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Based on interview and document review the hospital failed to arrange for the patient's discharge and transfer for 1 of 11 patients reviewed, Patient #1 (P-1), when the patient was discharged to the community rather than to the nursing home where he was receiving care.

Findings include:

Medical record review revealed P-1 was admitted to the Emergency Department (ED) on 7/10/2015 at 1:04 a.m. with diagnoses that included altered mental status secondary to acute alcohol intoxication.

A review of P-1's ED notes dated 7/10/2015, revealed P-1 was agitated, verbally abusive and scratching and biting ED staff. P-1's breathalyzer alcohol level upon arrival was 0.143. P-1 reportedly got drunk at his nursing home, fell and hit his head. P-1 was observed in the ED for approximately 12 hours.

The ED discharge note dated 7/10/2015 at 1:13 p.m. revealed that upon discharge P-1 was alert and oriented, answering questions appropriately, denied pain and had no new focal neurological findings. P-1 had stable vital signs and was able to ambulate without difficulty or assistance.

A social work note dated 7/10/2015 at 5:50 p.m. revealed that P-1 was to have been discharged back to the nursing home, but this did not occur and P-1 was discharged to self care. Law enforcement and adult protection were notified of the concern immediately.

During an interview on 9/2/2015 at 2:05 p.m. Registered Nurse-D, (RN-D) stated she cared for P-1 in the special care unit of the ED on 7/10/2015. RN-D stated when P-1 was discharged he was alert and oriented and walking steadily. P-1 stated he had a safe ride home and was clinically sober. RN-D stated she was not aware that P-1 was from a nursing home and did not appear to be a vulnerable adult. P-1's discharge order indicated he was to be discharged home. RN-D stated someone from the nursing home later called to inquire as to P-1's discharge time/date/status, and she realized he had been discharged to the wrong destination. RN-D stated she immediately called her supervisor, and law enforcement and adult protection were immediately notified. RN-D stated the demographic information in the electronic medical record indicated only an address for P-1 and she did not realize the address listed was actually for a nursing home.

During an interview on 8/26/2015 at 2:25 p.m., Social Worker-E, (SW-E) stated she was notified of the discharge error on 7/10/2015. SW-E stated she notified adult protection and law enforcement of the concern and that P-1 was a missing person for several hours. During an interview on 8/28/2015 at 10:00 a.m., the administrator from the nursing home where P-1 resided stated on 7/9/2015 P-1 left the building on a pass after dinner. P-1 later called the facility and stated he was lost and unable to return. Facility staff called law enforcement, who found P-1 and brought him back to the facility on 7/10/2015 after midnight. When P-1 arrived back at the facility, facility staff suspected he was intoxicated, P-1 admitted he had been drinking and had a scrape on his forehead. P-1 was sent to the local hospital's ED. Facility staff were not contacted by the hospital when P-1 was discharged. On 7/10/2015 at about 5:30 - 6:30 p.m., P-1 was found in his room by nursing home staff. P-1's condition was stable, however P-1 was complaining of a headache and nausea. The nursing home staff contacted the hospital to let them know that P-1 was at the nursing home.

The policy titled Standard for the Emergency Nursing Provision of Care, undated and provided by facility staff revealed under the section titled Discharge Assessment: Discharge planning and implementation is multidisciplinary and involves both medical and social ancillary services as needed. The assessment and plan involves communication with the patient, family and any other involved caregivers. Included in the assessment and plan are resolved and ongoing needs.