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Based on interview and record review the facility failed to ensure patients were free from harassment for one (#3) of six patients reviewed for patient rights from a total of 17 patients, resulting in the risk of negative outcomes. Findings include:

On 5/1/18 at 0800 review of the 3/18/18 complaint allegation to the state agency revealed an allegation that the emergency department (ED) physician (later identified as staff U) told patient #3 "This is an emergency room for people who are dying, not to do pregnancy tests." And "It's not a drive through you can just pick off a menu to have what you want." The complaint allegations also stated "the physician made her feel that the physician didn't want to find out why she was feeling fatigued and nauseated and she (patient #3) would seek help elsewhere."

On 5/1/18 at 1300 a review of the closed clinical record for patient #3 revealed an admission to the ED on 3/18/18 at 1404 for complaints of "possible pregnancy, fatigued, dizzy and nauseous since this morning". A physician examination by ED physician Staff U was done on 3/18/18 at 1434 with the only complaints as noted above. Patient's home medications included birth control pills and an antidepressant. A urinalysis and urine pregnancy test were done and noted as negative. Patient #3 was discharged with instructions to follow up with primary care physician with in 24-48 hours.

On 5/1/18 at 1400 a review of the facility complaint and grievance logs dated 12/11/17 to 4/30/18 revealed three grievances and one complaint filed related to ED physician staff U.

On 1/18/18 a grievance was filed by an ED patient that alleged ED physician staff U was "extremely rude and dismissive of patient's needs."

On 2/22/18 a grievance was filed by an ED patient that alleged ED physician staff U "never introduced herself, was extremely rude." The patient was a 6 year old and the mother asked for a new physician and was told "no" by staff U. The mother left the ED and went back to the waiting room and waited for physician U to go off duty and then re-registered and had her daughter seen by another physician in the ED.

On 4/3/18 a grievance was filed by an ED patient that alleged ED physician staff U "refused to show test results" to the patient when asked.

On 4/27/18 a complaint was filed by an ED patient that alleged ED physician staff U was "very insensitive" to her young daughter in the ED.

On 5/2/18 at 1140 staff H the patient experience representative was interviewed regarding the above noted complaints and grievances. Staff H stated "There have been many concerns with (staff U)" adding "she is very good clinically but very abrupt with patients." Staff stated we have a new ED physician group. The old ED physician group manner was going to let her go because of the concerns. When the new ED group took over the new medical director (staff R) wanted to keep her on and mentor her. He (staff R) has spoken to her about the concerns voiced by patients.

On 5/1/18 at 1200 the ED director staff D, was asked about concerns with ED physician staff U. Staff D stated he is new in his position but that there have been many concerns from both staff and patients about staff U being rude and abrupt. He stated a staff member showed him several social media posts of patients writing complaints about (staff U) on their social media posts. Staff D stated the ED Medical director was going to talk with her about it.

On 5/2/18 at 1115 the ED medical director staff H was queried about the complaints and concerns with staff U. Staff H stated he was aware of the concerns with staff U when he took over, but that staff U wanted to stay on. Staff H stated he spoke with her and gave her a list of expectations, and told her not to get a bad report (complaint from patients or staff about her behavior). He stated "I explained she had to be companionate and caring towards the patients at all times. I gave steps to take like, walk away, get another physician or staff member to take over. There were concerns with her treatment of both patients and staff. I have seen some improvement, but she gets very defensive when questioned or challenged. She is a very stoic person and very direct and abrupt. I have had to speak to her twice since then about patient complaints and talk to her after each shift if a concern". Staff H said the ED director staff D has informed him of concerns that he (staff D) was made aware of on social media, and he has spoken to Staff U about them. When asked, staff H stated all of the expectations and consults with staff U were verbal, and he had nothing in writing to show what was in place to address the concerns.

The facility placed a call to staff U who was a midnight ED physician and left a message to call the facility. No return call was received prior to exit.

On 5/2/18 at 1350 the facility policy titled "Patient Rights" dated revised 1/18 documented the following: Purpose- "to render personalized and compassionate care to patients in ways that respect dignity of each person. . .7. The patient has the right to be free from all forms of abuse or harassment."

Based on interview and record review, the facility failed to fully implement it's discharge planning process to ensure that a discharge plan was completed and implemented prior to discharge, and discharge needs met for one (#4) of four patients reviewed for discharge planning, out of a total sample of 17, resulting in unmet care needs, and discharge to an allegedly unsafe environment. See specific tag:

A 0820 - Failure to complete and implement the discharge care plan prior to discharge

Based in interview and record review, the facility failed to ensure that the discharge plan was completed and that interventions for assessed needs were implemented prior to discharge for one (Patient #4) of four patients reviewed for discharge planning out of a total sample of 17, resulting in unmet care and safety needs, and discharge to an allegedly unsafe environment. Findings include:

On 5/1/18 at approximately 1300, Patient #4's clinical record was reviewed and revealed the following information:

A face sheet documented that Patient #4 was a female who was brought to the emergency department (ED) by ambulance on 3/12/17 with admission diagnoses which included Shock, Acute Encephalopathy (brain disease), and Altered Level of Consciousness. ED documentation revealed the patient was non verbal when she arrived, and was unable to sign consents for admission and treatment.

Documentation revealed that the Emergency Medical Service Responders (EMS) reported that her boyfriend had called EMS because she had fallen out of her chair and he was unable to lift her off the floor. Documentation noted that EMS reported that she was found on the floor of her trailer naked with her hair duct taped to her body, with garbage piled up to the ceiling along the walls.

Documentation revealed that the patient's hair was matted into a ten pound (weight) dread lock that was visibly infested with bedbugs and lice. The ED Physician's assessment documented a large deformity along the midline of her abdomen, which radiology studies confirmed as multiple abdominal hernias. The radiology reports also documented that Patient #4 's right kidney was "missing".

The ED nursing note, dated 3/11/17 at 2014 documented, "patient arrived non verbal with unkempt hair, insects noted to be crawling in approximately 5 - 6 feet of matted hair. Duct tape noted to be stuck in hair also. Hair in dirt piles and insects. Hair was removed due to bugs. Toenails are long and curled over. Per EMS, friend called. Patient had no electricity. Patient is cold to touch, unable to obtain temperature."

The patient was admitted to the intensive care unit (ICU) on 3/12/18 at 0027 with diagnoses of Severe Hypothermia (cold body temperature) with Rhabdomyolysis (blood evidence of a large amount of muscle destruction, possibly due to crushing injury or a long period of time in one position on a hard floor). The admission order documented, "Admit to inpatient status (Expected to stay 2 mid-nights or More): Reason: severity of illness; for Severe Hypothermia with Rhabdomyolysis, Hypokalemia (low blood potassium, a possible symptom of kidney dysfunction), Severe Debility, Abdominal Hernia, Encephalopathy. Level of Care: Intensive/Critical Care."

Documentation revealed that the patient was resistant to care and refused to disclose her date of birth or apply for financial assistance to pay for her hospitalization once her delirium resolved. Her clinical record listed her birthdate as 01/01/1900 and her age as 117 years old, and her insurance as self pay. Per interview with the director of Case Management (Discharge Planning), Staff I, on 5/1/17 at 1430, Patient #4's delinquent hospital bill was sent to "Collections", due to the patient's failure to pay her bill or apply for Medicaid.

An ED Nursing Assessment dated 3/11/17 at 2013 documented, "Home Environment: Home. Can return to present living situation: No". The patient's Glasgow Coma Score (scoring system to describe the level of consciousness after a brain injury) was 10 out of 15 ( 3-8 = coma , 9 - 12 = moderate brain damage).

An ED physician's note, dated 3/11/17 at 1934 documented, "Delirious" and, "The patient is extremely unkempt with long curled toenails, a large dreadlock in her hair that weighs at least 10 pounds with bedbugs crawling all over it. The patient is confused and does not have any obvious signs of trauma but is not talking. Patient is not wearing clothing and has her hair wrapped around her like clothes with duct tape all wrapped around it. I did speak with the patient's boyfriend who states that she has been living with him in the trailer for the last 25 years. He describes that he was unaware that apparently her room is floor to ceiling garbage. He states that she is very resistant to receiving medical care. she has had a bulge in her abdomen for years but has never had it looked at. He states that she fell out of her chair today and he was unable to help her get back up and that is why he called 911."

A Social Work note dated 3/14/17 at 1408 documented, "It is unclear if Adult Protective Services (APS) has been contacted to investigate the alleged home situation and the extreme unkempt physical condition of the patient. Social Work (SW) will contact APS due to the nature of the patient's condition and inability to care for herself."

A SW note dated 3/15/17 at 1326 documented , "SW contacted APS due to the condition of the patient upon arrival to the ED. Patient also assessed by Psychiatrist. Evaluation deemed patient cognitively impaired. Patient likely to need alternate placement and guardian. Awaiting APS evaluation."

Nursing Noted documented that the patient refused care and medications and was sometimes combative.

An attending physician's progress noted dated 3/14/17 (no time indicated) documented, "Placement needed. Psychiatry to evaluate."

A physician's note dated 3/15/17 (no time indicated) noted that Patient #4 was "in denial (delusional) about health status", and that her hypokalemia (low blood potassium) was not improving due to the patient refusing to take her medications. It also noted that the patient's hypertension (high blood pressure) was uncontrolled. The Attending Physician documented on this note, "Unable to discharge - not safe- until evaluated by Adult Protective Services".
A Psychiatrist Consultation report dated 3/15/17 at 1157 done for a reason noted as, "competency" documented that the patient refused to disclose her birth date when asked, and "appeared somewhat mildly paranoid". The evaluation noted, "Her understanding regarding her medical issues and her ability to care for self is limited. She has poor insight and judgement. She was not able to answer questions related to informed consent in a satisfactory manner. Affect is constricted. She has not been taking care of herself. There is evidence of paranoia and vagueness."
The psychiatrist's "plan" noted, "At this time, the patient lacks insight and judgement and is unable to take care of herself. She fails to realize that she is putting herself in jeopardy by not going to the doctors, and following up. She is over estimating her ability to care for herself. I believe that the patient lacks capacity to make her own decision and a proxy should be identified. Once the patient is medically cleared, she can be discharged to a nursing facility or subacute rehab (a residential rehabilitation center)."

The Psychiatrist also documented in the Physician's Progress notes on 3/15/17 (no time indicated), ""Lacks capacity to make her own decisions and a proxy should be identified."

There was no documentation to indicate that the psychiatrist's plan was communicated to discharge planning or to the attending physician. There was no competency evaluation done by a second physician as needed for the facility to Petition to Probate Court for a legal guardian to be assigned. There was no documentation that this was added to the patient's discharge plan.

A Resident physician's progress note, dated 3/16/17 at 1040 noted, "Psychiatry deemed patient lacks capacity to make decisions. Needs Proxy. APS contacted by social worker. Awaiting if accepted."

The Attending Physician wrote an order to discharge Patient #4 on 3/17/17 at 1205, "Medically stable for discharge home."

There was no documentation that APS visited or assessed the patient, or had further contact with the facility about Patient #4 before the patient was discharged two days later, on 3/17/18.

Review of Nursing Care Plans for Patient #4 revealed a Discharge Planning Plan of Care dated 3/15/17 at 1557 that was blank (not filled in). A Nursing Care Plan for Potential injury to self or others (adult) was dated 3/12/17 but not completed or filled out.

There was no nursing note documenting the patient's discharge, or that her indwelling urinary catheter was removed prior to discharge.

A Discharge Assessment Report for Patient #4, signed by the physician and patient on 3/17/17 at 1541 included the following diagnoses, "Unable to Care for self". The discharge instructions included instructions for the patient to follow up with a primary care physician within one week, and a prescription for amlodipine (a medication to control high blood pressure) 5 milligrams twice daily.

On 5/2/18 at approximately 1440, Staff I stated, "The discharge plan isn't filled out. I think she must have been discharged before we expected. The attending physician doesn't attend daily rounds with the care team. The resident physician does, and should communicate with the attending physician anything brought up by the team during rounds. The Case Manager who was responsible isn't here any more. It's everybody's responsibility to make sure she didn't go home to an unsafe environment. She had no insurance, and no money to pay for the hospitalization. Social work should have worked on getting her a guardian through probate court. The attending physician should have documented a competency evaluation after the psychiatrist did, in order for the Social Worker to be able to process the Probate Court petition for certification. I'm only speculating, but I'd say that we discharged her home before things were ready due to a lack of communication."

On 5/2/18 at approximately 1510, Patient #4's attending physician, Staff L was interviewed by telephone and stated that Patient #4 was medically stable for discharge on 3/17/17, and that it was Case Management's responsibility to make sure that competency determination paperwork and Probate Court Certifications were done prior to discharge. Staff L stated that he had no reason to keep the patient in hospital any longer, as she was medically stable and her ability to care for herself at home and discharge to a possibly unsafe living situation were not reasons to keep a patient in hospital. When asked what had changed between his note on 3/15/17 and his decision to discharge the patient on 3/17/17, Staff I stated, "I remember the discharge planner was on that case. I must have talked to the discharge planner and the social worker before I discharged her. They would have made sure that everything was in place." Staff L was asked whether he had evaluated Patient #4's mental competency after the Psychiatrist had deemed her not competent. Staff L stated that he could not remember. Nothing was documented.

On 5/2/18 at approximately 1530, Staff M, the 2W Unit Manager (where Patient #4 was before discharge from the hospital) was interviewed. Staff M stated, "I see a documentation that they were recording input and output from the urinary catheter on 3/17/17, but I don't see any documentation that they removed it." Staff M stated that the nurse who did the discharge should have written a discharge note on the clinical record, but there wasn't one.

On 5/2/18 at approximately 1532, the nurse who was responsible for discharging Patient #4 was interviewed by telephone and stated that she remembered removing Patient #4's indwelling urinary catheter before she was discharged because the patient wanted to refuse, and kicked her during the removal.

On 5/2/18 at approximately 1540, Staff N, the Patient Registration Manager was interviewed regarding Patient #4. Staff N provided documentation that she had contacted Patient #4 and offered to assist her with applying for Medicaid to pay her hospital bill, both during and after her admission, but Patient #4 refused assistance and refused to provide her date of birth or social security number.

On 5/2/18 at approximately 1540, per patient request, Patient #4 was contacted again by telephone. The Complainant was confused, repetitive, hostile, accusative and often incoherent. The complainant became agitated and repeated the same sentences over and over and could not be redirected to end the phone conversation gracefully. When asked, the complainant stated that she did not have a physician because she didn't need one. Patient #4 complained that the hospital had "lied" to her by telling her that she had high blood pressure and giving her a prescription for blood pressure medicine. The complainant said that she still had the prescription, as she didn't fill it as, "It was all lies."

On 5/4/18 at approximately 1600, review of the facility policy entitled, "Case Management", dated 11/6/17 revealed the following documentation, "Development of the Plan of care is a coordinated confidential, interdisciplinary process which recognizes patient preferences, needs and self care potential. (Discharge Planning) occurs usually within one business day of the admission and then is reassessed as needed at appropriate intervals during the hospitalization. The discharge planning evaluation must include the likelihood of a patient's capacity for self-care or the possibility of the patient being cared for in the environment from which he/she entered the hospital. The hospital must complete the evaluation on a timely basis..."