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100 HOSPITAL DRIVE

BENNINGTON, VT 05201

EMERGENCY SERVICES

Tag No.: A1100

Based upon interview and record review, the facility failed to ensure the emergency needs of patients in accordance with acceptable standards of practice were provided regarding appropriate discharge services and notification for the complaint-focus patient [Patient #1] related to transportation for the cognitively impaired patient back to a group home and guardian notification of the discharge from the Emergency Department.
Findings include:

Review of Patient #1's "Emergency Department [ED] Visit Chart Record" for 7/10/23 reveals Pt.#1, a resident at a therapeutic community residence [group home] for the developmentally disabled, was transported to the Emergency Department [ED] by the Bennington EMS [Emergency Medical Services] ambulance with complaints of abdominal pain and chest discomfort.
Pt.#1's "ED Visit Chart Record" reveals under "General Appearance" the patient is listed under "Assessed Disability" as "Developmentally Delayed". Pt.#1's primary medical history lists the patient as diagnosed with Schizophrenia, and review of ED Physician Notes record Patient #1 assessed as "cognitively impaired". The ED record lists the complainant as the next of kin and records the relationship as "guardian" along with a contact phone number. The ED event history records the patient as having been received at the ED at 6:52 PM on 7/10/23, triaged, signed out by the ED Physician, ready for discharge, then removed from the ED tracker at 12:50 AM on 7/11/23. Pt.#1's "Disposition Assessment" dated 7/11/23 at 12:49 AM records the cognitively impaired group home patient as "able to safely manage at home". Additionally, Nursing Notes include "Discharge instructions covered with patient, who expresses understanding and raises no questions."

Review of the facility's "Discharge Process Emergency Department-policy 2416 [revised 3/5/2020, approved 4/13/2021]" includes "Patients are assessed to determine from a cognitive and or functional status if it is safe for him/her to leave unaccompanied."
The "Discharge Process Emergency Department" policy also includes "If the patient is a resident of a nursing home or community care home discharge instructions will be reviewed with the staff receiving the patient."

Review of the facility's "Documentation Guidelines Emergency Department- policy 2418 [revised 11/9/2022, approved 1/20/2020]", states "Documentation is a critical component in high quality patient care and safe, effective nursing practice." Under 'Functional Discharge/Planning', the policy reads "Assess living situation to help determine discharge planning needs." Under 'Discharge Summary/Education', the policy instructs staff to document "transfer time, mode of transfer, status during transfer. Name of individual who received the hand off Documentation ..."

An interview and record review were conducted with the Assistant Director of the Emergency Department [ADED] on 7/31/23 at 12:02 PM. The ADED confirmed there was no documentation in Pt.#1's medical record regarding Pt.#1 's discharge destination, how S/he would be transported to the [undocumented] destination, and no documentation that the patient's listed guardian was notified that Pt.#1 was being discharged [without transportation] from the ED. The ADED confirmed Nursing Notes recorded Pt.#1's guardian had called the ED during the patient's stay requesting an update on the patient. The ADED stated it was his/her expectation that transportation would be arranged prior to discharging the patient out of the facility, that the patient's guardian would be notified of the patient's discharge, and that this information would be documented in Pt.#1's medical record but it was not. The ADED stated that S/he would 'not feel safe' being discharged from the facility alone, without transportation, at '1:00 AM in the morning'.
Per review of the complainant's report dated 7/13/23, Pt.#1 stated that after being discharged S/he was unsure how to get back to the group residence and ended up getting lost - S/he eventually found their way back to the hospital ED around 3:30 AM. The hospital ED then called the police to provide transportation to the patient back to his/her group home. Per interview with the ADED, when Pt. #1 returned to the ED, S/he was not registered as a patient and therefore there was no documentation that S/he had returned and that police had to be contacted to transport the patient to the group home.
An interview and record review were conducted with the Chief Nursing Officer [CNO] on 7/31/23 at 12:34 PM. The CNO confirmed Pt.#1's medical record documented the patient as "Developmentally Delayed", "cognitively impaired", and with a history if Schizophrenia. The CNO confirmed the facility's policies include instructions for staff to assess patients "to determine from a cognitive and or functional status if it is safe for him/her to leave unaccompanied" and "If the patient is a resident of a nursing home or community care home discharge instructions will be reviewed with the staff receiving the patient." The CNO confirmed Pt.#1's medical record listed the patient as being discharged alone at 12:50 AM on 7/11/23, with no documentation that transport was arranged to take the patient's back to their group home, and no documentation that the patient's guardian or group home staff were notified that the patient was being discharged. The CNO stated S/he was "disappointed" that the facility's process had allowed Pt. #1 "to be discharged to the streets at 1:00 AM."