HospitalInspections.org

Based on document review and interview, the facility failed to ensure a discharge plan was implemented for 1 of 5 patients (patient #1), out of a total sample of 11, when Patient #1 was brought to the facility's Emergency Department by Emergency Medical Services (EMS) from the Extended Care Facility (ECF) where he was a resident and was not discharged back to the ECF resulting in the potential for poor patient outcomes. Findings include:


On 06/26/18 at 1230 a medical record review of patient #1 revealed that the patient was a 69-year-old male who presented to the Emergency Department (ED) on 04/14/18 at 0813. He was admitted to ED room 0114A and received a medical screening by the Emergency Department Physician at 0826. The patient had an CT scan (commuted tomography scan), a chest x-ray, and an EKG (electrocardiogram).

On 06/26/18 at approximately 1300, during review of the medical record, it was noted that during his admission registration, patient #1 was sitting in a "wheelchair" and presented a current driver's license and a current chauffeurs license and confirmed that the address on both were the same and his "current" address. "Social History" given to registration and stated patient "lives by self in apt, 2 kids, 0 pets, employed and works in housekeeping." There was no documentation that the patient arrived via EMS from an ECF.

During an interview and record review on 06/27/18 at approximately 1100 with the Staff AA, Director of Nursing at Extended Care Facility 2 , it was confirmed that patient #1 was a resident of the extended care facility and was transferred via EMS to the hospital on 4/14/18.

On 06/27/18 at approximately 1140, during an interview with Staff J and Staff K, it was determined that they were the staff assigned to Patient #1 upon admission to the ED on the morning of 04/14/18. Neither one of them recalled taking report from EMS. Staff K stated that "when a patient comes in by EMS, a nurse does need to take report, whether they got the information from EMS that the patient was from an ECF is really unknown. If it doesn't get passed on or paperwork handed over I guess we really don't know". Staff K also stated that she did not take report on Patient #1 when he was brought to the Emergency Department. Staff J also confirmed that he did not take report on Patient #1 when he was brought to the Emergency Department.

On 06/27/18 at approximately 1240, during an interview with Staff D, Manager of Accreditation & Regulation and and Staff H, Patient Representative for Complaints/Grievances, it was determined that Patient #1 never entered the grievance process at the facility. At the same time and date, during review of the document titled "Grievance Log" dated from 04/01/18 to present date, it was confirmed that the patient, nor any family member, entered a complaint in behalf of Patient #1, for this event. Patient #1 was not known as a previous or returning patient to the facility. Patient #1 had no prior admissions to the facility, so it was unknown if he had a guardian or a POA (Power of Attorney), he presented to the Emergency Department per EMS, received a medical screening, was treated, and discharged home instead of back to the nursing home where he had been admitted, as a patient, on 04/13/18.