HospitalInspections.org

Based on medical record review, facility policies, and staff interviews, the Governing Body:

i. Failed to ensure that patient care and services were administered in a safe and effective manner;

ii. Failed to ensure that policies and procedures were established to ensure the safe discharge of a patient during inclement weather.

Cross refer A0115 as it relates to the facility's failure to protect and promote patients' rights.

Cross refer A0799 as it relates to the facility's failure to ensure a safe discharge.

Based on medical record review, facility policies, and staff interviews, the facility failed to protect and promote Patient #1's rights to a safe discharge to home. As a result of the facility's non-compliance, Patient #1 suffered potential harm as a result of driving under the influence of prescribed narcotics during inclement whether.

Findings:

A review of the medical record revealed that Patient #1 presented to the facility through the facility's Emergency Department (ED) on 01/16/18, with a complaint of sudden onset lower back pain. Patient #1 was admitted under the service of a surgeon (MD, Credential #6) and scheduled for surgery. Patient #1 underwent a successful laparoscopic appendectomy (removal of the appendix through small incisions) on 01/16/2018. A further review of the record revealed that on 01/17/18 Credential #6 assessed Patient #1 and found him/her to be stable for discharge. The record revealed that Patient #1 verbalized concerns regarding transportation to the LPN (Employee #8) The Licensed Clinical Social Worker (LCSW, Employee #3) was notified. The record reflected that after speaking with the LCSW, arrangements were made at Patient #1's request to delay discharge until 2:00 p.m. On 01/17/18 at 2:33 p.m. the LPN (Employee #8) printed Patient #1's discharge instructions, and Patient #1 was discharged at 2:54 p.m.

A review of the facility admission log dated 01/16/18 revealed that Patient #1 was admitted to the facility on observation status.
A review of the medical record dated 01/17/18 at 7:35 a.m. revealed a discharge order written by the Credential #6.
A review of the MD ' s (Credential #6) Progress Notes dated 01/17/18 at 7:33 a.m. revealed that Patient #1 was scheduled to be discharged on 01/17/18 with a possible delay due to inclement weather.
A review of the Licensed Clinical Social Worker ' s (Employee #3) notes dated 01/17/18 at 11:15 a.m. revealed that Patient #1 verbalized a concern regarding driving home or having anyone pick him/her up from the facility, and that Patient #1 requested to remain at the facility until approximately 2:00 p.m. The patient indicated that he/she would either drive his/her own personal vehicle or have someone come to get him/her. Per the LCSW note, Patient #1's nurse was updated and made aware that the patient would wait until 2:00 p.m. on 01/17/18 to be discharged.

A review of the Case Manager (CM) Ancillary Note written by Employee #7 on 01/17/18 at 11:17 a.m. revealed that Patient #1 was independent with all his/her Activities of Daily Living (ADLs) prior to admission. There were no anticipated discharge needs identified for Patient #1 during the discharge assessment. A further review of the note revealed that Patient #1 had running water, electricity, refrigerator, and heat at home. The anticipated discharge plan was for the patient to return to home with self-care.

A review of the Medication Administration Record dated 01/17/18 revealed that Patient #1 was administered oxycodone (Percocet) 10-325 mg by mouth at 12:12 p.m. A further review revealed that Employee #8 administered the medication to the patient.

A review of the medical record revealed that the patient's discharge instructions were printed by the Employee #8 on 01/17/18 at 2:33 p.m. A further review revealed that the discharge instructions revealed information regarding the patient's prescriptions, follow-up appointment, diet, activity, and wound care. A continued review revealed that the patient was not to drive while on pain medications.

A review of the Event Management Sheet revealed that Patient #1 was discharged from the facility on 01/17/18 at 2:54 p.m.
During an interview with the RN Clinical Supervisor (CS, Employee #1) on 04/06/18 at 10:48 a.m. in the Conference Room, he/she stated that patients can discharge without a driver if they can get home safely and have not been administered any narcotics. Employee #1 added that if a patient cannot get a ride, or if a patient had been administered a narcotic the day of discharge, transportation would be arranged via Uber, taxi, or non-emergency EMS. Employee #1 further stated that if a patient refused transportation and wanted to drive home after being administered a narcotic, the risk manager and MD would be notified. After reviewing Patient #1's discharge documentation, Employee #1 acknowledged that there was no documentation regarding whether the patient had been advised not to drive as the patient had been administered a narcotic approximately two (2) prior to discharge. Employee #1 stated that his/her expectation of the nursing staff would be to document if a patient had made other arrangements to leave the facility if a narcotic had been administered prior to discharge. Employee #1 added that he/she would have expected the nurse to contact the MD and make him/her aware of the patient's status.

During an interview with the Pharmacist (Employee #4) on 04/06/18 at 12:48 p.m. in the Conference Room, Employee #4 explained that Percocet 10-325 given by mouth has a peak time approximately one and half (1.5) to two (2) hours after administration. The employee confirmed that Percocet is a narcotic that can be sedating, and it typically recommended that a person not drive a vehicle while on the medication.
During an interview with the CNO (Chief Nursing Officer, Employee #2) on 04/06/18 at 1:48 p.m. in the Conference Room, the CNO stated that Employee #6 and Employee #8 were on vacation out of the state and unable to be reached for interview.

A subsequent interview with the Chief Nursing Officer on 04/06/18 at 2:54 p.m. in the Conference Room, revealed that there were no videos of Patient #1 leaving the facility on 01/17/18. The CNO explained that video is only pulled and saved if an event occurs that requires the video to be archived or copied. The CNO stated that the video loops and re-records over the old video. The CNO explained that Patient #1 never contacted the facility to complain about any issues, and the first notification that the facility had regarding Patient #1 was through the news media. The CNO stated that a local news station reached out to the facility and stated they were running a story about Patient #1 being discharged during the State of Emergency, which had been initiated due to inclement weather. The CNO stated the facility contacted Patient #1 after they learned about the news story.

A latter interview with the CNO on 04/06/18 at 3:50 p.m. in the Conference Room revealed that the facility did recognize there were no policies related to a patient being discharged while on narcotic pain medication. The CNO stated that the facility's ED was currently the only department that had an existing policy that covered the topic of patient discharge while on a narcotic. The CNO stated that the facility was aware that there was an opportunity for improvement in the discharge process. The CNO acknowledged that Patient #1 was discharged approximately two (2) hours after receiving a Percocet 10-325 mg without a driver. The CNO also acknowledged that the MD's discharge instructions stated that the patient was not to drive while taking the pain medication and added that the patient should not have driven him/herself home. The CNO stated that the facility had a meeting on 03/22/18 and discussed potential changes to policy and documentation regarding patients that are discharging while on narcotic pain medications.
The CNO acknowledged that the facility currently, and at the time of patient #1's discharge from the facility, had no policies pertaining to safe patient discharge during inclement weather and during a State of Emergency. The CNO stated that the facility management and department directors would be meeting again on 04/11/18 to discuss the implementation of new safe discharge policies and protocols. The CNO confirmed that no changes have currently been adopted.

During an interview with the Transport Supervisor (Employee #5) on 04/06/18 at 12:33 p.m. in the Conference Room, Employee #5 stated that the transport department does not document whether a patient has a driver or not. Employee #5 stated that the department does retain a record of how the patient left, i.e., if they left via EMS, private vehicle, taxi, or Uber. Employee #5 stated that he/she remembered Patient #1 because he/she took the patient to his/her car by wheelchair and had to break the ice off the patient's car door to open it. Employee #5 stated that the patient got directly into the driver's seat, and the vehicle started up immediately after the key was engaged. Employee #5 stated that Patient #1 never verbalized any concerns regarding driving home or if the roads were dangerous. Employee #5 added that he/she asked Patient #1 if he/she wanted to have someone come and pick him/her up, and that Patient #1 declined. Employee #5 stated that he/she remember that Patient #1 had a lot of patient's belongings bags, and was wearing a coat. Employee #5 added that the patient never got into the back seat of the vehicle at any time, and the patient did not state that he/she was in pain.

During an interview with the Case Manager (Employee #7) on 04/06/18 at 2:58 p.m. in the Conference Room, Employee #7 stated that he/she completed the initial discharge screening for Patient #1 on 01/17/18. Employee #7 stated that Patient #1 was determined to be independent based on the assessment. The only concern the patient had during the assessment was whether his/her insurance was going to pay as the patient was admitted under an observation status versus a full admission status. Employee #7 stated that the patient never voiced any concerns regarding getting home or having fears or concerns about driving. Employee #7 explained that the patient stated that he/she was going to be discharging to his/her mother's home, so he/she would have assistance after his/her discharge from the facility. Employee #7 added that had the patient indicated that he/she was concerned about being discharged for any reason, the concerns would have been addressed by the facility.

During an interview with the LCSW (Employee #3) on 04/06/18 at 3:11 p.m. in the Conference Room, Employee #3 stated that he/she received a call from nursing on 01/17/18 reporting that Patient #1 was having difficulty with transportation. Employee #3 explained that based on the call, he/she assumed the patient did not have a vehicle. When Employee #3 called and spoke with Patient #1, Patient #1 was offered a ride via Uber or non-emergent EMS. Employee #3 stated that he/she explained to Patient #3 that the facility would pay for the patient's transport. The LCSW stated that the patient did not want anyone driving if the roads were dangerous. The patient requested to not to be discharged from the facility until 2:00 p.m. The LCSW stated that he/she felt the request was reasonable and added that if the patient had expressed a time later than 2:00 p.m., he/she would have honored the request. The LCSW explained that he/she notified the nurse that the patient would not be discharged until 2:00 p.m., and did not hear from the patient again. The LCSW stated that the patient did not verbalize that he/she was unhappy or worried about leaving the facility after a 2:00 p.m. discharge had been arranged. The LCSW stated that if the patient had expressed fear or concern about going home that day, the surgeon and nurse would have been notified to see what other arrangements could be made. The LCSW added that there were other patients discharging the same day, and the patients were discharged throughout the facility on 01/17/18.


A review of the facility's "Inclement Weather Plan," last revised 03/21/2016, revealed that there were no written guidelines or objectives that addressed Patient Discharge during inclement weather. A further review revealed that the plan did not address how to monitor or assess for a safe discharge during a State of Emergency.
A review of the facility's "Emergency Operations Plan," last revised 08/2017, revealed that there were no written guidelines or objectives that addressed Patient Discharge during inclement weather. A further review revealed that the plan did not address how to monitor or assess for a safe patient discharge during a State of Emergency.

A review of the facility Bylaws, Article IV, "Board of Directors," section (1), revealed that the affairs of the facility are governed by the Board.

A review of the facility policy, 4659039, "Right and Responsibilities of Patients Policy," last revised 08/01/2014, revealed that the patient has a right to the provision of care in a safe setting. A further review revealed that the Patient Safety Committee, Environment of Care Committee, Infection Control Committee, the Security Department, and the Risk Management Programs seek to eliminate risks to the patient.
A review of the facility policy, 3630711, "Patient Discharge or Inter-Agency Transfer Policy," last revised 02/01/2016, revealed that the patient discharge should include patient education materials, prescriptions, if any, medication reconciliation record, and discharge instructions. The subject of the patient education materials distributed to the patient and/or family/caregiver should be documented on the discharge instructions. A further review revealed that when the patient leaves the hospital, the nursing staff should complete the discharge function for inpatients in the computer. Further review revealed that all patients should be escorted by a facility hospital staff member to their vehicle via wheelchair or ambulatory if they request.

A review of the facility policy, 2041, "Safe Preparation, Administration, and Documentation of Medications," last revised 05/2017 revealed that patients should receive education on all new medications and should be closely monitored for side effects.
A review of the facility admission log dated 01/16/18 revealed that Patient #1 was admitted to the facility on observation status.
A review of the medical record revealed that Patient #1 signed consent for a CT with contrast on 01/16/18 at 3:02 p.m. A further review revealed the patient signed the surgical consent on 01/16/18 at 4:06 p.m. and the general consent for treatment on 01/16/18 at 11:04 a.m.
A review of the medical record revealed an order for oxycodone (Percocet) 10-325 dated 01/16/18. The administration by mouth and to be administered every four (4) hours as needed for pain.

A review of seven (7) employee files (#1, 2, 3, 4, 5, 7, and 8) revealed that all files contained evidence of current licensure, department orientation, and annual competency testing.
Review of one (1) credential file (#6) revealed the file contained current licensure, DEA certificate, insurance, appointment, privileges, and quality reviews.
Review of nine (9) additional medical records were reviewed (#2, 3, 4, 5, 6, 7, 8, and #9). All nine (9) patients were noted to have an appropriate discharge and consent forms signed.

Based on medical record review, facility policy, and staff interviews, the facility failed to ensure a safe discharge for one (1) patient (#1), which resulted in the patient driving home while on narcotic pain medication. In addition, the facility failed to ensure that polices and procedures addressed the discharge of a patient during a State of Emergency related to inclement weather.

Cross refer A0043 as it relates to the Governing Body's failure to ensure that patient care is provided in a safe and effective manner..

Cross refer A0115 as it relates to the facility's failure to protect and promote patients' rights.


Findings:

A review of the medical record revealed that Patient #1 presented to the facility through the facility's Emergency Department (ED) on 01/16/18, with a complaint of sudden onset lower back pain. Patient #1 was admitted under the service of a surgeon (MD, Credential #6) and scheduled for surgery. Patient #1 underwent a successful laparoscopic appendectomy (removal of the appendix through small incisions) on 01/16/2018. A further review of the record revealed that on 01/17/18 Credential #6 assessed Patient #1 and found him/her to be stable for discharge. The record revealed that Patient #1 verbalized concerns regarding transportation to the LPN (Employee #8) The Licensed Clinical Social Worker (LCSW, Employee #3) was notified. The record reflected that after speaking with the LCSW, arrangements were made at Patient #1's request to delay discharge until 2:00 p.m. On 01/17/18 at 2:33 p.m. the LPN (Employee #8) printed Patient #1's discharge instructions, and Patient #1 was discharged at 2:54 p.m.

A review of the facility admission log dated 01/16/18 revealed that Patient #1 was admitted to the facility on observation status.
A review of the medical record dated 01/17/18 at 7:35 a.m. revealed a discharge order written by the Credential #6.
A review of the MD ' s (Credential #6) Progress Notes dated 01/17/18 at 7:33 a.m. revealed that Patient #1 was scheduled to be discharged on 01/17/18 with a possible delay due to inclement weather.
A review of the Licensed Clinical Social Worker ' s (Employee #3) notes dated 01/17/18 at 11:15 a.m. revealed that Patient #1 verbalized a concern regarding driving home or having anyone pick him/her up from the facility, and that Patient #1 requested to remain at the facility until approximately 2:00 p.m. The patient indicated that he/she would either drive his/her own personal vehicle or have someone come to get him/her. Per the LCSW note, Patient #1's nurse was updated and made aware that the patient would wait until 2:00 p.m. on 01/17/18 to be discharged.

A review of the Case Manager (CM) Ancillary Note written by Employee #7 on 01/17/18 at 11:17 a.m. revealed that Patient #1 was independent with all his/her Activities of Daily Living (ADLs) prior to admission. There were no anticipated discharge needs identified for Patient #1 during the discharge assessment. A further review of the note revealed that Patient #1 had running water, electricity, refrigerator, and heat at home. The anticipated discharge plan was for the patient to return to home with self-care.

A review of the Medication Administration Record dated 01/17/18 revealed that Patient #1 was administered oxycodone (Percocet) 10-325 mg by mouth at 12:12 p.m. A further review revealed that Employee #8 administered the medication to the patient.

A review of the medical record revealed that the patient's discharge instructions were printed by the Employee #8 on 01/17/18 at 2:33 p.m. A further review revealed that the discharge instructions revealed information regarding the patient's prescriptions, follow-up appointment, diet, activity, and wound care. A continued review revealed that the patient was not to drive while on pain medications.

A review of the Event Management Sheet revealed that Patient #1 was discharged from the facility on 01/17/18 at 2:54 p.m.
During an interview with the RN Clinical Supervisor (CS, Employee #1) on 04/06/18 at 10:48 a.m. in the Conference Room, he/she stated that patients can discharge without a driver if they can get home safely and have not been administered any narcotics. Employee #1 added that if a patient cannot get a ride, or if a patient had been administered a narcotic the day of discharge, transportation would be arranged via Uber, taxi, or non-emergency EMS. Employee #1 further stated that if a patient refused transportation and wanted to drive home after being administered a narcotic, the risk manager and MD would be notified. After reviewing Patient #1's discharge documentation, Employee #1 acknowledged that there was no documentation regarding whether the patient had been advised not to drive as the patient had been administered a narcotic approximately two (2) prior to discharge. Employee #1 stated that his/her expectation of the nursing staff would be to document if a patient had made other arrangements to leave the facility if a narcotic had been administered prior to discharge. Employee #1 added that he/she would have expected the nurse to contact the MD and make him/her aware of the patient's status.

During an interview with the Pharmacist (Employee #4) on 04/06/18 at 12:48 p.m. in the Conference Room, Employee #4 explained that Percocet 10-325 given by mouth has a peak time approximately one and half (1.5) to two (2) hours after administration. The employee confirmed that Percocet is a narcotic that can be sedating, and it typically recommended that a person not drive a vehicle while on the medication.
During an interview with the CNO (Chief Nursing Officer, Employee #2) on 04/06/18 at 1:48 p.m. in the Conference Room, the CNO stated that Employee #6 and Employee #8 were on vacation out of the state and unable to be reached for interview.

A subsequent interview with the Chief Nursing Officer on 04/06/18 at 2:54 p.m. in the Conference Room, revealed that there were no videos of Patient #1 leaving the facility on 01/17/18. The CNO explained that video is only pulled and saved if an event occurs that requires the video to be archived or copied. The CNO stated that the video loops and re-records over the old video. The CNO explained that Patient #1 never contacted the facility to complain about any issues, and the first notification that the facility had regarding Patient #1 was through the news media. The CNO stated that a local news station reached out to the facility and stated they were running a story about Patient #1 being discharged during the State of Emergency, which had been initiated due to inclement weather. The CNO stated the facility contacted Patient #1 after they learned about the news story.

A latter interview with the CNO on 04/06/18 at 3:50 p.m. in the Conference Room revealed that the facility did recognize there were no policies related to a patient being discharged while on narcotic pain medication. The CNO stated that the facility's ED was currently the only department that had an existing policy that covered the topic of patient discharge while on a narcotic. The CNO stated that the facility was aware that there was an opportunity for improvement in the discharge process. The CNO acknowledged that Patient #1 was discharged approximately two (2) hours after receiving a Percocet 10-325 mg without a driver. The CNO also acknowledged that the MD's discharge instructions stated that the patient was not to drive while taking the pain medication and added that the patient should not have driven him/herself home. The CNO stated that the facility had a meeting on 03/22/18 and discussed potential changes to policy and documentation regarding patients that are discharging while on narcotic pain medications.
The CNO acknowledged that the facility currently, and at the time of patient #1's discharge from the facility, had no policies pertaining to safe patient discharge during inclement weather and during a State of Emergency. The CNO stated that the facility management and department directors would be meeting again on 04/11/18 to discuss the implementation of new safe discharge policies and protocols. The CNO confirmed that no changes have currently been adopted.

During an interview with the Transport Supervisor (Employee #5) on 04/06/18 at 12:33 p.m. in the Conference Room, Employee #5 stated that the transport department does not document whether a patient has a driver or not. Employee #5 stated that the department does retain a record of how the patient left, i.e., if they left via EMS, private vehicle, taxi, or Uber. Employee #5 stated that he/she remembered Patient #1 because he/she took the patient to his/her car by wheelchair and had to break the ice off the patient's car door to open it. Employee #5 stated that the patient got directly into the driver's seat, and the vehicle started up immediately after the key was engaged. Employee #5 stated that Patient #1 never verbalized any concerns regarding driving home or if the roads were dangerous. Employee #5 added that he/she asked Patient #1 if he/she wanted to have someone come and pick him/her up, and that Patient #1 declined. Employee #5 stated that he/she remember that Patient #1 had a lot of patient's belongings bags, and was wearing a coat. Employee #5 added that the patient never got into the back seat of the vehicle at any time, and the patient did not state that he/she was in pain.

During an interview with the Case Manager (Employee #7) on 04/06/18 at 2:58 p.m. in the Conference Room, Employee #7 stated that he/she completed the initial discharge screening for Patient #1 on 01/17/18. Employee #7 stated that Patient #1 was determined to be independent based on the assessment. The only concern the patient had during the assessment was whether his/her insurance was going to pay as the patient was admitted under an observation status versus a full admission status. Employee #7 stated that the patient never voiced any concerns regarding getting home or having fears or concerns about driving. Employee #7 explained that the patient stated that he/she was going to be discharging to his/her mother's home, so he/she would have assistance after his/her discharge from the facility. Employee #7 added that had the patient indicated that he/she was concerned about being discharged for any reason, the concerns would have been addressed by the facility.

During an interview with the LCSW (Employee #3) on 04/06/18 at 3:11 p.m. in the Conference Room, Employee #3 stated that he/she received a call from nursing on 01/17/18 reporting that Patient #1 was having difficulty with transportation. Employee #3 explained that based on the call, he/she assumed the patient did not have a vehicle. When Employee #3 called and spoke with Patient #1, Patient #1 was offered a ride via Uber or non-emergent EMS. Employee #3 stated that he/she explained to Patient #3 that the facility would pay for the patient's transport. The LCSW stated that the patient did not want anyone driving if the roads were dangerous. The patient requested to not to be discharged from the facility until 2:00 p.m. The LCSW stated that he/she felt the request was reasonable and added that if the patient had expressed a time later than 2:00 p.m., he/she would have honored the request. The LCSW explained that he/she notified the nurse that the patient would not be discharged until 2:00 p.m., and did not hear from the patient again. The LCSW stated that the patient did not verbalize that he/she was unhappy or worried about leaving the facility after a 2:00 p.m. discharge had been arranged. The LCSW stated that if the patient had expressed fear or concern about going home that day, the surgeon and nurse would have been notified to see what other arrangements could be made. The LCSW added that there were other patients discharging the same day, and the patients were discharged throughout the facility on 01/17/18.


A review of the facility's "Inclement Weather Plan," last revised 03/21/2016, revealed that there were no written guidelines or objectives that addressed Patient Discharge during inclement weather. A further review revealed that the plan did not address how to monitor or assess for a safe discharge during a State of Emergency.
A review of the facility's "Emergency Operations Plan," last revised 08/2017, revealed that there were no written guidelines or objectives that addressed Patient Discharge during inclement weather. A further review revealed that the plan did not address how to monitor or assess for a safe patient discharge during a State of Emergency.

A review of the facility Bylaws, Article IV, "Board of Directors," section (1), revealed that the affairs of the facility are governed by the Board.

A review of the facility policy, 4659039, "Right and Responsibilities of Patients Policy," last revised 08/01/2014, revealed that the patient has a right to the provision of care in a safe setting. A further review revealed that the Patient Safety Committee, Environment of Care Committee, Infection Control Committee, the Security Department, and the Risk Management Programs seek to eliminate risks to the patient.
A review of the facility policy, 3630711, "Patient Discharge or Inter-Agency Transfer Policy," last revised 02/01/2016, revealed that the patient discharge should include patient education materials, prescriptions, if any, medication reconciliation record, and discharge instructions. The subject of the patient education materials distributed to the patient and/or family/caregiver should be documented on the discharge instructions. A further review revealed that when the patient leaves the hospital, the nursing staff should complete the discharge function for inpatients in the computer. Further review revealed that all patients should be escorted by a facility hospital staff member to their vehicle via wheelchair or ambulatory if they request.

A review of the facility policy, 2041, "Safe Preparation, Administration, and Documentation of Medications," last revised 05/2017 revealed that patients should receive education on all new medications and should be closely monitored for side effects.
A review of the facility admission log dated 01/16/18 revealed that Patient #1 was admitted to the facility on observation status.
A review of the medical record revealed that Patient #1 signed consent for a CT with contrast on 01/16/18 at 3:02 p.m. A further review revealed the patient signed the surgical consent on 01/16/18 at 4:06 p.m. and the general consent for treatment on 01/16/18 at 11:04 a.m.
A review of the medical record revealed an order for oxycodone (Percocet) 10-325 dated 01/16/18. The administration by mouth and to be administered every four (4) hours as needed for pain.

A review of seven (7) employee files (#1, 2, 3, 4, 5, 7, and 8) revealed that all files contained evidence of current licensure, department orientation, and annual competency testing.
Review of one (1) credential file (#6) revealed the file contained current licensure, DEA certificate, insurance, appointment, privileges, and quality reviews.
Review of nine (9) additional medical records were reviewed (#2, 3, 4, 5, 6, 7, 8, and #9). All nine (9) patients were noted to have an appropriate discharge and consent forms signed. Patients that had been administered narcotics were noted to have a designated driver.