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Based on hospital policy, document review, medical record review, observation, and interview, nursing service failed to provide for adequate supervision and evaluation of clinical performances of non-licensed nursing staff who were assigned special duties to ensure patient safety for 1 of 1 (Mental Health Technicians (MHT) #1) technicians observed sleeping while on duty while watching a patient on 1:1 patient safety supervision.

The findings included:

Nursing Services failed to ensure the patient's safety needs were being met while being on 1:1 observation with very minute 15 checks.
Refer to A 0397.

Based on hospital policy, document review, medical record review, observation, and interview, nursing services failed to ensure staff were capable of following assignments and monitored patients at safety risk for 1 of 1 (Mental Health Technicians (MHT) #1) MHTs observed sleeping while on duty while performing 1:1 safety observations of a patient.

The findings included:

1. Review of the hospital's 15 Minute Checks and 1:1 Observation policy revealed, "...PURPOSE: To establish guidelines for the treatment team to accurately and consistently assess the patient and to establish appropriate actions toward preventing the patient from self-harm behaviors...Any patient who verbalizes ideations involving thoughts of self-harm or suicide, thoughts of harming others, or other self-harm behaviors (i.e. [such as], falls) will be placed on either 15 minutes assessment and documentation or 1:1 Observation (staff member constantly with the patient not more than an arm's length away and documents at 15 minute intervals) depending on the intensity of the thoughts and feelings or behaviors...PROCEDURE:...A staff member will be assigned to stay within a reasonable distance to ensure patient safety while on a 1:1 status...the staff member should be able to directly see and hear the patient at all times...The staff member assigned to the 1:1 will document patient checks every 15- minute on the 1:1 Observation Flow Sheet ..."

2. Review of the hospital's "Expectations of Employee Behavior" policy revealed, "...The following actions are examples of behaviors that could result in immediate termination...Sleeping or the appearance thereof while working..."

3. Medical record review for Random Patient (RPt) #5 revealed a date of birth of 10/20/70. RPt #5 was admitted to the hospital on 7/2/19 with diagnoses that included Schizophrenia, Hepatitis C, Dementia, Increase Ammonia Level, Chronic Kidney Disease, Psychosis, Hypertension, GERD, and Idiopathic Neuropathy.

Review of the Nurse Admit Assessment completed 7/2/19 revealed, "...admitted due to decline in mental status. Pt [patient] had been yelling, very forgetful, wandering and constantly trying to leave the NH [nursing home]. Pt is confused and often psychotic...Patient alert and oriented x [times] 2, disoriented, intermittently confused, cooperative, episodes of yelling, irritable, impulsive, anxious, responds to questions. Denies SI [suicidal ideations] and HI [homicidal ideations]..."

Review of the History and Physical performed 7/3/19 revealed, "...female with history of schizophrenia, CVA [cerebrovascular accident], and dementia, who was sent from her nursing home per their report that she had been yelling, wandering, trying to elope, and was confused and psychotic..."

Review of the Physical Therapy Evaluation completed 7/8/19 revealed, "...Patient was referred to physical therpy for evaluation and treatment due to general muscle weakness with poor balance and increased fall risk...Patient should have standby assistance with mobility secondary to patient's poor balance and being a fall risk..."

Review of a Nurse Progress Note dated 7/27/19 revealed, "...[named hospital psychiatrist] brought it to this nurse and charge nurse...attention that patient was walking unsteadily in dayroom unassisted. [named hospital psychiatrist] asked that we see if patient's physician, [named medical doctor], wanted patient to be placed on a 1:1 observation for safety concerns..."

Review of a Nurse Progress Note dated 7/27/19 revealed, "...[named medical doctor] called back and said to place patient on a 1:1 observation and she would be back in tomorrow to see patient and follow up..."

A physician's order dated 7/27/19 revealed, "...Patient behavior requires 1 to 1 Observation..."

A Behavioral Health Daily Progress Note dated 7/27/19 revealed, "...Patient is seen and staff consulted...Depressed mood with anxious affect...irritable mood and easily agitated...Requires frequent redirection. Awaiting placement...Suicidality Denies Homicidality None..."

A physician's Progress note dated 7/28/19 revealed, "...Unsteady gait/fall risk PT following and pt now on 1:1 for safety/fall precautions..."

Review of the Nurse Shift Reassessment dated 7/28/19 revealed, "...Behavior-Flat affect. No aggressive behavior noted...continue 1:1...Suicide Risk Assessment...Ideations Denies..."

A physician's Progress note dated 7/29/19 revealed, "...pt now on 1:1 for safety/fall precautions..."

4. Observations on the Senior Care Unit (SCU) in RPt #5's room on 7/29/19 at 9:41 AM, revealed RPt #5 lying on her bed on her left side with her eyes closed.

Mental Health Tech (MHT) #1 was sitting in a chair at the end of the patient's bed with her left foot propped up on a chair. MHT #1's eyes were closed and she appeared to be asleep. The MHT had the Patient Observations sheet on the chair in front of her with the last noted entry timed at 9:00 AM. There was no documentation of every 15 minute checks from 9:00 AM - 9:41 AM. MHT #1 was approached by the Director of Quality Services, and she opened her eyes appearing startled.

5. In an interview in RPt #5's room on 7/29/19 at 9:42 AM, MHT #1 was asked if she had been asleep. She stated, "I had dozed off."

In an interview in the Dual Diagnosis Unit hallway on 7/29/19 at 9:47 AM, the Director of Quality Services was asked if MHT #1 was asleep. She stated, "Don't ask me that."

In an interview in the conference room on 7/30/19 at 2:32 PM, the Chief Nursing Officer stated, "In that particular incidence [MHT #1 observed with her eyes closed] that will be a learning experience for my supervisors to assign someone that has been asked to stay over to the floor instead of a stationary position. That particular staff member had worked the night before and was asked to stay over..."

6. Review of the working schedule confirmed MHT #1 had reported to work at 7 PM on 7/28/19 was still on duty on 7/29/19 at 9:41 AM when the observation was made.

Based on hospital policy, document review, medical record review, and interview, 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 8 (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 and the hospital's failure to report and investigate an adverse event placed all patients relying on the hospital's transportation services for discharge in an IMMEDIATE JEOPARDY AND PLACED PATIENTS IN A SERIOUS AND IMMEDIATE THREAT for their safety and well-being.

The hospital's failure to ensure all patients had an adequate discharge plan that identified the availability and capability of family and/or friends to provide follow-up care in the home, and the failure to ensure all staff were knowledgeable in the discharge planning process and measures to implement when concerns were identified placed all patients relying on the hospital's transportation services for discharge 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 8 (Patient #1) sampled discharged patients reviewed.
Refer to A-0806

Based on hospital policy, document review, medical record review, and interview, the hospital failed to develop and implement an effective discharge plan for all patients who had been identified as a potential risk for adverse health consequences without a discharge plan, and ensure the discharge plan included appropriate family, conservator and supportive living interactions in order to demonstrate reasonable assurance of continued care; and the hospital failed to ensure the hospital's transportation services adhered to hospital polices and conducted themselves in a manner that emphasized patient safety as a priority for 1 of 8 (Patient #1) sampled discharged patients reviewed.

Due to the failure of the hospital to ensure all patients were discharged in a manner that ensured the patient's safety and the facility's failure to investigate and report an adverse event related to the hospital's transportation service placed all patients relying on the hospital's transportation services for discharge in a IMMEDIATE JEOPARDY AND A SERIOUS AND IMMEDIATE THREAT for their safety and well-being.

The findings included:

1. Review of the hospital's Discharge Planning policy revealed, "...Patients will be assessed for discharge planning needs on admission. They will be reassessed for changes in their post discharge needs periodically during their inpatient stay. Family, friends and other persons involved in the patient's care may be involved in planning as needed. Planning the patient's discharge may involve addressing several issues, including but not limited to:
Intermittent or long-term placement
Return to nursing home/elderly housing community
Return to family with home health services and equipment
Ongoing treatment of multiple co-existing medical/physical problems
Continuing care with community providers/social service agencies
It is the responsibility of the nursing staff, social workers and counselors to ensure that discharge planning and follow through occurs...Patients are initially assessed for possible discharge planning needs at the time of the nursing admission assessment..."

2. Review of the hospital's "Discharge policy revealed, "...To facilitate timely, appropriate, and continuous post-discharge care, discharge planning begins when the patient enters the treatment setting. The patient's physical, psychological, social, spiritual, economic, and legal status will be assessed. Available support people/systems will also be assessed...The following hospital departments and individuals will be notified of each patient's discharge...Referral source (if applicable)...The discharging nurse will discuss with the patient and/or the family, the patient's health status and how his/her condition(s) can affect other aspects of daily living. Before leaving the hospital, the patient, and if appropriate-the family, will receive instructions regarding follow-up care, any restrictions on activity, diet, and discharge medications as indicated by the physician...MENTAL HEALTH UNIT Discharge Criteria...Prior to discharge of the patient, the following assurance will be made by appropriate staff...That the patient has appropriate family or community support...That an aftercare plan has been completed and appropriate referrals made to provide reasonable assurance of continued care..."

3. Review of the hospital's Transportation Policy revealed, "...Employees are expected to follow all operating instructions, safety standards and guidelines set by the companies and/or official regulating agencies...The Goal of the "Transportation Policy" is to protect our patients, employees and the public...Rules for Drivers:...Each van will have a route manifest which will reflect the name, address, and phone number of each patient currently riding in the van. The driver and rider should review the manifest daily and make note of any corrections needed. Ultimately the Transportation Supervisor should be reviewing and updating the manifest to make sure it is always accurate...The Transportation Supervisor will notify the transportation staff in writing each day if there are any temporary or recent changes which are not yet noted on the van's current manifest. The Supervisor should maintain a copy of the notice...The van driver will complete a Pre-Trip Transportation checklist before taking vehicle off of facility premises...G. Patient Transport Considerations...Assessing clinical needs and safety of patient for transport. All patients will be evaluated for appropriateness of transport and safety prior to transport. The specific needs of the patient must be the primary consideration when determining if transportation is required and/or appropriate. These may include, but are not limited to...Psychiatric and Medical Diagnosis need to be considered regarding the effect of transportation on the patient's status or the safety of other passengers...All patients shall be transported in a safe manner...Driver Code of Conduct...Employees involved in patient transport should be able to know how to get to the destination or location and should have in-service education regarding a) vehicle logs..."

4. Review of the hospital's Incident Reporting-Risk Management Program policy revealed, "...It is the policy of (facility name) to utilize the Risk Management Program techniques to promote safety, pro-actively focus on loss prevention, and detect hazardous events and circumstances. It must provide a systematic, multi-disciplinary approach to managing and reporting incidents of injury, damages, and loss...An "incident" is an unanticipated event which was not consistent with the standard of care and/or operation of the facility and may have occurred due to a violation of policy and procedures. It results in, or nearly causes, a negative impact on a patient(s) receiving care at the facility, or visitor(s) at the facility. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury up to death. The Incident Report will help the various facility committees and administration in identifying potential areas of risk ad implementing measures to improve the overall quality of care throughout the facility...Any facility staff member who witnesses, discovers or has direct knowledge of an incident must complete an Incident Report before the end of the shift/work day...If the incident involves a patient, staff must chart relevant information in the patient's medical record. When documenting incidents in the medical records, staff will chart precisely what happened without making reference to an "error" or that an Incident Report was completed..."

5. Medical record review for Patient (Pt) #1 revealed the Pt's date of birth was 2/10/79. The Pt was admitted to the hospital on 7/5/19 with diagnoses that included Bipolar Disorder, Depressed Type, Borderline Personality Disorder, and Intellectual Disability.

Review of the Summary Sheet, the Patient Registration Information sheet, and the Health Passport revealed Pt #1's address and emergency contact information did not match. There was no documentation the hospital staff attempted to verify the patient's actual address.

Review of the Health Passport for Pt #1 provided by the supported living facility dated 4/2/19 revealed, [current address, legal conservator, and phone number]...SPECIAL INSTRUCTIONS [Pt #1] should be within arms reach of you at all times in the community and at home to ensure that [Pt #1] remains safe..."

Review of the Psychiatric Evaluation for Pt #1 performed 7/5/19 revealed "...female with a long history of psychiatric illness, presented from Supported Living Facility with suicidal thoughts. Her care home reports that she has been regressing over the past 2 week. She has been displaying self injurious behaviors such as banging her head...and biting her arm. She reports that she cut her arm with a piece of glass 2 weeks ago because she became angry...Admits to self destructive behavior when angry or grieving over her mother...She reports when she is self-destructive "it does make her feel better." Paranoid. Preoccupied with internal stimuli. Constantly hearing voices of her "stepfather telling her to kill herself." Having recurrent mood swings with self injurious behavior. Depressed mood with flat affect. States she feels hopeless, helpless and worthless at times. She will be admitted for medication stabilization and placed on one-to-one for safety ...Justification for Hospitalization...Failure of treatment at a lower level of care, Hallucinations, delusions, agitation, anxiety, depression resulting in significant loss of functioning, Dangerous to self, others or property with need for controlled environment, Emotional or behavioral conditions and complications requiring 24 hours medical and nursing care, Need for ECT, special drug therapy, or other therapeutic program requiring continuous hospitalization, Failure of social or occupational functioning, Inability to meet basic life and health needs, Environment..."

Review of the Nurse Admit Assessment performed 7/5/19 revealed the Emergency Contact information was not completed.

Review of the Psychosocial Assessment performed 7/6/19 revealed "...Where is patient currently living...24/7 [24 hours a day/7 days a week] SUPERVISED HOUSING...Presenting Problem...experience suicidal thoughts and attempts, self mutilation by hands and head ...Education Special Education...Functioning Level BELOW AVERAGE...Describe the quality and nature of relationships in the patients life...HAS BEEN LIVING AT [named supportive living facility] SUPPORTIVE HOUSING SINCE AGE 23...Deficit-Limitation #1 POOR IMPULSE CONTROL Deficit-Limitation #2 POOR INSIGHT WITH MENTAL ILLNESS Deficit-Limitation #3 POOR SOCIAL SKILLS...Function-Cognitive Functioning Deficit...Where will patient go upon discharge [named supportive living facility] SUPPORTIVE LIVING, 24/7 SUPERVISION How will patient be transported home [named supportive living facility ] SUPPORTIVE LIVING WILL PICK UP PATIENT...High Risk Psychosocial Issues Requiring Treatment Planning and Social Services Interventions MULTIPLE ATTEMPTS OF SUICIDE, SELF-MUTILATION...What are the anticipated social work role(s) in treatment and discharge planning? FACILITATE DAILY EDUCATIONAL GROUPS, STAFF PATIENTS PROGRESS WITH TREATMENT TEAM, SCHEDULE OUTPATIENT MENTAL HEALTH APPOINTMENT, ARRANGE TRANSPORTATION UPON D/C [discharge] , NOTIFY [named supportive living facility] PRIOR TO DISCHARGE..."

Review of a Psychiatrist Progress Note dated 7/6/19 revealed, "...Patient seen and staff consulted. Impulsive. Unpredictable. 1:1 for safety and SIB [self-injurious behavior]. States her heart started beating fast and legs started shaking which made her scratch wound over head..."

Review of a Nurse Progress Note dated 7/6/19 revealed, "...CNA [Certified Nursing Assistant] reported that [Pt #1] jump up from her bed and went to TV [television] and rubbed the laceration on her head against the corner of the TV...redirected...to not harm herself..."

Review of the Discharge Planning note dated 7/6/19 revealed, "...[Patient #1] states she resides at...[address noted on Patient Registration Information sheet and Health Passport, not the one note on the Summary Sheet which was different]...Counselor attempt to call number patient provided as...house manager, but was wrong number...Will try again tomorrow...[named supportive living facility] TRANSPORATION...". There was no documentation the discharge planning counselor attempted to verify the patient's actual address or attempted to verify the telephone number of the patient's support system.

Review of the Discharge Planning note dated 7/7/19 revealed, "...counselor spoke with [named supportive living facility] house supervisor [Supervisor of Resident Support (SRS)]...who confirmed that patient can return home. She [SRS] asked that counselor call [SRS] prior to patient's discharge...[SRS] states patient gets bored and has time to think, pt begins to self mutilate self, swallow bottles tops, straws, etc [etcetera], anything she can...reports pt has her moments when she doesn't want to harm herself, and other times at any given moment she may began to harm herself..."

Review of a Daily Progress Note dated 7/9/19 revealed, "...Patient seen and staff consulted...States she has PICA [medical term for an abnormal craving for and eating of substances not normally eaten of no nutritional value] and swallows screws and batteries...On one-to-one for safety..."

Review of a Patient Anatomical Assessment Report completed 7/11/19 revealed, "...self inflicted are that was resolving prior to admission, pt reports she reinjured herself last pm [evening] using a comb, comb removed from the room..."

Review of a Nurse Progress Note dated 7/11/19 revealed, "...pt has self inflicted laceration to left forearm...small amount of blood noted...an approximately 1 1/2 [symbol for inch] jagged piece of glass was taken from pt. pt states she found the piece of glass "last week" outside in courtyard area..."

Review of the Discharge Planning note dated 7/12/19 revealed, "...[Hospital Counselor #1] made attempts to reach [named supportive living facility SRS]- left vmail [voice mail] for d/c [discharge] on 7/15/19... that patient is scheduled for d/c on 7/14/ or 7/15..."

Review of the Discharge Planning note dated 7/15/19 at 2:54 PM revealed, "...[Hospital Counselor #1] spoke with [Patient #1's Conservator]...to confirm someone will be at the facility [supportive living facility] waiting for patient to be dropped off. [Patient #1's Conservator] reports she gave counselor [the hospital's counselor] direct number to someone at the facility [supportive living facility] to call [hospital] counselor back...[hospital] counselor did not get any calls or have any vmails to confirm...[Pt #1] will be trasnporte [transported] to address of [address noted on Summary Sheet, not the Patient Registration Information sheet and Health Passport which were different]...". There was no documentation the hospital's discharge hospital counselor made additional attempts to contact the SRS or other staff at the supportive living facility prior to the patient's discharge. There was no documentation the hospital discharge counselor verified the patient's actual address prior to discharge.

Review of the Discharge Care Plan completed 7/15/19 revealed, "...Patients Contact Information Address...[address]..." The address listed matched the patient Summary Sheet, but did not match the Patient Registration Information sheet or the Health Passport. Further review of the Discharge Care Plan revealed, "...Patients Discharge Transportation Hospital Transport...Date of Discharge 07/15/2019...". There was no documentation any hospital staff attempted to verify the patient's address.

Review of the hospital's Interdisciplinary Treatment Plan Master Sheet revealed, "...Anticipated Discharge Date 07/20/2019...Patient Liabilities...Limited Support System Resistant to Treatment...Initial Discharge Criteria...Reduction of Life-Threatening or Endangering Symptoms to Within Safe Limits Ability to Meet Basic Life and Health Needs, Adequate Post-Discharge Living Arrangements, Improved Stabilization in Mood, Thinking, and-or-Behavior, Constant or Close Observation No Longer Required Initial Discharge Plan...Return to Previous Living Arrangement Group Home Outpatient Therapy with Psychiatrist or Therapist..."

Review of a physician's order dated 7/15/19 revealed, "...DISCHARGE TO HOME..."

Review of the hospital's nursing Patient Observations forms dated 7/5/19-7/15/19 revealed the last time nursing made observations of Patient #1 was on 7/15/19 at 2:30 PM.

There was no documentation in the nursing notes, Daily Shift Reassessments, or other areas of Patient #1's chart indicating the date, time or discharge status of Patient #1 or if the patient had been discharged from the hospital.

6. In a telephone interview with Pt #1's Conservator on 7/29/19 at 10:58 AM, the Patient's Conservator reported she had received a phone call from Hospital Counselor #1 informing her that Patient #1 was on the hospital transport bus and going to be delivered to her home. The Patient's Conservator stated, "I asked her [the hospital counselor] if she had called [named supportive living facility] because she [Patient #1] lives alone and there was no one in the home to receive her. I told her [the hospital counselor] no one was there, she [the hospital counselor] said never mind that she would take care of it".

The Patient's Conservator stated the Hospital Counselor called her back a second time and said that no one was at the patient's home and the Hospital Counselor wanted her to call the home and tell them to let the patient in. The Patient's Conservator stated she asked the Hospital Counselor where they had taken Patient #1 and the Hospital Counselor told her they dropped Patient #1 off at an address that the patient hasn't lived at in over 3 years.
The Patient's Conservator stated she told the Hospital Counselor that wasn't her home. The Patient's Conservator stated she called the supportive living facility and told them what had happened.

The Patient's Conservator stated that some time later the Hospital Counselor called her back and told her that some strangers had seen Patient #1 on the side of a road, picked her up, gave her candy to eat and then dropped her off on the side of a busy highway. The Hospital Counselor told the Patient's Conservator that Patient #1 had later reported to hospital staff that there were a lot of other people on the hospital transportation bus and they kept yelling at her telling her to get off the bus even though she was at the wrong address. The hospital counselor stated that Patient #1 said she "felt pressured and got off the bus."

7. In an interview in the conference room on 7/30/19 at 10:45 AM, Hospital Counselor #1 and the Social Services Director (SSD) were asked what the process was when they were assigned a new patient.
Hospital Counselor #1 stated, "We get the referral first. It has the patient's name, admit date, insurance info...we have slots we fill in...if it doesn't match, we go to the patient; if not a reliable source, we contact the emergency contact or referral source or the one on the registration form..."
Hospital Counselor #1 was shown the Summary Sheet and the Patient Registration Information sheet for Pt #1 and verified the information did not match. She was then asked where Patient #1 was sent upon discharge and she stated, "I actually sent her to the address that's on the demographics [Summary Sheet]. It was an error on my part...initially I put the address that's on the form on the note. I did make calls to them and left messages, but I never got to talk to [named supportive living facility house manager] at all...I try to go back and make sure I have the correct information myself..."
Hospital Counselor #1 was then was asked if Pt #1 was safe to be left alone and she stated, "She's [Patient #1]capable of being alone but she does need assistance with day to day things, like medication management."
Hospital Counselor #1 was asked if she had seen the Health Passport for Patient #1 and she stated, "No, ma'am." Hospital Counselor #1 was given the opportunity to read Patient #1's Health Passport "Special Instructions" section and was asked if the patient was safe being dropped off at a home she didn't live in and she stated, "Absolutely not." At this point in the interview the SSD interrupted and stated, "She actually caught her mistake. We sent the driver back. He [the driver] went to [named supportive living facility] headquarters where she [Pt #1] was and laid eyes on her to make sure she was ok..."
Hospital Counselor #1 then stated, "When I realized they [the hospital's van transport service] had been given the wrong address, I tried to contact the driver, but he was driving and couldn't answer the phone."
Hospital Counselor #1 was asked if she documented any of the information and she stated, "I don't think I did."
Hospital Counselor #1 and the SSD were both asked what transportation company was used and Hospital Counselor #1 stated, "In house transportation."
The SSD and Hospital Counselor #1 were asked how Patient #1 got to the supportive living facility headquarters and Hospital Counselor #1 stated, "She [Patient #1] used to live at the house he [the hospital van driver/transporter] took her to and we were told the neighbors took her [Patient #1] to [named supportive living facility]. It was definitely an error..." Both Hospital Counselor #1 and the SSD stated the incident had not been investigated or reported as an unusual incident.

8. In an interview in the conference room on 7/30/19 at 11:40 AM, the Manager of Social Services (SS) was asked what she could recall about the transportation incident involving Patient #1 and she stated "[Named the SSD] came to my office to discuss everything that had went on. We got in touch with [named van driver/transporter #1]. I called him and wanted to see what he knew".
The SS manager stated the van driver/transporter had gone back to the address that Patient #1 had been dropped off and he had seen a man and a woman in their yard and asked them if they had seen Patient #1. The van driver/transporter stated the man and woman told him they took Patient #1 to an address Patient #1 had given them. The SS manager stated the van driver/transporter asked the man and woman to show him where they had taken Patient #1. The SS manager stated the van driver/transporter then went to that address and it was the supportive living facility headquarter's office.
The SS manager stated the van driver/transporter spoke to the Director at the supportive living facility's headquarters and was told Patient #1 was there at the headquarters and would be transported to the supportive living facility by the supportive living facility.
The SS manager stated, "...We apologized for the mix up and they said everything was fine and there was nothing else we needed to do...".
The Manager of SS was then asked if she had completed an incident report and investigated the incident and she stated, "No, I didn't."

9. In an interview in the conference room on 7/30/19 at 11:50 AM, van driver/transporter #1 was asked to describe the incident regarding Pt #1 and he stated, "She [Patient #1] got added to the route late. The address given was where I took her to. She [Patient #1] got out and told me it was the wrong address and she was going to make a phone call. That happens a lot. I told her I took her to the address I was given, then she said she was going to use the phone."
Van driver/transporter #1 was asked if he let Pt #1 use his phone and he stated, "No, she didn't ask...less than a minute later I got a call from [named the SS Supervisor of Outpatient Services] my supervisor asking me if I was still there [at the address that Patient #1 was dropped off], I told her yes and she said for me to wait there a minute. She called me back and told me to bring [Pt #1] back to [the hospital]. I was just about to pull out of the driveway but I couldn't because a van had stopped behind me. When I finally got free, I looked farther than I could see or she could have walked and I couldn't find her. I left and dropped another patient off and I got another phone call from my supervisor telling me to go back and try to find her. I found a guy that told me he took her to a doctor's office. I had to bribe him $20.00 in gas money to show me where she was. He told me he took her to a doctor's office on [named busy highway]. She was across the street from [named a local private school] in a doctor's office..."
Van driver/transporter #1 was asked at what time he lost sight of Pt #1 and he stated, "She [Patient #1] got out of the van and said she was using the phone. I didn't know she was walking anywhere, you couldn't see her out of the van...she had actually gone across the street and gotten into a car with the people about 6 or 7 houses down from the house [the patient was dropped off at]. When I found her, I called [named the Manager of SS] immediately and let her speak to them. They said she had been discharged and it was ok for me to leave."

There was no documentaion the Transporter Supervisor had reviewed the transport manifest log to ensure the transport information was accurate and there was no documentation the van driver/transporter completed the the pre-trip transportation checklist before taking the vehicle off the premises. There was no documentation patient transport considerations were assessed such as patient safety or specific patient needs evaluated prior to transporting patients.

10. In a telephone interview on 7/30/19 at 2:59 PM, the supportive living facility's Healthcare Coordinator was asked what she could recall regarding the incident with Pt #1 and she stated, "[Patient #1's Conservator] called me and told me they [the hospital] were going to discharge her [Patient #1] and put her on a bus. I got a hold of [Hospital Counselor #1] and she told me she [Patient #1] was already on the bus. I told her we would pick her up tomorrow due to no staffing. She [Hospital Counselor #1] said ok and she would call the van driver and have her brought back to [the hospital]". The Healthcare Coordinator continued and stated, "After that, around 4:00 [PM], I was in my office in the back [supportive living headquarters] and heard [Pt #1] talking. She [Patient #1] was out of breath. I asked her what she was doing there. She [Patient #1] told me they [hospital van driver/transporter] took her to the wrong house. About an hour later the bus [van/transporter] driver came to the office [supportive living headquarters] and said he was there to bring her [Patient #1] back to [the hospital]. I told him we were going to keep her..."
The Healthcare Coordinator was asked how Pt #1 arrived at the supportive living headquarters and she stated, "[Pt #1] told us once she was dropped off [by the hospital van driver/transporter], she went to another client's home, but they weren't home, so she went to another door and knocked and a woman let her in and gave her some tea and some candy". The Healthcare Coordinator stated Patient #1 stated, "when the woman's boyfriend got home later, they took her somewhere on [named a busy highway] and dropped her off".
The Healthcare Coordinator stated that Patient #1 was very tired and out of breath when she got to the supportive living facility headquarters.
The Healthcare Coordinator was asked if Pt #1 was seen by a physician and she stated, "We took her to a minor medical clinic because she said her arm hurt. Everything was fine..."

11. In an interview in the conference room on 7/31/19 at 9:45 AM, Hospital Counselor #1 was asked who she had contacted at the supportive living facility about Pt #1's pending discharge and she stated, "I did initial contact trying to reach [Patient #1's Conservator]. Someone here actually made contact with her on Saturday and let her know she [Patient #1] was going to be discharged on Monday. I left several messages; they never called me back. On that Monday [7/15/19] I had a voice mail from [Patient #1's Conservator] asking me to call her because she had not been notified about the discharge. I talked to [Patient #1's Conservator] and she basically was asking why she hadn't been called. I told her I had left several messages for her and no one had called me back. She told me she would check to make sure somebody would be there and then she told me to go ahead and send her."

12. In an interview in the conference room on 7/31/19 at 9:55 AM, the Manager of SS was asked if law enforcement had been notified when they had discovered Pt #1 was dropped off at the wrong address and was missing and she stated, "No, I spoke with [Director of the supportive living facilty] around 4:00 PM when our driver was there and [Pt #1] was safe..."

13. In a telephone interview on 7/31/19 at 10:51 AM, the Director of the supportive living facility was asked what she could recall regarding Pt #1 and she stated, "[Patient #1] arrived on Monday around 4:00 PM. She was very scared, anxious, agitated, tearful, and very thirsty. She [Pt #1] said the van from [the hospital] 'dropped me at my old house and I told him I don't live there anymore but he left me anyway.' About 30 minutes later, the van driver and a man arrived at our office. He put me in touch with his office [the Manager of SS]. She was left there. There was no one home in that house. She had no phone and no means to contact anyone. She said a neighbor saw her walking on the street and gave her a ride to somewhere on [named busy highway] a couple of blocks from our office...when she [Pt #1] saw the driver and the man, she was terrified. We didn't put her back on the bus. She was really sweaty when she got here...Somebody [hospital staff] talked to our Medical Coordinator. She was told she [Pt #1] was going to be discharged Tuesday [7/16/19]. We were supposed to pick her up at the hospital..."

14. In an interview in the conference room on 7/31/19 at 10:57 AM, the Social Services Supervisor (SSS) of Outpatient Services was asked what her role was regarding transportation services and she stated, "The counselors send me the people who are being discharged on a daily basis and I give them to the driver/transporters. Sometimes if we know the day before we go ahead and give it to them."
The SSS was asked how many transporters were employed by the hospital and she stated "2"
The SSS was asked what type of training the driver/transporters received regarding patient safety and transportation and she stated, "I don't know. They do know to look at the discharge form for the correct address."
The SSS was asked if there was any paper work, or log documenting the routes, addresses, and names of the patients and she stated, "the counselors send the email; I print it out and put it on the counter and go over where the patient is going. If they don't email it; sometimes they type it and bring it to me."
The SSS was asked if she saved any of those requests; particularly the request for Pt #1 and she stated, "If it's in my email I do." The SSS then verified she did not have the request for Pt #1 to be transported because it was not sent by email.
The SSS was asked if the hospital kept a log of the times the driver/transporters left the hospital and the times the returned and she stated, "No ma'am."
The SSS was asked what she could recall about Pt #1 and she stated, "I was called by the counselor who stated she believed the address was wrong. I asked [Driver/Transporter #1] to make sure the address was correct. He had already left with her. When I asked him to bring her back to the building he stated she had already gotten off the van. I asked him to look for her and bring her back. That's it..."

15. In a telephone interview on 8/1/19 at 9:10 AM, the Supervisor of Resident Support (SRS) at the supportive living facility confirmed Pt #1 lived in a home that she supervised. The SRS was asked if she was ever contacted by the hospital regarding Pt #1's status and discharge plans and she stated, "Yes ma'am, right after she got there someone called me to make sure she could come back home...I told them we needed at least 24 hours notice to get her staff back in her home."
The SRS was asked what type of safety concerns did Pt #1 have and she stated, "She [Patient #1] is physically and verbally aggressive, has self-harming behaviors."
The SRS was asked if Pt #1 should have been left alone and she stated, "No ma'am. She [Patient #1] does things to try to harm herself...has to be reminded to watch for cars before crossing the street...she could have harmed herself. She's never left alone because of the behaviors she presents."
The SRS was asked if she was contacted prior to the Patient #1's discharge and she stated, "No, because I was on leave. I actually went up there [to the hospital] and gave them [named the supportive living facility's Healthcare Coordinator's] name and phone number as the point of contact for [Patient #1's] discharge because I knew I was going on leave. It was on a sticky note and I gave it to the person at the reception area when I dropped off clothes for [Pt #1]..."

16. On 8/1/19 at 9:16 AM, the Chief Clinical Sustainment Officer entered the conference room and verified the hospital had no transportation logs for the month