside [registered nurse] please update ... on how long patient needs to be in isolation for COVID and when [he/she] leaves in the taxi so that they know when to expect ...[Patient #1] home. Patient care team updated ... above."

During an interview on 1/23/24 at 9:43 PM, CM #1 stated he/she did not know if the primary nurse called the ALF before Patient #1's discharge. The CM stated he/she expected the nurse would have done what was asked of him/her to do. The CM further stated it was not his/her responsibility to call the ALF if the patient discharged safely.

During an interview on 1/23/24 at 12:30 PM, LN #3, who discharged the patient on 12/17/23, stated the patient had dementia but he/she would not know the level of the patient's condition without cognitive evaluation. LN #3 stated the patient was able to follow instructions during the discharge process. LN #3 recalled that the patient needed shoes and he/she picked-up shoes from "Claire's" (where donated clothing for patients who needed clothes were stored). The LN added Patient #1 wore regular clothing before discharge.

During the same interview, when asked if he/she called the ALF before discharge as requested in the Case Management Discharge Summary, dated 12/17/23 (the document was shown to LN #3), LN #3 stated after he/she called for patient's transfer from patient's room to the discharge lobby, he/she "got busy on something" and went for a lunchbreak. LN #3 added he/she remembered during his/her lunchbreak that he/she did not call the ALF. LN #3 stated he/she called ALF and left a voicemail later that afternoon. He/she could not remember if ALF returned the call.

When asked if he/she was trained to call the ALF after patient discharge, LN #3 stated "nobody said anything to coordinate somebody to get home." When asked if there was documentation of the call made to ALF, he/she stated he/she documented it in the medical record, but the LN could not find the note in EPIC (the hospital's electronic health record). While the LN was checking his/her EPIC account, LN #3 remembered that he/she send a text message to CM #1 through the hospital's secure text messaging system.

Review of LN #3's text message, dated 12/17/23 at 3:07 PM, revealed: " ...I just got a chance to call them, I apologize[.]" "went to voicemail[.]"

Review of the State of Alaska (AK) Health Facilities Licensing and Certification complaint "Intake Information," AK #00004480, revealed: on "12/17/23 at 3:30 PM, Staff found ... [Patient #1] out on the driveway. Temperature 35 degrees with excessive snow accumulation this year (>70 inches)." Further review of the intake information revealed Patient #1 was " ... on the ground, with no jacket ..." outside the ALF.

Review of the hospital's "Discharge of Patient Process," dated 11/2023, revealed: " ...Attachment A: Provider and Hospital Caregiver responsibilities ...On the day of discharge, the nurse calls the designated caregiver to inform them of the patient's discharge order. If the nurse cannot make the phone call, the caregiver call is delegated to the charge nurse. The phone call to the designated caregiver is documented in EPIC ..."
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