HospitalInspections.org

Based on interview and record review, the facility failed to provide a safe setting for 1 (Pt.#4) of 3 patients sampled who sustained a fall with injury. Findings include:

Review of the medical record revealed that Pt #4 is a 68-year-old-male, with a history of Subdural Hematoma (blood clot between the brain and skull) on the right side secondary to falling (05/2022), Bipolar disorder, schizophrenia, atrial fibrillation, hypertension, hyperlipidemia, and type 2 diabetes. Pt #4 presented to the facility Emergency Department (ED) after reports of aggressive behavior at the Extended Care Facility (ECF) where he resides. Pt. #4 arrived at the facility ED on 11/29/22 at 1044 and was triaged as Emergency Severity Index (ESI) level 3 (non-emergency). Pt. #4 was admitted to the Psychiatric unit on 11/30/22 for 'Agitation'. During his stay, Pt #4 was noted to have marked mental status changes, followed by physical decline, which led to Pt #4 being unable to sit up, stand or walk. Pt. #4 would eventually require emergency surgery to repair a bleeding vessel in his brain.

Review of document titled "Safety Event Manager" demonstrated that Pt #4 suffered an unwitnessed fall on 01/09/22 at 0027 and again on 01/20/23 at 1657. The 'Event Summary' from the first fall (01/09/22) described the event as "Pt called out from his room, was found by MHT (Mental Health Tech) laying on the floor next to the bathroom in his room in a puddle of excrement. Pt was examined by RN and had no apparent injury. Attending physician, Nurse supervisor, attending internal medicine physician, on-call unit ACL, and unit manager were all contacted and performed a 'post-fall' huddle. Internal medicine examined the pt, recommended that pt be observed 'closely' and that 'fluids be pushed'. An EKG was ordered and performed, due to Pt #4's previous history of atrial fibrillation (irregular heart rhythm). Pt #4 was placed on fall precautions and line of sight observation for safety."

Review of "RLDatix-Safety Event Manager" document (Event ID HUJ18293083), dated 01/21/23 and authored by Staff EE stated under 'Factual Description of the event'-"Pt had a witnessed fall in hallway outside dining room. He was standing in line for dinner and lost balance, fell backwards onto his backside. He did not hit his head. One staff member witnessed the fall and another patient in the hallway attempted to assist him to the floor but was unable to fully do so. Pt vitals are stable, he is alert and oriented times four, blood sugar is 99. He reports that he felt 'dizzy'."

On 05/17/23 at 1000, Vice-President (VP) of Nursing Staff D revealed that Staff X witnessed the second fall event. An interview was conducted with Registered Nurse (RN) Staff X on 05/17/23 at 1122. Staff X was asked to recall what she had witnessed. Staff X stated, "The patients were in line for lunch. About 5-10 of them were lined up in the hall. I was sitting at the nurse's station and a patient told me that another patient fell. I grabbed the vital sign machine and got a blood sugar." Staff X was then asked if she saw the patient fall, Staff X stated, "I did not." Staff X was next asked if she observed a decline in Pt #4 following the fall. Staff X stated, "Yes, he declined. We all noticed there was a time when he stopped coming to groups. Everybody noticed that he got quieter. He has delusions, uses a lot of profanity and is usually the first to 'stir the pot.' After the fall, we moved him to (room) 56, which is right in front of the nursing station."

Review of 'Admit/Progress Note' dated 01/20/23 at 1746, authored by Physician Staff Z revealed, "Called to assess (Pt #4) ...who was said to have had a witnessed fall in the hallway. This was witnessed by a staff member and another patient. Patient was said to have fallen backward onto his bottom ...He reports that he did not hit his head ...upon completion of my examination, patient was accompanied back to the dining room, when he was noticed to have a very noticeable shuffling gait." 'Plan' section of this document states "Xray of the bilateral hips, Tylenol 650mg every four hours as needed."

Review of 'Computed Tomography Reports' dated 02/08/23 at 0922 revealed the findings of the exam as, "There is a left subdural hematoma (blood clot pressing on the brain). The hemorrhage (bleeding) has acute (new) and subacute (older) components. The hematoma measures up to 3 cm in transverse dimension and exerts mass effect on the left cerebral hemisphere. Subfalcine herniation (brain displacement) is seen with approximately 1.4 cm of left-to-right midline shift. No skull fracture."

On 05/17/2023 at 0909 Clinical Informatics Staff V was asked to review Radiology orders for previous CT scans. Upon locating a scan from 01/10/23 (1 day after fall #1) the radiology report stated "previous hematoma completely resolved." Staff F was queried if this new finding indicated that Pt.#4 had no evidence of of bleeding on 01/10/23? Staff F stated, "That's correct."

Based on interview and record review, the facility failed to provide a safe discharge plan for 1 (patient #5) of 3 patients (Pt) reviewed for discharge planning, resulting in a poor outcome and potential for harm for the patient. Findings include:

Review of the medical record revealed that patient (Pt.) # 5 is a 56-year-old female brought to the facility Emergency Department (ED) on 10/11/22 for allegedly refusing to take her medications and fighting with staff at the group home where she lived. Upon arrival, Pt.#5 is described as very angry and paranoid, refusing to talk, and highly suspicious of staff. Pt.#5 has an extensive history of psychiatric treatment for paranoid schizophrenia and was admitted to the psychiatric unit for psychosis.

Review of progress note dated 10/07/2022 revealed Social Work was aware of APS (Adult Protective Services) involvement and that APS worker requested staff keep her updated on treatment and placement plans.

Review of progress note dated 11/03/2022 authored by Staff N revealed "Pt was visited by APS worker who gave her a copy of guardianship paperwork and upcoming court date of Dec. 22, 2022".

Review of 'Behavioral Health Discharge Summary' dated 11/09/22 (day of Pt.#5's discharge) revealed, "There is nobody who was willing to keep her. The patient has a legal guardian. We have discussed this with the legal guardian. The patient has been prepared for discharge on 11/09/22 and will be returned to the group home she came from ....She has been discharged in stable condition, as stable as she is expected to be."

Review of Psychiatry Progress notes revealed multiple entries of conflicting information regarding the presence of a legal guardian for Pt.#5. Review of the medical record on 05/17/23 revealed no documentation that Pt. #5 had ever had a guardian, and the demographics sheet or 'face sheet' listed the patient's guardian as 'self'.

An interview was conducted with treating Psychiatrist Staff M and Medical Director Staff F at 1400 on 05/16/23. Staff M was asked, 'What if APS asks you not to discharge a patient?' Staff M replied, "I would not discharge if they were not ready. There is no reason for me to discharge a patient if readmit is inevitable."
Staff M was next asked if he would discharge pt #5 to a homeless shelter. Staff M stated, "I will never discharge to a shelter, she (pt #5) will not stay. I have had to discharge patients to homeless shelters in the past." Staff M was next asked if discharging Pt.#5 to a homeless shelter placement office was a safe plan. Staff M replied, "I would not." Staff M was queried why he discharged Pt.#5 to a homeless shelter placement office. Staff M stated, "I didn't, she was to return to the group home."

On 05/16/23 at 0905, an interview was conducted with Social Work (SW) Staff N. Staff N was questioned regarding the discharge plan for Pt.#5. Staff N stated, "I spoke with the group home, and they would not allow her to return secondary to her behaviors. We contacted multiple group homes and many she (Pt.#5) would refuse to go to, and most would not accept her due to her behaviors. So upon discharge, we placed her in a shelter." Staff N was questioned as to which shelter? Staff N stated, "We transported her to (office-name redacted). That's a screening center for the homeless in Detroit." Staff N was next asked if Pt.#5 was screened and placed. Staff N stated, "I don't know. We don't contact (office-name redacted). There are no appointments. It's a walk-in during day hours."
Staff N was next asked 'When is the discharge plan completed? Staff N stated, "When they physically leave the hospital, the discharge plan ends. My part of it, at least." Staff N was next queried if she had frequent and ongoing discussions with the Adult Protective Service (APS) worker who had petitioned Pt.#5, and was seeking court appointed guardianship? Staff N stated, "I don't know if I spoke to her. I'd have to see the documentation."

Review of Social Work 'Progress Notes' from day of discharge 11/09/22 at 1115, authored by Staff N demonstrated that Pt.#5 did not have a safe discharge plan in place, "Pt. has repeatedly refused to go to a Room and Board. She was given the opportunity to speak to (group home manager), yet refused to accept a room. Pt states that she is going to be picked up from the hospital by family members. Everyday she states that she is leaving tomorrow. Yesterday she stated she was leaving on Friday. Pt has no known family and no good phone numbers. Pt. is currently her own guardian. Will follow." Staff N next added, "Upon discharge, pt will be placed in a shelter. She will follow up with (name redacted -Mental Health Service)." There was no mention of APS notification of the discharge in the note.

On 05/18/23 at 1032 an interview occured with APS worker identifed in progress notes. APS worker stated she was not notified of Pt #5's discharge until 11/10/2022 (day after discharge). APS worker stated patient was never seen by discharge destination facility, APS filed a missing person report, and that the patient was eventually found days later in another ED in Detroit.