HospitalInspections.org

Based on interviews, medical record reviews, and policy review, it was determined that the facility failed to provide a safety during discharge, resulting in Patient #1's injury and rehospitalization, in 1 of 2 patient records reviewed.

Findings included:
Review of Patient #1's medical record reveals that patient was an 80-year-old, Spanish speaking patient with a history of dementia, admitted for syncope (loss of consciousness for a short time) and epistaxis (bleeding from the nose) on 02/14/2023. The Patient had orders for discharge with home health on 02/18/2023.
Review of the nursing assessment shows the RN (registered nurse) documented the patient was alert and oriented to person and place (A&Ox2). Further review shows that the patient was discharged to the hospital lobby and left unattended.

In an interview with Risk Management, they stated the RN asked the patient if he needed to call family for a ride, the patient stated "I already called my daughter."

Review of patient discharge instructions on 02/18/2023 at 10:00AM, there was no indication that any family member was notified. The discharge instructions were also noted to be in English, not Spanish.

In an interview on 03/28/2023 at 1140 AM with Staff A/Charge Nurse, she disclosed that when she has a discharged patient, she will review the chart for any additional conditions holding up a discharge. If a patient is compromised such as wheelchair bound, confused or any other disabilities the patient is closely monitored. The Case Manager will notify the nurse if the patient has any conditions of discharge. The family or transport are notified, once the family arrives the patient is taken downstairs by the assigned nurse or tech for discharge.

In an interview with Staff B/RN, she revealed that when she has a discharge order she would first see if there are any conditions (example: awaiting consult clearance) "holding back the discharge. I then would clear all conditions and parameters and discharge patient. I then notify the next of kin to see if patient is being picked up or in need of transport." She stated they have a discharge lounge (designed for patients with no parameters, and a nurse is there at all times) however she does not discharge her patients there unless they are "walkie talkie" (Alert and oriented to person, place, time, and situation.) "When discharge is complete I or the PCT [Patient Care Technician] will bring the patient down in a wheelchair. We never leave them alone; we assist them in the vehicle as well."

Interview on 03/28/2023 at 1:30PM with Vice President of Quality and Director of 2Central disclosed that the facility does not have a policy for nursing staff on discharging patients. She stated there is no policy in place that we can find.

Policy for Assessment and Reassessment dated 2022 states. . . the patient/significant other shall be involved in discharge. . .

Review of a medical record from another local hospital reveals that Patient #1 was brought there on 02/19/2023 at 5:01 PM by family after they were notified by law enforcement. Patient #1 was found sitting on a bus stop bench for over 24 hours after being discharged from the [facility]. The patient possibly injured his head. He has an abrasion to the right temporal region of his scalp; he is also sunburned. Patient unable to elaborate further on any condition, he was pleasant and only oriented to self, not time or place. The patient is obviously dehydrated and sunburned, he was also very hungry. Food and drink were provided. The patient sustained sunburn to bilateral forearms, cheeks, forehead, and legs. The diagnosis was Sunburn, Acute kidney injury, Rhabdomyolysis, Hyperkalemia, Leukocytosis and Dementia.