HospitalInspections.org

Based on the review of 7 closed medical records and 4 open medical records it was determined that the hospital failed to provide 1 of the 10 patient with an appropriate discharge that would avoid adverse consequences and promote safe after-care.

The 60+ year old patient #1 arrived via EMS to the emergency department at 0945 from group home with documentation of guardianship, code statue, medication regiment and pertinent medical history. Patient #1 had cognitive deficits. Patient #1's chief complaint was swelling to the right side of the face. The patient was examined, testing done, and imaging performed. After a few hour in the emergency department the patient was found to be stable for discharge. The ED clinician treating patient #1 documented "no acute findings and no signs of trauma. Given the chief complaint and the report of EMS and the group home opinion, there may be malingering components of this visit. Patient safe for d/c home."

Patient #1 was provided with discharge instruction and discharged from the hospital. According to patient# 1 medical record documentation, patient #1 was discharge to home independently on public transportation at 1555 on the same day as presenting to the hospital.

The hospital failed to notify either patient #1's guardian or the patient's group home of the patient's discharge, even though both were clearly identified in the record. Both the guardian and the group home were under the assumption that the patient #1 remained in the hospital overnight and was continuing to receive care. One day post discharge local law enforcement encountered the patient in a town miles away from either the hospital or the group home. It was through this encounter that the guardian and group home were made aware that patient #1 was not receiving treatment at the hospital.

The hospital failed to assess the discharge needs of patient #1 and failed to plan for patient #1's cognitive deficits when discharging with a bus pass. The hospital also failed to notify the legal guardian or care-givers from the residential setting. This lack of assessment denied the patient a safe discharge.