HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to ensure the Patient could ambulate safely prior to discharge for one (1) of four (4) Patients (P), P # 1.

The finding include:

On February 5, 2025, clinical record review for P # 1 revealed the following:
The "Patient Care Timeline" reads in part:
"November 26, 2024
9:12 PM - arrival complaint - rescue
9:17 PM - chief complaints - fall
10:12 PM - Fall risk - High risk for falls - YES
12:24 AM - Pain Assessment on discharge was same.
Condition stable.
Patient discharged to home.
Patient education completed: NO
Education taught to; patient
Teaching method used was discussion.
Understanding of teaching was poor.
Patient was discharged via wheelchair.
Discharged with self.
Valuables were give to: patient.

Differential/Questionable Diagnosis: Mental health issue, consider ICH (intracranial hemorrhage) or mass or CVA (cardiovascular accident) give the fact that right leg is not working but there is conflicting stories.

Chief complaint
Patient presents with Fall
Here via EMS (Emergency Medical Services) after a fall. Reports was trying to put shoes on and socks slipped on the carpet and slid down to the ground. Back scraped up against metal bed frame. States could not get up on own and required EMS to come and help."

Record review revealed no documentation that P # 1 could ambulate safely prior to discharge. P # 1 arrived via ambulance from a fall and was a high risk for falls on assessment. P # 1 was discharged with self via wheelchair.

A review of the "Patient Rights and Responsibilities" provided to Patients on admission reads in part "You have a the right to be kept safe...".

On February 5, 2025 at 10:30 AM, Staff Member (SM) # 2 indicated there was no documentation of safe ambulation prior to discharge. SM # 2 stated "the Physician would not discharge the Patient if the Patient was unable to ambulate."

Based on document review and interview, it was determined that the facility failed to ensure discharge planning was completed and discussed with the Patient prior to discharge for one (1) of four (4) Patients (P), P # 1.

The finding include:

On February 5, 2025, clinical record review for P # 1 revealed the following:
The "Patient Care Timeline" reads in part:
"November 26, 2024
9:12 PM - arrival complaint - rescue
9:17 PM - chief complaints - fall
10:12 PM - Fall risk - High risk for falls - YES
12:24 AM - Pain Assessment on discharge was same.
Condition stable.
Patient discharged to home.
Patient education completed: NO
Education taught to; patient
Teaching method used was discussion.
Understanding of teaching was poor.
Patient was discharged via wheelchair.
Discharged with self.
Valuables were give to: patient.

Differential/Questionable Diagnosis: Mental health issue, consider ICH (intracranial hemorrhage) or mass or CVA (cardiovascular accident) give the fact that right leg is not working but there is conflicting stories.

Chief complaint
Patient presents with Fall
Here via EMS (Emergency Medical Services) after a fall. Reports was trying to put shoes on and socks slipped on the carpet and slid down to the ground. Back scraped up against metal bed frame. States could not get up on own and required EMS to come and help."

Record review revealed no documentation of discharge planning or discussion with P # 1 prior to discharge. P # 1 arrived via ambulance from a fall and was a high risk for falls on assessment. P # 1 was discharged with self via wheelchair. There was no documentation of how and whom the Patient left with or would be able to provide care post discharge. There was no documentation of written discharge instructions provided to the patient.

The facility's policy for discharge was requested at three (3) times and was not provided.

On February 5, 2025 at 10:30 AM, Staff Member (SM) # 2 indicated there was no documentation of a discharge plan or discussion with the Patient prior to discharge. SM # 2 indicated that Patients are discharged to the waiting area to wait for ride post discharge if there is no one present at the time of discharge. SM # 2 stated "the Physician would not discharge the Patient to an unsafe situation."