HospitalInspections.org

Based on interview and record review the facility failed to assess discharge needs, form a safe discharge plan, notify the responsible party and ensure discharge to a safe environment for one (#1) of three vulnerable Emergency Department patients reviewed for discharge planning. (See specific tags)

A - 0800 The facility failed to assess discharge needs for one (#1) legally incapacitated and physically impaired Emergency Department patient, resulting in his being lost on the street for 18 hours after he was discharged home alone via public transportation (bus) after an orthopedic procedure with sedation without the facility informing the patient's legal guardian or the Group Home of the patient's discharge.

Based on interview and record review, the facility failed to assess discharge needs for one (#1) legally incapacitated and physically impaired Emergency Department (ED) patient out of three cognitively impaired ED patients reviewed out of a total of six patients reviewed for discharge planning, resulting in the facility's failure to notify the Legal Guardian or the patient's Group Home of the Patient's discharge, resulting in the patient being missing for 18 hours during freezing temperatures and sustaining a leg laceration, after he was discharged home alone via bus after an orthopedic procedure with sedation. This has the potential to effect any physically or cognitively impaired patient brought to the ED alone by ambulance as well as any unaccompanied patient undergoing a procedure with sedation in the ED with the potential to cause serious injury or adverse outcome. Findings include:

On 2/27/19 at approximately 1530, Patient #1's clinical record was reviewed with Staff A and Staff B and revealed the following:

Patient #1 was a 52 year old male who was brought to the facility Emergency Department (ED) by ambulance on 2/21/19 at 1032 for "Left leg Pain and Swelling after a Fall." An ambulance (EMS) "Envelope of Life" transfer form noted that Patient #1 had a legal guardian and resided at a Group Home (assisted living). The address and telephone numbers of both the Group Home and the Legal Guardian (professional guardianship service) were noted on the form. This form also noted that Patient #1's medical problems included fracture of left (L) femur neck (hip), alcohol abuse, muscle weakness and difficulty walking. The form documented that Patient #1's injury was a fall at his "nursing home" on 2/21/19. His mental status was documented as slightly impaired as he was not oriented to time (Alert and Oriented (A + O) x 3 out of 4). The EMS narrative note documented that report (summary of information on the patient) was given by the EMS to the nursing staff when they transferred Patient #1 to their care.

A facility facesheet listed a different address for Patient #1 from the one documented on the EMS paperwork (Group Home's address), and recorded that he was his own responsible party. There was no documentation to indicate that facility Patient Registration personnel had reviewed the information on the EMS transfer forms to determine the patient's true home address and responsible party.

An ED triage assessment documented by Staff Nurse M and Staff Nurse N on 2/21/19 at 1056 contained four contradictory notations for the patient's history of his present illness, three of which were crossed out. The entry that was not crossed out noted that the patient reported, "hip surgery some time in the recent past, fell two days ago (n.b. EMS documentation given to the facility noted the fall occurred on 2/21/19), and has increased difficulty walking, now with cane/walker, tender to move. Drinker. Patient (pt) from (Name and telephone number of Group Home noted)." The reason for the ED visit was documented as, " fall s/p (after) left hip surgery." His cognition was documented as intact (A + O x 4). The nursing triage assessment noted that Patient #1 had a history of jaw and leg surgeries from prior fractures due to falls. There was no assessment of his living situation or any documentation that EMS documentation or documents transferred from the Group Home were reviewed.

An ED Nursing Assessment documented by Staff M dated 2/21/19 at 1130 documented that Patient #1 was at high risk for falls with a Hendrich II Fall Risk Score of 9 (>5 is at risk for falls). The fall risk assessment documented the nurse assessed Patient #1's judgement as impaired. There was no documentation to indicate that Paperwork received from the EMS or Group Home was reviewed. There was no documentation to indicate that Patient #1's living situation, guardianship status or discharge planning needs were reviewed or assessed.

A "Consent for Treatment" was verbally obtained by a nurse for Patient #1 on 2/21/19 at 1103, despite the patient's status as a legally incapacitated person. There was no documentation to indicate that the Legal Guardian's consent for treatment was requested. A "Consent for Procedure" form for "procedural sedation and hip reduction" was signed by the patient on 2/21/19 at 1330. There was no documentation to indicate that the Legal Guardian's consent for the procedure was requested or that the patient's legal guardian or his Group Home were notified.

An ED Physician's Documentation by Staff O dated 2/21/19 at 1113 documented that Patient #1 reported he had a fall in "Rehab" "three days ago" and had hip surgery a week prior to that. Past medical history was documented as "Bilateral Jaw Surgeries from previous fall, Hip Replacement, and Rod in left hip". Staff O documented that Patient #1 had some cognitive impairment, noting that he was alert and oriented x 3 (out of 4) and was "a somewhat poor historian." The documentation noted that X-rays showed posterior dislocation of the left hip prosthesis (artificial hip) and that the patient signed consents for procedural sedation and reduction (repair of the dislocated hip). This documental also noted that Patient #1 was sedated with 70 milligrams (mg) of propofol (injectable sedative hypnotic used for induction of anesthesia or for short procedures) for the dislocated hip repair procedure. After the procedure Patient #1 was placed in a knee immobilizer and given multiple doses of an oral narcotic pain medication and treated with an intravenous solution for hyponatremia (low sodium level). Patient #1 was then cleared for discharge by Staff O pending results of a neck and head computerized tomography (CT) scan. There was no documentation to indicate that Staff O had reviewed Patient #1's paperwork received by the facility from the EMS or the Group Home. There was no documentation to indicate that Staff O had assessed Patient #1's living situation, ability to ambulate safely, ability to care for himself safely after discharge from a procedure with sedation, presence of a responsible adult to drive him home after the procedure his guardianship status, or his discharge planning needs.

An ED Physician documentation by Staff Y dated 2/12/19 at 1636 documented that she reevaluated Patient #1 prior to discharge. Staff O noted that Patient #1 was A + O x 3 and was given another dose of acetaminophen/hydrocodone (narcotic pain medication) for pain prior to discharge. Staff O documented, "At this time patient is deemed stable for discharge with follow-up with his orthopedic surgeon at (other hospital)." "Final Disposition" was documented as, "discharge to home, follow up with orthopedic surgery." There was no documentation to indicate that the facility had assessed Patient #1 's discharge needs or checked whether he had a responsible adult to drive him home after his procedure. There was no documentation to indicate that Patient #1's ability to ambulate safely without assistance was assessed. There was no documentation to indicate that Patient #1's status as a legally incapacitated individual with a court appointed legal guardian was noted. There was no documentation to indicate that Patient #1's living situation was evaluated or noted. There was no documentation to indicate that paperwork transferred to the facility by the EMS was reviewed.

An ED discharge summary by Staff Nurse L dated 2/21/19 at 2037 documented that Patient #1 was discharged to the lobby in stable condition with a left knee immobilizer. There was no documentation to indicate that Patient #1's safe discharge needs were assessed. There was no documentation that Patient #1's ability to be safely discharged alone to the lobby was assessed. There was no documentation that Patient #1's ability to ambulate safely without assistance was assessed. There was no documentation to indicate that Patient #1's living situation was assessed or reviewed. There was no documentation to indicate that legal guardian and Group Home information (provided on arrival at the ED) was reviewed prior to discharge. There was no documentation to indicate that Patient #1's legal guardian or the Group Home were contacted prior to discharge. There was no documentation of why staff did not follow the facility policy that required a patient to be driven home by a responsible adult (no public transportation) after a procedure with sedation.

Discharge Instructions dated 2/21/19 at 2039 documented that Patient #1 was given a prescription for opioid pain medications. The discharge instructions included patient information noting, "there is a high risk for complications after a hip dislocation." Patient instructions included the following, "If you received conscious or procedural sedation, please see instructions below: for the next eight hours you should be watched by a responsible adult to look for any worsening of your condition." The Discharge Instructions (Patient Education) form was blank in the signature fields (not signed by either the patient or the health care provider).

A Clinical Events Note by ED Patient Representative Staff K documented 2/22/19 at 1527 noted the following, "Spoke with patient this morning at approximately 0630 in regards to getting home. Patient called sister for transportation, however the phone was disconnected. patient left the ER at approximately 0700 with bus ticket and transfer stating he was taking the bus home."

A Case Management/Social Work Note dated 2/22/19 at 1340 noted, "Received transferred call from Guardian Company about Pt (patient) who was reportedly discharged yesterday. Pt was not a mental health patient and Social Work (SW) was not consulted. Spoke with Charge Nurse and transferred call." There was no other Case Management or Social Work documentation for Patient #1.

On 2/27/19 at approximately 1500 a facility "Safety Event Entry" dated 2/22/19 at 1434 was provided for review. This documented the facility investigation and root cause analysis (RCA) into an incident regarding Patient #1 dated 2/22/19 at 2000. The event description was noted as, "patient was sent in from group home, Patient was seen and discharged home by staff to waiting room instead of group home being called. " The document and RCA was labeled, "Incomplete still under review."

On 2/27/19 at approximately 1400, the facility Risk Manager, Staff I was interviewed during a review of the facility Safety Event regarding Patient #1 dated 2/22/19 at 2000. Staff I was asked what happened and stated, "The patient spent the night in the ED lobby. In the morning, he asked the ED Patient Representative (Staff K) for a ride home. We offered him a phone to call his sister but the number was disconnected. (Staff K) gave him a bus ticket to get home. We only found out about the incident on Saturday (2/22/19) when his Legal Guardian called us, so we haven't finished our root cause analysis of the incident yet or identified corrective measures."

On 2/27/19 at approximately 1435, Staff Nurse N was interviewed regarding Patient #1. Staff N said, "He had a hip dislocation from a fall. I was told by the EMS that he was from a "shady Rehab (rehabilitation facility)". He was a poor historian. He said he had a hip replacement surgery one week ago but his scar was clearly an older scar. Other than being a poor historian, he was alert and oriented for me. He came in alone and didn't have any visitors. We normally get a whole stack of papers from the EMS. Normally I would give the stack of papers to the doctor. I don't believe I knew he had a guardian. He wasn't a mental health patient so there wouldn't be any trigger to call Case Management."

On 2/27/19 at approximately 1450 the Director of Nursing, Staff B was interviewed and reported that ED nurses should receive a packet of documents about the patient from the EMS staff and should review the information contained in the documents before scanning them into the electronic medical record (EMR). Staff B stated that documentation that Patient #1 had a Legal Guardian and lived in a Group Home was scanned into Patient #1's EMR and should have been reviewed by the nurse and the physician as part of their initial patient assessment.

On 2/27/19 at approximately 1510, the ED Patient Representative Staff K was interviewed and reported that she first noticed Patient #1 in the ED lobby at approximately 0630 when he came up to the reception desk and asked to use the phone to call his sister. Staff K said, "He said that her number was disconnected and asked for a bus ticket. I looked at our ticket book and saw that he'd already been given a bus ticket and a bus transfer so I told him that we'd already given him one. He said, "oh yeah" and pulled it out of his pocket. At first he said he came from 2E (second floor inpatient unit) and said they sent him down. I looked in the computer and saw that he was discharged from the ED and I told him that. I saw him leave."

On 2/28/19 at approximately 0828 Patient #1's legal guardian Staff T was interviewed by telephone. Staff T reported that Patient #1 was unsteady on his feet and used a wheelchair for mobility since his hip replacement surgery after a fall with fracture three months ago. Staff T stated that Patient #1 fell on 2/21/19 while trying to reach for a shirt in his closet. The Group Home staff sent him by ambulance (EMS) to the ED to be evaluated after this fall as he had pain and swelling in his prosthetic hip. Staff T stated that in addition to paperwork provided to the hospital by the EMS, the Group Home always sent a copy of his Group Home Medical Record Face Sheet and legal guardianship papers with each patient when they sent them to the hospital. Staff T stated that she called the ED on 2/21/19 at 1330 to check on Patient #1 and spoke to his assigned nurse (first name given) and identified herself as Patient #1's legal guardian. Staff T stated that the Group Home notified her on 2/22/19 that Patient #1 still hadn't returned from the ED so she called the facility on 2/22/19 at 1247 and found out that the patient was discharged. Staff T stated that she was very upset that the facility had discharged Patient #1 without notifying either her or the Group Home Staff and said that they were all very upset and concerned as it was 19 degrees Fahrenheit and icy outside and nobody knew where he was. Staff T said that he was sent to the hospital without his wheelchair and she was very worried about his safety as he was very unsteady on his feet and liable to fall. Staff T stated that she complained to facility ED management and Case Management management on 2/22/19 at approximately 1250 that Patient #1 was discharged without notifying either the legal guardian or the group home.

On 2/28/19 at approximately 1000 the facility policy entitled, "Discharge Planning Case Management", revised 1/2019 was reviewed and revealed the following statements:

"The responsibility of the Case Management Department is to collaborate with the physician, nursing, other departmental staff as well as the patient/family/caregiver in planning and implementing effective and realistic aftercare."

"Case Managers should routinely open these types of cases: Patients that have had surgical procedures that will need assistance of some type in getting back home, Patients that reside at an assisted living/adult foster care home/group home, No family members available to assist patient in completing plans."

On 2/28/19 at approximately 1300 the facility policy entitled, "Guidelines for Moderate Sedation for Short Term Therapeutic, Diagnostic or Surgical Procedures", revised 2/2019 revealed the following statements, "Outpatients receiving IV sedation should be informed that they need a designated adult driver (not public transportation) to return them home following/after the procedure. Patients who have received anesthesia in the outpatient setting should be discharged in the company of a responsible, designated person."