HospitalInspections.org

Based on record review and staff interview it has been determined that the hospital failed to reassess the patients discharge needs and notify the patients guardian of a change in the discharge plan for 1 of 1 Patient with a court appointed guardian, Patient ID #1.

Findings are as follows:

Review of the record for patient ID #1, reveals that s/he was brought to the hospital emergency department (ED), on 1/18/2025 at approximately 10:30 AM, by ambulance from the skilled nursing facility (SNF) for a psychiatric assessment. While at the SNF the patient allegedly attempted to physically assault staff, making racial slurs and verbally aggressive. Records indicate a history which includes anxiety, depression, and a chronic alcohol problem.

The Record also indicates the patient has had similar behaviors while in the ED in the past. While in the ED, the patient denied exhibiting the behaviors alleged. The patient was noted to be demanding, and ordered the staff the s/he be returned to the SNF. The patient denied any physical complaints during this visit.

Review of the Physicians note reveals he spoke with the facility, and they refused to take the patient back due to a concern for their employees' safety. The record noted that the patient's guardian stated he spoke with the facility, and they agreed to take the patient back. A nursing note indicated the nurse spoke with the facility, and they could not take the patient back right away.

The patient was seen by the hospitals Social Worker on 10/18/2025 at 10:45 AM. This note indicated a discharge plan for the patient to return to the SNF with medication management. The note also stated she interviewed the patient's guardian and informed him of the plan for the patient to return to the SNF on Monday to which the Guardian agreed.

The nurses note states nursing spoke to the DON at the nursing home, who reported they did not have a room to accommodate the patient's return on the weekend but would have a meeting on Monday to explore this possibility. The patient was aware of this conversation and requested to call his guardian. The patient called his guardian, and he is aware that the patient will be spending the weekend in the ED. The Primary nurse was aware of the plan. Notes indicated that the next morning at 8:15 AM when given breakfast the patient became verbally aggressive with staff telling them to F .... Off. This behavior continued until at approximately 12:10 PM the patient attempted to leave the ED to go out to smoke a cigarette. The patient was noted to be verbally aggressive and pushed the staff with his/her walker.

The patient was found attempting to leave via the ambulance entrance and was redirected back to bed with security present. The patient refused to remain in the ED and requested to sign out AMA (against medical advice). The Patient was allowed to sign the AMA form with the physician, then walked out of the ED and waited for a friend to pick him/her up.

During an interview with the Social Worker and Director of Case Management on 1/22/2025, both were unaware that the patient had signed out against medical advice.

During an interview with the Emergency Department Nurse Manager on 1/22/2025 at approximately 1:00 PM, she informed the surveyor that this patient is well known to the ED staff, and they were unaware that the patient had a court appointed guardian.

During an interview with the hospitals the Risk Manager on 1/22/2025 at approximately 11:00 AM, she was unable to explain why the patient's legal guardian was not contacted prior the the patients release.

The hospital failed to contact the patient's legal guardian when the patient refused to remain in the ED.