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Based on interview, record review, and facility policy review, the facility failed to ensure an individual's emergency department (ED) records were transmitted upon discharge for one (1) of ten (10) sampled patients, Patient #2 (P2).

Patient #2 (P2) was transported to the facility's ED, via emergency medical services (EMS), on 01/10/2022, from the long term care (LTC) facility that he/she resided in. However, the facility's ED Physician documented P2 seemed competent, and the patient was discharged from the ED in a cab to return "home," which was the LTC facility he/she resided at.

The findings include:

Review of the facility's policy entitled, "ED-Discharge/Follow-up Care Instructions for Emergency Department Patients", last reviewed 04/2021, revealed the purpose was to instruct patients of their discharge instructions and ensure the patient had a a Physician for his/her follow-up care.

Review of the EMS run sheet dated 01/10/2022, revealed P2 was transported from the LTC facility in which he/she resided at 11:00 PM. Continued review revealed documentation noting P2 had fallen, hitting his/her head; however, without reported loss of consciousness. Per review of the EMS run sheet, P2 was assessed as alert and oriented "x4" (oriented to person, place, time, and situation). Further review of the EMS run sheet revealed Patient #2 arrived at the facility's ED via EMS on 01/10/2022, at 11:13 PM, related to a fall at the LTC where he/she resided.

Review of P2's hospital ED record revealed the ED Physician noted P2 seemed to be competent, and as stable at the time of discharge.

Review of the ED Patient Care Timeline dated 01/10/2022, at 11:28 PM through 01/11/2022, at 9:21 AM, revealed P2 arrived to the facility on 01/10/2022, at 11:28 PM, from a LTC facility. Continued review revealed triage (process of quickly examining sick or injured people) was initiated at 11:30 PM, and the chief complaint (CC) for P2 was updated to include Fall and Hyperglycemia (high blood sugar). Further review revealed at 12:33 AM, on 01/11/2022, orders for laboratory work (labs) and imaging (computerized tomography [CT] of the head/spine) were placed. Review further revealed P2 allowed the CT imaging to be performed, and the CT of his/her head/spine were both negative for injury. In addition, review revealed multiple attempts were made to draw P2's ordered labs, vital signs and blood sugar checks with the patient refusing all attempts.

Additional review of the ED Patient Care Timeline dated 01/10/2022 through 01/11/2022 at 9:21 AM, revealed at 9:16 AM, on 01/11/2022, P2 was discharged from the ED in stable condition, and he/she left in a cab, alone.

Review of the ED Provider Notes dated 01/11/2022, revealed P2 reported "kids and toys" caused him/her to fall at home. Continued review of the ED Provider Notes revealed P2 was alert and oriented; however, declined to allow a full medical screening exam (MSE). Further review revealed the Medical Provider documented P2 "vehemently" crossed his/her arms and stated he/she wanted to go home and had money to do so. Review of the ED Key Information revealed the "home" P2 was referring to was the LTC facility.

During an interview on 04/10/2024 at 2:10 PM, the ED Charge Nurse stated she was familiar with the incident that occurred on 01/10/2022; however, did not know anything about P2's discharge. The Charge Nurse stated there had been "immediate" education provided to ensure patients were discharged appropriately. She stated her expectation was if an individual arrived via EMS from an outside facility, such as a long term care (LTC) facility, the individual was to be returned to the facility via EMS, and not per cab.

(The facility declined to provide a copy of the incident report and Root Cause Analysis (RCA) for the State Survey Agency [SSA] Surveyor's review).

In interview on 04/10/2024 at 3:03 PM, Registered Nurse (RN) #4 stated she was "fairly new" to the ED, but had received education on appropriate patient disposition in her orientation. RN #4 further stated she would review a patient's EMS run sheet and consult with the patient's guardian, as applicable.

In an interview on 04/11/2024 at 9:14 AM, RN #5, stated there were "checks and balances" to utilize, related to disposition of a patient from an outside facility. He stated phone reports, the EMS run sheet, and patient transfer sheets were options to use to ensure patients were discharged appropriately.

During an interview with the Director of Emergency Services (DES) on 04/11/2024 at 9:27 AM, she stated she had reviewed the incident report involving P2 and met with the ED Leadership as the facility determined there had been a failure in the discharge process, and education was provided. The DES stated based on P2's recollection of events leading to the fall, the focus of the facility's staff education became recognizing dementia patients and following the proper processes for discharge of patients. She stated the facility's internal investigation regarding the incident revealed a failure to follow its discharge process, compounded by "inaccurate" patient information.