HospitalInspections.org

Based on medical record review, document review, and interview, in one (1) of seven (7) medical records, the facility failed to identify and analyze an opportunity for improvement.

Findings:

The facility's policy and procedure titled, "Discharge from the Emergency Department," last revised 2/2/2023, stated, " ...Any patient who resides in supportive housing with coordination of care (i.e. medical/psychiatric services) will be dispositioned as a discharge, but transportation from the Emergency Department will be provided back to their residence. The Emergency Department staff will discuss disposition and appropriate mode of transportation with the residence staff before transportation requests are made..."

Review of Patient #1's medical record identified this patient was brought to the emergency department via ambulance from a skilled nursing facility on 07/13/2024 at 9:24 PM. On 07/14/2024 at 12:19 AM, Patient #1 was discharged. There was no documented evidence that discharge disposition and mode of transportation were discussed with the skilled nursing facility staff, nor that return transportation from the emergency department to the skilled nursing facility was provided, as per facility policy.

On 07/15/2024 at 2:53 PM, Patient #1 returned to the emergency department via ambulance from a skilled nursing facility. At 3:11 PM, Patient #1 completed triage and was moved to the EZ-Care Area. There was no documented evidence that Patient #1 was identified to have arrived from a skilled nursing facility and would require return-transportation.

Video surveillance footage, dated 07/15/2024 from 3:07 PM, identified that Patient #1 left the EZ-Care Waiting Area without being seen on 07/15/2024 at 4:02 PM.

On 07/16/2024 at 4:24 PM, Patient #1 returned to the emergency department, accompanied by their daughter, who requested a psychiatric evaluation for Patient #1. A Physician Progress Note written by Staff K (Chief of Emergency Services) on 07/16/2024 at 6:10 PM, stated "FYI [for your information] this patient resides at the [skilled nursing facility] and should not be discharged on his own, as he has tendency to wander and get lost. Please call [administrator at skilled nursing facility] if patient being discharged."

During interview of Staff L (Associate Executive Director, Emergency Services) on 07/29/2024 at 12:55 PM, Staff L stated that they became aware of an incident regarding Patient #1 when they met the administrator of Patient #1's skilled nursing facility during the patient's visit on 7/16/2024. Staff L stated that the administrator informed them Patient #1 had recent visits to the emergency department, that they wander around the skilled nursing facility, and that they wanted to have the patient evaluated for decisional capacity. Staff L stated they spoke with [Staff K] to relay the information they had received.

During interview of Staff K (Chief of Emergency Services) on 07/30/2024 at 11:50 AM, Staff K stated they spoke with the administrator of the skilled nursing facility and were informed that "the patient never made it back" to the skilled nursing facility after their 07/15/2024 emergency department visit, and that the patient had a tendency to wander. Staff K stated they reviewed this medical record to determine if the medical standard of care had been met. Staff K confirmed that no concerns were identified nor was the incident escalated for further investigation.

During interview of Staff J (Director of Regulatory Department) on 7/26/24 at 2:14 PM, when asked whether the facility had any reports regarding Patient #1, Staff J confirmed no VOICE reports [incidents/occurrences] were filed for this patient.

The facility's policy and procedure titled, "Notification and Investigation of Adverse Events," revised date 03/05/2024, stated, " ...[Purpose] Early identification and reporting of events to Risk Management ...to reduce the probability of such an event occurring in the future...[Objectives of the Event Investigation] Assisting in the prevention of similar incidents in the future through thorough analysis of data and the human and systemic factors that contributed to the incident ...[How and When to Report] Immediately by telephone, or within 24 hours, but as soon as practical, the staff member should enter the report electronically in VOICE ...All incidents and occurrences are to be entered in the Voicing Our Incidents, Concerns, and Encounter (Voice Report) within 24 hours ..."

During interview of Staff M (Director of Risk Management/Clinical Services) on 07/29/2024 at 12:20 PM, Staff M stated that the facility has an internal incident reporting system called "Voice." Staff M confirmed no "Voices" were received by the Emergency Department for this incident, and that this was the first they had been informed of this event.

Based on medical record review, document review, video surveillance review, and interview, the facility failed to meet the needs of patients in accordance with acceptable standards of practice.

Findings:

The facility failed to: (A) Identify a patient residing in a skilled nursing facility; (B) Provide return transportation for a patient residing in a skilled nursing facility; (C) Ensure consistent practice in reviewing the Ambulance Call Reports (ACR).
(See Tag A-1104)

Based on medical record review, document review, video surveillance review, and interview, in one (1) of four (4) medical records, the facility failed to: (A) Identify a patient residing in a skilled nursing facility; (B) Provide return transportation for a patient residing in a skilled nursing facility; (C) Ensure consistent practice in reviewing the Ambulance Call Reports (ACR).

The failure to identify patients residing in skilled nursing facilities potentially placed patients at risk for inappropriate provision and coordination of care.

Findings:

Review of Patient #1's medical record identified this patient presented to the emergency department on three separate occasions:

On 07/13/2024 at 9:24 PM, Patient #1 was brought in by ambulance from a skilled nursing facility with a chief complaint of dental pain. The Ambulance Call Report (ACR - a pre-hospital care report completed by ambulance staff that details a patient's care/treatment during emergency transportation), dated 07/13/2024 at 9:20 PM, indicated that Patient #1 was brought into the hospital from a "nursing home." At 9:28 PM, Patient #1 completed triage and was moved to the EZ-Care Area (Fast-track: area in the emergency department designated to provide care to patients presenting with non-urgent complaints). Patient #1 was evaluated and was discharged on 07/14/2024 at 12:19AM.

On 07/15/2024 at 2:53 PM, Patient #1 returned to the emergency department via ambulance from a skilled nursing facility with a chief complaint of dental pain. The Ambulance Call Report, dated 07/15/2024 at 3:31 PM, indicated that Patient #1 was brought into the hospital from a "nursing home." At 3:11 PM, Patient #1 had completed triage and was moved to the EZ-Care Area. Patient #1's name was called to be seen and evaluated, once at 5:40 PM and twice at 6:01 PM, without response. Patient #1 was documented as left without being seen (LWBS) and was "discharged" from the electronic medical record (EMR) system.

On 07/16/2024 at 4:24 PM, Patient #1 walked into the emergency department accompanied by their daughter, who requested a psychiatric evaluation for Patient #1. Patient #1 remained admitted in the inpatient unit at the time of this survey.

Findings for (A):

The facility's policy and procedure titled, "Discharge from the Emergency Department," last revised 2/2/2023, stated, " ...Any patient who resides in supportive housing with coordination of care (i.e. medical/psychiatric services) will be dispositioned as a discharge, but transportation from the Emergency Department will be provided back to their residence ..."

Review of Patient #1's medical record identified there was no documented evidence on 07/13/2024 nor 07/15/2024, that Patient #1 was identified to have arrived from a skilled nursing facility and would require return-transportation.

During interview of Staff E (Emergency Department Registered Nurse) on 07/26/2024 at 10:51 AM, Staff E confirmed they triaged Patient #1 on 7/15/2024, but could not specifically recall this encounter. Staff E stated that information about the patient arriving from a skilled nursing facility would typically be given in the verbal report from the ambulance staff, and that ambulance staff would hand the triage nurse any paperwork from the skilled nursing facility. Staff E stated that the triage nurse would "type a note in the Chief Complaint section of the Triage Note" to indicate that the patient is from a skilled nursing facility.

During interview of Staff F (Emergency Department Staff Registered Nurse) on 07/26/2024 at 11:32 AM, Staff F confirmed they triaged Patient #1 on 07/13/2024, but could not specifically recall this encounter. When asked to describe the process of receiving a patient from a skilled nursing facility from ambulance staff, Staff F stated that they would write a note in the Chief Complaint section indicating the patient was from a skilled nursing facility. Staff F added that ambulance staff does not always verbalize that patients are from a skilled nursing facility, but that "it is very rare that a patient will come to the facility without paperwork from the nursing home."

During interview of Staff K (Chief of Emergency Services) on 07/29/2024 at 11:57 AM, Staff K stated that they reviewed Patient #1's medical record when they were made aware of the incident involving Patient #1. Staff K stated that based on their review, it appeared that the triage nurse was not aware that Patient #1 had arrived from a skilled nursing facility, and that it is "common practice to ask where the patient came from."

During interview of Staff N (Director of Nursing, Emergency Services) on 07/30/2024 at 11:08 AM, Staff N stated that it is the expectation that the triage nurse would ask ambulance staff where the patient was from and would communicate this information to the care team. When asked how this information would be communicated, Staff N stated that the facility has a process for triage nurses to document in the electronic medical record from where the patient arrived. Staff N stated that staff would select a location from a preselected list of choices within the Triage Note. When asked to provide a policy which delineated these expectations, Staff N stated they were unable to provide a policy.

There was no documented evidence that the emergency department staff identified that Patient #1 arrived from a skilled nursing facility, although the ambulance care reports indicated Patient #1 was picked up from a "nursing home." There were discrepancies between staff's practice and administration's expectations for how to verify and where to document that patients arrived from skilled nursing facilities. The facility policy and procedure lacked guidance directing emergency department staff to verify from where patients arrived with ambulance personnel, and where to document this information for return transportation to be arranged.


Findings for (B):

The facility's policy and procedure titled, "Discharge from the Emergency Department," last revised 2/2/2023, stated that it was the responsibility of the medical and nursing staff to: "Collaborate with social work to address any social needs the patient has prior to discharge ...Any patient who resides in supportive housing with coordination of care (i.e. medical/psychiatric services) will be dispositioned as a discharge, but transportation from the Emergency Department will be provided back to their residence. The Emergency Department staff will discuss disposition and appropriate mode of transportation with the residence staff before transportation requests are made..."

Review of Patient #1's medical record identified that on 7/13/2024, there was no documented evidence of the location to which Patient #1 was discharged, nor of Patient #1's mode of transportation upon discharge. On 7/15/2024, video surveillance footage (dated 07/15/2024 from 3:07 PM) identified that Patient #1 left the EZ-Care Waiting Area without being seen on 07/15/2024 at 4:02 PM.

In addition, there was no documented evidence of collaboration with social work services, the arrangement or provision of return-transportation to Patient #1's skilled nursing facility, nor that Patient #1's disposition and appropriate mode of transportation was discussed with skilled nursing facility staff, as per facility policy. The facility's policy also lacked guidance directing staff of the details to be documented during patients' emergency department discharge.

During interview of Staff K (Chief of Emergency Services) on 07/26/2024 at 2:49 PM, Staff K confirmed that social work services was not contacted to arrange and coordinate return-transportation to the skilled nursing facility for Patient #1's discharge on 07/14/2024 at 12:19 AM.

During interview of Staff P (Emergency Department Physician Assistant) on 07/29/2024 at 11:33 AM, Staff P stated that when patients from a skilled nursing facility are being discharged to return to the skilled nursing facility, the provider contacts the social worker to arrange for transportation and to coordinate the discharge with the skilled nursing facility.

During interview of Staff N (Director of Nursing, Emergency Services) on 07/30/2024 at 11:08 AM, when asked about the expectations for discharge documentation, Staff N stated that documentation at the time of discharge typically includes if the patient is being picked up by ambulance, what the condition of the patient is at the time the patient leaves, and vital signs, depending on the acuity of the patient. Staff N explained that the registered nurse is not always the last staff member to interact with the patient, so they do not always document the patient's final discharge, condition, or mode of departure.

During interview of Staff K (Chief of Emergency Services) on 07/30/2024 at 11:50 AM, Staff K stated they spoke with the administrator of the skilled nursing facility and were informed that "the patient never made it back" to the skilled nursing facility after their 07/15/2024 emergency department visit, and that Patient #1 had a tendency to wander. Staff K stated that they reviewed this medical record to determine if the medical standard of care had been met. Staff K confirmed that no concerns were identified nor was the incident escalated for further investigation.


Findings for (C):

The facility's policy and procedure titled, "Triage Policy," last reviewed 01/24/2024, stated, "All EMS call reports [Ambulance Care Reports] will be reviewed by the triage provider and signed/timed once the ACR is completed."

Review of Patient #1's medical record identified that the Ambulance Call Reports dated 07/13/2024 and 07/15/2024 noted Patient #1 to have arrived from a "nursing home," but this information was not documented by the emergency department staff.

During interview of Staff E (Emergency Department Registered Nurse) on 07/26/2024 at 10:51 AM, when asked to describe the process of receiving a patient from ambulance staff, Staff E stated that the triage nurse takes a verbal report from the ambulance staff and signs the tablet (the electronic device containing the Ambulance Care Report) after the verbal report is received.

During interview of Staff H (Clerical Associate) on 07/26/2024 at 12:20 PM, Staff H stated that the Ambulance Call Report is sometimes faxed to an area separate from the triage areas that is not monitored for incoming faxes but is checked periodically for faxes that have been received. Staff H stated that clerical associates will write patients' medical record numbers on the Ambulance Call Reports and place them in a location to be scanned into the medical records.

During interview of Staff K (Chief of Emergency Services) on 07/29/2024 at 11:57 AM, Staff K stated that any provider can access the Ambulance Call Report online and do not rely on the faxed copies. Staff K explained that providers can only see what has been entered and uploaded by ambulance personnel at the time. Staff K stated that the reports are not routinely reviewed and are typically only looked at when questions arise. Staff K explained that the reports are not always completed at the time the verbal report between ambulance personnel and emergency department staff is given, and that reports are typically made available between 30 minutes to one (1) hour after the patient has been received. Staff K confirmed that patients may have completed and exited the triage area by that time.

During interview of Staff N (Director of Nursing, Emergency Services) on 07/30/2024 at 11:08 AM, when asked about the expectations of the ambulance triage nurse with the Ambulance Care Report, Staff N stated that the triage nurse receives a verbal report from ambulance staff, reviews the ambulance staffs' tablet for the digital Ambulance Call Report, and signs the tablet to confirm the transfer of care has occurred. The "Triage Policy," which speaks to the signed/timed review of the completed Ambulance Call Report by the triage provider was shared and discussed with Staff N. Staff N acknowledged the Ambulance Call Report is not always completed when verbal report is given, the tablet is signed, and transfer of care occurs.