HospitalInspections.org

The Condition of Participation: Patient Rights was out of compliance.

Findings included:

Based on record review and interviews, the Hospital failed to ensure on Patient's (#1) representative and legal guardian had the right to make informed decisions for his/her care; Patient #1 was discharged from the Hospital Emergency Department (ED) with his/her mother without his/her legal guardian's knowledge and was missing for three days without access to his/her medications (including antipsychotic medication).

Cross Reference:
482.13(b)(2)- Informed Consent (A0131)

Based on record review and interviews, the Hospital failed to ensure on Patient's (#1) representative and legal guardian had the right to make informed decisions for his/her care; Patient #1 was discharged from the Hospital Emergency Department (ED) with his/her mother without his/her legal guardian's knowledge and was missing for three days without access to his/her medications (including antipsychotic medication).

Findings include:

The Hospital Policy titled "Advance Directives, Healthcare Proxy, and Designation of a Health Care Agent", dated 4/26/23, indicated the following:
-At the time of patient registration, each adult patient is asked whether or not he/she has made provision for medical advance directives through a health care proxy and designation of a health care agent.
-The Access Services Representative will confirm that the information is still current and update it if needed. If Access Services Representative receives a copy of the document, he/she scans the document into the electronic medical record.

The Hospital Policy titled "Patients' Rights and Responsibilities", dated 6/23/22, indicated the following:
-The Patient's who are unable to make decisions of physical or mental limitations or because they are minors are protected by the patient's guardian, health care agent or legal representative.
-To have an advance directive and expect the hospital to honor the intent of that directive to the extent permitted by law and Hospital policy.

Patient #1 arrived at the Hospital Emergency Department accompanied by his/her group home staff on 11/24/23 at 8:58 P.M. for a behavioral health evaluation after making suicidal statements and a history of schizophrenia.

Review of Patient #1's medical record indicated the Patient was triaged on 11/24/23 at 9:01 P.M. by RN #1; Patient #1 denied suicidal/homicidal ideation but reported being assaulted at his/her group home. Physician Assistant (PA) #1 evaluated Patient #1 in the Emergency Department. Patient #1 told PA #1 he/she was stuck and pushed by a group home staff member, denied suicidal ideation or homicidal ideation, and did not have any injuries on examination. The group home staff member accompanying Patient #1 told PA #1 the Patient's mother has told the Patient to say he/she was suicidal before. Patient #1 was evaluated by the Psychiatric Services Social Worker (SW) #2 on 11/25/2023 for a behavioral health consult and evaluation of suicidal ideation. Patient #1 was evaluated to be low risk for suicide and could continue treatment outside of the Hospital. Patient #1's mother was consulted, and she stated she and the group home shared legal guardianship of Patient #1, and she wanted to seek a different facility for the Patient to reside at following the alleged assault at his/her current group home. It was recommended to have Hospital care management/social work follow up with Patient #1 and discharge Patient #1 to his/her mother when available. SW #1 reviewed Patient #1's medical record and determined no advance directives were on file for the Patient and Patient #1 was offered to complete a Health Care Proxy; no paperwork was scanned into Patient #1's record indicating the Patient was under legal guardianship. The plan was confirmed to discharge Patient #1 home with his/her mother. Patient #1 discharged from the Hospital Emergency Department with his/her mother on 11/25/23 in the evening.

Further review of Patient #1's medical record indicated the Patient returned to the Hospital Emergency Department on 11/28/23 at 5:33 P.M. with Emergency Medical Services (EMS). EMS reported to Physician #1 that Patient #1 was kidnapped by his/her mother. Physician #1 documented Patient #1 was reportedly released to his/her mother, who was not his/her legal guardian; there was a concern about where the Patient and he/she was brought in for evaluation. Patient #1 had not taken his/her medications in four days. Nursing documentation indicated a detective also arrived with Patient #1; the Patient's mother turned him/her into the police on 11/28/23. Further investigation by psychiatric services Licensed Mental Health Counciler indicated Patient #1 has a legal guardian, who is not the Patient's mother, and the Patient's mother was removed from his/her guardianship in 2015.

During an interview with SW #1 on 1/22/24 at 12:44 P.M., she said she reviewed the record for Patient #1's discharge but did not meet with the Patient. She said Patient #1 had alleged abuse at his/her group home and was cleared psychiatrically by psychiatric services. She said there was no documentation in Patient #1's record to support his/her mother's claim of having legal guardianship over the Patient, however, due to the allegation of abuse at the Patient's group home and it was a safe discharge plan to send the Patient home with his/her mother.

During an interview with RN #1 on 1/22/24 at 2:54 P.M., she said works in triage in the Emergency Department. She said she did not recall Patient #1. She said Access (registration) staff meet with patients when they arrive to the Emergency Department. She said medical staff reconcile medication lists for patients. She said advance directives, health care proxies, and guardianships are reconciled by either access staff or the Emergency Department primary nurse but was not sure. She said the triage nurse does not determine if a patient has a representative or advance directive.

During an interview with PA #1 on 1/23/24 at 7:30 A.M., she said Patient #1 did not have any visible injuries during evaluation. She said Patient #1 had flat affect, answered her questions, but did not seem reliable as a historian. She said the staff member from the Patient's group home had a binder with the Patient's information in it, but she did not review it. She said she was told by psychiatric services that Patient #1's mother had joint custody/guardianship over him/her. She said verification of advance directives would be performed with review of paperwork from a facility transferring a Patient to the Emergency Department. She said social services/ psychiatric services confirm advance directives/guardianships for Patients in the emergency department.

During an interview with SW#2 on 11/23/24 at 8:00 A.M., she said she evaluated Patient #1 for a behavior health crisis concerns. She said Patient #1 was anxious/nervous, provided limited history, and was adamant on not returning to his/her group home. She said the group home staff member accompanying Patient #1 was unable to answer most of her questions. She spoke with Patient #1's nurse who did not have much information regarding the Patient. She asked Patient #1 for an emergency contact, and he/she provided her with his/her mother's phone number and said she was his/her guardian. She said she spoke with Patient #1's mother who told her she was the Patient's co-guardian of Patient #1 along with his/her group home. She said she spoke to staff at Patient #1's group home who confirmed an event did occur with Patient #1 and another staff member, however, she did not get confirmation of who was the legal guardian for Patient #1. She said she was not sure whose responsibility it is to confirm guardianship of patients in the Emergency Department.

During an interview with the Patient Access Manager on 1/23/24 at 9:00 A.M., she said access staff meet with all patients arriving at the Emergency Department for registration. She said initially access staff will obtain basic information such as name, date of birth, and address, and print an ID band for a patient. Once the Patient is moved to an Emergency Department bed, the access staff completes the registration process including gathering insurance, consents, demographics, and other information. She said access staff do not typically look for, collect, or ask for advance directive, health care proxy, or guardianship information.

During an interview with PA#2 on 1/23/24 at 9:30 A.M., she said she saw Patient #1 the morning of 11/25/23 prior to his discharge. She said medical staff only verify guardianship if there is a need related to medical care/decision making. She said social services/case management typically verify advance directives of patients. She said on arrival to the Emergency Department, the RN assigned to a patient will usually confirm guardianship/ health care proxy/advance directives from the patients and any available paperwork with a patient. She said Patient #1 was medically stable, social work and psychiatric services informed the discharge disposition was for him/her to go home with his/her mother, and she felt the Patient was safe to discharge with that plan.

During an interview with RN #2 on 1/23/24 at 12:15 P.M., she said she did not recall Patient #1. She said if a patient presents to the Emergency Department with a guardianship, access staff will confirm that guardianship. She said once a patient is brought into the Emergency Department and safe, the staff will reach out to the patient's guardian to inform them the patient is in the Emergency Department and that information is generally available in a patient's electronic medical record.

During an interview with RN #3 on 1/23/24 at 12:30 P.M., she said she took over Patient #1's care on 11/25/23. She said Patient #1's binder included a face sheet indicating his/her mother was a co-guardian with Patient #1's actual guardian. She said Patient #1's binder did not contain a copy of the actual guardianship to be available for review. She said the group home staff who was originally with Patient #1 at the Emergency Department was aware of the plan to discharge the Patent with his/her mother. She said another staff member from the group home arrived at the Emergency Department and was upset the Patient was going to be discharged with his/her mother but did not stay in the Emergency Department. She said Patient #1 was discharged with his/her mother with a safety plan from the Emergency Department.

During an interview with the Associate Clinical Nursing Officer of Emergency Services on 1/23/24 at 1:15 P.M., she said access staff meet with patients coming into the Emergency Department for registration. She said part of the registration process includes entering if the patient has a responsible party, health care proxy, or legal guardian and scanning any documentation provided into the electronic medical record. She said if there are discrepancies regarding the advance directive status, health care proxy, or guardianship of a patient, social services/case management could obtain documentation for verification.

The Hospital failed to ensure Patient #1's legal guardian was contacted after arriving at the Emergency Department on 11/24/23 to allow for informed decisions to be made regarding his/her care; the Patient was discharged with his/her mother without the legal guardian's knowledge or consent resulting in the Patient missing several days of his/her medications, search for the Patient by law enforcement, and return to the Hospital Emergency Department for Patient #1.