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Based on staff interviews and record review the facility failed to fully develop and implement preventive actions to address deficient practice and opportunities for improvement identified as the result of a quality case review of the care and services for an Emergency Department (ED) patient. Findings include:

Per record review Patient #1 presented to the ED via ambulance on 8/1/14 at 2:31 PM with a chief complaint of AMS (Altered Mental Status); hypotension, and a 20 pound weight loss over the past month. The note, by ED Physician #1 indicated the patient had been transferred to the ED from the local VA clinic. The ambulance report confirmed that Patient #1 was transferred from the VA clinic location and identified his/her mental status as confused, although oriented to time, place and date. The patient reported to ED Physician #1 that the VA clinic had been trying to contact him/her, but s/he didn't know why, and when s/he went to the clinic they sent him/her to the ED. The record revealed the patient had a history of AMS as well as alcoholism, his/her appearance was unkempt, and s/he complained of right lower abdominal pain and shaking chills. Diagnostic testing completed in the ED included lab work, showing a mild hypokalemia, and mildly elevated liver enzymes. The patient was treated with IV fluid replacement and potassium repletion and his/her vital signs returned to normal. The record indicated the transfer of care from ED Physician #1 to ED Physician #2 at approximately 4:35 PM and a consultation was obtained with a Hospitalist in the Admitting Service, who documented: "we were consulted with the question of FTT (Failure to Thrive). Although [patient] certainly has failure to thrive and [his/her] housing conditions are likely unsuitable for healthy living, [patient] is HD stable now and wants to go home. [His/her] endocrine issues could be worked up closely as an outpatient, and [patient] needs outpatient case management for [his/her] living situation." There was no documentation regarding Patient #1's mental status and no evidence that a mental status evaluation had been completed by any of the ED physicians or Hospitalist, other than documentation, twice, that the patient was alert and oriented times 3. An ED nursing note, at 11:23 PM on 8/1/14, stated the nurse had spoken with the patient's sister who was aware the patient was going home (the record indicated the sister was located in Massachusetts). Per interview, on the morning of 9/17/14, the ED Nurse Manager stated the patient's sister had been contacted prior to discharge as the patient could not remember his/her home address and the address in the medical record did not appear accurate. Patient #1 was discharged home via cab and the discharge instructions provided to to him/her directed the patient only to schedule an appointment with his/her primary care provider as soon as possible. Patient #1 returned to the ED, via ambulance at 1:57 AM on 8/2/14, just 2.5 hours after s/he had been discharged. The Medical Evaluation conducted by ED Physician #3 stated "......patient was seen and discharged to home earlier today......was found by PD [police department] wandering, unable to find where [s/he] lived." Patient #1 was admitted at that time and discharged 2 days later to the VA hospital for further follow up.

ED Physician #1, who had evaluated and provided care to Patient #1 in the first 2-3 hours of admission to the ED stated, during interview at 5:02 PM on 9/16/14, that Patient #1 "....definitely had altered mental status..I would say moderately confused ...could state [his/her] name, date and place but couldn't answer other questions...was very sick, cachexic, weight loss ...and I felt [s/he] needed to be admitted..." S/he stated s/he had obtained information from the patient's chart and acknowledged s/he did not have any communication with the VA Clinic.

During interview, at on 9/17/14, the Family Medicine Resident who had evaluated Patient #1 on the evening of 8/1/14, for admission status, stated that ED Physician #2 had requested a consultation, hoping that we could admit the patient but didn ' t feel like s/he had anything to go on because the patient was failing to thrive at home, had lost weight, and wasn't appropriately able to care for him/herself. S/he stated that although the patient had a lot of medical conditions and it was difficult to determine what the patient's baseline was, following treatment in the ED the patient's BP had improved and s/he was hemodynamically stable and was therefore discharged.

During interview, at 3:06 PM on 9/17/14, ED Physician #3, the ED Quality Medical Director stated that s/he had reviewed, on 8/3/14, Patient #1's medical record for the 8/1/14 & 8/2/14 ED visits, as part of his/her normal quality review process for all ED patients returning to the ED within a 72 hour period. S/he further stated that s/he had conducted a more formal review, in September 2014, of those ED visits, after having received information, related to a concern brought to the facility's attention, from an outside source, regarding a question of the appropriateness of Patient #1's discharge on the evening of 8/1/14. ED Physician #3 stated that s/he could not determine Patient #1's mental status from review of the patient's medical record. S/he stated that, although the record identified the patient as alert and oriented to person, place and date, it did not reflect the patient's full mental status. Physician #3 further acknowledged there was a failure by physicians to obtain any information from the referring VA Clinic and s/he would have expected contact with the referring clinic to have occurred to obtain information about the patient and the reason for referral to the ED. ED Physician #3 also stated that although ED Physicians #1 and #2 had expressed opinion regarding inpatient admission for Patient #1 on the evening of 8/1/14, ED physicians do not have admitting privileges and must rely on the Admitting Service to determine inpatient admission status. S/he stated that if there is disagreement between the services there is a process in place to work towards resolution, however that process was not implemented in this case. In addition, although Social Service (SS) staff are available 24 hours per day, Physician #3 confirmed that SS was not contacted regarding this patient, prior to discharge from the ED, to assure appropriate outpatient support services were available. Physician #3 further acknowledged that as a result of his/her review, this case was referred back to the Admitting Service Quality physician, because "these problems are circumvented when the patient is actually admitted to the hospital where they can obtain the proper services and disposition and communication piece." Physician #3 stated, in addition, a reminder was sent to the ED provider group to communicate back to the referring service, to get a better understanding of why the patient was referred to start with. Despite these actions, there was no evidence that any follow up would occur with Admitting Services, nor had any further action regarding SS referral, been taken to assure reduction of the likelihood of reoccurrence of a similar event.