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Based on record review and interviews, the hospital failed to ensure the medical record contained a current reconciled medication list for 1 (#1) of 20 (#1-#20) patients reviewed for medications on assessment in the emergency department.
Findings:

Review of the hospital's policy number ED-M2, titled "Medication Reconciliation for Emergency Department Patients" last revised May 2013 with a last review date of May 2024 revealed in part:
"Purpose: To provide a consistent medication reconciliation process for Emergency Department patients in accordance with Joint Commission patient safety goals.
Policy: A list of patient medications will be obtained at the time of entry into the Emergency Department on all patients and will be included as a part of the permanent medical record."

Review of Patient #1's EMS transport report dated 12/02/2024 revealed the following medications listed for Patient #1: Lurasidone, prenatal, Sertraline.

Review of Patient #1's emergency department visit medical record dated 12/02/2024 revealed no home medication reconciliation had been completed upon entry to the emergency department and prior to discharge.

On 01/09/2025 at 9:05 AM, S1DOR verified S4RN was currently on FMLA and was not available for interview. S1DOR verified S4RN was the nurse who admitted the patient in the ER and provided the majority of care for the patient.

On 01/09/2025 at 10:25 AM, an interview was conducted with S2DES. She stated medication reconciliation would not be reviewed between the nurse and the patient during triage. S2DES stated her expectation of her nursing staff is to complete medication reconciliation with the patient once the patient is brought back to the exam room and the full initial assessments are being completed.

On 01/09/2025 at 11:04 AM, an interview was conducted with S5RN who was the nurse who triaged the patient on 12/02/2024 upon her arrival to the emergency department. He confirmed he did not ask her about what medications she was currently prescribed at the time or if she had been compliant with them because medication reconciliation was not a triage task.

On 01/09/2024 at 11:13 AM, a telephone interview was conducted with S6RN. S6RN verified he was the nurse who discharged Patient #1 from the emergency department. He stated all of the discharge paperwork had already been completed by the time her arrived for his shift and was just waiting for social services to set up transportation for Patient #1. He confirmed he did not complete a medication reconciliation for Patient #1.

On 01/09/2024 at 11:39 AM, a telephone interview was conducted with S3MD. She stated her "pattern of practice was to only write about a patients' medications when she was making adjustments to them" so if there was nothing written about the medications, she had not made adjustments to them. She confirmed she did not complete a medication reconciliation for Patient #1's medications.

Based on record review and interviews, the hospital failed to ensure all patient records included complete documentation of outcomes of hospitalization, complete disposition of care, and complete provisions for follow-up care. This deficient practice was evidenced by failure of the hospital to ensure the treating licensed practitioner completed an accurate and complete discharge summary to include follow-up care for 1 (#1) of 20 (#1 - #20) sampled patient records reviewed for discharge summaries.
Findings:

A review of Patient #1's medical record revealed she was brought to the emergency department (ED) by EMS on 12/02/2024 at 2:49 PM after an altercation with her aunt (custodial guardian) for a psychiatric evaluation. Patient #1 was evaluated by S3MD and S9RES at 4:33 PM. Further review revealed social services was the only consult ordered for Patient #1, which was placed by S3MED at 4:33 PM and completed by S7SW at 6:09 PM. A discharge disposition and orders to discharge home were placed by S3MD at 6:38 PM and Patient #1 left the facility at 8:42 PM.

Review of S9RES's "Full ED Note" on 12/02/2024 revealed in part "ED Course Progress Note": 6:37PM- Social work has seen the patient and spoke to both the patient, her mother, and her aunt regarding the altercation occurred earlier today. At this time, there is no need for PEC as the patient is not suicidal, homicidal, and she has not had any hallucinations. Patient is not a danger to herself or others at this time and will be discharged home. Fetal heart tones were 140 bpm prior to discharge. Diagnosis: Altercation and Aggressive behavior. ED Disposition: Home." The record failed to reveal provisions for follow-up care.

Review of S3MD's attestation revealed in part "The patient is a 17-year-old Afro-American female who is pregnant and lives with her aunt and cousin. She had a verbal altercation with her aunt and cousin and reportedly threatened harm to her aunt. The patient denies this statement. The patient is under the custody of the aunt secondary to her legal concerns. Patient presents with aggressive behavior at home. Social work consulted and evaluated patient. No indication for PEC or inpatient care. The ED social worker spoke with the outpatient case manager who is very familiar with the patient. Patient safe for ED discharge. Will go home with aunt."

On 01/09/2024 at 11:39 AM, a telephone interview was conducted with S3MD. She stated instructions were provided for Patient #1 to return to the ED if needed.

Based on record review and interviews, the hospital failed to include a discharge plan evaluation in the patient's medical record for use in establishing an appropriate discharge plan and the results of the evaluation being discussed with the patient. This deficient practice was evidenced by failure to assist/provide 1 (#1) of 20 (#1 - #20) patients with a discharge plan for follow-up care from the ED.
Findings:

Review of the hospital's policy numbered CC-110, titled "Discharge Planning" last revised August 2017 and last reviewed in April 2024 revealed in part:
"Purpose: To identify patients admitted to the hospital that are in need of discharge planning, to provide these identified patients with a discharge plan of care and to communicate appropriately to the patients and to agencies that will be providing follow up care.
Policy: 1. Preparations for discharge are a continuous, interdisciplinary process that begins on admission and is inclusive of all identified needs. 2. The Discharge Plan will be reviewed and updated on an ongoing basis and based on the patient's continuing needs. Reassessment of the discharge plan will be ongoing, and updates will be documented in the patient's medical record."

Review of the hospital's policy numbered ED-D2, titled "Discharge/Transfer" last revised December 2021 and last reviewed in May 2024 revealed in part:
"Purpose: To assist the patient in leaving the Emergency Department and to terminate emergency services/charges to discharged patient.
Policy: Upon discharge each patient will receive detailed discharge instructions for continued care and appropriate referral for continued care."

Review of Patient #1's EMS report revealed in part Patient #1 was found standing outside talking to police following an altercation with her aunt (custodial guardian) where she had become aggressive and threatening her and was non-compliant with her psychiatric medications. Patient #1 was 8-months pregnant. Patient #1 was transported by EMS to hospital for psychiatric evaluation at the request of Patient #1's aunt and DCFS case worker.

Review of Patient #1's medical record revealed in part Patient #1 arrived in the ED via EMS on 12/02/2024 at 2:49 PM and was triaged as a level 2, emergent acuity, at 2:56 PM for a psychiatric evaluation. Patient #1 was seen by S3MD and S9RES at 4:33 PM. S3MD consulted social services on 12/02/2024 at 4:33 PM and the consult was completed by S7SW at 6:09 PM. S3MD and S9RES placed the disposition order to discharge at 6:38 PM and at 8:42 PM on S8SW was able to obtain transportation, Patient #1 was discharged.

Review of Patient #1's discharge instructions documented by S5RN on 12/02/2024 at 6:57 PM revealed the following:
"Final Disposition - Discharged
Discharge To - Home
Discharge Instructions - Given printed discharge instructions; Education given related to Follow-Up after Discharge; Verbalized Understanding of D/C instructions, medications regimen; Verbalizes understanding of signs and symptoms to return to ED
Discharge Instructions Explained To - Patient
Patient Left ED - Ambulatory; Valuables with patient; No acute distress noted upon discharge
Patient Left ED with Who? - Self"

Review of Patient #1's patient education provided at discharge titled "Medical Clearance for Psychiatric Care - General Information, English" revealed the following special instructions for Patient #1:
"You were seen in the emergency department after a verbal altercation. Please return to the emergency department for any new or worsening symptoms, or for any new symptoms you are unable to manage on your own at home." In fine print at the bottom of the page reads "Follow up with your doctor within 3 days, unless otherwise instructed. The Emergency Room is always available for worsening conditions if you cannot contact your doctor. If you need a doctor, call us." No other discharge instructions were included related to follow-up for pregnancy and/or OB provider appointment(s) instructions and no instructions regarding psychiatric/mental health and/or community health resources.

On 01/09/2025 at 9:05 AM, S1DOR verified S4RN was currently on FMLA and was not availlable forinterview. D1DOR verified S4RN was the admitting nurse for Patient #1 in the emergency department and provided the majority of care for the patient. S4RN was also the nurse who documented in Patient #1's medical record the discharge instructions were given to her.

On 01/09/2024 at 11:13 AM, a telephone interview was conducted with S6RN. S6RN stated he was the nurse who discharged Patient #1 from the emergency department. He stated all of the discharge paperwork had already been completed by the time her arrived for his shift and was just waiting for Social Work to set up transportation for Patient #1. He confirmed he did not complete any additional discharge instructions or education for Patient #1 prior to her discharge from the ED.

On 01/09/2024 at 11:39 AM, a telephone interview was conducted with S3MD. She confirmed no discharge education or follow-up instructions were included in Patient #1's discharge orders regarding pregnancy and/or OB provider appointment(s).