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Based on documentation review and interviews, it was determined the Hospital failed to ensure preventive actions were implemented after the identification of an adverse event.

Findings include:

1) Medical record review indicated Patient #1 was discharged on 6/15/11 from the Hospital inpatient unit to the Skilled Nursing Facility (SNF) for rehabilitation.

2) The Director of Clinical Operations (Director) was interviewed in person at various times during the 8/1/11-8/2/11 survey. The Director said on Friday, two days after Patient #1 had been discharged, she received a call from the SNF informing her they were sending Patient #1 back to the Hospital because he/she was a level III sex offender and therefore could not be at the SNF. The Director said up until this point Patient #1's status as a level III sex offender was unknown because Patient #1 had not provided information related to his/her Level III sex offender status when hospitalized. The Director said she was not familiar with the law, so she sought advice from other facilities, but did not get answers to her questions.

The Director said since the SNF had agreed to place Patient #1 on 1:1 observation and keep Patient #1 at the SNF until Monday, 6/20/11 and she was unsure of what the law required; she had not notify anyone at the Hospital, or enter information in the medical record about Patient #1's level III sex offender status.

3) Review of documentation indicated Patient #1 was brought to the Hospital ED on Saturday, 6/18/11, at 12:38 PM, for evaluation of leg cramps. The physical examination and laboratory test results were unremarkable. Patient #1 was discharged back to the SNF in stable condition at 2:48 PM. Documentation did not indicate Patient #1's Level III sex offender status was noted.

4) The Director said, and documentation indicated Patient #1 was discharged on Monday 6/20/11 from the SNF back to the Rest Home where he/she resided prior to hospitalization. However, Patient #1 was deemed inappropriate for admission, due to a abdominal bloating, constipation and leg pains and was sent to the Hospital's ED. Patient #1 was assessed and admitted to an inpatient unit on 6/21/11.

5.) The Director said a meeting was held 6/20/11 to discuss Patient #1's discharge needs. The Director said that since this incident, no change had been made to the discharge process to ensure those patients, who were newly identify or previously identified as a Level III sex offender, were referred/discharge to an appropriate care setting.

6.) Review of documentation indicated the Social Worker arranged for Patient #1's discharge. Patient #1 and Patient #1's Attorney were involved in the discharge process and agreeable to the discharge placement. Patient #1 was discharge, on 6/23/11, to a Rehabilitation facility who were made aware of Patient #1's Level III sex offender status.