HospitalInspections.org

Based on hospital policy, medical record review, an audio recording, and interview, the hospital failed to develop and implement an effective discharge plan for patients for post discharge care for 1 of 3 (Patient #1) sampled discharged patients reviewed.

Due to the failure of the hospital to ensure all patients were discharged in a manner to ensure personal safety placed all patients relying on transportation company services for discharge in an IMMEDIATE JEOPARDY AND PLACED PATIENTS IN A SERIOUS AND IMMEDIATE THREAT for their safety and well-being.

The findings included:

The hospital failed to develop and implement an effective discharge plan for patients identified with potential risk of adverse health consequences without a discharge plan for 1 of 3 (Patient #1) sampled discharged patients reviewed.
Refer to A-0800

Based on policy review, medical record review, an audio recording, and interview, the hospital failed to develop and implement an individualized and effective discharge plan for all patients identified with potential risks of adverse health consequences without a discharge plan for 1 of 3 (Patient #1) sampled discharged patients reviewed.

Due to the failure of the hospital to ensure all patients were discharged in a manner to ensure personal safety placed all patients relying on transportation company services for discharge in an IMMEDIATE JEOPARDY AND PLACED PATIENTS IN A SERIOUS AND IMMEDIATE THREAT for their safety and well-being.

The findings included:

1. The hospital's "DISCHARGE PLANNING PROCESS" policy dated 3/15/17 revealed, "...The purpose of this policy is to ensure discharge plans are coordinated and individualized...Discharge planning process provides for continuing care as needed with...transportation..."

2. The hospital's "EMERGENCY DEPARTMENT PATIENT DISCHARGE" policy dated 1/20/16 revealed, "...The purpose of this procedure is to establish guidelines for discharge from the Emergency Department...Nursing staff documents from the "Depart" tab the appropriate disposition, mode of discharge, and patient condition..."

3. The Pre-hospital Patient Record dated 12/2/2020 at 8:57 PM revealed Emergency Responders arrived at Patient #1's home after he complained of chest pain. Upon arrival, Patient #1 was "sitting up in wheelchair" and stated he had pain on the left side of his chest that was non-radiating. Patient #1 stated his chest began to hurt earlier in the day during his dialysis treatment. The patient was given an albuterol treatment (used to treat or prevent difficulty breathing, wheezing, and shortness of breath) at dialysis and his chest pain improved. Patient #1 was also given a medication that he stated looked like an aspirin, but the patient was not sure what the medication was.
Patient #1 was "carried and placed onto stretcher". The patient stated he felt short of breath and his chest pain started about 2 hours ago when he was sitting in his wheelchair. Oxygen at 1 Liter per binasal cannula was placed on the patient and the patient stated it helped his shortness of breath. Patient #1 was administered aspirin 324 milligrams and transported to the Emergency Department (ED). Emergency Medical Services (EMS) arrived at the ED on 12/2/2020 at 9:49 PM.

The hospital ED log revealed Patient #1 arrived on 12/2/2020 at 10:03 PM by ambulance with the chief complaint of "Leg pain-swelling, Back pain."

Triage notes dated 12/2/2020 at 10:25 PM revealed the Patient presented to the ED with "lower back and bilateral pain that started today". The ED Triage Assessment Pain Score revealed the patient complained of pain. The Emergency Severity Index (ESI) was 3 which means the patient should be seen within 30 minutes. Active Problems included Hypertension, Kidney Disease, and Transient Ischemic Attack.

Review of the ED Physician note revealed, "...Time seen...12/02/2020...22:10:00 [10:10 PM]...presents with chest pain...onset 14 hours ago...episodic with multiple episodes...Chest pain, diffuse, anterior, mild pain, pressure, sharp...no back pack...initially seen in ambulance bay...Heart Score:3...Low Risk...Justification for Discharge Home...Diagnosis: Anterior Chest Wall Pain...Condition: Stable...Disposition: Discharged: Time 12/02/2020 23:19 [11:19 PM], to home...Follow-up with primary care provider in 3-5 days..."

The ED note dated 12/2/2020 at 11:54 PM by Registered Nurse (RN) #1 revealed, "...ED Disposition: Discharge...Mode of Discharge: Stretcher...ED Discharged: Home...ED Condition: Good, Stable..."

An audio recording dated 12/3/2020 at 12:07 AM revealed ED Staff Member #1 called Patient #1's insurance provider for transportation home from the ED. The transportation provider stated Patient #1 was "listed" as a "stretcher" and asked ED Staff Member #1 if this "was still relevant". ED Staff Member #1 stated, "...I guess...know what...let me see...hold on 1 sec [second]...no...doesn't need a stretcher..." The transportation provider asked ED Staff Member #1 if Patient #1 was ambulatory and ED Staff Member #1 stated, "...yes he is..." There was no documentation what time Patient #1 left the ED with the transportation provider. There was no documentation of the patient's status upon leaving with the transportation provider.

Review of the transportation provider ticket revealed Patient #1 was picked up from the hospital on 12/3/2020 at 3:22 AM. There was no documentation how the patient was placed in the transportation provider's vehicle. The transportation provider ticker documented at 4:03 AM the patient was "dropped" off at their house. There was no documentation how the patient got out of the transportation provider's vehicle.

Review of an EMS record dated 12/3/2020 at 5:39 AM revealed EMS was called to the scene of a "SICK PARTY" and found Patient #1 had been dropped off at the wrong address after being discharged from the hospital. The patient had been outside for approximately 1-2 hours in a cold environment. Patient #1 was shoeless and did not have a coat on. The patient's skin was cold, and the patient was shivering. Patient #1's family arrived to the scene and stated the patient had been dropped off at the wrong house by the transportation provider. EMS recorded the patient's vital signs as a blood pressure of 156/96, heart rate of 111, temperature 97.3, and respiratory rate was 16. The patient refused transport back to the hospital and was escorted home to the correct address by EMS.

During a telephone interview on 12/9/2020 at 11:53 AM, Family Member #1 stated, "...the hospital usually called when they are discharging [Patient #1] but this time they didn't...tried to call the ED but no one answered the phone...When he didn't come home...assumed he had been admitted...Then the police knocked on my door and said the neighbor had found him on her porch. The ambulance came and checked him out, then put him on the stretcher and rolled him to our house, he was only 2 doors down...". When asked if he had any injuries, Family Member #1 stated, "...still sore from falling...scrapped his fingers, knees, elbows and the side of his forehead on the driveway...did not have a coat or shoes on, only socks because he left home on a stretcher in an ambulance...He goes by ambulance on a stretcher 3 days a week to dialysis...".
When asked if Patient #1 walked around the house, Family Member #1 stated, "...[Patient #1] falls easily so he only walks with my assistance or with his cane...has dementia and doesn't walk good that why he uses an ambulance...".
Family Member #1 stated, "...he [Patient #1] told me the hospital took him to the waiting room and a man came in and called his name and said he was his transportation. The man assisted him to the car. When they got to the house, the man got him out of the car and just left."
When asked if she reported this to the hospital, Family Member #1 stated she called the hospital the next morning and talked to a woman who was very rude and only told her "that doesn't sound like something they would do."

During an interview on 12/9/2020 at 1:30 PM, RN #2 stated she spoke with Family Member #1 on the phone about Patient #1. RN #2 stated she pulled up the information while she was on the phone and saw where he was discharged through the insurance transportation company. RN #2 stated she called the insurance transportation company and verified they had the correct address.

During an interview on 12/9/2020 at 1:30 PM RN #1 was asked about Patient #1. RN #1 stated after Patient #1 had been discharged, the patient was sitting in a wheelchair at the nurses' station. RN #1 does not know what time Patient #1 left the ED and does not remember him going to the waiting room. RN #1 stated it can be anywhere from 30 minutes to 4 hours before transportation picks up patients after they are discharged. RN #1 verified they do not sign any type of transfer log or make a note when insurance transportation arrived to pick up the patients.

During a telephone interview on 12/10/2020 at 11:46 AM, the Director of Risk Management was asked how the hospital could provide evidence Patient #1 was discharged per stretcher as documented in the medical record. The Director of Risk Management stated arranging transportation was a "courtesy request."
In a subsequent interview on 12/17/2020 at 8:35 AM, the Director of Risk Management clarified her comment and stated, "As a facility we contact insurance companies for transportation assistance when a patient is unable to secure a safe discharge to their destination. Ambulatory patients are occasionally placed in the lobby awaiting the arrival of their transportation. There may be patients that the facility has contacted a Taxi as a courtesy in the lobby as well."

During a telephone interview on 12/16/2020 at 9:51 AM, Advanced Emergency Medical Technician (AEMT) #1 stated he responded to the call on 12/3/2020 at 5:39 AM for Patient #1. The AEMT stated the Police responded first and then called for an "unknown medical". AEMT #1 stated the Patient's family member came to the scene then they placed the Patient on a stretcher and took him 2 doors down to the correct house. The AEMT stated the Patient had no obvious injuries.
When asked what the weather was at the time, AEMT #1 revealed the temperature was in the 40's and it was damp.
When asked about the Medical Assessment of Abnormal Gait, AEMT #1 revealed the Patient did not have a steady gait; had onset of dementia and might have had a previous CVA.

During a telephone interview on 12/16/2020 at 10:15 AM, Paramedic #1 verified information from AEMT #1. When asked about the abnormal gait, Paramedic #1 revealed he believed the Patient had a previous stroke and was weak on one side.

During a telephone interview on 12/16/2020 at 11:07 AM, ED Staff Member #1 was asked how she would handle a situation where a transportation service had conflicting information from what the ED staff had and ED Staff Member #1 stated she would have a nurse come to the phone and talk with the transportation service.
When asked if she recalled a situation involving a non-ambulatory patient without assistance being left at he wrong house, ED Staff Member #1 stated, "No."
When asked about the incident with Patient #1, ED Staff Member #1 could not recall who she had spoke with about Patient #1's transportation.