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Based on medical record review, policy review and interview, Emergency Department staff did not ensure the assisted living facility (ALF) that the patient resided at was notified of the patient discharge for 3 of 6 patient visits (Patient #1, 25 and 26).

Findings include:

Review of policy ED-05, Emergency Department Standards of Care last revised 05/2017 under Discharge/Transfer revealed that appropriate hand-off communication should be provided to the next facility.

Review of policy #CSC0098, Guidelines for the Discharge of the Patient and Discharge Plan last approved 05/02/17 revealed that Care Management responsibilities include arranging for transportation if applicable and completing hand-off communication with the facility the patient is being discharged to.

Interview on 11/06/18 at 09:30 AM with Staff (C) and Staff (K), ED Nursing revealed that if a patient presents to the ED from an ALF, the ALF is notified prior to the patient's discharge.

Review of Patient #1 ED record dated 06/03/18 revealed no documentation to indicate the ALF was contacted regarding the patient's visit and subsequent discharge.

Review of Patient #25 ED record dated 06/14/18 revealed no documentation to indicate the ALF was contacted regarding the patient's visit and subsequent discharge.

Review of Patient #26 ED record dated 08/04/18 revealed no documentation to indicate the ALF was contacted regarding the patient's visit and subsequent discharge.


Interview with Staff (A), Patient Safety and (C), ED Nursing on 11/06/18 at 02:30 PM verified the above findings.