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Based on review of the facility's policies and procedures, medical record review (#s 1-10), observations during a facility tour and staff interviews and statements, it was determined that the facility failed to provide care to the patient in a safe setting.

Findings were:

On 09/06/16 to 09/08/16, an EMTALA investigation was completed regarding the patient's inappropriate discharge. Employee #9 was again interviewed on 10/25/16. His/her previous interviews were reviewed with him/her and the employee was asked if any of his/her previous statements had changed and if he/she wanted to add anything. Employee #9 stated that his/her previous statements had not changed. Employee #9's additional statement is listed as the interview of 10/25/16.

Review of the facility's policy and procedure entitled, "Patient Rights and Responsibilities," revised 05/2016, A. Patient Rights (III)(8) indicated that the facility recognizes that each patient has the right to receive care in a safe environment free of neglect, exploitation, verbal, mental, physical or sexual abuse.
Review of the facility's Patient Safety Plan (2015-2016) revealed that the Hospital Safety Plan was designed to improve patient safety, reduce risk and respect the dignity of those served by assuring a safe environment. The leaders of the organization are responsible for fostering an environment through their personal example; emphasizing patient safety as a core organization value; providing education to medical staff, hospital staff and health care learners regarding the commitment to elimination of preventable harm events; supporting proactive reduction in healthcare errors; and integrating patient safety priorities in the new design and redesign of all relevant organization processes, functions and services.
Review of the facility's Emergency Department (ED) log and patient #'s 1 medical record revealed that the patient presented to the emergency department (ED) via a private ambulance from a nursing home (NH). Review of the the patient's record revealed that the NH reported that the patient was combative and had thrown an oxygen tank at a staff member.

The triage (assessment by a nurse to determine medical priority) was performed and patient #1 was triaged as a level three (3) patient and an identification bracelet was placed on the patient's right wrist. The patient's vital signs were essentially within normal limits. The triage RN noted patient to be alert and talking. A medical screening was performed. The patient had a history of end-stage COPD (chronic obstructive pulmonary disease-a disease that causes patients to have trouble breathing in and out, due to long-term damage to the lungs) and was currently on 2 liters (L) of oxygen by nasal cannula, which was her/his baseline. Physician orders included laboratory tests, x-rays, and a CT (computerized tomography scan takes cross-sectional images, or slices, inside the body) scan of the head. The record revealed that physician orders were carried out and patient assessments and re-assessments were completed by the ED staff throughout the remainder of that shift. The record revealed that shift change for medical and nursing staff occurred between 7:00 a.m. and 8:00 a.m. and at 9:13 a.m., the patient was discharged in error from the ED by employee #9.

During an interview on 09/07/16 at 3:00 p.m. in the nursing conference room, employee #9 stated that she/he had been an RN for twenty-six (26) years and had been employed in the ED for the last eleven (11) years. The RN stated that she/he works the day shift and remembered the patient and the patient's family well. The RN recalled that she/he was assigned a patient who had discharge orders written. The outgoing RN reported that she had not given the patient the discharge instructions. The RN stated that there were two (2) patients who were similar in size, hair, and looks in that six (6) bed ward, and that she/he noted that one of these two (2) patients was up getting dressed assisted by the nurse technician (NT). The nurse stated that she/he went up to patient #1 and asked if this was her name (the name of another patient that was really being discharged) and asked her/him if her/his doctor was (the name of the other patient's doctor) and that was she/he was ready to be discharged. Patient # 1 verbally acknowledged the RN's questions. The RN reviewed the discharge instructions with Patient #1 and escorted her/him from the ED. The nurse stated that she/he soon realized that she/he had discharged the wrong patient and she/he ran outside to try to catch the patient when she/he saw that patient #1 was being escorted back into the ED by her/his family. The RN stated that patient #1 had been gone less than thirty (30) minutes. The nurse stated that the patient's family was upset about the incident and that there was no paperwork from the NH. The patient was discharged later that day back to the NH.

During an interview on 09/09/16 at 10:15 a.m. in the nursing conference room, employee #9 stated that she/he came on at the change of shift and did not know the patients that had been assigned to her/him. The RN stated that she/he noted that the nurse technician (NT) had a patient up and was helping that patient dress to get ready to be discharged. The nurse stated that she/he assumed that this was the patient to be discharged and that she/he went over to patient #1 and started to give the patient her/his discharge instructions. The RN stated that patient #1 agreed that the name the RN called her/him (which was another patient's name) was indeed her/his name and that the physician the RN quoted was her/his physician. The nurse then stated that patient #1 stated that she/he was to see the social worker and that she/he walked with patient #1 over to the social worker's office and left her/him there and returned to the ED area. After approximately five (5) to ten (10) minutes later, the nurse realized her/his mistake and returned to the social worker's office to look for the patient. On not finding patient #1, the nurse went out of the ambulance entrance triage area to look for the patient and saw patient #1 and her/his family coming back into the ED. The nurse apologized for her/his mistake and brought patient #1 back to her/his area of the ED to finish the testing that was currently in progress. A sitter was obtained for patient #1 as she/he had attempted to leave several times before.

During an interview on 10/25/16 at 10:10 a.m., in the nursing conference room, Employee #9 (RN) stated that now, she/he checked the patient's armband every time she/he gave medications or administered a treatment or discharged a patient. The RN stated that proper patient identification consisted of the patient's name and date of birth. For certain medications, a nurse would get another nurse to verify medication dosages. The RN stated that they have increased the use of a bar scanner especially for medications and certain tests and treatments, and that the bar scanner assured proper patient identification. The nurse stated that the facility had sufficient bar scanners and that if one did not work correctly, the Help Desk would be called to get the scanner fixed. The nurse stated that presently, a yellow code appears on the computer system to flag all nursing home patients in order for nursing to identify these high risk patients. The nurse stated that all discharged patient remain in a special area or zone until their transportation arrives to take them back to the nursing home.
Further review of the medical record revealed documentation from physician #6 that the patient had eloped and was found outside by the patient's family as they were entering the ED. Documentation revealed that the patient was oriented to self and situation upon return to ED. The record further revealed that the nursing and medical staff performed assessments and reassessments including additional testing to assess the patient's respiratory status as she/he had been without her/his oxygen during the time she/he was discharged in error.

During an interview on 09/07/16 at 2:30 p.m. in the nursing conference room, physician #6 (attending physician) stated that he/she had not discharged the patient until after the CT of the head was obtained. The physician stated that the patient had a complete workup and that blood gases (measure of the amount of oxygen in the blood) were checked as the patient had been off of O2 during that period. In speaking with the NH and the family, the M.D. stated that there was no evidence that the patient had not returned to stable condition
Tour of the facility on 09/08/16 at 11:00 a.m. and 10/25/16 at 4:30 p.m. with the ED director revealed the ED had multiple patient treatment areas, each with a separate nursing station. Each treatment area was comprised of multiple patient bays. Ambulance services utilized a dedicated entrance/exit. All entry points into the ED were located on a highly congested street and sidewalk Tour of this area on 10/25/16 at 4:30 p.m., again revealed an environment that was heavily congested with people and vehicles including a large homeless population.
It was determined that the facility failed to properly identify patient #1, and that patient #1 was discharged in error, putting the patient at a possible risk of harm or injury. Patient #1 was also disoriented at times and was without his/her necessary oxygen for an undetermined amount of time. Patient #1 left the hospital unaccompanied and was found by the patient's family approximately two blocks away from the ED wandering around alone in the above noted environment.

Based on review of the facility's policies and procedures, medical record review (#s 1-10), staff interview and statements, and tour of the facility, it was determined that the facility failed to follow its plan of care and failed to properly identify a patient leading to the patient being discharged in error.

Findings were:
On 09/06/16 to 09/08/16, an EMTALA investigation was completed regarding the patient's inappropriate discharge. Employee #9 was again interviewed on 10/25/16. His/her previous interviews were reviewed with him/her and the employee was asked if any of his/her previous statements had changed and if he/she wanted to add anything. Employee #9 stated that his/her previous statements had not changed. Employee #9's additional statement is listed as the interview of 10/25/16.

Review of the facility's policy and procedure entitled "Plan of Care-Interdisciplinary," Standard PC.01.03.01 (B)(1) revised 10/2015 revealed that it is the policy of the facility to develop an interdisciplinary and individualized plan of care, treatment, and services appropriate to the patient ' s specific assessed needs. The plan is maintained, revised, modified, or terminated based on re-assessment, the results of diagnostic testing, the patient's response, achievement of goals, and/or transfer to another setting or discharge.
Review of the facility's policy and procedure entitled "Patient Identification," revised 05/2014 revealed that is was the policy of the facility to accurately identify each patient in a timely manner, thus promoting patient safety. The policy provides a standardized method of identifying each patient presenting for care, treatment or service, then matching the service provided to ensure the quality of patient care. This would be accomplished at the point of access and throughout the health system as care, treatment or service is provided. Patient identification starts when the patient presents to the health system and does not end until care, treatment and service has been terminated and/or the patient is discharged. Prior to providing care, treatment and/or service, all employees must ensure the patient has been properly identified. Patient identifiers are data that identify a specific patient. Alert and oriented patients should identify themselves by stating their name and date of birth. For unconscious or disoriented patients, employees will check identification band/armband for patients ' names and dates of birth and have information confirmed by nurse, caregiver or family member. The facility allows the use of the armband for identification. In order for the armband to be used for identification, it must contain two (2) acceptable identifiers: name and date of birth.

Review of the facility's Emergency Department (ED) log and patient #'s 1 medical record revealed that the patient presented to the emergency department (ED) via a private ambulance from a nursing home (NH) The record stated that the NH reported that the patient was combative and threw an oxygen tank at a staff member.

The triage (assessment by a nurse to determine medical priority) was performed and patient #1 was triaged as a level three (3) patient and an identification bracelet was placed on the patient's right wrist. The patients vital signs were essentially within normal limits. The triage RN noted patient to be alert and talking. A medical screening was performed. The patient had a history of end-stage COPD (chronic obstructive pulmonary disease-a disease that causes patients to have trouble breathing in and out, due to long-term damage to the lungs) and was currently on 2 liters (L) of oxygen by nasal cannula, which was her/his baseline. Physician orders included laboratory tests, x-rays, and a CAT scan of the head. The record revealed that physician orders were carried out and patient assessments and re-assessments were completed by the ED staff throughout the remainder of that shift. The record revealed that shift change for medical and nursing staff occurred between 7:00 a.m. and 8:00 a.m. and at 9:13 a.m., the patient was discharged in error from the ED by employee #9.

During an interview on 09/07/16 at 3:00 p.m. in the nursing conference room, employee #9 stated that she/he had been an RN for twenty-six (26) years and had been employed in the ED for the last eleven (11) years. The RN stated that she/he works the day shift and remembered the patient and the patient's family well. The RN recalled that she/he was assigned a patient who had discharge orders written. The outgoing RN reported that she had not given the patient the discharge instructions. The RN stated that there were two (2) patients who were similar in size, hair, and looks in that six (6) bed ward, and that she/he noted that one of these two (2) patients was up getting dressed assisted by the nurse technician (NT). The nurse stated that she/he went up to patient #1 and asked if this was her name (the name of another patient that was really being discharged) and asked her/him if her/his doctor was (the name of the other patient's doctor) and that was she/he was ready to be discharged. Patient # 1 verbally acknowledged the RN's questions. The RN reviewed the discharge instructions with Patient #1 and escorted her/him from the ED. The nurse stated that she/he soon realized that she/he had discharged the wrong patient and she/he ran outside to try to catch the patient when she/he saw that patient #1 was being escorted back into the ED by her/his family. The RN stated that patient #1 had been gone less than thirty (30) minutes. The nurse stated that the patient's family was upset about the incident and that there was no paperwork from the NH. The patient was discharged later that day back to the NH.

During an interview on 09/09/16 at 10:15 a.m. in the nursing conference room, employee #9 stated that she/he came on at the change of shift and did not know the patients that had been assigned to her/him. The RN stated that she/he noted that the nurse technician (NT) had a patient up and was helping that patient dress to get ready to be discharged. The nurse stated that she/he assumed that this was the patient to be discharged and that she/he went over to patient #1 and started to give the patient her/his discharge instructions. The RN stated that patient #1 agreed that the name the RN called her/him (which was another patient's name) was indeed her/his name and that the physician the RN quoted was her/his physician. The nurse then stated that patient #1 stated that she/he was to see the social worker and that she/he walked with patient #1 over to the social worker's office and left her/him there and returned to the ED area. After approximately five (5) to ten (10) minutes later, the nurse realized her/his mistake and returned to the social worker's office to look for the patient. On not finding patient #1, the nurse went out of the ambulance entrance triage area to look for the patient and saw patient #1 and her/his family coming back into the ED. The nurse apologized for her/his mistake and brought patient #1 back to her/his area of the ED to finish the testing that was currently in progress. A sitter was obtained for patient #1 as she/he had attempted to leave several times before.

During an interview on 10/25/16 at 10:10 a.m., in the nursing conference room, Employee #9 (RN) stated that now she/he checked the patient's armband every time she/he gave medications or administered a treatment or discharged a patient. The RN stated that proper patient identification consisted of the patient's name and date of birth. For certain medications, a nurse would get another nurse to verify medication dosages. The RN stated that they have increased the use of a bar scanner especially for medications and certain tests and treatments, and that the bar scanner assured proper patient identification. The nurse stated that the facility had sufficient bar scanners and that if one did not work correctly, the Help Desk would be called to get the scanner fixed. The nurse stated that presently, a yellow code appears on the computer system to flag all nursing home patients in order for nursing to identify these high risk patients. The nurse stated that all discharged patient remain in a special area or zone until their transportation arrives to take them back to the nursing home.
Further review of the medical record revealed documentation from physician #6 that the patient had eloped and was found outside by the patient's family as they were entering the ED. Documentation revealed that the patient was oriented to self and situation upon return to ED. The record further revealed that the nursing and medical staff performed assessments and reassessments including additional testing to assess the patient's respiratory status as she/he had been without her/his oxygen during the time they were discharged in error.

During an interview on 09/07/16 at 2:30 p.m. in the nursing conference room, physician #6 (attending physician) stated that he/she had not discharged the patient until after the CT of the head was obtained. The physician stated that the patient had a complete workup and that blood gases (measure of the amount of oxygen in the blood) were checked as the patient had been off of O2 during that period. In speaking with the NH and the family, the M.D. stated that there was no evidence that the patient had not returned to stable condition
Tour of the facility on 09/08/16 at 11:00 a.m. and 10/25/16 at 4:30 p.m. with the ED director revealed the ED had multiple patient treatment areas, each with a separate nursing station. Each treatment area was comprised of multiple patient bays. Ambulance services utilized a dedicated entrance/exit. All entry points into the ED were located on a highly congested street and sidewalk Tour of this area on 10/25/16 at 4:30 p.m., again revealed an environment that was heavily congested with people and vehicles including a large homeless population.
It was determined that the facility failed to properly identify patient #1, and that patient #1 was discharged in error, putting this patient at a possible risk of harm or injury. Patient #1 was also disoriented at times and was without his/her necessary oxygen for an undetermined amount of time. Patient #1 left the hospital unaccompanied and was found by the patient's family approximately two blocks away from the ED. The environment was heavily congested with people and vehicles including a large homeless population. The facility also failed to include in their nursing care plan: the proper monitoring of the patient after discharge, transportation issues, and the effective transfer of the care of the patient from one caregiver to another caregiver.

Based on review of the facility's policies and procedures, medical records (#s 1-10), staff interviews and statements and observations made during a tour of the facility, it was determined that the facility failed to have a discharge plan that ensured that the care of the patient after the patient left the ED area was followed.

Findings were:

On 09/06/16 to 09/08/16, an EMTALA investigation was completed regarding the patient's inappropriate discharge. Employee #9 was again interviewed on 10/25/16. His/her previous interviews were reviewed with him/her and the employee was asked if any of his/her previous statements had changed and if he/she wanted to add anything. Employee #9 stated that his/her previous statements had not changed. Employee #9's additional statement is listed as the interview of 10/25/16.

The facility did not have a policy and procedure that addresses the Discharge Process in the Emergency Department. Review of the facility's policy and procedure entitled "Discharge Planning Process, Inpatient Stay," revised 06/2016, revealed that The Care Management Team would interact with patients and patient's families/representatives to facilitate the discharge planning process. Discharge planning process must be thorough, clear and understood by all care team members. As such, the discharge planning process is an interdisciplinary, coordinated effort by which designated staff address the individual care needs of the patient as he/she moves through the continuum of care. (1)(h) Identification of High Risk Patients-A patient will be considered "high risk" if he/she has...altered mental status/cognitive deficit. (2) Intervention/Planning-(7) Coordinate discharge disposition, home health services, community referrals, transportation and other social services needs with patient caregiver or family. Patients will be provided options for service delivery and their preference will dictate the referral process.
Review of the facility's Emergency Department (ED) log and patient #'s 1 medical record revealed that the patient presented to the emergency department (ED) via a private ambulance from a nursing home (NH) The record stated that the NH reported that the patient was combative and threw an oxygen tank at a staff member.

The triage (assessment by a nurse to determine medical priority) was performed and patient #1 was triaged as a level three (3) patient and an identification bracelet was placed on the patient's right wrist. The patients vital signs were essentially within normal limits. The triage RN noted patient to be alert and talking. A medical screening was performed. The patient had a history of end-stage COPD (chronic obstructive pulmonary disease-a disease that causes patients to have trouble breathing in and out, due to long-term damage to the lungs) and was currently on 2 liters (L) of oxygen by nasal cannula, which was her/his baseline. Physician orders included laboratory tests, x-rays, and a CAT scan of the head. The record revealed that physician orders were carried out and patient assessments and re-assessments were completed by the ED staff throughout the remainder of that shift. The record revealed that shift change for medical and nursing staff occurred between 7:00 a.m. and 8:00 a.m. and at 9:13 a.m., the patient was discharged in error from the ED by employee #9.

During an interview on 09/07/16 at 3:00 p.m. in the nursing conference room, employee #9 stated that she/he had been an RN for twenty-six (26) years and had been employed in the ED for the last eleven (11) years. The RN stated that she/he works the day shift and remembered the patient and the patient's family well. The RN recalled that she/he was assigned a patient who had discharge orders written. The outgoing RN reported that she had not given the patient the discharge instructions. The RN stated that there were two (2) patients who were similar in size, hair, and looks in that six (6) bed ward, and that she/he noted that one of these two (2) patients was up getting dressed assisted by the nurse technician (NT). The nurse stated that she/he went up to patient #1 and asked if this was her name (the name of another patient that was really being discharged) and asked her/him if her/his doctor was (the name of the other patient's doctor) and that was she/he was ready to be discharged. Patient # 1 verbally acknowledged the RN's questions. The RN reviewed the discharge instructions with Patient #1 and escorted her/him from the ED. The nurse stated that she/he soon realized that she/he had discharged the wrong patient and she/he ran outside to try to catch the patient when she/he saw that patient #1 was being escorted back into the ED by her/his family. The RN stated that patient #1 had been gone less than thirty (30) minutes. The nurse stated that the patient's family was upset about the incident and that there was no paperwork from the NH. The patient was discharged later that day back to the NH.

During an interview on 09/09/16 at 10:15 a.m. in the nursing conference room, employee #9 stated that she/he came on at the change of shift and did not know the patients that had been assigned to her/him. The RN stated that she/he noted that the nurse technician (NT) had a patient up and was helping that patient dress to get ready to be discharged. The nurse stated that she/he assumed that this was the patient to be discharged and that she/he went over to patient #1 and started to give the patient her/his discharge instructions. The RN stated that patient #1 agreed that the name the RN called her/him (which was another patient's name) was indeed her/his name and that the physician the RN quoted was her/his physician. The nurse then stated that patient #1 stated that she/he was to see the social worker and that she/he walked with patient #1 over to the social worker's office and left her/him there and returned to the ED area. After approximately five (5) to ten (10) minutes later, the nurse realized her/his mistake and returned to the social worker's office to look for the patient. On not finding patient #1, the nurse went out of the ambulance entrance triage area to look for the patient and saw patient #1 and her/his family coming back into the ED. The nurse apologized for her/his mistake and brought patient #1 back to her/his area of the ED to finish the testing that was currently in progress. A sitter was obtained for patient #1 as she/he had attempted to leave several times before.

During an interview on 10/25/16 at 10:10 a.m., in the nursing conference room, Employee #9 (RN) stated that now, she/he checked the patient's armband every time she/he gave medications or administered a treatment or discharged a patient. The RN stated that proper patient identification consisted of the patient's name and date of birth. For certain medications, a nurse would get another nurse to verify medication dosages. The RN stated that they have increased the use of a bar scanner especially for medications and certain tests and treatments, and that the bar scanner assured proper patient identification. The nurse stated that the facility had sufficient bar scanners and that if one did not work correctly, the Help Desk would be called to get the scanner fixed. The nurse stated that presently, a yellow code appears on the computer system to flag all nursing home patients in order for nursing to identify these high risk patients. The nurse stated that all discharged patient remain in a special area or zone until their transportation arrives to take them back to the nursing home.
Further review of the medical record revealed documentation from physician #6 that the patient had eloped and was found outside by the patient's family as they were entering the ED. Documentation revealed that the patient was oriented to self and situation upon return to ED. The record further revealed that the nursing and medical staff performed assessments and reassessments including additional testing to assess the patient's respiratory status as she/he had been without her/his oxygen during the time she/he was discharged in error.

During an interview on 09/07/16 at 2:30 p.m. in the nursing conference room, physician #6 (attending physician) stated that he/she had not discharged the patient until after the CT of the head was obtained. The physician stated that the patient had a complete workup and that blood gases (measure of the amount of oxygen in the blood) were checked as the patient had been off of O2 during that period. In speaking with the NH and the family, the M.D. stated that there was no evidence that the patient had not returned to stable condition
Tour of the facility on 09/08/16 at 11:00 a.m. and 10/25/16 at 4:30 p.m. with the ED director revealed the ED had multiple patient treatment areas, each with a separate nursing station. Each treatment area was comprised of multiple patient bays. Ambulance services utilized a dedicated entrance/exit. All entry points into the ED were located on a highly congested street and sidewalk Tour of this area on 10/25/16 at 4:30 p.m., again revealed an environment that was heavily congested with people and vehicles including a large homeless population.
It was determined that the facility failed to properly identify patient #1, and that patient #1 was discharged in error, putting this patient at a possible risk of harm or injury. Patient #1 was also disoriented at times and was without his/her necessary oxygen for an undetermined amount of time. Patient #1 left the hospital unaccompanied and was found by the patient's family approximately two blocks away from the ED. The environment was heavily congested with people and vehicles including a large homeless population. The facility also failed to include in their nursing care plan: the proper monitoring of the patient after discharge, transportation issues, and the effective transfer of the care of the patient from one caregiver to another caregiver.