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Based on a review of medical records, EMS report, interviews with staff, and submitted photographs, it was determined that the facility ' s governing body failed to provide proper oversite of the facility ' s discharge process when one patient out of 10 sampled (Patient #1) was removed from the hospital and placed on the sidewalk outside the facility by staff. Patient #1 (P#1) was readmitted to the facility with a diagnosis of dehydration and possible sepsis.

Findings:
Cross- reference A-0802 as it relates to the facility ' s governing body being knowledgeable of P#1 needs upon discharge. The facility ' s governing body did not provide appropriate oversite to transition P#1 from an acute inpatient setting to post hospital discharge care.

Based on a review of medical records, interviews with staff, and submitted photographs, it was determined that the facility ' s governing body failed to provide proper oversite of the facility ' s discharge process when one patient out of 10 sampled (Patient #1) was removed from the hospital and placed on the sidewalk outside the facility by staff. Patient #1 (P#1) was readmitted to the facility with a diagnosis of dehydration and possible sepsis. Additionally, upon re-admission on 10/15/21 P#1 medical record revealed ant bites on his body from the period he was placed outside by hospital staff.

Findings:

Cross- reference A-0063 as it relates to the facility ' s governing body being knowledgeable of P#1 needs upon discharge. The facility ' s governing body failed to provide proper oversite of the facility ' s discharge process when one patient out of 10 sampled (Patient #1) was removed from the hospital and placed on the sidewalk outside the facility by staff. Patient #1 (P#1) was readmitted to the facility with a diagnosis of dehydration and possible sepsis. Additionally, upon re-admission on 10/15/21 P#1 medical recorded documented ant bites on his body from the period, he was placed outside by hospital staff.

Cross- reference A-0802 as it relates to the facility ' s governing body being knowledgeable of P#1 needs upon discharge. The facility's governing body did not provide appropriate oversite when P#1 was removed from the hospital and placed on the sidewalk outside by staff. P#1 was discovered by a local citizen on the sidewalk unresponsive confirmed by audio call to 911.

Based on a review of medical records, submitted photographs, video footage from law enforcement dash camera, staff and local official's interviews, a review of surveillance video and policy and procedures, it was determined the facility failed to protect a patient's right to privacy and care in a safe environment when one patient out of 10 sampled (Patient #1) was placed outside of the facility on the sidewalk by facility staff. P#1 was readmitted to the facility with a diagnosis of dehydration and possible sepsis.

Cross Reference A-0802 as it relates to the facility to failure to protect P#1 right to care in a safe setting as P#1 required a double-arm (two assisted personnel on both of the patient supporting the arms) assist to be removed from a wheelchair and placed on the sidewalk outside the facility by staff,despite P#1's inability to walk on his own, suprabuic catheter attached to urinary drainage bag, and psychatric condition . P#1 was readmitted to the facility with a diagnosis of dehydration and possible sepsis.

Based on a review of medical records, submitted photographs, video footage from law enforcement dash camera, staff and local official ' s interviews, a review of surveillance video and policy and procedures, it was determined the facility failed to protect a patient ' s right to privacy and care in a safe environment when one patient out of 10 sampled (Patient #1) was placed outside of the facility on the sidewalk by facility staff. P#1 was readmitted to the facility with a diagnosis of dehydration and possible sepsis.

Cross Reference A-0802 as it relates to the facility's failure to protect P#1 right to privacy in a care setting as P#1 required a double-arm (two assisted personnel on both of the patient supporting the arms) assist to be removed from a wheelchair and placed on the sidewalk outside the facility by staff. P#1 was exposed and vulnerable on the sidewalk to ants and pedestrian traffic. P#1 was readmitted to the facility with a diagnosis of dehydration and possible sepsis.

Based on a review of medical records, submitted photographs, video footage, staff and local official ' s interviews, a review of surveillance video and policy and procedures, it was determined the facility failed to ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to preventable hospital readmissions for one patient of 10 sampled (Patient #1). The facility removed Patient (P)#1 with security escort from the facility and placed him on the sidewalk outside the facility. P#1 was later discovered by local law enforcement outside the facility on the sidewalk and readmitted to the facility.

Cross Reference A-0802 as it relates to the facility's failure to properly transition P#1 from an acute inpatient care setting to post discharge care and reduce factors leading to a preventable readmission. P#1 required a double arm (two assisted personnel on both of the patient supporting the arms) assist to be removed from a wheelchair and placed on the sidewalk outside the facility by staff. P#1 was readmitted to the hospital with a diagnosis of dehydration and possible sepsis.

Based on a review of medical records, submitted photographs, video footage, staff and local official ' s interviews, a review of surveillance video and policy and procedures, it was determined the facility failed to ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to preventable hospital readmissions for one patient of 10 sampled (Patient #1). The facility removed Patient (P)#1 with security escort from the facility and placed him on the sidewalk outside the facility. P#1 was later discovered by local law enforcement and readmitted to the facility.

Findings included:
A review of P #1 ' s medical record revealed that P#1 was brought to the facility ' s ED and admitted to the hospital on 9/6/21 at 7:00 p.m. with a diagnosis of urinary tract infection (UTI) and sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body ' s response to their presence). P#1 was found dancing in the street and when Emergency Medical Services (EMS) was called, P#1 advised EMS that his family was trying to kill him because he had an affair with his dad. P#1 stated he does not feel safe at home. P#1 had a past medical history of schizophrenia (a serious mental disorder in which people interpret reality abnormally), HIV (a virus that attacks the body's immune system) infection, and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Further review of P#1 medical record revealed that P#1 had a history of prostate (a small walnut-shaped gland in males that produces fluid that nourishes and transports sperm) cancer treatment with radiation, the radiation altered his digestive and urinary system. P#1 required the use of a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder).

9/7/21, 11:07 a.m. - P#1's activities of daily living were documented in nursing notes as independent. Nutrition was adequate, mental status was oriented (the ability to recognize self, time, and situation). P#1 needed physical therapy, occupational therapy, and speech evaluations.

On 9/8/21 at 10:52 a.m. Case Manager (CM) CM FF completed Pt#1 discharge planning evaluation. CM FF documented P#1 lives with his girlfriend and her son. CM FF noted that P#1 is a psychiatric patient, will be evaluated and discharged to a psychiatric hospital. Further review of P#1 ' s medical record documented that CM FF was not able to see P#1 as he was being abusive. CM noted she would follow and assist P#1 as needed.

On 9/9/21 at 10:33 a.m. a progress note documented P#1 was placed on a 1013 ( a legal psychiatric hold deeming a patient a danger to themselves or other an requiring transfer to a emergency receiving facility)because he threatened to harm a nurse.

On 9/10/21 at 8:20 a.m. Medical Doctor (MD) ZZ documented that P#1 was medically cleared for discharge to an inpatient psychiatric facility. Further review of the record revealed that P#1's sepsis had resolved. P#1 completed a course of antibiotics, and his white blood count was normal. MD ZZ noted P#1's discharged condition was good and he is medically cleared for discharge to an inpatient psychiatric facility.

On 9/10/20 at 2:00 p.m. Case Manager (CM) AAA documented that P#1 had been denied by psychiatric facility (PF) PF #1 and PF #2 due to medical acuity. CM AAA further noted that P#1 ' s chart had also been faxed to PF (#3, #4, #5, #6, #7, #8,#9,#10,#11,#12,#17).

On 9/13/21 at 11:36 a.m. CM NN noted that P#1 ' s referral had been declined at PF (#1, #2, #4, #5,#6,#8,#9,#11,#12,#17) due to medical acuity as related to the use of a suprapubic catheter. Further review revealed that CM NN also faxed P#1 ' s referral to PF (#13, #14, #15, #16,#18). At 5:00 p.m. CM NN documented that P#1 was declined at PF #14.

On 9/15/21 at 1:54 p.m. CM NN documented that P#1 had been declined at PF #3 and all psychiatric facilities had been exhausted. P#1 ' s referral was declined at PF (#1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14,#15,#16,#17,#18) due to medical acuity related to use of suprapubic catheter. CM NN documented she would reach out to a psychiatric provider for further assistance.

On 9/24/21 at 10:03 a.m. CM FF noted that she met with P#1 who was alert and oriented. CM FF asked P#1 if he can return to the home of the lady, he was living with prior to coming into the hospital, P#1 said he does not know if she is living there or not as he had not spoken with her since being in the hospital. CM FF stated that when P#1 was asked where he would go if he was discharged P#1 responded he is from another state and that he would go back to that state if discharged. P#1 ' s medical record revealed that CM FF contacted P#1's cousin whose information was on P#1's medical record. P#1's cousin stated that P#1 cannot go back to the place he was living prior to admission. CM FF noted that P#1's distant relative suggested a nursing home for P#1 and that P#1 cannot reside with her.

On 9/26/21 at 10:00 a.m. P#1's medical record revealed that P#1 was uncooperative and belligerent. P#1's medical record revealed the facility staff witnessed P#1's taking a threatening stance and physically swinging at the hospital's security. MD BBB ordered restraint, P#1 was chemically restrained with Geodon and COVID swab was completed.

On 10/8/21 at 1:00 p.m. CM FF documented that P#1 had been declined by all psychiatric facilities and the psychiatric nurse practitioner had recommended rescinding P#1 ' s 1013 (legal order for involuntarily inpatient emergency psychiatric treatment)

On 10/9/21 at 1:10 p.m. P#1's medical record revealed that P#1 refused to eat, talk, take his medications and declined to be discharged to a nursing facility or shelter. The provider (attending MD) was notified, and a speech re-evaluation was considered.

On 10/10/21 at 9:32 a.m. RN PP documented that P#1 looks weak and lethargic but alert. P#1 ate 20% of breakfast. P#1 allowed the staff to get his vital signs and RN PP documented that P#1's vital signs were within the normal ranges (Blood Pressure 109/72, Heart Rate 79, Pulse 98%- was this pulse ox??). P#1 refused medication.
On 10/10/21 at 3:36 p.m. a nursing note by RN PP documented that P#1 was found lying on the floor at 3:15 p.m.

On 10/11/21 at 10:30 a.m. RN EEE documented that P#1 was very lethargic and spoke in a low voice. RN EEE noted it looked like P#1 was unable to swallow and a speech evaluation was ordered.

On 10/11/21 at 1:25 p.m. Speech and Language Pathologist (SLP) DDD documented that she attempted to see P#1 at the bedside with RN EEE. SLP DDD noted that P#1 had an obvious dry mouth, she further documented that P#1 declined oral care.

On 10/11/21 at 1:40 p.m. RN EEE noted that SLP DDD was consulted due to P#1 ' s inability to swallow. RN EEE further noted that SLP DDD gave P#1 a cup of water, P#1 appeared he could not maneuver the cup well and RN EEE tried to help him. P#1 was successful with holding the cup in his left hand. P#1 dumped the water in his lap. P#1 slapped the nurse in the nose and lip with his right hand.

On 10/12/21 at 6:25 a.m. a nursing note revealed P#1 refused assessment of lungs and heart. P#1 was lethargic and refused to talk. P#1 refused his scheduled medications. P#1 waved his hand to say no.

On 10/12/21 at 9:56 a.m. a nursing note from RN MM revealed that a case manger entered P#1 room to inform him of his discharge order that was in place since 10/7/21. The case manager asked P#1 if there if he had family to care for him or a place to go. P#1 shook his head no. The case manager informed P#1 of the KEPRO Medicare appeal process; P#1 stated he wanted to call to appeal the discharge. The case manager assisted P#1 with dialing the number and handed him the phone to complete the conversation. P#1 held the phone to his ear and did not speak. P#1 dropped the phone out of his hand. When the case manager picked up the phone there was no one on the line. The case manager asked P#1 if he wanted to call KEPRO Medicare appeals again, P#1 yelled, "Get the f- -k out of my room! Leave me the f- -k alone!"

On 10/13/21 at 11:21 a.m. an ancillary note from CM FF documented that NP OO was unable to do a face to face with P#1. NP OO planned to attempt the decision-making via telehealth (virtual healthcare consultation).

On 10/13/21 at 1:47 p.m. a consultation note by NP OO documented that P#1 chief complaint in his own words were, "I don' t want to be discharged. I don ' t want a guardian. Leave me alone! Leave me alone!"
NP OO documented the reason for the evaluation was to determine whether or not P#1 will require legal guardianship to make decisions for him. P#1 did not appear to be responding to internal stimuli during the interview.
NP OO ' s examination revealed that P#1 was observed lying in bed. P#1 made intermittent eye contact with the camera. P#1 was alert but refuses to respond to questions regarding orientation. P#1 simply would shake his head no. P#1 ' s speech was noted to be variable (mumbling at times and clear at others). P#1 was able to state he did not want to be discharged and does not want a guardian named. P #1 appeared to follow the conversation, but refused to speak except saying "leave me alone" P#1 denied any suicidal ideation by shaking his head not when asked. NP OO was unable to assess P#1 ' s cognitive function because P#1 did not respond to most questions. NP OO noted that P#1 did appear to understand he may have a legal named to make decisions and take over his finances.

Evidence of Decision- Making Capacity was documented in the medical record as followed by NP OO. It is noted that all 5 elements must be present for a patient to be deemed able to have decision making capacity.
1. Understanding of the issues, the illness, the resent for treatment: Present as evidence by (AEB) patient stated he did not want to be discharged and does not want a guardian.
2. Appreciation of facts and consequences: Present AEB patient stated he did not want to be discharged and does not want a guardian.
3. Logical chain of reasoning: Present AEB patient stated he did not want to be discharged and does not want a guardian.
4. Ability to express consistent choice: Present AEB patient stated he did not want to be discharged and does not want a guardian.
5. Absence of suicidal ideation: Present AEB patient stated he did not want to be discharged and does not want a guardian.

Physician AA (Hospitalist) Discharge Summary dated 10/14/2021 at 9:53 a.m., for Patient #1 was reviewed. The discharge summary revealed that Patient #1 was admitted to the facility on 9/6/2021 at 7:00 p.m. The patient had a history of HIV on treatment with confusion and was admitted with concerns for sepsis and urinary tract infection. While in the emergency room psychiatry was consulted. Medicine asked for admission for possible infection. Partial review of the time line while patient #1 was in in the hospital revealed the following:
9/8/2021- Sepsis resolving;
9/13/2021-Patient medically cleared for discharge to in- patient (psychiatric) facility;
9/15/2021- Patient more abusive to the staff today;
9/20-9/21/2021- Patient uncooperative with care sitter at bedside on 1013 (IVC) awaiting in-patient transfer to in-patient (psychiatric) facility;
9/22/2021- Refused psychiatric evaluation yesterday to be seen today;
9/26/2021- Verbally abusive to the staff, and very aggressive today restrained by the police;
9/27/2021-Medically stable, "Homicidal" awaiting transferring in-patient (psychiatric) facility;
10/03/2021- 1013 (IVC) renewed;
10/9/2021-Patient denies having suicidal ideations at this time and 1013 rescinded as recommended by psychiatry. Medically cleared for discharge;
10/11/2021- Pt was found on the floor yesterday without any evidence of injury- "Pt still discharge.";
10/14/2021-No acute event overnight, remains uncooperative with care. Case Manager worked on discharge and patient will be discharged to a shelter today.

Documented attempt to contact local shelters was not found in the medical record.
On 10/14/21 at 10:20 a.m. RN PP noted that P#1 was discharged, and his discharge education packet was given to him.

On 10/14/21 at 10:00 a.m. Director of Case Management (DCM) LL noted that she spoke with P#1 with the Manager of Public Safety (MPS) CC present. DCM LL documented that she reviewed the important message from the Medicare notice (KEPRO notice) with P#1. DCM LL documented that P#1 signed the form and stated he did not want to appeal his discharge. DCM LL noted that P#1 was informed he would be discharged in a few moments. DCM LL further noted that P#1 was offered to be transported to any homeless shelter of his choice. DCM LL documented that P#1 said he did not want to go to a shelter. DCM LL documented that P#1 would be given his discharge paperwork, assist the patient with dressing, and escorted off the premises by security.


A surveillance video review of a facility provided video titled " IP Camera 13 med Surg 2" revealed:

At 10:16:13: MPS CC standing at the front of P#1 ' s room, PSO DD, and another officer went into P#1's room.

At 10:17:53: PSO DD was pushing P#1 in a red wheelchair out from P#1 s room and MPS CC with another officer were observed coming out from his room. P#1 is visible with his head down and eyes appear closed. P#1 ' s catheter is across his lap. Camera quality of surveillance video becomes delayed. An unidentifiable individual is also seen leaving P#1 room at this time.

A surveillance video review of a facility provided video titled "IP camera 4 lab Cath" revealed:
10/14/21 at 10:27:31: Security was observed walking towards the facility's STEMI door that led to the parking lot.

At 10:27:41.: P#1 was observed in a wheelchair being pushed by PSO DD and another security officer carrying a bag.

At 10:27:49: Observed P#1 sitting in the wheelchair while being pushed across the hallway towards to exit door.

A surveillance video review of a facility provided video titled "IP Camera 7 ER outside" revealed:

At 5:21: P#1 was sitting on a red wheelchair with three public safety officers including MPS CC and PSO DD. PSO DD was pushing P#1 while the two other officers were walking behind him.

At 5:36: P#1 was pushed across the parking lot towards the sidewalk.

At 5:58: P#1 was pushed close to the sidewalk and the video surveillance view was obstructed by trees at 6:00.

A review of 911 audio call on 10/20/21 at 4:20 p.m. with the Deputy Chief of Police (DCP)(GG) at the police department revealed the call was made on 10/14/21 at 10:38 a.m. by a local citizen. The caller reported a man was laying on the sidewalk on the corner of an intersection in front of the facility's Emergency Department. The caller said it appeared the man had just left the hospital since he had tubes coming from his body.

A review of six photographs (no date or time noted on photographs) submitted by the complainant portrayed images of P#1 on the sidewalk in front of the facility. Three of the six images displayed P#1 required a double arm assist (Two individuals on both sides of patient) that lifted P #1 from the wheelchair. Three of the six images captured P#1 lying on the ground on his side. P#1 ' s catheter bag (urine drainage bad collect urine) and tubes were observed on the ground with exposed dark urine in the catheter tubing. A facility entrance sign is captured in the background.

A review of local law enforcement car footage (no date or time noted) captured P#1 on the ground on his side.

A review of the Emergency Medical Services (EMS) report from 10/14/21, revealed that EMS arrived on the scene to P#1 at the 11:45 a.m. P#1 was found lying on the sidewalk outside the facility in obvious distress. The patient's heart rate was 140 beats per minute (bpm) (normal adult heart rate is 60-90 bpm); blood pressure was 87/55 (normal blood pressure is not less than 90/60). The oxygen saturation (percent of oxygen in the bloodstream) was 87 (normal is 95 or higher). The temperature was normal, at 98.9 degrees Fahrenheit. P#1 was observed to be in a mental stupor (a state of being nearly unconscious), pupil reaction was sluggish, breathing was shallow, the radial pulse was thready (small, fine), there were rales in the lungs (sounds heard when there was fluid in the airways), capillary refill (a quick test of the nail bed to measure blood flow to the tissues) was delayed. The heart was monitored with a 12-lead EKG, and a normal saline IV drip was started at 11:52 a.m. The vital signs taken at 11:57 a.m., revealed an increase in blood pressure to 95/55, a decrease in heart rate to 125, and a respiratory rate of 13. At 12:00 p.m. the heart rate had decreased 116, and P#1 was loaded onto a stretcher and taken into the facility's Emergency Department (ED). Care was transferred to the ED at 12:30 p.m.

A Review of the ED Provider Notes by MD II on 10/14/21 at 12:37 p.m. revealed that P#1 had a history of depression, schizophrenia, and HIV. P#1 presented to the ED via Emergency Medical Services (EMS) for altered mental status. P#1 was found on the corner of an intersection near the facility sitting on the ground not responding to questions or commands. P#1 had been discharged from the facility that morning, 10/14/21, at 10:20 a.m., after being hospitalized for over 30 days for a Urinary Tract Infection (UTI). The provider notes revealed that P#1 had not been picked up from the facility and was left outside after being discharged. The report regarding P#1 by Emergency Medical Services (EMS) upon arrival to the ED was a blood pressure of 80/55 and the heart rate ranged from 130-150. After EMS administered normal saline, P#1's blood pressure increased to 124/87 and the heart rate lowered to 113. The neurological assessment by MD II revealed that P#1 did not answer questions or follow commands. A stroke assessment was initiated, and neurology was consulted. The neurologist did not believe P#1 had a stroke. P#1's presentation and results were discussed with case management, who would evaluate the patient. The clinical impression was Sepsis. P#1 was admitted to the Medical-Surgical unit in stable condition.

A Review of the ED nurse notes by RN HH on 10/14/21 at 1:00 p.m., revealed P#1 was alert and oriented to self only and ants were crawling on the patient. There was a Foley catheter (established to be a suprapubic catheter) to a bedside bag with cloudy, dark yellow urine with sediment in the bag. A note by RN HH on 10/14/21 at 2:15 p.m. revealed P#1 was becoming more alert, opening eyes by voice, and answering simple questions.

A review of the facility's incident log from 7/1/21 to 10/19/21 revealed that there was an allegation of an inappropriate discharge event type for P#1. Further review of the log failed to reveal any other inappropriate discharge. A detailed review of the incident report revealed that on 10/14/21 at 10:30 a.m., P#1 was discharged to the street by the security from the facility's med surg 2 unit. P#1 was weak and needed assistance to the wheelchair. Security transported P#1 to nearby street and assisted him out of the chair and sat him on the ground.

An interview took place with the Deputy Chief of Police (DCP) DCP GG on 10/20/21 at 4:20 p.m. at the Police Department. DCP GG said a call was received from the facility ' s public safety officer earlier on the morning of 10/14/21, and a request was made for the police department to stand by while a patient was removed from the hospital. DCP GG said that on 10/14/21 at 10:38 a.m., an officer responded to an emergency call about a male who had passed out at the stop sign. DCP GG further explained that a police officer arrived and found P#1 incoherent on a sidewalk in front of the facility. DCP GG said they were informed the facility had physically removed and medically cleared P#1 for discharge. DCP GG explained that from his experience the facility had wanted the police officer to be present as an official arm of the government so that P#1 would become the police ' s liability. DCP GG explained that when he arrived at the scene, he found P#1 unresponsive at the sidewalk and he did not believe that P#1 was unruly. DCP GG said he went into to hospital to get information about P#1, but the hospital was not cooperative and cited Health Insurance Portability Accountability Act (federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient ' s consent or knowledge). DCP GG explained he believed in cases of emergency the facility was supposed to give information to the police department. DCP GG explained that he was able to find out P#1 ' s residence and he spoke with P#1's roommate on 10/18/21. DCP GG said P#1's roommate explained that P#1 had no family in the area and P#1 had issues with his bladder coupled with a mental health crisis. DCP GG said P#1's roommate stated she was unable to care for P#1 as much as P#1 needed and she had her issues. DCP GG said P#1's roommate had not heard anything from the hospital.

An interview with the Manager of Public Safety (MPS) MPS CC took place on 10/21/21 at 9:56 a.m. in the conference room. MPS CC explained that he received an email invite to a meeting hosted by the facility's Chief Financial Officer (CFO) and he logged on to the WebEx meeting on 10/14/21 at 9:30 a.m. MPS CC said the CEO, CNO, CFO, inpatient director, DCM LL all participated at the meeting. MPS CC said his participation was minimal and the conversation at the meeting was about discharging P#1. MPS CC said he was instructed to assist the clinical staff in getting P#1 discharged. MPS CC explained that he was informed that if P#1 wished to contest his discharge they were to cease and continue on a different line. MPS CC said P#1 did not contest his discharge. MPS CC also said they were informed if P#1 asked for placement into a nursing care home or made any objection, the security team were to cease the discharge and turn his case back over to care management. MPS CC explained that nobody told P#1 he had to leave because he understood he was being discharged. MPS CC explained the reason why security was involved when P#1 was going to be discharged was that they were familiar with P#1 and the staff was nervous about how he would react. MPS CC further explained that there was an incident with P#1 when he walked out of his room trying to leave the facility against medical advice (AMA). MPS CC said two security officers tried to talk him down and P#1 took a swing at one of the officers. The officers got him turned around and took him back to his room. MPS CC said when P#1 was asked where he wanted to go, P#1 was unclear about which apartment and made vague references. MPS CC said he told P#1 he could not take him off-campus. MPS CC said he heard a nurse asking P#1 if there was anybody P#1 wanted to call. P#1 said he did not want to call anyone. MPS CC said he also heard a nurse ask if he wanted to wait to have his cellphone charged and P#1 said he did not want to wait. MPS CC said they got P#1 to the corner as far as the security can go on the sidewalk, got him set up, safe from ant biting and they left. MPS CC said when they left P#1 seemed to be okay. MPS CC explained that prior to going upstairs to P#1 ' s room after the WebEx meeting, he called the nearby police department. MPS CC explained that it was a courtesy call-in case P#1 would try to harm somebody. MPS CC said P#1 has had two assaults and it was a precautionary measure. MPS CC further explained that he told the police department that the person they were discharging had two violent admissions and requested for an officer in case of criminal trespassing. MPS CC said the police department acknowledged the call and said if the situation became worse, they would come.

An interview was conducted with the Public Safety Officer (PSO) (DD) on 10/21/21 at 10:35 a.m. in the B Conference Room. PSO DD said that he had been working at the facility for six years. PSO DD acknowledged that he was aware of P#1. PSO DD said that on the day the incident occurred the security team went up to P#1 ' s room with a wheelchair. PSO DD further explained that P#1 got into the wheelchair with little to no assistance. PSO DD said that they pushed P#1 out through the side door of the main hallway to the facility ' s Cath lab. PSO DD explained that P#1 did not say anything about not wanting to leave the hospital. PSO DD further explained he did not recall P#1 saying anything about where he wanted to go. PSO DD said P#1 did not seem upset about leaving the hospital. PSO DD explained that they took him outside the front of the ED to the sidewalk. PSO DD stated that P#1 said he wanted to go and was okay with leaving the hospital. PSO DD explained that P#1 stood up from the wheelchair and then he sat down. PSO DD said P#1 had a bag but PSO DD does not know what was in it. PSO DD said P#1 wanted to go out of the hospital. PSO DD said he thought P#1 was coherent and clear and did not seem weak. PSO DD said the safety officers dropped P#1 off and came into the building. PSO DD explained that he had not experienced a situation like this where a patient is dropped at the sidewalk.

A telephone interview was conducted with the Hospitalist (MD) AA on 10/21/21 at 3:20 p.m. in the conference room. MD AA acknowledged that P#1 was her patient for two days. MD AA explained that P#1 was in his 60 ' s with a past medical history of HIV infection and schizophrenia. P#1 was admitted to the hospital for a UTI and sepsis. P#1 completed his treatment but then he was very aggressive. MD AA said P#1 had been at the hospital for a while before she took over. She said that at some point P#1 was aggressive refusing care and wouldn ' t talk or eat. MD AA said psychiatric was consulted and P#1 was advised to be put on 1013. MD AA said P#1 continued to be non-cooperative, refused care, labs, eat or exercise and sometimes he is aggressive to medical staff. MD AA further explained that at some point, the psychiatric team reevaluated P#1 and said he didn't need to be on 1013 anymore. MD AA said P#1 continued to be uncooperative with medical care, and P#1 would refuse everything. MD AA said sometimes P#1 would tell the staff he would punch if they came near him. MD AA said the providers were waiting for the psychiatric team to clear P#1 for discharge to a psychiatric facility. MD AA said P#1 wouldn ' t talk or let anybody examine him however P#1 looked stable, but he was refusing care. MD AA explained that the day she took over caring for P#1 the psychiatric team said P#1 had the capacity to make decisions: he had the 4 competencies to make a decision and it was P#1 ' s choice to refuse care. MD AA said when she came to work on 10/14/21, P#1 ' s case manager called her and ask if P#1 was medically stable and said they would try to find the best way to discharge P#1. MD AA said she reviewed P#1's vital signs which were fine and nursing notes: he was refusing care as usual. MD explained that she went to see P#1 and tried to talk to him, and P#1 would just nod his head. P#1 made a gesture like he didn't want to talk, denied pain, and had no questions. MD AA said P#1 was hemodynamically stable but looked weak and felt he needed to go to a rehabilitation center, but P#1 was refusing care and refused to go to a rehabilitation center. MD AA explained that her impression was that P#1 should be discharged to a shelter which he also refused. MD AA said when P#1 was refusing everything they needed to get the psychiatric team to determine P#1 ' s capacity to make decisions. MD AA further explained that the psychiatric team said P#1 had the capacity to make decisions, so I saw no reason to keep him in the hospital further. MD AA explained that she was asked and felt P#1 was stable for discharge and there was nothing medically they were doing for him at the hospital. MD AA explained that If patients are sick and don ' t want to leave, they are given the choice to appeal the discharge but P#1 refused to appeal his discharge.
A follow-up interview with MD AA took place on 11/16/21 at 1:15 p.m. via telephone. MD AA stated that a physical assessment of P#1 was difficult because he (P#1) refused to allow anyone to examine him. P#1 also refused medications and other treatments. MD AA explained that P#1 had been determined to be competent to make decisions by a behavioral health provider. MD AA recalled that P#1 appeared weak prior to discharge. MD AA explained that she had been under the impression that P#1 was discharged to a shelter. MD AA explained that a disposition to a rehab facility where P#1 would receive physical therapy was preferred but he (P#1) refused. MD AA stated that in her opinion, P#1 was medically stable for discharge on 10/14/21.


A telephone interview took place with Registered Nurse (RN) EE on 10/21/21 at 3:57 p.m. in the B conference room. RN EE acknowledged she recalled when P#1 was first admitted. RN EE said P#1 was more coherent than the day he left. RN EE explained that P#1 declined as the week progressed and became less verbal. RN EE said P#1 was on 1013 because he threatened a staff member. RN EE said P#1 would have sitters with him. RN EE explained that P#1 was schizophrenic, aggressive, and would not let people touch or care for him. RN EE further explained that the psychiatric nurse was trying to get P#1 placed in a psychiatric facility but he was always denied. RN EE said the morning before P#1 was discharged, the case management team had a meeting and she was notified by DCM LL and MPS CC at the nurses ' station that they had to get P#1 out, so she printed out the discharge paperwork and called RN PP. RN EE said RN PP, DCM LL, and RN EE went to P#1 ' s room and MPS CC came in with them. RN EE said they got P#1 dressed, gave him his discharge papers, packed up his bags and security wheeled him out. RN EE said P#1 did not object to leaving. RN EE said they kept offering P#1 different places, but he refused everything. RN EE explained that they set up Uber (car service) transportation for a patient on 10/20/21 who was sent to a homeless shelter, but P#1 refused every option that was offered to him.

An interview was conducted with the Director of Case Management (DCM) LL on 10/21/21 at 4:10 p.m. in the conference room. DCM LL explained that she had been working at the hospital for about two years. DCM LL acknowledged that she recalled P#1, she explained that P#1 had an extended stay for the previous visit and is still currently at the hospital. DCM LL explained that the psychiatric nurse practitioner saw P#1 a week prior to his discharge, his 1013 was rescinded and P#1 was cleared for an outpatient follow-up and was medically cleared for discharge by the medical doctor. A discharge order was placed and was never rescinded. DCM LL further explained that P#1 was medically cleared several days before he left. DCM LL said once P#1 ' s 1013 was rescinded he continued to stay at the facility with a discharge order. DCM LL said on 10/12/21 she told RN MM to notify P#1 that he had the right to appeal his discharge and notify him of the discharge order. DCM LL said security informed P#1 that the nurses would help him get dressed and he would be escorted off the premises. DCM LL said P#1 did not object to leaving. DCM LL further explained that CMS is clear with the patient having the right to self-determination and that if P#1 had wanted to go to the shelter they would have arranged transportation for him, but he refused. DCM LL said the nurse helped P#1 get dressed, P#1 was alert, oriented, and walked from the bed to wheelchair and that was the last she saw him. DCM LL said security escorted P#1 out of the facility.

An interview took place with NM HHH on 11/16/21 at 11:27 am in the conference room. NM HHH acknowledged she was on the unit when P#1 was discharged on 10/14/21. NM HHH said RN PP went to get P#1 dressed and expressed concern to her (NM HHH) that P#1 was weak. NM HHH said she went into P#1's room to see P#1. NM HHH said she was with MPS CC, and they assisted P#1 to get into the wheelchair. NM HHH said she saw that P#1 was weak and expressed her concerns to the Director of Inpatient Service (DIS) III. NM HHH said she told DIS III P#1 was too weak and she can ' t believe P#1 was being discharged. NM HHH explained that she told DIS III she had to go see where the security was to drop off P#1. NM HHH said P#1 could say his name but did not have much strength when she put P#1 on the wheelchair. NM HHH exp