HospitalInspections.org

Based on observation, interview, record review and document review, the facility failed to:
1) Ensure a patient who was noted to be wheelchair bound upon admission had a plan for meeting those needs upon discharge from the facility (See Tag A-0800)

2) Ensure a patient was reevaluated for the appropriate assistive device upon discharge. (See Tag A-0802)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutory mandated care to patients.

Based upon interview, record review and document review, the facility failed to ensure a patient who was noted to be wheelchair bound upon admission, had a plan for meeting those needs upon discharge from the facility. The failure to identify the discharge needs placed the patient at risk for potential harm or injury upon discharge.

Findings include:

Patient 1 (P1) was admitted to the Emergency Department on 11/18/2022 at 9:04 AM, with a chief complaint of weakness. Patient (pt.) was triaged as an urgent acuity (Emergency Severity Index - ESI- 3). Patient was identified as being homeless.

A Triage note dated 11/18/2022 at 9:04 AM, documented P1 was picked up at a shelter, found in the bathroom on the floor, pt. usually wheelchair bound and able to transfer self, today was too weak to get up off the floor when pt. came out of the wheelchair.

A nursing assessment dated 11/18/2022 at 9:23 AM, documented patient ambulates without difficulty. Normal range of motion. No contractures, deformities.

A nursing assessment dated 11/18/2022 at 10:43 AM, documented:
- P1's prior mobility status as independent.
- P1's safety and judgement documented as impaired.
- P1's neurologic basic assessment documented as alert, affect calm, cooperative, and appropriate.

The nursing assessment lacked documentation identifying the patient's home environment.

A Rehabilitation Services note dated 11/18/2022 at 10:43 AM, documented patient was homeless, normally independent, patient stated ambulates without any assistive device and able to care for self. Patient was uncooperative and required constant cueing and encouragement to participate. Patient refused to ambulate at this time despite encouragement. Patient was later seen ambulating with front wheel walker without assistance with steady gait. No skilled physical therapy (PT) indicated at this time.

A physician reexamination/reevaluation note dated 11/18/2022 at 11:27 AM, documented patient was wheelchair bound secondary to back issues. Patient was also noted to have diabetes which patient had failed to disclose earlier. Patient had a blood sugar of 327 without evidence of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). Had no complaints and moving all 4 extremities. Patient did not want to work with physical therapy. Plan to discharge back to shelter with wheelchair.

A nursing note dated 11/18/2022 at 11:58 AM, documented patient ambulated with steady gait with walker.

On 11/28/2022 at 2:00 PM, the Emergency Department (ED) Nursing Director and Nursing Manager verbalized no attempts were made to contact the shelter to locate patient's wheelchair, explained difficulty in reaching anyone in past attempts to call the shelter. Verbalized a physical therapist was assigned in the ED seven days a week during daytime hours. The ED had a case manager dedicated to the ED Monday- Friday 9:00 AM - 5:00 PM, and currently training new a case manager for week-end coverage. On 11/18/2022, no case manager was working exclusively in the ED.

On 11/29/2022 at 1:00 PM, the Emergency Services Medical Director explained during the patient's last hospitalization in October, the patient had been provided with a wheelchair due to back pain or weakness. The physician explained there was a data entry issue during the registration process when the patient presented to the ED on 11/18/2022, which prevented the ED physician from being able to view the previous visits information and the patient's past medical history.

On 11/30/2022 at 7:15 AM, the hospital video (no audio) from 11/18/2022 inside the ED, revealed the patient lying quietly on a gurney, moving all four extremities while attempting to kick off blankets. At 10:52 AM, a physical therapist was observed with the patient and a walker. The patient attempted to rise to a standing position with the walker but was not able or willing. At 11:30 AM, the patient was cooperative with the physician and the nurse. At 11:50 AM, security arrived at the patient's bedside. At 11:54 AM, the patient was provided a new walker by the nurse and the walker was adjusted to the patient's height. There was no evidence the patient was trained on how to use the walker.

Upon discharge, the video revealed the patient ambulating out of the ED ambulance entrance with a walker and the assistance of two security guards, one on each side of the patient holding onto the patient and assisting to steer the walker. The patient was observed with the right hand on the right handle grip of the walker and the left hand holding the bar in the center of the walker. The patient was observed leaning over the walker. with the patient's head nearly touching the top of the walker. At 12:01 PM, the video displayed the patient going down on both knees with both security guards remaining at the patient's side. The guards lifted the patient back to a standing position by the arms and continued to walk towards the street. The patient continued to walk leaning over the walker and requiring the assistance of the security guards to steer the walker.

On 11/30/2022 at 11:30 AM, the Registered Nurse (RN) responsible for P1's care on 11/18/2022, explained the patient had refused to leave, and was concerned about the weather. The RN verbalized the patient did not want to return to the shelter but was not questioned as to why and the nurse had assumed it was because of the weather. The RN was not aware of who had notified security requesting assistance to escort the patient out of the ED after being discharged. The RN did not request the assistance of the discharge planner or social worker. There were no attempts made to locate the patient's wheelchair or to provide a new one. The RN revealed the patient was provided with a bus pass. The RN acknowledged the patient was not provided with discharge instructions, walker training or a prescription that had been written. The RN indicated security had already left with the patient when the RN was realized the discharge instructions had not been provided.

On 12/01/2022 at 9:15 AM, the security guards Security Guard 1 and Security Guard 2 who assisted the patient out of the ED, verbalized their assistance was requested by the ED charge nurse for a patient that was refusing to leave.

Security Guard 1 indicated the patient told the guards the patient could not walk., When escorting the patient out of the ED, the patient had initially walked on their own. The guard indicated the distance from the ED ambulance entrance to where the patient was left was approximately 200 - 300 feet and took about 20 minutes to get there. The guard verbalized the patient requested to go to Hospital 2 across the street.

Security Guard 2 verbalized the patient was ambulating with the walker and the guard's assistance when approximately 10 feet from the ED exit, the patient went down on their knees. The security guard explained the patient kept leaning over, slumping over, and stopping. The guard indicated it felt like the patient could not walk and took quite a bit more assistance. The guard acknowledged the patient was not offered to return to the facility. The patient was escorted by the security guards across the street, off hospital property, and then informed the patient the Hospital 2 was to the left of where the patient was left unassisted with the walker.

On 12/1/2022 at 2:00 PM, the Emergency Department physician who had provided care to P1 on 11/18/2022, verbalized the patient's chief complaint was weakness and this had been a chronic condition for approximately the last 3-4 months. The patient was known to be non-compliant. The physician explained a physical therapist was available in the ED and would have notified the physician if there were concerns about the patient discharge or a need to observe the patient longer.

A review of Hospital 2's medical record revealed on 11/18/2022 at 12:59 PM, the patient arrived by ambulance to the emergency department.

On 12/1/2022 at 11:30 AM, a telephone conversation with P1 revealed the patient was blind and could only see shadows, had been unable to walk alone and did not request to go to another hospital.

The patient's medical record lacked documented evidence:
- Nursing documentation indicating the patient was uncooperative and security was notified due to the patient refusing to leave or was refusing care.
- The facility had attempted to locate the patient's wheelchair for discharge or requested assistance from social services or case management.
- The patient had received discharge instructions, or any signed forms indicating the patient understood any verbal or written discharge instructions.

Facility policy, ED Standards of Care Practice, last revision date 01/27/2022 documented:
- Standard II, present and potential patient problems are documented in the patient's medical record to facilitate the development of patient outcomes and the nursing care plan to achieve those outcomes.
- Standard V, nursing interventions are consistent with discharge planning objectives, begins upon admission, includes verbal and written instructions regarding aftercare, includes principle of safety and are documented, including reassessments and changes to the plan of care.
- Standard VI, outcomes of nursing actions (interventions) are evaluated and evidenced by the results and modifications of the plan of care are documented.

Based upon interview, record review and document review, the facility failed to ensure a patient was reevaluated for the appropriate assistive device upon discharge. The failure to reevaluate the discharge plan placed the patient at risk for potential harm or injury upon discharge.

Findings include:

Patient 1 (P1) was admitted to the Emergency Department on 11/18/2022 at 9:04 AM with chief complaint of weakness. Patient (pt.) was triaged as an urgent acuity (Emergency Severity Index - ESI- 3). Patient was identified as being homeless.

A Triage note dated 11/18/2022 at 9:04 AM documented patient was picked up at a shelter, found in the bathroom on the floor, P1 usually wheelchair bound and able to transfer self, today was too weak to get up off the floor when patient came out of the wheelchair.

A nursing assessment dated 11/18/2022 at 9:23 AM documented patient ambulated without difficulty. Normal range of motion. No contractures, deformities.

A nursing assessment dated 11/18/2022 at 10:43 AM documented:
- P1's prior mobility status as independent.
- P1's safety and judgement documented as impaired.
- P1's neurologic basic assessment documented as alert, affect calm, cooperative, and appropriate.

The nursing assessment lacked documentation identifying the patient's home environment.

A Rehabilitation Services note dated 11/18/2022 at 10:43 AM documented patient was homeless, normally independent, patient stated ambulates without any assistive device and able to care for self. Patient was uncooperative and required constant cueing and encouragement to participate. Patient refused to ambulate at this time despite encouragement. Patient was later seen ambulating with front wheel walker without assistance with steady gait. No skilled physical therapy (PT) indicated at this time.

On 11/30/2022 at 7:15 AM, the hospital video (no audio) from 11/18/2022 inside the ED, revealed the patient lying quietly on a gurney, moving all four extremities while attempting to kick off blankets. At 10:52 AM, a physical therapist was observed with the patient and a walker. The patient attempted to rise to a standing position with the walker but was not able or willing. At 11:30 AM, the patient was cooperative with the physician and the nurse. AT 11:50 AM, security arrived at the patient's bedside. At 11:54 AM, the patient was provided a new walker by the nurse and the walker was adjusted to the patient's height. There was no evidence the patient was trained on how to use the walker.

Upon discharge, the video revealed the patient ambulating out of the ED ambulance entrance with a walker and the assistance of two security guards, one on each side of the patient holding onto the patient and assisting to steer the walker. The patient was observed with the right hand on the right handle grip of the walker and the left hand holding the bar in the center of the walker. The patient was observed leaning over the walker, with the patient's head nearly touching the top of the walker. At 12:01 PM, the video displayed the patient going down on both knees with both security guards remaining at the patient's side. The guards lifted the patient back to a standing position by the arms and continued to walk towards the street. The patient continued to walk leaning over the walker and requiring the assistance of the security guards to steer the walker.

A physician reexamination/reevaluation note dated 11/18/2022 at 11:27 AM, documented patient was wheelchair bound secondary to back issues. Patient was also noted to have diabetes which patient had failed to disclose earlier. Patient had a blood sugar of 327 without evidence of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). Had no complaints and moving all 4 extremities. Patient did not want to work with physical therapy. Plan to discharge back to shelter with wheelchair.

A nursing note dated 11/18/2022 at 11:58 AM documented patient ambulated with steady gait with walker.

On 12/1/2022 at 9:15 AM, Security Guard 2 verbalized the patient was ambulating with the walker and the guard's assistance when approximately 10 feet from the ED exit, the patient went down on their knees. The security guard explained the patient kept leaning over, slumping over, and stopping. The guard indicated it felt like the patient could not walk and took quite a bit more assistance.

On 11/30/2022 at 11:30 AM, the Registered Nurse (RN) responsible for P1's care on 11/18/2022, explained the patient had refused to leave, and was concerned about the weather. The RN verbalized the patient did not want to return to the shelter but was not questioned as to why and the nurse had assumed it was because of the weather. The RN was not aware of who had notified security requesting assistance to escort the patient out of the ED after being discharged. The RN did not request the assistance of the discharge planner or social worker. There were no attempts made to locate the patient's wheelchair or to provide a new one. The RN revealed the patient was provided with a bus pass. The RN acknowledged the patient was not provided with discharge instructions, walker training or a prescription that had been written. The RN indicated security had already left with the patient when the RN was realized the discharge instructions had not been provided.

On 12/1/2022 at 2:00 PM, the Emergency Department physician who had provided care to P1 on 11/18/2022, verbalized the patient's chief complaint was weakness and this had been a chronic condition for approximately the last 3-4 months. The patient was known to be non-compliant. The physician explained a physical therapist was available in the ED and would have notified the physician if there were concerns about the patient discharge or a need to observe the patient longer.

A review of P1's medical record revealed a Discharge Instruction/Summary of Care form dated 11/18/2022 at 11:59 AM, which documented the following:
Problems: Hypokalemia, Hyperglycemia, Diabetes
- Follow-up instructions with a named clinic or primary care physician within 1-2 days
- Prescription for Metformin 500 milligrams by mouth 2 times/day for 30 days

P1's medical record lacked documented evidence the facility reevaluated the patient after the patient was unable to safely ambulate independently with assistance of a front wheeled walker upon discharge from the Emergency Department. A review of a video showing P1 during the Emergency Department admission and discharge and interview with the security guard who assisted the patient out of the ED revealed P1 could not independently ambulate with a front wheeled walker without the assistance of the security guards.