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Based on observations, staff interviews, clinical record and document reviews, and review of the hospital's policies and procedures, Hospital 1's noncompliance with the requirements under EMTALA occurred as a result of Hospital 1's failure to follow its policy and procedure for patient discharge from the Emergency Department (ED) when Patient 100 was discharged home to an environment that was unsafe and interventions were not in place to address his physical and psychosocial needs. [Cross-Reference 2409]

Findings:

During a concurrent interview and emergency medical record review on 6/11/24 at 9:10 a.m., Assistant Nurse Manager G stated Patient 100 arrived in the ED on 1/26/2024 at 11:48 a.m. She stated he was triaged (prioritization of injured/sick patients based on their need for emergency treatment) at an ESI (Emergency Severity Index) level of 3 (urgent).

(Orientation Tool: Alert and Oriented (A&O) x1, x2, x3, x4 - stands for orientation to person (x1), place (x2), time (x3), and situation (x4). A patient who is oriented x1 means they are only oriented to themselves (confused about place/time/situation). A patient oriented x2 is oriented to themselves and where they are, but confused about time/situation, etc. This tool is commonly used to describe the mental status of patients in healthcare settings and serves as an evaluation tool for understanding a patient's cognitive abilities and identifying potential concerns.)

A review of Patient 100's ED Provider Notes, dated, "1/26/2024 5:48 PM," indicated, "History of Present Illness: [Patient 100] was a 77-year-old male with a prior stroke, vascular dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain [mayoclinic.org], diabetes and hypertension ... they (family) have been unable to fully clean or turn him. He is incontinent of urine and stool, so he has essentially been sitting in incontinence for several days ... patient's wife is disabled (does not walk) and [son] himself is also disabled and is too weak to turn his father ... his current situation at home is very unsafe ... Patient's son arrived ... States ... the patient cannot come back home under any circumstances. 'The doors will be locked.' ..."

Review of Patient 100's medical record indicated a social worker (SW T) submitted an Abuse Report (regarding Patient's 100 home living situation) to (local county) Adult Protective Services (APS) on 1/26/24 at 3:50 p.m., that indicated Patient 100 "...Has multiple caregivers quit because patient is verbally abusive ... patient's son states ... they (family) have been unable to fully clean or turn him... They have been unable to find a caregiver to assist... current situation at home is very unsafe..."

Review of a Physical Therapy (PT) evaluation, dated 1/30/2024 (three days prior to discharge home), indicated Patient 100 was not fully cognitively intact at the time of the assessment and, "...Patient currently unaware where he is located..." (i.e., not oriented to place). The evaluation indicated Patient 100, "Requires 24-hour assistance..." with toileting, mobility, and ADL's (Activities of Daily Living, a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). The evaluation indicated Patient 100 was unable to transfer (sit to stand, bed to chair, chair to bed) because he was, "unable due to left lower extremity (leg) pain and weakness" and was unable to be assessed for Gait (walking) as he was unable to bear weight (support his body weight during activities like standing/walking).

A review of Patient 100's seven-day ED stay, from 1/26/24 to 2/2/24, indicated staff and providers documented his mentation fluctuated between oriented and confused: On 1/26/24 at 5:48 p.m., Physician V documented, " ...does not appear to understand the ramifications of his words and actions on his overall care." On 1/26/24 at 7:22 p.m., a Registered Nurse (RN) documented, "... asking for wire cutters so he could cut his wires off and escape. Attempted to reorient patient without success ..." On 1/27/24 at 5:17 a.m., an RN documented, "Pt states he is a manager at Safeway and drives to work every day." On 1/29/24 at 12:04 p.m., a provider documented, "Patient currently unaware where he is located..." and, On 1/31/24 at 10:16 a.m., the wound nurse documented, "Patient is awake, but not able to make needs known effectively at this time... Unable to follow simple commands..."

Review of Patient 100's medical record indicated his mental status on 2/2/24, the day of his discharge: At 12:56 p.m., Physician B documented, "Addendum: Hold patient additional light (sic) since there appears to be a waxing and waning mental status pattern..." At 3:25 p.m. (the afternoon of discharge), CM D further documented, "...Canceled (ambulance) request. Patient's mental status (was) waxing and waning therefore HBS (Hospitalist, physician) has suspended discharge and will watch again overnight."

During an interview on 6/12/24 at 10:35 a.m., when asked about her discharge work with Patient 100, CM D stated Patient 100's mental status, "was being questioned," and many times he was alert and oriented but she thought he was overestimating his ability to care for himself.

Review of a letter from Napa County Adult Protective Services, dated 2/2/2024 at 5:22 p.m., indicated APS SW (APS Social Worker) wrote to Hospital 1 about Patient 100's impending discharge. The letter indicated, "This letter is in response to notification that your facility intends to discharge a patient back to his home. Please be advised that APS believes discharging this patient does not comply with California Health & Safety Code... and/or Medicare regulations... The services needed to ensure a safe discharge have not been put in place. APS is therefore requesting that the discharge of (Patient 100) be postponed until such time that the necessary services are in place... In the case of (Patient 100), the services necessary to meet his continuing health care needs include a caregiver or other in-home support agency that can assist (Patient 100) with meals, medications, incontinent care, and all other activities of daily life... APS is opposed to discharging (Patient 100) until such time the 'appropriate arrangements for posthospital care' are available. Discharging in the absence of necessary services is not an acceptable discharge plan..."

During an interview on 6/12/24 at 2:46 p.m., Social Worker F (SW F) stated she became involved in Patient 100's discharge at approximately 5 p.m., that evening (2/2/24) and she was aware of the APS letter.

Review of SW F's medical record documentation of that evening's events indicated she documented the incident on 2/3/24 at 6:51 p.m. (the following day). SW F documented, "(Hospital 1) received a fax from Napa County APS at 5:22PM indicating they do not feel that we have created a safe discharge for the patient and would advise against sending him home. Social worker called and spoke with... management (Director C) who state (sic) that (Hospital 1) has fulfilled its role of creating a safe discharge plan..."

Further review of Patient 100's medical records on the evening of his discharge indicated at 7:30 p.m., an RN documented, "... Pt is currently alert and oriented to person and place...," and at 8:21 p.m. (immediately prior to ambulance transfer back home), an RN documented, "... Pt is currently alert to person only... He states it is 2034 (the year) ... Pt is also requesting for a phone so that he can call out sick from his job as the manager of Safeway..."

Review of Patient 100's ambulance trip sheet, dated 2/2/24 (discharge from Hospital 1 to home) indicated the EMT's (Emergency Medical Technicians) documented the Transfer of Care form (authorization for treatment and transport) was signed by Hospital 1's ED nurse (prior to departure) due to Patient 100's, "...confusion." The EMT's documented Patient 100 required ambulance transportation, "...due to confused mental state, and being bedridden," and indicated they arrived at Patient 100's home at approximately 8:51 p.m. The EMT's documented that enroute to the home, "Pt (patient) exhibited confusion during transport, continuously thought EMT was a grocery store employee and discussed being at Albertson's instead of the Hospital."

Continued review of the 2/2/34, ambulance trip sheet indicated once at the home, the EMT's met the new caregiver. The EMT's documented, "...Lockbox (with house key) to house was empty, caretaker attempted contacting family with no success. Caretaker contacted Social Worker (at Hospital 1) who contacted a locksmith. Waited with the patient in ambulance to keep warm... Napa PD (Police Department) arrived for unknown reason... Locksmith was able to open door, 2 police officers cleared home premises before we took patient to bedroom, house was empty... " The EMT's documented they transferred care of Patient 100 (to the caregiver) at 10:45 p.m.

During a telephone interview on 6/13/24 at 8:26 a.m., APS Supervisor (APS S) stated she was on-call the weekend of Patient 100's discharge on 2/2/24 (Friday). She stated her office was concerned all week (during Patient 100's seven-day stay) because he had a hard time keeping caregivers, his family could not provide the care he needed, and Patient 100 did not seem to understand the level of care he actually needed. APS S stated on 2/2/24, her department advised Hospital 1 (in the letter) that the pending discharge was unsafe. . APS S stated she spoke to SW F, and told her APS was concerned about Patient 100's home and care situation. SW F informed her that Patient 100 would be getting four hours of caregiver assistance per day. APS S stated she was still not comfortable with the discharge plans after speaking with SW F and felt Patient 100 was being discharged too early; she stated there was no one (family) at home, and the caregiver may not last.

During the same interview on 6/13/24 at 8:26 a.m., APS S stated she received a call on Saturday (2/3/24), from Patient 100's family who told her they saw (on a doorbell camera) the caregiver leave the home at 1 a.m. APS S stated she called the PD to conduct a welfare check at the home in the morning. The PD reported to her that there was no caregiver present, and Patient 100 did not have access to food nor to a telephone.

Review of Patient 100's ambulance trip sheet, dated 2/3/2024, indicated a Paramedic and an EMT were on-scene at Patient 100's house at 10:23 a.m. (approximately twelve hours after he was discharged from Hospital 1's ED the prior night). The Paramedic and EMT documented, "...dispatched ... with pd (Police Department) on scene... pt was found laying (sic) in bed with napa fire assessing pt. no family or caregiver at home. pt A&O 4 (alert and oriented, not confused) ... (patient) stated he came home from the hospital last night via ambulance transfer. pt was released from (Hospital 1) last night. pt family was out of town. pt was left uncared for. pt stated he wasn't sure where anyone was 'they abandoned me' pt did not have anything to eat or drink since leaving the hospital as pt could recall... per PD patient is being taken back to the hospital to get reevaluated and to set up a plan for pt to receive care of the hospital due to not having care for pt at home currently..."

During a virtual/video interview on 6/13/24 at 9:27 a.m., Physician B stated he recalled the discharge had been complicated involving complicated family dynamics. Physician B stated Patient 100 had been medically cleared for discharge approximately two days prior to his 2/2/24 discharge but his family could not take care of him. Physician B stated he was aware of Patient 100's, "waxing and waning," mentation on 2/2/24, prior to discharge, and stated he was holding him overnight out of abundance of caution. When asked why Patient 100 was then discharged a few hours later, Physician B stated patient discharges were a team activity, not a decision made just by him.

During an interview on 6/13/24 at 10:22 a.m., Director C stated she oversaw Patient 100's discharge plan over his week's stay in the ED and ensured it was, "moving along." She stated his plan was to return home with four hours of caregiver assistance. Director C was asked how four hours of daily care would meet Patient 100's needs when Hospital 1's PT evaluation indicated he required twenty-four hours of daily care, and she stated it was, "not an ideal plan." When asked how Hospital 1's discharge plan was safe, Director C stated it was the, "safest he (Patient 100) would allow." She stated a Home Health Nurse was scheduled to go to the home three times a week.

During an interview on 6/12/24 at 8:35 a.m., Quality Staff W stated the facility did not have a policy specifically addressing ED Boarders (Patients like Patient 100 who stay in the ED for an extended period because they did not meet hospital admission criteria). She stated Hospital 1's ED policies would cover these patients.

Review of ED policy titled, "Patient Flow in the Emergency Department," subtitled, "ESI Priority III - Urgent" (Approved 11/2021 and reviewed 05/2024), indicated, "Patients with illnesses or injuries that are not immediately life or limb threatening but require prompt medical attention and require two or more resources. If the patient is not ESI priority 1 or 2, the next decision point asks how many different resources might this patient consume in order for the physician to reach a disposition decision..." The policy identified Resources as, "Labs (blood, urine) ... ECG, Imaging including x-ray, MRI... IV fluids (hydration)... special consultation..."

Review of ED policy titled, "Patient Flow in the Emergency Department," subtitled, "5.0 Procedures" (Approved 11/2021 and reviewed 05/2024), indicated, "5.4 Discharges in the Emergency Department 5.4.1 Once the medical emergency has been determined and stabilized or resolved, the patient is admitted, transferred or discharged ... The physician collaborates with other disciplines ... to determine appropriate discharge needs ... At the time of discharge patient's physiological and/or psychosocial special needs is taken into consideration ..."


41175

Based on observation, interview, and record review, the facility failed to follow its policy for patient discharge from the Emergency Department (ED), when one of 20 sampled patients (Patient 100) was discharged home to an environment that was unsafe and did not meet his needs. Patient 100 was an elderly male who had a history of vascular dementia (a general term describing problems with reasoning, planning, judgment, memory, and other thought processes), diabetes mellitus (DM; a group of common endocrine diseases characterized by sustained high blood sugar levels) and was bed-bound (inability to leave the bed; unable to stand, transfer, or walk independently). While in the ED from 1/26/24 to 2/2/24: a) Patient 100 exhibited hostile behaviors including refusal of care and medications and yelling profanities and insults at staff; b) Patient 100's mentation (ability to think or reason) ranged from oriented and cognitively clear to confused; c) Per Hospital 1's PT (Physical Therapy) evaluation, Patient 100 required, "24-hour assistance..." with toileting, mobility, and ADLs (activities of daily living, fundamental skill required to independently care for oneself, such as eating, bathing, and mobility); and, d) Patient 100's family moved out of the family home, citing their inability to provide for his care. Hospital 1 discharged Patient 100 to his home with four hours of daily caregiver assistance (trained staff to provide care), indicating he would be alone in his house for 20 hours per day. This deficiency: 1) Caused Patient 100 to have no food for approximately 12 hours, placing him at risk of diabetic coma (a life-threatening condition caused by dangerously high or low blood sugar levels, rendering a person unconscious); 2) Prevented Patient 100 from calling for assistance when he was unable to access his phone; 3) Placed him at risk of harm when he was unable to call for help or walk to safety in the event of an emergency (e.g., fire); 4) Caused Patient 100 to be alone in his home from 1 a.m. until the following morning, when emergency responders arrived; 5) Caused Patient 100 to be transported back to the ED approximately 12 hours after his was discharged home due to emergency responders' determination that he was not safe; and, 6) Caused Patient 100 psychosocial distress when he verbalized he felt abandoned.

Findings:

Review of Patient 100's ambulance trip sheet, dated 1/26/24 (the beginning of Patient 100's seven-day stay in the ED) indicated EMS found Patient 100 lying in bed, alert but refusing to answer orientation questions (cognitive assessment tool used in healthcare settings to evaluate a patient's cognitive abilities), and, "extremely verbally abusive." EMS documented, "... Per family on the scene, pt's (patient's) caregiver had not been to the residence in over 4 days and pt (patient) noted to be covered in feces and urine." EMS documented family reported Patient 100 had bed sores (ulcers/wounds on the skin surface due to prolonged pressure). EMS documented, "Family stated that they have requested multiple caregiving agencies to assume care of the pt, however many have either quit or refused to provide services. Pt is bed bound and cannot perform basic activities of daily living such as feeding or cleaning himself on his own. Pt was found in diapers and blankets with copious amounts of feces and urine..." EMS documented they transported Patient 100 to Hospital 1 (ED).

During a concurrent interview and emergency medical record review on 6/11/24 at 9:10 a.m., Assistant Nurse Manager G stated Patient 100 arrived in the ED, via ambulance and alone, on 1/26/2024 at 11:48 a.m. She stated he was triaged (prioritization of injured/sick patients based on their need for emergency treatment) at an ESI (Emergency Severity Index) level of three (urgent). His nurse documented he had bed sores, was agitated, and was alert and oriented x2 (to person and place, but not time and situation). She stated he was diagnosed with major vascular neurocognitive disorder and unspecified agitation.

[Orientation Tool: Alert and Oriented (A&O) x1, x2, x3, x4 - stands for orientation to person (x1), place (x2), time (x3), and situation (x4). A patient who is oriented x1 means they are only oriented to themselves (confused about place/time/situation). A patient A&O x2 is oriented to themselves and where they are but confused about time/situation. A patient A&O x3 is oriented to themselves, where they are, and what time it is. A patient A&O x4 means they are oriented to themselves, where they are, what time it is, and what situation they are in (e.g., in a hospital due to a fall). This tool is commonly used to describe the mental status of patients in healthcare settings. It serves as an evaluation tool for understanding a patient's cognitive abilities and identifying potential areas of concern.]

A review of Patient 100's ED Provider Notes, dated, "1/26/2024 5:48 PM," indicated, "History of Present Illness: [Patient 100] was a 77-year-old male with a prior stroke, vascular dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain [mayoclinic.org], diabetes and hypertension ... they (family) have been unable to fully clean or turn him. He is incontinent of urine and stool, so he has essentially been sitting in incontinence for several days ... patient's wife is disabled (does not walk) and [son] himself is also disabled and is too weak to turn his father ... recommended to [son] take [Patient 100] to the emergency room again for assistance in finding SNF (Skilled Nursing Facility) placement as his current situation at home is very unsafe ... Patient's son arrived ... States ... the patient cannot come back home under any circumstances. 'The doors will be locked.' ..."

Review of Patient 100's medical record indicated a social worker (SW T) submitted an Abuse Report (regarding Patient's 100 home living situation) to (local county) Adult Protective Services (APS) on 1/26/24 at 3:50 p.m., that indicated Patient 100 was an elderly male with, "...vascular dementia, diabetes, prior stroke, diabetes... who came to the ED with caregiver concerns. SW T documented Patient 100, "...Has multiple caregivers quit because patient is verbally abusive ... patient's son states that since they brought (Patient 100) home from the emergency room on 1/23/2024, they have been unable to fully clean or turn him... They have been unable to find a caregiver to assist in the past 3 days. It is highly likely that the wounds noted to the buttocks on 1/23 in the ED have grown significantly worse... current situation at home is very unsafe..."

Review of a Physical Therapy (PT) evaluation, dated 1/30/2024 (three days prior to discharge home), indicated Patient 100 was not fully cognitively intact at the time of the assessment. The evaluation indicated Patient 100's cognition was, "Alert and Oriented to: person..." and his safety judgment was, "fair based on his limited cognition..." The evaluation further indicated, "...Patient currently unaware where he is located..." (i.e., not oriented to place). The evaluation indicated Patient 100, "Requires 24-hour assistance..." with toileting, mobility, and ADL's (Activities of Daily Living, a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. [National Institutes of Health.gov]).

Continued review of the PT evaluation, dated 1/30/2024, further indicated Patient 100's current level of function was, "bed level only." The evaluation indicated Patient 100 was able to move in bed (scooting, rolling, sitting) with, "moderate assistance.....The patient is able to voluntarily assist in a task but requires a moderate amount of contact assistance... The therapist performs 25% to 75% of the task for the patient." The evaluation indicated Patient 100 was unable to transfer (sit to stand, bed to chair, chair to bed) because he was, "unable due to left lower extremity (leg) pain and weakness." The evaluation indicated Patient 100 was unable to be assessed for Gait (walking) as he was unable to bear weight (support his body weight during activities like standing/walking).

A review of Patient 100's seven-day ED stay, from 1/26/24 to 2/2/24, indicated approximately thirty-five staff and provider medical record entries with documentation of Patient 100's various hostile behaviors. A Nursing Note, dated, "1/26/2024 12:52 PM," indicated, " ...pt (patient) verbally abusive, SW (Social Worker) told to leave, pt refusing to cooperate ..." A Nursing Note, dated, "1/27/2024 12:10 PM," indicated, " ... Patient pleasant during this interaction. About 30 minutes later patient was yelling ..." A Nursing Note, dated "1/28/2024 5:10 AM," indicated, " ... Patient becoming verbally and physically aggressive with staff. Patient attempting to punch and kick staff, calling female staff bitches ... Patient continues to yell at staff ..." A Physician Consult Note, dated, "1/29/2024 12:04 PM," indicated, " ... Patient was uncooperative, wanted me to leave the room immediately ... subsequently after multiple attempts, patient started to yell profanities ..." A Case Management Note, dated, "1/31/2024 9:03 PM," indicated, " ... pt has been refusing to eat, refusing medications, refusing to cooperate with care and refused to work with PT ..." A Nursing Note, dated, "2/1/2024 6:56 AM," indicated, " ... Pt took a few sips of juice, then spit it on me."

Further review of Patient 100's medical records over his seven-day stay in the ED indicated staff and providers documented his mentation fluctuated between oriented and confused:
On 1/26/24 at 3:52 p.m., a social worker documented, "...MD (doctor) reports pt is alert and oriented x2..."
On 1/26/24 at 5:48 p.m., Physician V documented, " ...does not appear to understand the ramifications of his words and actions on his overall care."
On 1/26/24 at 7:22 p.m., a Registered Nurse (RN) documented, "... asking for wire cutters so he could cut his wires off and escape. Attempted to reorient patient without success ..."
On 1/27/24 at 5:17 a.m., an RN documented, "Pt states he is a manager at Safeway and drives to work every day."
On 1/28/24 at 03:21 a.m., an RN documented, "Pt A&Ox3 upon assessment ..."
On 1/28/24 at 05:10 a.m., an RN documented, "Patient yelling in room, wanting to know what is going on..."
On 1/28/24 at 7: 49 p.m., an RN documented, "... pt states call my mom so I can get out in here..."
On 1/29/24 at 12:04 p.m., a provider documented, "Patient currently unaware where he is located..."
On 1/30/24 at 10:13 p.m., an RN documented, "... alert to self, mostly aware of surroundings. Occasional nonsensible, rambling statement but reorients easily..." and,
On 1/31/24 at 10:16 a.m., the wound nurse documented, "Patient is awake, but not able to make needs known effectively at this time... Unable to follow simple commands..."

Review of Patient 100's medical record, dated 2/2/2024 at 9:59 a.m. (the morning of discharge), indicated Case Manager D (CM D) documented per HBS (Hospital Based Service; hospital physician [not an ED physician] care provider), "...patient is alert and oriented. SW (social worker) met with patient and plan is for home with HH RN (Home Health Registered Nurse)." She documented the RN would provide wound care and (assess) safety of home and PT and Social Worker services would be provided. CM D documented Patient 100 was agreeable to hiring a part-time caregiver, he did not want his family contacted at that time, he had a hidden key at home if there was no one home to receive him, and he would be transported by ambulance.

Further review of Patient 100's medical records indicated his inconsistent mental status on 2/2/24, the day of his discharge:
At 9:01 a.m., a physician documented, "Mental Status - calm, A/O x4 ... he appeared very clear of mind... patient appears to be able to make his own medical decisions and financial decisions..."
At 12:56 p.m., Physician B documented, "Addendum: Hold patient additional light (sic) since there appears to be a waxing and waning mental status pattern..."
At 4:30 p.m., a social worker documented, "At 8:46 AM... they spoke with the ED MD regarding capacity letter and was informed that they are unable to sign letter due to the patient having capacity still... At 9 AM... patient was alert/oriented x 4... At 3:16 PM... Patient (sic) son was informed that patient does have the capacity to make his own decisions..."
At 3:25 p.m. (the afternoon of discharge), CM D further documented, "...Canceled (ambulance) request. Patient's mental status (was) waxing and waning therefore HBS has suspended discharge and will watch again overnight."

During an interview on 6/12/24 at 10:35 a.m., when asked about her discharge work with Patient 100, CM D stated she did not have a lot of direct interaction with Patient 100. CM D stated the Social Workers were the lead staff on his case as his needs were related to concerns at home with his family and with caregivers; she stated she addressed clinical/medical issues. CM D stated she had set up Home Health services for Patient 100 regarding his need for wound care. CM D stated Patient 100 did not want the facility to contact his family and claimed his family was financially abusing him. When asked about his mental status, CM D stated he could be both, "cooperative and not cooperative." CM D stated Patient 100's mental status, "was being questioned," and many times he was alert and oriented but she thought he was overestimating his ability to care for himself. When asked about her documentation that Patient 100's mental status was, "waxing and waning," CM D stated he was alert and oriented x4 and then was, "less so." CM D stated she did not directly assess his cognition herself but obtained the information from Nursing staff or the HBS.

Review of a letter from Napa County Adult Protective Services, dated 2/2/2024 at 5:22 p.m., indicated APS SW (APS Social Worker) wrote to Hospital 1 about Patient 100's impending discharge. The letter indicated, "This letter is in response to notification that your facility intends to discharge a patient back to his home. Please be advised that APS believes discharging this patient does not comply with California Health & Safety Code... and/or Medicare regulations... The services needed to ensure a safe discharge have not been put in place. APS is therefore requesting that the discharge of (Patient 100) be postponed until such time that the necessary services are in place... In the case of (Patient 100), the services necessary to meet his continuing health care needs include a caregiver or other in-home support agency that can assist (Patient 100) with meals, medications, incontinent care, and all other activities of daily life... APS is opposed to discharging (Patient 100) until such time the 'appropriate arrangements for posthospital care' are available. Discharging in the absence of necessary services is not an acceptable discharge plan. APS remains committed to assisting you, within the Department's protocol and available resources, in returning (Patient 100) to the community..."

During an interview on 6/12/24 at 1:50 p.m., Case Manager E (CM E) confirmed he was the case manager who took over for CM D after her shift was over at approximately 3:30 p.m., on 2/2/24. CM E stated he personally interviewed Patient 100 (on the afternoon of discharge) and he was alert at that time and a caregiver was waiting for him (to arrive) at his home. He stated the Physician (Physician B), the Social Worker, and manager were aware of Patient 100's impending discharge. CM E stated he did not remember the contents of the APS letter that arrived around 5 p.m., and stated not only it was unusual to get a letter like this from APS, but he had also never gotten one like it in the past. When asked whom he told about the letter, CM E stated he would have to refer to his notes; he stated he was vigilant about documenting (in his notes).

Review of CM E's documented notes on 2/2/24, indicated at 4:15 p.m., CM E, "Spoke to pt at bedside who was in agreement with plan to DC (discharge) back home... Patient was oriented to name, place, time..." At 6:19 p.m. CM E documented he spoke to Director C regarding, "... letter from APS. Per management ok to send patient back home with caretaker...MD (Physician B) updated, stated ok to DC pt." At 7:08 p.m., CM E documented, "...Currently alert to name and place (not time or situation) ..."

During an interview on 6/12/24 at 2:46 p.m., Social Worker F (SW F) stated she became involved in Patient 100's discharge at approximately 5 p.m., that evening (Social Worker U [SW U] had worked with him previously). She stated everything was, "wrapped up," and she was trying to help get Patient 100 out the door. She stated she got the APS letter and reached out to Manager I, but she did not hear back from her as she had already left the facility; she stated she got a response from Director C. SW F stated she had never received a letter from APS like the one written for Patient 100. She stated she called APS, spoke to the APS manager (APS S) and had a long conversation regarding Patient 100's discharge plan.

Review of SW F's medical record documentation of that evening's events indicated she documented the incident on 2/3/24 at 6:51 p.m. (the following day). SW F documented, "(Hospital 1) received a fax from Napa County APS at 5:22PM indicating they do not feel that we have created a safe discharge for the patient and would advise against sending him home. Social worker called and spoke with... management (Director C) who state (sic) that (Hospital 1) has fulfilled its role of creating a safe discharge plan, including reaching an agreement with the patient to accept a caregiver, having a caregiver in place upon discharge, extensive conversations with family members, and the entire medical care team. Per (Director C) it is still acceptable to discharge patient. HBS doctor (Physician B) also feels that a discharge is still appropriate." SW F documented that she called APS and had a lengthy conversation with the supervisor (APS S) about Hospital 1's discharge plan. SW F documented, "(APS S) is still not completely confident in the discharge plan, however states that it is ultimately up to (Hospital 1) if they feel the plan is safe..."

Further review of Patient 100's medical records on the evening of his discharge indicated at 7:30 p.m., an RN documented, "... Pt is currently alert and oriented to person and place...," and at 8:21 p.m. (immediately prior to ambulance transfer back home), an RN documented, "... Pt is currently alert to person only... He states it is 2034 (the year) ... Pt is also requesting for a phone so that he can call out sick from his job as the manager of Safeway..."

Review of Patient 100's ambulance trip sheet, dated 2/2/24 (discharge from Hospital 1 to home) indicated the EMT's (Emergency Medical Technicians) documented the Transfer of Care form (authorization for treatment and transport) was signed by Hospital 1's ED nurse (prior to departure) due to Patient 100's, "...confusion." The EMT's documented Patient 100 required ambulance transportation, "...due to confused mental state, and being bedridden," and indicated they arrived at Patient 100's home at approximately 8:51 p.m. The EMT's documented that enroute to the home, "Pt (patient) exhibited confusion during transport, continuously thought EMT was a grocery store employee and discussed being at Albertson's instead of the Hospital."

Continued review of the 2/2/34, ambulance trip sheet indicated once at the home, the EMT's met the new caregiver. The EMT's documented, "...Lockbox (with house key) to house was empty, caretaker attempted contacting family with no success. Caretaker contacted Social Worker (at Hospital 1) who contacted a locksmith. Waited with the patient in ambulance to keep warm... Napa PD (Police Department) arrived for unknown reason... Locksmith was able to open door, 2 police officers cleared home premises before we took patient to bedroom, house was empty... Note: null (no) phone number entered in (Hospital 1's)... spot (on the transfer documentation), pt does not have a phone number and family does not want to be contacted." The EMT's documented they transferred care of Patient 100 (to the caregiver) at 10:45 p.m.

Further review of the medical record revealed SW F's untimed note, dated 2/3/24, that indicated she received a phone call from the care agency (where the caregiver worked) and was informed Patient 100 arrived home (on 2/2/24) and was with the caregiver, however he could not find his key and no one was answering the door. SW F documented she attempted to reach Patient 100's family but no one answered. SW F documented she informed [Hospital 1] management, who asked that a locksmith be called. SW F's documentation indicated, "Received call from caregiver stating that she noted a mattress, sheets, and mens (sic) clothing out in the yard as if patient had been kicked out. Social worker (SW F) called ... PD (Police Department) who went out to the home. They spoke to neighbors who report that wife was home earlier today but not now. Patient was able to get into home safely with caregiver with help of locksmith and PD..."

During a telephone interview on 6/13/24 at 8:26 a.m., APS Supervisor (APS S) stated she was on-call the weekend of Patient 100's discharge on 2/2/24 (Friday), and received many calls about the situation. APS S confirmed that Hospital 1 had submitted an Abuse Report to her office when Patient 100 was first admitted to the ED on 1/26/24, regarding his family living situation. APS S stated her office was concerned all week (during Patient 100's seven-day stay) because he had a hard time keeping caregivers, his family could not provide the care he needed, and Patient 100 did not seem to understand the level of care he actually needed.

During the same interview on 6/13/24 at 8:26 a.m., APS S stated, on 2/2/24, her department advised Hospital 1 (in the letter) that the pending discharge was unsafe. APS S stated it was not common for her department to send that type of letter to Hospital 1. APS S stated she spoke to SW F, and told her APS was concerned about Patient 100's home and care situation. SW F informed her that Patient 100 would be getting four hours of caregiver assistance per day. APS S stated she was still not comfortable with the discharge plans after speaking with SW F and felt Patient 100 was being discharged too early; she stated there was no one (family) at home, and the caregiver may not last. She stated APS tried to work with Hospital 1 because they knew discharging him home was not a viable option. APS S stated she was not aware Hospital 1 was going to discharge Patient 100 that night. She stated, "I don't know why he couldn't stay at (Hospital 1)." She stated Patient 100 would be going into a dark, empty house and would only get two hours of care that night (as the caregiver had been waiting two hours for him to arrive). APS S stated the best placement for Patient 100 would have been a facility like a Skilled Nursing Facility or a Board and Care but Hospital 1 was, "pushy," regarding Patient 100's discharge. She stated a nurse called her with concerns about, "pressure... to get him out the door," and SW U (the Social Worker who been working on the discharge) was aggressive. APS S stated they could not prevent the discharge as it was up to the hospital.

During the same interview on 6/13/24 at 8:26 a.m., APS S stated she received a call on Saturday (2/3/24), from Patient 100's family who told her they saw (on a doorbell camera) the caregiver leave the home at 1 a.m. APS S stated she called the PD to conduct a welfare check at the home in the morning. The PD reported to her that there was no caregiver present, and Patient 100 did not have access to food nor to a telephone.

Review of Patient 100's ambulance trip sheet, dated 2/3/2024, indicated a Paramedic and an EMT were on-scene at Patient 100's house at 10:23 a.m. (approximately twelve hours after he was discharged from Hospital 1's ED the prior night). The Paramedic and EMT documented, "...dispatched ... with pd (Police Department) on scene... pt was found laying (sic) in bed with napa fire assessing pt. no family or caregiver at home. pt A&O 4 (alert and oriented, not confused) ... (patient) stated he came home from the hospital last night via ambulance transfer. pt was released from (Hospital 1) last night. pt family was out of town. pt was left uncared for. pt stated he wasn't sure where anyone was 'they abandoned me' pt did not have anything to eat or drink since leaving the hospital as pt could recall. pt does not recall a caregiver being at his home when he was there. per PD patient is being taken back to the hospital to get reevaluated and to set up a plan for pt to receive care of the hospital due to not having care for pt at home currently..."

During the same interview on 6/13/24 at 8:26 a.m., APS S stated she was not surprised Patient 100 returned to the ED on 2/3/24, because it was not a safe discharge to begin with. She stated they had to wait for a locksmith to enter the house, and no one determined if there was food at the home. APS S stated SW U called her (verbalizing) she was upset, when Patient 100 returned to the ED.

During a virtual/video interview on 6/13/24 at 9:27 a.m., Physician B stated he had taken over the care of Patient 100 on 1/27/24, discharged him on 2/2/24, and readmitted him on 2/3/24. He recalled the discharge had been complicated involving complicated family dynamics. Physician B stated Patient 100 had been medically cleared for discharge approximately two days prior to his 2/2/24, discharge but his family could not take care of him. He stated the Social Worker was very involved with Patient 100's discharge and initially, Patient 100 was going to go to a Skilled Nursing (Nursing Home) or Board and Care facility, but he did not want to pay for a Board and Care, and he wanted to go home. Physician B stated Patient 100 was, "completely clear" (cognitively), when he (the patient) let him know he did not want to go to a facility (like Skilled Nursing) at discharge.

During the same virtual interview on 6/13/24 at 9:27 a.m., Physician B stated he was aware of Patient 100's, "waxing and waning," mentation on 2/2/24, prior to discharge. Physician B stated he was holding him overnight out of abundance of caution. When asked why Patient 100 was then discharged a few hours later, Physician B stated patient discharges were a team activity, not a decision made just by him; he stated he trusted the Case Managers, Social Workers, and bedside Nurse's judgements. Physician B stated the Social Worker was going to ensure a caregiver would be at the house to take care of him when needed. Physician B stated he was not aware that only four hours of caregiving was arranged for Patient 100. When queried if he thought four hours was enough to meet Patient 100's daily needs, Physician B stated he refused to speculate, and added that as a Physician, this was not his area of expertise, but was up to the Case Managers and Social Workers. Physician B stated he was aware APS was in the background to ensure a safe discharge but was not sure at what point they were involved. When asked if he was aware APS wrote a letter to Hospital 1 on 2/2/24, indicating they felt his impending discharge was unsafe, Physician B stated he was not aware.

During an interview on 6/13/24 at 10:22 a.m., Director C stated she oversaw Patient 100's discharge plan over his week's stay in the ED and ensured it was, "moving along." She stated his plan was to return home with four hours of caregiver assistance. Director C stated Patient 100 refused twenty-four hours/day of caregiver help but agreed to a reduced amount of four hours per day. Director C was asked how four hours of daily care would meet Patient 100's needs when Hospital 1's PT evaluation indicated he required twenty-four hours of daily care, and she stated it was, "not an ideal plan." When asked how Hospital 1 ensured Patient 100 would have food at home and access to food, as he was bedbound, she stated it was the care providers' responsibility to arrange for food. When asked how Hospital 1's discharge plan was safe, Director C stated it was the, "safest he (Patient 100) would allow." She stated a Home Health Nurse was scheduled to go to the home three times a week, and APS was involved. When asked why Hospital 1 moved forward with the discharge when Patient 100's mental status was documented as, "waxing and waning," Director C stated it was her understanding that he met the two criteria for discharge: He was at his cognitive baseline, and caregivers had been arranged for him at home. She stated she was not aware Physician B had documented holding him for another night of observation. When asked why Hospital 1 moved forward with the discharge when they were notified that APS felt the discharge was unsafe, Director C stated SW F had called and spoken to APS (APS S), explained and clarified the plan, and APS S was in agreement (at the end of the conversation).

During an interview on 6/12/24 at 8:35 a.m., Quality Staff W stated the facility did not have a policy specifically addressing ED Boarders (Patients like Patient 100 who stay in the ED for an extended period because they did not meet hospital admission criteria). She stated Hospital 1's ED policies would cover these patients.

Review of ED policy titled, "Patient Flow in the Emergency Department," subtitled, "ESI Priority III - Urgent" (Approved 11/2021 and reviewed 05/2024), indicated, "Patients with illnesses or injuries that are not immediately life or limb threatening but require prompt medical attention and require two or more resources. If the patient is not ESI priority 1 or 2, the next decision point asks how many different resources might this patient consume in order for the physician to reach a disposition decision..." The policy identified Resources as, "Labs (blood, urine) ... ECG, Imaging including x-ray, MRI... IV fluids (hydration)... special consultation..."

Review of ED policy titled, "Patient Flow in the Emergency Department," subtitled, "5.0 Procedures" (Approved 11/2021 and reviewed 05/2024), indicated, "5.4 Discharges in the Emergency Department 5.4.1 Once the medical emergency has been determined and stabilized or resolved, the patient is admitted, transferred or discharged ... The physician collaborates with other disciplines ... to determine appropriate discharge needs ... At the time of discharge patient's physiological and/or psychosocial special needs is taken into consideration ..."