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Based on record review and interview, facility staff failed to report an adverse safety event for 1 of 1 patient (Patient #1), in a total universe of 10 medical records reviewed.

Findings include:

A review of the facility policy #7528826, titled "Event Reporting, AW (Ascension Wisconsin)", last revised 1/18/2020, revealed: "Purpose/Rationale: Appropriate actions will be taken following all patient or visitor events, whether they are near misses or have resulted in harm. Definitions: Events: any happening or occurrence, with or without injury, that is inconsistent with routine operations or that is an adverse event. Event Report: a confidential on line report describing the facts surrounding the event. This report enable the involved departments to take corrective action and improve the quality of health care provided through review of the circumstances. Procedure-Response to Events: Patient Events: Any associate who witnesses, discovers, or is involved in a patient event should first ensure that medical treatment is provided and appropriate steps are taken to minimize the immediate potential for a future event. Entry into the ERS (Event Reporting System) should occur as timely as possible and before the end of an individual's shift."

A review of Patient #1's medical record revealed Patient #1 who has a history of cognitive impairment was admitted to the facility on 7/29/2022 for a neck infection and discharged home on 8/5/2022 via a Lyft ride arranged by Care Management. Patient #1 received intravenous (IV) antibiotics from 7/29/2022 to 8/1/2022 when antibiotics were changed to oral medication.

Review of the facility complaint, received 8/10/2022, revealed: Patient #1 was discharged on 8/5/2022 with a Lyft (transportation service) driver. An incomplete address was supplied to the driver resulting in Patient #1 being brought to the wrong city and subsequently being returned to the hospital. Upon re-arrival to the hospital, it was noted Patient #1's IV access was not removed on discharge. Timely follow up with the Care Management team regarding the importance of providing a complete address when arranging a Lyft ride and with nursing services to confirm IV access is removed before discharge.

During an interview on 8/29/2022 at 4:15 PM, Nurse Manager H stated, "When Patient #1 returned to the hospital on 8/5/2022, I saw that s/he still had an IV (intravenous catheter) in his/her hand. I removed it before the second Lyft ride arrived. I discussed the importance of checking for IV's prior to discharge during staff huddles."

During an interview on 8/30/2022 at 10:00 AM, Quality Coordinator F stated, There is not a Event Report for Patient #1. The follow up from our patient complaint/grievance reporting system did result in correction of the safety event through communication with the team at our team huddle. When asked if a Event Report should of been completed for this event, Coordinator F stated, "Yes."