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Based on observations, interviews and record reviews the hospital failed to protect and promote Patient 1's rights when:

The hospital failed to ensure patients received care in a safe setting for one of three patients, Patient (Pt) 1, when Pt 1 was brought in by ambulance on 8/26/24 to the hospital's Emergency Department (ED) with a chief complaint of a ground level fall at home with a large bruise to the forehead and after being evaluated, treated and stabilized, was discharged to the nearest bus stop and not provided a safe transport home. Pt 1 was elderly, non-English speaking and had a history of dementia and determined to be ready for discharge on 8/26/24 at 10:43 p.m. Pt 1's clinical record documented she was discharged to the bus stop. Staff where aware buses did not run at that time of night. Pt 1 spent the night in the hospital lobby. The following morning 8/27/24 Pt 1 was escorted to the nearest bus stop and family was not contacted. Hospital social services was not consulted and utilized to evaluate safe transport home after discharge. (Refer to A-0144)

The cumulative effects of these systemic problems resulted in the hospitals inability to ensure care in a safe and effective manner for Pt 1 in accordance with the statutory-mandated Condition of Participation for Patient Rights.

Based on interview and record review, the hospital failed to ensure patients received care in a safe setting for one of three patients, Patient (Pt) 1, when Pt 1 was brought in by ambulance on 8/26/24 to the hospital's Emergency Department (ED) with a chief complaint of a ground level fall at home with a large bruise to the forehead and after being evaluated, treated and stabilized, was discharged to the nearest bus stop and not provided a safe transport home. Pt 1 was elderly, non-English speaking and had a history of dementia and determined to be ready for discharge on 8/26/24 at 10:43 p.m. Pt 1 was not provided safe transport home and clinical record documented provided bus stop. Staff where aware buses did not run at that time of night. Pt 1 apparently spent the night in the hospital lobby. The following morning 8/27/24 Pt 1 was escorted to the nearest bus stop and family was not contacted to provide a safe transport home. Hospital social services was not consulted and utilized to evaluate safe transport home after discharge.

These failures resulted in the hospital not ensuring a safe environment of care upon discharge, not treating Pt 1 with dignity and respect, and resulted in Pt 1 staying in an unknown area of the hospital overnight and wandering the streets of a local rural town approximately 10 miles from the hospital. Pt 1 was not found until the morning of 8/27/24 and experienced the night and early morning without food, water, shelter, and comfort. These failures resulted in extreme worry and mental anguish for family members of Pt 1.

Findings:

During an interview on 8/28/24, at 9:39 a.m., with Pt 1's Daughter (Dtr), the Dtr stated Pt 1 went by ambulance to the hospital on 8/26/24 for a fall with laceration to her forehead and was expecting the hospital to call when Pt 1 was ready to be discharged and she never received a call. Dtr stated she reached out to the hospital in the morning when she had no missed calls and was informed that Pt 1 was discharged by bus at 10:43 p.m. on 8/26/24. Dtr stated she asked for clarification and was told staff would not know more until the shift that discharged her came back in tonight because they could not locate any notes to indicate how Pt 1 left except by bus at 10:43 p.m. Dtr also stated that hospital staff told her the cameras for the ED were down and she could file a missing person request with the police department. Dtr stated on Pt 1's previous visit on 7/30/24 Pt 1 had a diagnosis of underlying dementia. Dtr stated the hospital was able to set up transport home for her last ED visit on 7/30/24. Pt 1 does not drive. Dtr stated she was never notified of her discharge on 8/26/24. Dtr stated on 8/27/24 around 3:13 p.m. Pt 1 was found by the police wandering around a rural town about 10 miles from the hospital.

During a review of Pt 1's face sheet (provides demographic information to include name, date of birth, contact information, insurance information, etc.), dated 8/26/24, indicated Pt 1 was admitted on 8/26/24 at 5:34 p.m., no discharge time or date noted, 74 year old female, primary language is Spanish and an interpreter is needed; chief complaint: Ground Level Fall (GLF) Hematoma (bruise) on forehead; contact person Daughter (Dtr).

During a review of Pt 1's ED Note titled "Final Report" dated 8/26/24, at 8:27 p.m., indicated, Pt 1 arrived by ambulance at 6:03 p.m. for a ground level fall (GLF) and presented with a large hematoma to forehead, alert and oriented times 4, denied any loss of consciousness. Pt 1 has past medical history (PMH) of Hypertension (elevated blood pressure), arthritis (inflammation in joints causing pain and stiffness), depression (mental disorder that can affect a person's feelings, thoughts, behaviors, and sense of well-being). On physical exam Pt 1 is in "No acute distress, alert and oriented x 3 ... forehead hematoma, partially obstructing the right eye". At 9:44 p.m. per treating provider reexamination/reevaluation "discussed all results, diagnosis, treatment plan, prescriptions, and discharge home. The patient verbalized understanding and agrees to be discharged at this time. They [referring to Pt 1] understand to return to the ED for worsening of symptoms or concerns for their safety." Final diagnosis this visit: Traumatic hematoma of forehead and GLF both discharged at 9:47 p.m. to home or self-care, condition stable.

During a review of Pt 1's ED Physician Notes titled, "Final Report," dated 7/30/24, at 12:34 p.m., indicated Pt 1 came into the ED by ambulance on 7/30/24 at 11:50 a.m. for chief complaint of 5150 hold (a legal term for the involuntary psychiatric hospitalization of an adult who is experiencing a mental health crisis) for mental health evaluation "Per daughter PT [Pt 1] having Hallucinations". On physical exam Pt 1 presents as "agitated". Reexamination/Reevaluation done at 1:44 p.m. indicated, "Patient is medically clear for psychiatric evaluation". Medical Decision Making ED Course: " ... Patient denies any suicidal homicidal ideation has no neurodeficit has a history of dementia ...". Final diagnosis this visit: Acute psychosis (symptoms include hallucinations, delusions, disorganized thoughts, or behaviors, last about a month; causes brain damage, diseases, or substance abuse); elevated blood pressure; hypokalemia (low potassium level); dehydration (loss of fluids in body can cause increased thirst, tiredness, decreased urine output, dizziness, headaches, and confusion); medical clearance for psychiatric evaluation. Condition Stable.

Review of document titled, "Neurology/Stroke Note," dated 7/30/24 at 5:15 p.m., indicated, " ... Recommendations ... Discharge ... Impression Hallucinations ? (questionable) underlying dementia ... recommendations ... Outpatient neurology consultation ..."

During a concurrent interview and record review on 8/28/24, at 10:04 a.m. with ED Registered Nurse (RN) 13 Informaticist, Pt 1's electronic Health records (EHR) for ED visits on 8/26/24 and 7/30/24 were reviewed. Pt 1's EHR indicated on 8/26/24 Pt 1 arrived at 5:34 p.m. by ambulance for a ground level fall with large hematoma to forehead and was discharged to a bus on 8/26/24 at 10:43 p.m. RN 13 confirmed the bus does not run that late in this area but Pt 1's EHR does not indicate any other form of transportation used nor any family contacted about the discharge plan. RN 13 stated the EHR for Pt 1's ED visit on 8/26/24 does not indicate that Pt 1 has a diagnosis of dementia. RN 13 stated when patients who are confused or have dementia are discharged family is contacted and patient is placed in a secure area where they can be monitored until family arrives or transport is arranged for them to go back to their home. RN 13 stated the EHR for Pt 1's ED visit on 8/26/24 did not show that family was called for discharge of Pt 1. RN 13 stated Pt 1's EHR for ED visit on 7/30/24 indicated Pt 1 was brought in by ambulance as a 5150 gravely disabled patient and a psych evaluation was done that indicated Impression "Hallucinations ? (questionable) underlying dementia". RN 13 confirmed Pt 1 was discharged home on 7/31/24 by transport set up by social worker (SW).

During an interview on 8/28/24, at 12:18 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he started his shift in ED on 8/27/24 and around 7:30 a.m. he saw Pt 1 come to the registration window asking for assistance in Spanish and registration asked me to help because I speak and understand Spanish. LVN 1 stated Pt 1 wanted a taxi but did not have her wallet with her because she needed to go home. LVN 1 stated he tried to explain to Pt 1 where the bus stop was, but she asked for someone to show her instead. LVN 1 stated Pt 1 had her belongings with her, and he walked her to the bus stop but once outside the hospital Pt 1 stated, "I feel like I am drunk". LVN 1 stated Pt 1 told me she has a daughter, but she is pregnant and does not have family that can come and get her. LVN 1 stated he asked Pt 1 if she knew where she was going on the bus and she stated she lived near the airplanes and a clinic was across the street, LVN 1 stated he provided the name of the clinic and she agreed and told me she needed to go to a rural town about 10 miles from the hospital. LVN 1 stated he left Pt 1 at the bus stop after he pushed the button that informs the bus driver there is a passenger waiting for the bus. LVN 1 stated Pt 1 had told him that she had attempted to call her family earlier and did not know the results of that phone call. LVN 1 stated he knew Pt 1 was discharged the night before on 8/26/24 and did see her discharge paperwork. LVN 1 stated Pt 1 was answering questions appropriately.

During a concurrent interview and video review on 8/28/24, at 2:26 p.m. with Security Supervisor (SS), SS was able to bring up the video of the ED department on 8/27/24 at 7:45 a.m. and it showed Pt 1 and LVN 1 leaving the ED walking across the bridge Pt 1 was seen using the rail on the left side of the bridge for support while walking and once she let it go she appeared to be unsteady while walking. The SS stated the night shift Security Lead reviewed the video overnight and did not see Pt 1 leave the ED the night of 8/26/24. The SS confirmed some of the cameras have been down in the ED department and they are currently being worked on, so they had limited view in the ED itself.

During an interview on 8/29/24, at 7:45 a.m., with LVN 2, LVN 2 stated she works in the ED, and she was working on 8/26/24 from 7 p.m. to 7:30 a.m. LVN 2 stated she does recall discharging Pt 1 on 8/26/24. LVN 2 stated Pt 1 spoke Spanish and an interpreter was used. LVN 2 stated Pt 1 had told them that she did not know how to get ahold of her family. LVN 2 advised Pt 1 to speak with registration they would have her contact numbers and they can call for a ride for her. LVN 2 stated Pt 1 had informed them that her family works nights, and she did not have anyone to call until the morning, so she stayed in the lobby all night. LVN 2 stated she remembers seeing Pt 1 throughout the night when she brought other patients back into the ED. Pt 1 was still waiting in the ED lobby by the time she got off work at 7:30 a.m. on 8/27/24. LVN 2 stated when a patient has dementia and is being discharged, we have them wait in a more secure area in the back of the ED where we have access to them. LVN 2 stated she was not aware that Pt 1 had dementia. LVN 2 stated she did not investigate Pt 1's previous visits and only looked at her current visits. LVN 2 stated for those with dementia we make sure they are discharged with a family member, and she makes sure to document it in her notes. LVN 2 states we have needed to schedule transport for patients that need it before.

During an interview on 8/29/24, at 3:20 p.m. with EKG technician (TECH 1), TECH 1 stated he spoke with Pt 1's Dtr on 8/27/24. TECH 1 stated he noticed the Dtr seemed anxious and was loud and informed him that her mother, Pt 1, was discharged last night, and the hospital does not know where she is, and she mentioned Pt 1 had dementia. TECH 1 stated he remembered who Pt 1 was because she had a goose egg (large bruise) on her face. TECH 1 stated he went into the back of the ED and looked at the inter-facility log and noticed he could not find Pt 1's name on it and asked around about Pt 1. TECH 1 stated he looked up Pt 1 and saw she was discharged last night and noticed her visit did not mention Pt 1 had dementia. TECH 1 stated the Dtr was on the phone and then asked me what she should do, and I told her "I would call the police department and make a missing person report". TECH 1 said the Dtr was upset and was on the phone with Adult Protective Services (APS). TECH 1 stated he was going to see if he could find more information for her but when he came back the Dtr was gone.

During an interview on 8/29/24, at 4:18 p.m., with the Patient Relations Specialist (PRS), PRS stated Pt 1's Dtr came in at 11:50 a.m. on 8/27/24 and security called me to come speak with her. PRS stated the Dtr informed her that Pt 1 was missing and that she had already filed a missing person report and filled me in on how this had happened, provided a picture of her mom, and left her contact information. PRS stated she began looking into what happened to Pt 1 after her discharge and did multiple interviews and had staff look all inside of the facility and outside the surrounding of the facility and they were not able to locate her. PRS stated she let her own manager know what was going on and the footage from the cameras was reviewed. PRS stated she called the Dtr the following day and Pt 1 had been found in a rural town about 10 miles from the hospital.

During an interview on 8/30/24, at 12:55 p.m., with the Chief Nursing Officer (CNO), CNO stated the ED does not have a social worker (SW) on at night time. CNO stated if a patient needs a referral the face sheet is copied and placed on the SW desk with a message of what is needed for the patient and is addressed by the SW who comes in the next morning. The CNO stated she interviewed the staff that cared for Pt 1 on 8/26/24 and based on her interviews staff felt Pt 1 was alert and oriented. The CNO stated staff did not think it unusual for Pt 1 not to remember her contact numbers, none of her staff felt Pt 1 was in any danger or risk discharging her at night to herself. The CNO stated based on how Pt 1 presented the night of 8/26/24 her staff did what was appropriate for this patient. The CNO stated only issue is the documentation in Pt 1's chart for her discharge on 8/26/24 time 10:44 p.m. transportation type as bus and she understood the bus does not run that late at night.

During an interview on 8/3/24, at 10 a.m. with the Accreditation Regulatory Compliance Manager (ARM), ARM stated the facility did not have a separate discharge policy for the ED, so the "Discharge of the Adult Inpatient (PC 92)" is what is used.

During a review of the facility's policy titled, "Discharge of the Adult Inpatient (PC 92)" reviewed last on 6/22, indicated, "DEPARTMENTS: Hospital-wide POLICY: ... Discharge planning is to begin when the patient is admitted to the facility and is to be an ongoing planning process throughout their hospital stay. The patient, family and health care provider(s) from appropriate care disciplines are responsible or planning and coordination of the discharge ... GUIDELINES: A. The patient's Registered Nurse (RN) and Care Coordination will coordinate discharge-planning needs for the patient... 2. Staff will assist the patient, family and/or caregiver(s) in arranging, obtaining, or offering information appropriate to their discharge needs. 3. The patient will be assisted in contacting their family and/or caregiver(s) informing them of the impending discharge so timely preparation and transportation arrangements can be made. B. On Admission in Preparation for Discharge: 1. The admitting RN will document in Cerner: a. The patient contact information. B. Verify the patient primary care physician (PCP), transportation and preferred pharmacy ... d. Identify potential barriers to discharge (i.e. lack of insurance, transportation issues, homelessness, etc.) and notify Care Coordination. E. Verify transportation available for discharge ... D. Discharge Documentation in Cerner: 1. In Nursing Communication: for nursing units 4 through 7, ICU and ED in their appropriate sections ... E. Verify the Discharge Plan with and Document ... 3. Transportation Plan ... 9. The patient is escorted via wheelchair, or other appropriate mode of transport, and released to a responsible individual.

During a review of the facility's policy titled, "Patient's Right and Responsibilities (RI-01)", effective dated 1/24/19, indicated, " ... These rights and responsibilities are identified in the 'Patient Rights and Responsibilities' booklet ... Patients are informed of their rights and responsibilities upon admission to an inpatient setting, or upon initial presentation to an outpatient setting ..." Review of "Patient Rights and Responsibilities" dated 9/2017, indicated, "[name of hospital] complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity ... Each patient is entitled to compassionate and professionally competent care delivered with respect for each individual ... to be made comfortable ... 2. Have a family member (or other representative of your choosing) and you own physician notified promptly of your admission to the hospital ... 14. Receive care in a safe setting, free from mental, physical, sexual, or verbal abuse and neglect, exploitation, or harassment ... 17. ... You have the right to be involved in the development and implementation of your discharge plan. Upon your request, a friend or family member may be provided this information also ... 19. Designate a support person as well as a visitor or your choosing, if you have decision making capacity ..."