HospitalInspections.org

Based on interview and record review the facility failed to reassess the appropriateness of the discharge plan to ensure safe and effective transfer of the patient from hospital to post-discharge home care in 1 (SP#1) out of 4 sample patients (SP).

Findings include:

Sample Patient (SP) #1 Transport History dated 07/24/2020 at 4:20 PM documented the Transporter (Staff T) completed discharge transport for SP#1 to the main lobby.

Interview with the Registered Nurse (Staff N) on 07/30/2020 at 2:52 PM revealed SP#1 family was notified of patient's discharge. Stated confirmed family will be waiting at lobby. Stated patient was discharged around 4:00 PM and had no other communication with patient's family. Stated was notified by management around 7:00 PM that family was looking for SP#1.

Interview with the Hospital Investigator on 07/31/2020 at 10:41AM revealed SP#1 video footage as follows:
At 4:09 PM, observed patient (SP #1) leaving room via wheelchair by Staff T.
At 4:13 PM, observed Staff T with patient exiting the main entrance and patient transferred from wheelchair to the bench.
At 4:15 PM, observed Staff T go back into the facility through the main entrance. With the wheelchair. SP#1 observed sitting alone on the bench waiting for family to arrive.
At 4:28 PM, observed patient walking away from the facility.
At 7:13 PM, patient's family observed approaching Patient Experience staff.

Interview with Assistant Vice President Patient Experience on 07/30/2020 at 2:51 PM revealed, received a call in the evening of 07/24/2020 around 7:45 PM from Patient Experience staff to report staff trying to locate a patient that was discharged earlier. Stated search for patient initiated by facility staff and police was notified. Stated investigation conducted by facility leadership and police. Stated around 9:45 PM patient's family was notified patient found.

Review of SP#1 Emergency Department Provider Notes dated 07/24/2020 at 10:02 PM documented Chief Complaint: Altered Mental Status. The patient was actually just discharged earlier in the day however was sitting outside waiting for transportation, walked off property and went missing. Patient was located and returned to the hospital. Patient appears clinically dehydrated. Patient required readmission.

Interview with Executive Director Risk Manager on 07/30/2020 at 2:51 PM revealed opportunities for improvement were identified and Action Plan was created. Review of the Action Plan shewed it was initiated during the survey.


Review of the Action Plan initiated 07/30/2020 was not completed at the time of the survey. Completion date is 09/01/2020. Current status is ongoing.
The Patient Experience Department is the Responsible Party for the implementation of the action plan as follows:
1. Policy and Procedure: Develop a standard operating procedure that addresses transportation, handoff communication by Transport Staff to Patient Experience staff, wristband placement and log documentation. Evidence of Compliance: Policy approval, wristband and log documentation. Policy, Wristband and Log Documentation initiated 07/30/2020 and completed 07/30/2020.
2. Education: Patient Experience staff education on revised process at huddles and to leadership at Daily Huddles and Leadership Meeting. Transportation staff education on revised process. Evidence of Compliance: Attendance sign-in sheet. Education initiated 07/30/2020 and to be completed 09/01/2020.
3. Performance Monitoring: Develop monitoring tool, sample size, threshold, frequency of monitoring and reporting of results. Evidence of compliance: Conduct random observations of 20-patient discharges to home per month for 3-months. Target goal set for greater than 85% compliance. If threshold is sustained for 3-consecutive months, periodic spot checks. Results will be reported at Patient Safety Events Committee. Monitoring initiated 07/31/20202 and to be completed 09/01/2020.