HospitalInspections.org

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Based on interview, medical record review and review of hospital policies and procedures, the hospital failed to refer a severely autistic, developmentally delayed patient (Patient #1) to an appropriate facility, agency, or outpatient service, after discharging him from the Emergency Department, then placed him in an ambulance and transported him to Vancouver without family members present at the home, that lead ambulance staff to transport the patient to the nearest ED.

Failure to refer a developmentally delayed patient to an appropriate facility, agency or outpatient service after discharge, lead to an improper post-hospital disposition and an unsafe transition of care.

Findings include:

1. Review of a hospital's policy titled, "Discharge Planning," dated 6/18, showed that emergency department ED patients may be referred for discharge planning evaluation by a provider with an order entry to the personal health partners (PHP) staff, who will then evaluate the patient for discharge planning needs. The evaluation performed by the PHP staff, will be discussed with the patient or patient representative and they will participate in the development of his/her discharge plan. The policy goes on to show that patients in need of outpatient services or referrals will be provided information on accessing community or outpatient services. The PHP will ensure that appropriate follow-up with the patient's primary physician or LIP is established.

a. Review of a hospital's job description titled, "Personal Health Partner -Social Work," showed that PHP-SW is responsible for an ideal cross continuum care coordination, plus ensure that the patient and family experience seamless/safe transitions of care. They collaborate with PHP colleagues to coordinate and develop appropriate/safe next level of care arrangements, plus other principal duties.

2. Review of the patient's medical record showed a 16 year old with a significant past medical history for autism, bipolar disorder, and developmentally delayed (functional skills appear to range from 18 mons - 3 yr. old). The patient is largely non-verbal. Family members are unable to provide care to the patient, he resides temporarily in a community crisis stabilization services (CCSS) facility, managed by DSHS, in Lakewood (Family lives in Vancouver). Records showed that he was transported to Mary Bridge (MB) Children's ED on 6/6/18 at 7:12 PM, for behavioral problems, escorted by Lakewood PD after he became aggressive toward his crisis stabilization staff. Records described his behavioral problems as outbursts, violent actions, aggressive behavior to others, and self-harm. The medical record showed 8 ED encounters from January to June, 2018. The encounter on 6/6/18 showed that MB ED staff was familiar with the patient and his outbursts, but to reduce environmental stressors, staff prepared room #17 (reduce risk room) and placed him under 1:1 constant observation. The PHP-SW discharge plan in the record, showed that the patient will either return to his CCSS facility, Lakeland Village (Spokane), or home. However, 16 hours after his arrival, the CCSS facility informed the ED staff that they will no longer accept the patient back, due to his assault on staff and property damage. The ED staff continued to provide him observation and care for 3 days, until discharge. A conference call was arranged on 6/8/18 with hospital staff, other state agencies, representative from Lakeland Village (Spokane facility able to admit the patient) and the patient's mother to discuss patient's disposition. The mother was informed of the Spokane facility ready to accept her son, but, she refused due to the facilities care of adults only. Staff A, Pediatric Care Continuum Director, stated that during the call, the mother became hostile and began yelling on the phone, but staff was able to inform her that hospital staff will arrange discharge transportation to their home, then the call ended. A multi-disciplinary team debrief occurred and it was decided that the patient was medically cleared, plus mental health services assessed him as close to baseline- ready to be discharged into the community/family's home in Vancouver. On 6/8/18 at 7:18 PM, prior to the ambulance arrival, at the ED, the PHP-SW informed the mother, over the phone, that the hospital is arranging transportation back to the family's home, the mother replied that the family is not home in Vancouver, but in Oregon, then she hung up. The patient was loaded into a basic life support (BLS) ambulance and transported 130 miles to Vancouver. There the ambulance staff arrived at the family home but no family members or caregivers were present, to receive the patient. Then the ambulance staff transported the patient to the nearest ED at PeaceHealth Southwest. At 7:47 PM, a PHP - SW note showed that the PeaceHealth staff called and spoke to her to inform her that the patient is now in their ED. Further review of the record showed that MB staff communicated with family members only on the day of ED discharge, however, no documentation could be found that the patient was referred to an appropriate follow- up facility, agency, or outpatient service located in Vancouver or Pierce County.

3. During an interview on 8/8/18 at 11:15 AM, Staff A, Pediatric Care Continuum Director, stated that she is familiar with the patient's long history of behavioral problems. Staff A stated that his parents cannot care for him and tend to not act in his best interest. She explained, because he is under the care of DSHS crisis services, placement with the Spokane facility (Lakeland Village) was arranged by CCSS. The CCSS staff discussed the patient's transition into Lakeland Village with the family, but mother refused. Staff A added that state will not take away the parenting rights and she felt the state failed this child. After the CCSS facility refused to accept the patient back, staff felt it appropriate to transport the patient to Vancouver and receive community services there.

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