HospitalInspections.org

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Based on record review and interview the facility failed to ensure the hospital met the Condition of Participation for Patient Rights. The hospital failed to assure patient representative's rights were protected and promoted. Due to the severity of deficient practice at CFR 482.13(b)(2), an immediate jeopardy occurred under CFR 482.13 Patient Rights.

Findings:

A-0131 - Patient Right: Right to informed decisions regarding care: The facility failed to:

1) Notify legal guardians when patients were discharged from the emergency department (ED) to their place of residence.

This failed practice constituted an immediate jeopardy to Patient #1's health and safety that resulted in physical harm to the patient and had the potential for all patients with legal guardians or medical power of attorney to be at risk for harm. This situation was brought to the attention of the facility's administration on June 26, 2019 at 12:40 pm, at which time the facility was notified of the deficient practice and high risk to patients.

The immediacy was removed by the facility by June 27, 2019 at 8:15 am and confirmed by the on site survey team at 9:50 am.
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Based on record review and interview the facility failed to allow 1 patient's (#1) legal guardian out of 3 sampled patients with legal guardians, the right to make decisions about treatment plans and discharges from the emergency department (ED) which placed the patient in immediate jeopardy and caused serious harm. Specifically, the facility failed to notify the legal guardian when the patient was discharged after evaluation in the ED.

This failed practice resulted in physical harm for 1 patient (#1), (an incapacitated individual) when given a cab voucher from the ED and discharged to a local homeless shelter versus place of origin. Findings:

This situation was brought to the attention of the facility's administrator on June 26th, 2019 at 12:40 pm, at which time the facility was notified of the deficient practice and high risk to patients. The immediacy was removed by the facility by June 27th, 2019 at 8:15 am and verified by the onsite survey team at 9:50 am.

Patient #1

Record review on 6/5-6/2019 and 6/25-27/2019 of the Anchorage Fire Department, Prehospital Report revealed Patient #1 was transported from the Horizon House (Assisted Living Facility) to Providence Medical Anchorage Center (PMAC) ED.

Record review on 6/5-6/2019 and 6/25-27/2019 revealed Patient #1 had an active diagnosis list that included depression, homelessness, legal status (Office of Public Advocacy), opioid overdose, paranoid schizophrenia (a severe mental disorder that can result in hallucinations, delusions and extremely disordered thinking and behavior), neurocognitive disorder (decreased mental function due to medical disease other than psychiatric illness) and polysubstance abuse (consumption of more than one drug at once).

Record review on 6/5-6/2019 and 6/25-27/2019 revealed on 5/30/19 at 10:03 pm, Patient #1 presented to PAMC ED from his/her assisted living facility via ambulance complaining of chest pain. Patient #1 was later discharged from PAMC ED on 5/31/2019 at 12:48 am via taxi to a local area homeless shelter. There was no documentation of notification of the legal guardian at discharge.

Review on 6/5-6/2019 and 6/25-27/2019 of licensed nurse (LN) #3 ED note from 5/30/19 at 10:17 pm revealed the following: "Pt BIBA [brought in by ambulance] from Assisted Living Facility Horizon House 4140 Folker".

Review on 6/5-6/2019 and 6/25-27/2019 of Medical Doctor (MD) #1 ED encounter note dated 5/30/2019 at 10:40 pm, revealed the following: "Discharge Instructions: please follow up with the Alaska Heart Institute for further evaluation and care. If your symptoms worsen please return to the emergency department. Discharge References/Attachments: chest pain, noncardiac (English)". Patient #1 was discharged from PAMC ED on 5/31/19 at 12:48 am.

There were no additional discharge instructions in Patient #1's chart centered on the 5/30/2019 ED encounter.

Further review of Patient #1 medical record revealed the Patient was later transported back to PAMC ED on 5/31/2019 at 7:25 am with principal problems including multiple right facial bone fractures (complete or partial break in a bone) with skull base fracture to the sphenoid bone (a single bone, the body of which lies in the midline and articulates with the occipital bone and the temporal bone to form the base of the cranium). These injuries were acquired at the homeless shelter after discharge and transportation via taxi voucher provided by PAMC.

Review on 6/5-6/2019 and 6/25-27/2019 of the patient's electronic medical record (EMR) revealed documentation of full guardianship/conservationship (pursuant to AS 13.26.090 through .150) from the State of Alaska effective October 24th, 2016. The guardianship/conservationship outlined the following: "It has been shown through stipulation that by clear and convincing evidence the respondent is incapacitated, as that term is define by statute, and requires the appointment of a full guardian".

During an interview on 6/5/2019 at 8:30 am, when asked how staff would be made aware a patient has a legal guardian on file, LN#4 stated he/she it could be in the "free text" box in the patient's electronic medical record.
When asked how discharged patients retain cab vouchers, LN#4 stated the discharging LN requests taxi vouchers from the charge LN, then asks the patient where they would like to go, fills out the voucher and the patient waits in the lobby for the taxi to transport them to the designated location.

During an interview on 6/5/2019 at 3:20 pm with Patient #1, when asked about the events on 5/31/2019 the Patient reported being discharged from PAMC ED in a taxi but no recollection after the cab ride.

During an interview on 6/6/2019 at 5:05 am, when asked how staff was made aware of the guardianship status of patients, LN#5 stated the patient's Guardian was notified through the registration process.

During an interview on 6/6/2019 at 5:25 am Registrar #1 was asked how the registrar staff were made aware of a patient's guardianship status. Registrar #1 stated the legal guardian status was checked for all incoming patients to the ED by either record review or by listing of the patient's home address. If a guardian was notified the registrar staff documents this contact under the emergency contact box in the patient's EMR.

During an interview on 6/6/2019 at 8:35 am LN #1 confirmed there was no clear mechanism existing in the facility EMR system alerting staff of patient's guardianship status.

During a telephone interview on 6/6/2019 at 3:00 pm, the patient's guardian confirmed the facility did not make contact prior to the Patient being discharged from the ED via taxi on 5/31/2019 at 12:48 am.

Review of the facility policy number 4939594, titled "Discharge of Patient Process", last revised 8/2018, revealed in section B-2, "Notify the patient and designated care giver (or family/friend if appropriate and no designated caregiver) that a discharge order has been written. Review the care plan for identified discharge needs. If there are any unresolved needs, notify the case manager and/or attending physician as needed to assist with problem solution".
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