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Based on a review of the medical record, interviews with facility staff, a review of Medical Staff Rules and Regulations, and policy and procedures, it was determined that the facility failed to properly discharge one patient on a 1013 (Certification Authorizing Transport to an Emergency Receiving Facility and Report of Transportation) (P#1) out of 20 Sampled, without determining the availability of care or arrangements were made to ensure continued care.

Findings:

Cross-reference A0802 Discharge Planning- Patient Re-Evaluation as it relates to the facility failing to re-evaluate a patient who as on a 1013 prior to the patient's discharge.

Based on a review of the medical record, interviews with facility staff, a review of Medical Staff Rules and Regulations, and policy and procedures, it was determined that the facility failed to properly discharge one patient on a 1013 (Certification Authorizing Transport to an Emergency Receiving Facility and Report of Transportation) (P#1) out of 20 Sampled, without determining the availability of care or arrangements were made to ensure continued care.

A review of the Emergency Department (ED) physician's report by the Medical Doctor (MD) MM on 4/16/22 at 10:24 a.m. revealed that P#1 had been brought to the ED by ambulance for violent behavior. P#1 was over-sedated with potential respiratory compromise. P#1 was admitted to the Intensive Care Unit (ICU) on 4/16/22 at 1:05 p.m. for airway monitoring and management of violent and agitated behavior. P#1 was currently under a 1013 and would likely need an inpatient psychiatric facility when medically stable.

A review of a Social Services Initial Assessment by the Social Worker (SW) TT on 4/17/22 at 5:54 p.m. revealed that SW TT could not obtain information from P#1 due to the patient's confusion and disorientation. An attempt was made to call the primary contact, but there was no answer. The assessment revealed that P#1 lived alone, and a parent was the healthcare agent and decision-maker for P#1. P#1 had no health insurance. The disposition prior to inpatient admission was to discharge P#1 to a psychiatric facility. A medical record review failed to reveal further discharge planning by Social Services prior to discharge.

A review of the "Form 1013 - Certification Authorizing Transport to an Emergency Receiving Facility and Report of Transportation (Mental Health)" revealed that MD RR signed the form on 4/18/22 at 11:50 p.m., stating that P#1 appeared to be mentally ill, requiring involuntary treatment. P#1 presented a substantial risk of harm to himself or others and seemed to be unable to care for his physical health and safety as to create an imminently life-endangering crisis. An example was P#1 throwing objects at the door and staff.

A review of a Progress Note by MD GG on 4/18/22 at 12:22 p.m. revealed that P#1 was examined and continued to be psychotic despite medications. A review of a Progress Note by MD GG on 4/18/22 at 4:47 p.m. revealed that P#1 was examined by a psychiatrist and was under a 1013. Psychiatry recommended inpatient evaluation at the contracted psychiatric hospital. P#1 had incidentally tested positive for COVID-19 but had no symptoms.

A review of a Progress Note by Nurse Practitioner (NP) JJ on 4/18/22 at 5:23 p.m. revealed that P#1's behavior was escalating, and P#1 pulled out his Intravenous Therapy (IV). P#1 became violent, throwing equipment around the room and yelling at the staff. The Progress Notes further revealed that NP JJ spoke to Behavioral Health Connections for assistance and placement into an inpatient psychiatric unit. However, given P#1's active COVID-19 positive status, the facility would not be able to place P#1 until five days after testing positive for COVID-19.

A discharge order by NP JJ was entered on 4/19/22 at 7:22 a.m. for P#1 to go to another facility.

P#1 was given discharge instructions by RN HH on 4/19/22 at 7:41 a.m., with contact information to make an appointment with MD PP. Educational materials were provided to P#1 regarding diagnosis, signs to watch for prior to calling 911, and medications. P#1 verbalized understanding of post-hospital education. P#1 needed follow-up for health management and medication education.

A review of a Nursing Discharge Note on 4/19/22 at 7:42 a.m. by RN HH revealed that P#1 would be discharged to an acute skilled nursing facility. Transportation would be ambulatory (patient could walk), and P#1 would be transported in police custody.

Discharge notes by MD GG on 4/19/22 at 7:43 a.m. revealed that P#1's diagnoses was acute psychosis, agitated, and violent behavior.

A "Transition of Care Provider" letter was entered into the system by RN HH on 4/19/22 at 7:45 a.m. and was addressed to the other hospital.

A review of a Progress Note by the evening charge nurse (RN) HH on 4/19/22 at 8:05 a.m. revealed that at 6:20 a.m., NP JJ expedited the process to have P#1 placed at a facility with a higher level of care. The nursing supervisor (RN) SS was working to transfer P#1. The Progress Note revealed that P#1 was discharged under police custody to a different hospital.

A review of a Progress Note by NP JJ on 4/19/22 at 3:50 p.m. revealed that when NP JJ arrived on the unit, there were four security guards outside P#1's room. Per a report by NP DD, P#1 became aggressive and combative to staff and spat at NP DD. P#1 was also throwing equipment in the room. After speaking to MD GG on the phone, NP JJ called the police, as P#1 was assaulting staff and destroying property. The police department arrived at the patient's bedside, and NP JJ explained the incidents of aggression and assault to the police and that P#1 was currently on a 1013. P#1 was taken into custody by the police. The Progress Note revealed that P#1 was without evidence of respiratory distress versus stable. The Progress Notes further revealed that P#1 would be discharged and taken to a different hospital for treatment and management of acute psychosis.

A review of an incident narrative that was not dated or signed revealed that P#1 became combative several times. The night shift nursing supervisor sought alternative locations to house the patient as he became very dangerous to the ICU staff. The shifts began to change, and an NP suggested police be contacted, and the patient moved out of the facility to protect himself and others. The NP called the police. The Nursing Supervisor made a call to get permission to discharge a 1013. Once permission was granted, the patient was discharged and arrested by police. P#1 was then transported to the other hospital.

An interview was conducted with MD AA on 5/4/22 at 9:06 a.m. in the Boardroom. MD AA stated that P#1 was being given Precedex (a sedative), which kept P#1 calm enough to be managed safely. MD AA said only the ICU could safely administer Precedex and closely monitor P#1. MD AA said there was no psychiatric unit in-house, and P#1 could not be safely transported to another facility at that point. All the facility could do was try to manage P#1. When P#1 turned out to be COVID-19 positive, it reduced the chance of P#1 being moved to a psychiatric facility. The physicians decided to place P#1 in the ICU to let P#1 calm down for a couple of days. By the time MD AA left the ICU, P#1 was improving. MD AA said the plan was for the physicians to come together after P#1 improved and then decide what to do. The psychiatrist recommended sedation and did not say to transfer P#1. Transferring P#1 was not an option.

A telephone interview was conducted with RN EE on 5/4/22 at 11:30 a.m. RN EE stated that P#1 was one of the most violent patients she had ever dealt with, and the staff was scared. P#1 was very volatile. RN EE said that it was denied when the seclusion room in the ED was suggested. RN EE stated there was a lack of support from supervisors, and bedside nurses were left to manage the situation. RN EE said the physicians were trying to avoid intubating and sedating P#1. RN EE said the staff were working on transporting P#1 and were having trouble bringing P#1 to a safe environment. The day shift provider wanted to bring P#1 to the other hospital. RN EE said the other hospital had a psychiatric unit and seclusion rooms in the ED.

An interview was conducted with the Chief Nursing Officer (CNO) FF on 5/4/22 at 1:26 p.m. in the Boardroom. CNO FF first became aware of P#1 on 4/18/22. The following morning, CNO FF was getting ready to come into work and received a text message from MD GG about not being able to manage P#1. MD GG asked if the police department could be contacted. CNO FF asked MD GG not to call the police because the police had not been helpful in other situations. CNO FF told MD GG that she wanted to call security and social services to see about getting P#1 placed somewhere. CNO FF called the head of security to make sure security was on the unit and followed up with the placement at the psychiatric hospital. CNO FF said that 10-15 minutes later, someone in the ICU called the police. When CNO FF asked questions, she was told that P#1 had assaulted NP DD. CNO FF said she was rather shocked when the police proceeded to take P#1 into custody. CNO FF said a 1013 was used to transport patients, it was null and void, and there was no medical reason for P#1 to be at the facility. P#1 had been cleared as medically stable. CNO FF said the contracted psychiatric hospital would have declined a violent and combative patient. Some psychiatric facilities would have taken a COVID-19 patient. CNO FF said someone had talked about P#1 going to a different hospital since the other hospital had a unit for people under arrest. CNO FF said that when a patient was transferred, there would be discharge orders, information gathered, and a hand-off from the receiving facility between RNs. If it were a transfer to a different hospital, there would also be a physician-to-physician hand-off.

A telephone interview was conducted with RN Supervisor (RN) SS on 5/5/22 at 11:12 a.m. RN SS said P#1 was on a 1013 in the ICU, and the staff was trying to get P#1 to another facility. RN SS called the other hospital and was told a patient could not leave the ICU to go to the other hospital. A patient should not go from an ICU to an Emergency Room (ER). RN SS said the ICU was not medically indicated, and P#1 had already been in the ICU for 72 hours. RN SS said CNO (FF) knew that the other hospital was called. The police said once P#1 was discharged, P#1 would be arrested, and the police would decide what to do with P#1. RN SS said no one at the facility knew what the police would do with P#1.

A telephone interview was conducted with the night shift charge RN HH on 5/6/22 at 2:01 p.m. RN HH said the dayshift reported that P#1 had gotten violent at 4:00 p.m., and a code was called. P#1 broke out of restraints and was medicated. Everybody feared P#1. RN EE said one of the NPs called the police department. Police came and asked what had happened. The NP talked to the police. RN EE said from the arrangement made by the supervisor that P#1 was supposed to go to the other hospital. RN EE further said she heard the supervisor's conversation with the other hospital, and the supervisor at the other hospital had accepted P#1, according to RN SS.

A review of the Medical Staff Rules and Regulations, approved by the Governing Board on 6/17/14, "Article XII - Discharge Planning and Discharge Summaries," revealed that patients could not be discharged to an outpatient facility or physician's office for urgent or emergent procedures or diagnostic testing when the facility had the capacity and capability to provide care. Discharge planning would be an integral part of the hospitalization of each patient, and an assessment would commence as soon as possible after admission. The discharge plan and assessment would include an evaluation of the availability of appropriate services to meet the patient's needs after hospitalization. Discharge planning would include determining the need for continuing care, treatment, and services after discharge or transfer. Any individual who could not legally consent to his or her own care would be discharged only to the custody of parents, legal guardian, or another responsible party unless otherwise directed by the parent, guardian, or court order. The attending physician, along with hospital staff, would arrange for services needed to meet the patient's needs after discharge, when indicated.
A review of Article XIII - Transfer of Patients revealed that patients would be transferred to another hospital or facility based on the patient's needs and the hospital's capabilities. When patients were transferred, the attending physician would provide appropriate information to the accepting facility.

A review of the facility's policy entitled "Discharge Planning," last reviewed on 7/1/19, revealed that the discharge planning process would be initiated as early as pre-admission with ongoing reassessments and adjustments by all caregivers involved in the patient's care, including the Social Worker (SW) or Case Manager (CM). Further review revealed that discharge planning would include recommendations based on interdisciplinary team rounds, and the SW would be expected to attend scheduled rounds to identify potential discharge needs. Further review revealed that all patients would be given a choice when selecting a facility for their post-acute care. The patient's choice would be respected, but the SW would identify limitations of availability, payer source, and level of care as appropriate. The SW would act as a liaison between community resources, agencies, and the facility.

P#1 medical record was received from the other facility on 5/4/22. A review of the medical record revealed P#1 was received from facility #1. P#1 was confirmed to still maintain his 1013 status.

The receiving facility provided discharge paperwork from facility #1 dated 4/19/22, addressed to the receiving facility. The discharge paperwork contained P#1 ' s name, date of birth, medical record number, and visit date. The letter closed with contact information for facility #1.

The facility failed to reevaluate P#1 ' s needs prior to discharge and confirm an appropriate continuation of care. P#1 was transported from Facility #1 ' s ICU to the receiving hospitals Emergency Department. The receiving facility did not agree to continue the care of P#1 prior to transportation.