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Based on medical record review, staff interviews, review of facility policies/procedures and Medical Staff Clinical Rules, the facility failed to ensure its Emergency Department (ED) Staff followed its policies and procedures. Specifically, prior to discharge from the ED, the staff failed to document the patient's status related to his/her chief complaint, therefore the medical record did not contain evidence that the patient's discharge was safe. This failure created the potential for a negative patient outcome.

The findings were:

Facility policies/procedures, as well as Medical Staff Rules and Regulations ("Clinical Rules") were reviewed on 9/7/11. They revealed the following, in pertinent part:

"CLINICAL RULES OF THE MEDICAL STAFF," amended February 2011:

ARTICLE VIII. Medical Records...
"8.5 Emergency Medical Services Records
The Emergency Medical Services Department medical records must contain a pertinent history of illness or injury including the patient's vital signs; diagnostic and therapeutic orders; clinical observation to include the results of treatment; diagnostic impression, and conclusion at the termination of evaluation/treatment including final disposition; the patient's condition at discharge; and instructions for follow-up care given to the patient and/or family..."

The facility's policy titled "PLAN FOR PROVISION OF PATIENT CARE," dated 2009:

IX. POLICIES AND PROCEDURES...
6. PLAN FOR PATIENT CARE SERVICES...
B. Patient Care Services occur through organized and systematic processes designed to ensure the delivery of safe, effective, and timely care and treatment... Nursing staff and allied healthcare professionals function collaboratively with physicians and other professionals as part of an interdisciplinary team to achieve positive patient outcomes. When a patient is referred to other internal or external providers of care pertinent information is shared prior to the hand-off of care.

"II. HOSPITAL DEPARTMENTS
A. Direct Patient Care Departments include the following:
...Emergency Department...
C. Support Services include the following:
...Social Worker...
F. Integration of Patient Care and Support Services...
2. A collaborative, interdisciplinary team approach serves as a foundation for integration of Patient Care and Support Services. Positive interdepartmental communications are strongly encouraged among patient care areas, support services, and ancillary services in order to ensure continuity of patient care, maintenance of the patient's environment and positive patient outcomes..."

Review of sample medical records #1 was conducted on 9/6/11. The patient presented to the Emergency Department on 6/20/11 at 22:47 (10:47 p.m.), via ambulance and was discharged on 6/21/11, at approximately 10:45 a.m. The patient had a CT scan of the head, EKG (Electro Cardiogram), lab testing, and a blood alcohol test completed upon presentation to the ED, all of which revealed no acute process. The admitting physician documented, in pertinent part: "Chief Complaint: DECREASED MENTAL STATUS. This started unclear and is still present. [S/he] has been disoriented and confused. No alcohol recently or recent drug use..."

The patient was cared for by three physicians throughout his/her time in the ED. The discharging physician documented the following, in pertinent part:

"...At this point we are awaiting case management to assure [s/he] has a safe place to go... case management has seen here in the ED, Sending to day shelter, ambulatory and taking pos [orals], Patient counseled in person regarding the patient's stable condition, diagnosis and need for follow-up. Disposition: Condition: stable. Discharged. Discharge decision based on the following: patient's condition is stable; patient's condition is improved; patient is ambulatory; patient's exam is improved; no seriously abnormal test results; improving condition on repeat evaluation; social support is good; transportation is arranged; follow-up is available; clinical impression is consistent with outpatient treatment.

CLINICAL IMPRESSION: Changed mental status. Clinical picture does not suggest overdose, substance abuse, alcohol intoxication or hepatic encephalopathy..."

The patient was instructed to follow-up with a community medical clinic.

The admitting nurse documented, in pertinent part: "Acuity: LEVEL 2. Chief Complaint: ALTERED MENTAL STATUS... Alert... The patient is disoriented to place, time and situation. Patient's speech is abnormal..." The patient was cared for by three different nurses throughout his/her time in the ED. The final documented mental status assessment was done by the second nurse at 1:36 a.m. It stated, in pertinent part:
"best verbal response- disoriented... best motor response- obeys commands..."

The discharging nurse documented the following, in pertinent part:
"pt sitting upright on stretcher, eating food... Case Management called, awaiting until 10 a.m... The patient is sleeping... SW (Social Worker) at bedside for eval of patient. Pt answers questions by mumbling... Condition at departure: unchanged and stable. Patient reports pain level on departure as 0/10. Fall risk assessment completed. No fall risk identified. No learning barriers present. Discharge instructions provided and reviewed with the patient. Patient verbalized understanding. Written instructions provided in English. The patient was discharged home and unaccompanied at time of discharge. The patient left the Emergency Department ambulatory and via taxi and with fare provided... pt discharged to Shelter."

The only entry by the Social Worker that saw the patient stated the following, in pertinent part:
"SW met with pt in ED. Perpt [s/he] is homeless and has no family or friends to call. SW asked pt about emergency contact on face sheet..... Pt stated that person is no longer around. SW called number, it was disconnected. Pt agreed to go to .... day shelter at d/c, cab voucher provided to nursing."

An interview with the Director of Case Management was conducted on 9/6/11, at approximately 12:00 p.m. The Director stated a patient may be referred to Adult Protective Services on many conditions, one of which could be "when we see there is a situation that puts themselves or others at risk." When asked why Adult Protective Services was not consulted in this patient's case, s/he stated, "By all indications, [s/he] was up moving around, dressing, having no pain, and by what was documented it didn't seem [s/he] was disoriented." When asked if there was documentation that stated s/he was oriented, she stated there was not.

A telephone interview with the physician that discharged the patient was conducted on 9/7/11, at approximately 5:40 p.m. When asked the physician's involvement, s/he stated that s/he "vaguely" remembered the patient. The physician stated that the patient's off-going/previous physician "told me at 6:30 a.m. the plan was to have Case Management see the patient when [s/he] got in that morning to determine a place for the patient to go." When asked if the physician fully evaluated the patient upon taking over care, s/he stated, "Everyone is different. I go and lay eyes on them. I can't remember for sure, but I think [the patient] was sleeping when I assumed..." When asked if the physician evaluated the patient's chief complaint prior to discharge, as such was not specifically documented, s/he stated, "I usually do. In [this patient's] case of changed mental status, I spoke with [him/her] at least on one occasion and made an assessment on mental status..." The physician stated that his/her general approach to a reassessment of a patient's mental status would be to ask how the patient is doing, if the patient is hurting, where the patient is, what the date is, and where the patient is going to go. When asked if this is usually documented, s/he stated, "I try to. I don't know if I did in this case." When asked specifically about the patient's orientation prior to discharge, as it was not clearly documented, the physician stated, "I can't recall specifically... I feel comfortable saying I would not have discharged this patient if a danger to self." When asked about the documentation that existed, which stated the patient had improved and had social support, the physician stated that they were canned computer documentation entry responses that could be chosen from in the medical record system. S/he stated that when the patient came in, s/he was not capable of handling self, but upon discharge the patient was walking and feeding self. S/he also stated that because the patient was being referred to a shelter, that the social support was improved from the patient's baseline. The physician also stated, "I assessed [the patient] to the extent I thought I needed to... There are basically three options with a patient like this: A) discharge to street at midnight, B) let the patient sleep for the night, provide a hot meal, and see what we can do to help, or C) admit the patient for confusion." The physician stated that although s/he didn't document the patient's mental status carefully upon discharge, that his/her clinical assessment was the patient was improved from the initial presentation to the ED.

An interview with the nurse that discharged the patient was conducted on 9/7/11, at approximately 3:00 p.m. When asked about the patient, s/he stated, "I don't remember this patient, to be honest." When asked about the documentation that the patient was "unchanged," s/he stated, "I'd imagine I meant [s/he] was stable to be discharged... unchanged from when I met [him/her]." When asked if the nurse evaluated the patient's initial complaint prior to discharge, as such was not specifically documented, s/he stated, "Generally the initial complaint is re-documented or referred to again prior to discharge... If I didn't think the patient was safe to go to a shelter, I would have intervened..." When asked how a patient is determined safe for discharge, s/he stated, "They are ok if they are walking, eating, vital signs are stable, and they know where they're going..."

A telephone interview with the social worker/case manager that discharged the patient was conducted on 9/7/11, at approximately 9:45 a.m. When asked his/her involvement with the patient, s/he stated, "I was asked to meet with the patient a find a place for [him/her] to go. I was told [s/he] was ready to be discharged... The patient agreed to go to a day shelter and I explained to [him/her] from there they could direct [him/her] to an evening shelter." When asked if s/he called the shelter prior to the patient leaving the ED, s/he stated that s/he did not and does not do so unless it is a night shelter where a bed needs to be secured. When asked if s/he calls the case workers at the shelters, s/he stated, "No, I never have." When asked the procedure for the clients to get from a day to a night shelter, s/he stated, "The day shelter has no pull. They give options and tell them the time to be there... They are basically traffic directors." When asked if the s/he assessed the patient's mental status, s/he stated the patient answered basic questions, but was difficult to understand. S/he stated that the nurse and doctors normally do a full mental exam on the patient and that s/he had never been asked to do that. When asked if any financial resources were addressed for the patient, s/he stated s/he did not make any referrals. When asked if there were any other resources or discharge options available for the patient, s/he stated, "There were no others given that [s/he] had nowhere to live... I do not believe [s/he] had any other options... If the patient had Medicare, perhaps if s/he had a home returning to, I may have tried to get Home Health..." When asked if the patient would have been referred to Adult Protective Services, s/he stated s/he did not feel that there was a need for it at that time and that "APS is limited in what they can do to help elderly people... services depend on want or willing for the patient to participate or if a doctor states they need a guardian..."

In summary, although all discharging staff interviewed stated they would not have discharged the patient had it been unsafe, there is no documentation which clearly evidenced the patient's condition at discharge (as required by the Medical Staff Rules and Regulations) and that ancillary services were utilized to ensure the patient's continuity of care and outcome were positive (as stated in the facility's Provision of Patient Care policy). The patient's chief complaint was changed mental status and neither the nurse nor the physician, primarily responsible for the patient's discharge, who last cared for the patient documented that the patient's mental status was assessed to ensure a safe discharge.

Based on medical record review, staff interviews, review of facility policies/procedures and Medical Staff Clinical Rules, the facility failed to ensure its Emergency Department (ED) Staff followed its policies and procedures. Specifically, prior to discharge from the ED, the staff failed to document the patient's status related to his/her chief complaint, therefore the medical record did not contain evidence that the patient's discharge was safe. This failure created the potential for a negative patient outcome.

The findings were:

Facility policies/procedures, as well as Medical Staff Rules and Regulations ("Clinical Rules") were reviewed on 9/7/11. They revealed the following, in pertinent part:

"CLINICAL RULES OF THE MEDICAL STAFF," amended February 2011:

ARTICLE VIII. Medical Records...
"8.5 Emergency Medical Services Records
The Emergency Medical Services Department medical records must contain a pertinent history of illness or injury including the patient's vital signs; diagnostic and therapeutic orders; clinical observation to include the results of treatment; diagnostic impression, and conclusion at the termination of evaluation/treatment including final disposition; the patient's condition at discharge; and instructions for follow-up care given to the patient and/or family..."

The facility's policy titled "PLAN FOR PROVISION OF PATIENT CARE," dated 2009:

IX. POLICIES AND PROCEDURES...
6. PLAN FOR PATIENT CARE SERVICES...
B. Patient Care Services occur through organized and systematic processes designed to ensure the delivery of safe, effective, and timely care and treatment... Nursing staff and allied healthcare professionals function collaboratively with physicians and other professionals as part of an interdisciplinary team to achieve positive patient outcomes. When a patient is referred to other internal or external providers of care pertinent information is shared prior to the hand-off of care.

"II. HOSPITAL DEPARTMENTS
A. Direct Patient Care Departments include the following:
...Emergency Department...
C. Support Services include the following:
...Social Worker...
F. Integration of Patient Care and Support Services...
2. A collaborative, interdisciplinary team approach serves as a foundation for integration of Patient Care and Support Services. Positive interdepartmental communications are strongly encouraged among patient care areas, support services, and ancillary services in order to ensure continuity of patient care, maintenance of the patient's environment and positive patient outcomes..."

Review of sample medical records #1 was conducted on 9/6/11. The patient presented to the Emergency Department on 6/20/11 at 22:47 (10:47 p.m.), via ambulance and was discharged on 6/21/11, at approximately 10:45 a.m. The patient had a CT scan of the head, EKG (Electro Cardiogram), lab testing, and a blood alcohol test completed upon presentation to the ED, all of which revealed no acute process. The admitting physician documented, in pertinent part: "Chief Complaint: DECREASED MENTAL STATUS. This started unclear and is still present. [S/he] has been disoriented and confused. No alcohol recently or recent drug use..."

The patient was cared for by three physicians throughout his/her time in the ED. The discharging physician documented the following, in pertinent part:

"...At this point we are awaiting case management to assure [s/he] has a safe place to go... case management has seen here in the ED, Sending to day shelter, ambulatory and taking pos [orals], Patient counseled in person regarding the patient's stable condition, diagnosis and need for follow-up. Disposition: Condition: stable. Discharged. Discharge decision based on the following: patient's condition is stable; patient's condition is improved; patient is ambulatory; patient's exam is improved; no seriously abnormal test results; improving condition on repeat evaluation; social support is good; transportation is arranged; follow-up is available; clinical impression is consistent with outpatient treatment.

CLINICAL IMPRESSION: Changed mental status. Clinical picture does not suggest overdose, substance abuse, alcohol intoxication or hepatic encephalopathy..."

The patient was instructed to follow-up with a community medical clinic.

The admitting nurse documented, in pertinent part: "Acuity: LEVEL 2. Chief Complaint: ALTERED MENTAL STATUS... Alert... The patient is disoriented to place, time and situation. Patient's speech is abnormal..." The patient was cared for by three different nurses throughout his/her time in the ED. The final documented mental status assessment was done by the second nurse at 1:36 a.m. It stated, in pertinent part:
"best verbal response- disoriented... best motor response- obeys commands..."

The discharging nurse documented the following, in pertinent part:
"pt sitting upright on stretcher, eating food... Case Management called, awaiting until 10 a.m... The patient is sleeping... SW (Social Worker) at bedside for eval of patient. Pt answers questions by mumbling... Condition at departure: unchanged and stable. Patient reports pain level on departure as 0/10. Fall risk assessment completed. No fall risk identified. No learning barriers present. Discharge instructions provided and reviewed with the patient. Patient verbalized understanding. Written instructions provided in English. The patient was discharged home and unaccompanied at time of discharge. The patient left the Emergency Department ambulatory and via taxi and with fare provided... pt discharged to Shelter."

The only entry by the Social Worker that saw the patient stated the following, in pertinent part:
"SW met with pt in ED. Perpt [s/he] is homeless and has no family or friends to call. SW asked pt about emergency contact on face sheet..... Pt stated that person is no longer around. SW called number, it was disconnected. Pt agreed to go to .... day shelter at d/c, cab voucher provided to nursing."

An interview with the Director of Case Management was conducted on 9/6/11, at approximately 12:00 p.m. The Director stated a patient may be referred to Adult Protective Services on many conditions, one of which could be "when we see there is a situation that puts themselves or others at risk." When asked why Adult Protective Services was not consulted in this patient's case, s/he stated, "By all indications, [s/he] was up moving around, dressing, having no pain, and by what was documented it didn't seem [s/he] was disoriented." When asked if there was documentation that stated s/he was oriented, she stated there was not.

A telephone interview with the physician that discharged the patient was conducted on 9/7/11, at approximately 5:40 p.m. When asked the physician's involvement, s/he stated that s/he "vaguely" remembered the patient. The physician stated that the patient's off-going/previous physician "told me at 6:30 a.m. the plan was to have Case Management see the patient when [s/he] got in that morning to determine a place for the patient to go." When asked if the physician fully evaluated the patient upon taking over care, s/he stated, "Everyone is different. I go and lay eyes on them. I can't remember for sure, but I think [the patient] was sleeping when I assumed..." When asked if the physician evaluated the patient's chief complaint prior to discharge, as such was not specifically documented, s/he stated, "I usually do. In [this patient's] case of changed mental status, I spoke with [him/her] at least on one occasion and made an assessment on mental status..." The physician stated that his/her general approach to a reassessment of a patient's mental status would be to ask how the patient is doing, if the patient is hurting, where the patient is, what the date is, and where the patient is going to go. When asked if this is usually documented, s/he stated, "I try to. I don't know if I did in this case." When asked specifically about the patient's orientation prior to discharge, as it was not clearly documented, the physician stated, "I can't recall specifically... I feel comfortable saying I would not have discharged this patient if a danger to self." When asked about the documentation that existed, which stated the patient had improved and had social support, the physician stated that they were canned computer documentation entry responses that could be chosen from in the medical record system. S/he stated that when the patient came in, s/he was not capable of handling self, but upon discharge the patient was walking and feeding self. S/he also stated that because the patient was being referred to a shelter, that the social support was improved from the patient's baseline. The physician also stated, "I assessed [the patient] to the extent I thought I needed to... There are basically three options with a patient like this: A) discharge to street at midnight, B) let the patient sleep for the night, provide a hot meal, and see what we can do to help, or C) admit the patient for confusion." The physician stated that although s/he didn't document the patient's mental status carefully upon discharge, that his/her clinical assessment was the patient was improved from the initial presentation to the ED.

An interview with the nurse that discharged the patient was conducted on 9/7/11, at approximately 3:00 p.m. When asked about the patient, s/he stated, "I don't remember this patient, to be honest." When asked about the documentation that the patient was "unchanged," s/he stated, "I'd imagine I meant [s/he] was stable to be discharged... unchanged from when I met [him/her]." When asked if the nurse evaluated the patient's initial complaint prior to discharge, as such was not specifically documented, s/he stated, "Generally the initial complaint is re-documented or referred to again prior to discharge... If I didn't think the patient was safe to go to a shelter, I would have intervened..." When asked how a patient is determined safe for discharge, s/he stated, "They are ok if they are walking, eating, vital signs are stable, and they know where they're going..."

A telephone interview with the social worker/case manager that discharged the patient was conducted on 9/7/11, at approximately 9:45 a.m. When asked his/her involvement with the patient, s/he stated, "I was asked to meet with the patient a find a place for [him/her] to go. I was told [s/he] was ready to be discharged... The patient agreed to go to a day shelter and I explained to [him/her] from there they could direct [him/her] to an evening shelter." When asked if s/he called the shelter prior to the patient leaving the ED, s/he stated that s/he did not and does not do so unless it is a night shelter where a bed needs to be secured. When asked if s/he calls the case workers at the shelters, s/he stated, "No, I never have." When asked the procedure for the clients to get from a day to a night shelter, s/he stated, "The day shelter has no pull. They give options and tell them the time to be there... They are basically traffic directors." When asked if the s/he assessed the patient's mental status, s/he stated the patient answered basic questions, but was difficult to understand. S/he stated that the nurse and doctors normally do a full mental exam on the patient and that s/he had never been asked to do that. When asked if any financial resources were addressed for the patient, s/he stated s/he did not make any referrals. When asked if there were any other resources or discharge options available for the patient, s/he stated, "There were no others given that [s/he] had nowhere to live... I do not believe [s/he] had any other options... If the patient had Medicare, perhaps if s/he had a home returning to, I may have tried to get Home Health..." When asked if the patient would have been referred to Adult Protective Services, s/he stated s/he did not feel that there was a need for it at that time and that "APS is limited in what they can do to help elderly people... services depend on want or willing for the patient to participate or if a doctor states they need a guardian..."

In summary, although all discharging staff interviewed stated they would not have discharged the patient had it been unsafe, there is no documentation which clearly evidenced the patient's condition at discharge (as required by the Medical Staff Rules and Regulations) and that ancillary services were utilized to ensure the patient's continuity of care and outcome were positive (as stated in the facility's Provision of Patient Care policy). The patient's chief complaint was changed mental status and neither the nurse nor the physician, primarily responsible for the patient's discharge, who last cared for the patient documented that the patient's mental status was assessed to ensure a safe discharge.