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Based on interview and document review, the hospital failed to ensure all patient rights were protected when the facility discharged patient (P1) to his biological mother who had no parental and or legal rights to the child. The facility failed to ensure a safe discharge plan which included P1 being discharged in the care of his legal guardian. This deficient practice resulted in an immediate jeopardy (IJ) for P1.

A condition level deficiency was issued. See A0131.

An IJ was identified 3/2/23, related to patients receiving care in a safe setting, specifically related to safe discharge. The IJ was removed on 3/6/23, but the hospital remained out of compliance at the Condition of Patient Rights. See A0131

Based on interview and document review, the hospital failed to ensure all patient rights were protected for 1 of 10 patients when the facility discharged patient (P1) to his biological mother who had no parental and or legal rights to the child. The facility did not contact and ensure P1 had been discharged safely in the care of his legal guardian This deficient practice resulted in an immediate jeopardy (IJ) for P1.

The IJ began on 2/18/23, at approximately 1:48 a.m. when P1 was discharged to his biological mother who had no parental and or legal rights to the child. The facility did not contact and ensure P1 had been discharged in the care of his legal guardian. The Facility System Program Manager of Regulatory and Accreditation and Vice President (VP) of Hospital Operations, were notified of the IJ finding on 3/2/23, at 2:48 p.m. The IJ was removed on 3/6/23, at 2:01 p.m. following verification of an acceptable removal plan.

Findings include:

P1's emergency department (ED) medical record from hospital revealed on 2/17/23, P1 had been aggressive at home, threatening his guardians with a knife. P1 had been brought to the hospital via emergency medical services (EMS) who had been given the information related to guardian's name, address, and telephone number.

P1's progress notes indicated on 2/17/23, at 9:41 p.m. social worker (SW)-A had contacted P1's biological mother. P1's biological mother at that time told SW-A she did not have custody of P1, nor had she seen P1 since he was 10 months old. P1's biological mother had given SW-A the name and phone number of P1' s legal guardians. At 9:43 p.m. SW-A contacted P1's legal guardian (G)-A. G-A stated she was P1's legal guardian, and he had a different last name then what was in the medical record. SW-A told G-A the facility needed legal documents to make any changes to his medical record. P1's discharge recommendation indicated he would be discharged home to his guardians.

P1's discharge note in his medical record revealed on 2/18/23, at approximately 1:48 a.m. P1 had been discharged to his biological mother who had no parental and or legal rights to the child.

During an interview on 3/1/23, at 9:45 a.m. G-A stated she had woken up on 2/18/23, at approximately 4:40 a.m. and found P1 asleep on her bedroom floor, next to her bed. G-A stated she looked at her Ring camera which showed a white car dropping P1 off at her home at approximately 2:40 a.m. P1 entered the house with his passcode. G-A stated she knew P1's biological mother drove a white car. G-A stated when P1 woke up, he was afraid, and he told her he did not know what was going on at the time he had been discharged, and thought he was being given to someone else. G-A stated this caused more issues with P1's behaviors, he had feelings of abandonment and was suffering from post traumatic stress disorder (PTSD). G-A stated by sending P1 to the hospital, she thought he would come home with a plan to help with his behaviors, and not cause more behaviors. G-A stated P1's biological mother had lost all parental rights due to neglect and abuse. G-A further stated P1 had not seen his biological mother since the age of 1.

During an interview on 3/2/23, at 9:01 a.m. the head of the ED nursing department (RN)-B stated there were notes from SW-A and SW-B indicating P1's biological mother was not the guardian, and information was there for the guardian. RN-B stated all of P1's legal information was in his medical record; however, it was under another "tab," the "Media" tab. RN-B stated P1 should not have been discharged to his biological mother, but only to G-A.

During an interview on 3/2/23, at 9:28 a.m. RN-C stated she was the nurse who discharged P1. RN-C stated there had been concerns related to who P1's guardian was at the time he was in the pediatric ED. RN-C stated the discharging physician (MD-A) told her P1's biological mother was listed on the demographic sheet, and that she was to discharge P1 to her. RN-C stated this had not been the first time the legal guardianship or adoption papers were either not in the chart or documented accurately on the demographic sheet.

During an interview on 3/2/23, at 9:42 a.m. RN-D stated there had been concerns with who actually had been P1's guardian. RN-D stated she had contacted G-A at approximately 11:00 p.m. to update her on P1's condition, and G-A had informed her she was P1's legal guardian. RN-D stated this had not been the first time the legal guardianship or adoption papers were not easily located in the chart. RN-D stated this often had caused confusion with who the decision maker was for pediatric patients, and who had legal custody.

During an interview on 3/2/23, at 10:02 a.m. the pediatric ED nurse manager (RN)-E stated P1 should not have been discharged to his biological mother, and P1 should have been discharged to G-A.

During interview on 3/2/23, at 10:21 a.m. the patient liaison (PL)-A stated he had received a phone call from G-A. PL-A stated G-A had been upset, and informed him P1 had been discharged to his biological mother. PL-A stated he had found P1's legal information in P1's medical chart; however, it had been placed under the wrong tab. PL-A stated the legal documents which verified G-A was the legal guardian had been in P1's chart since 2016; however, this information did not get updated onto P1's demographic sheet.

During interview on 3/2/23, at 11:04 a.m. SW-A stated she had spoken to G-A on 2/17/23, who told her she was P1's guardian. SW-A stated she took this information and documented this in P1's medical chart. SW-A stated she had no knowledge of any guardianship papers in P1's medical chart. SW-A stated P1's demographic sheet showed P1's biological mother was the contact person, not G-A.

During interview on 3/2/23, at 11:11 a.m. the regulatory accreditation program manager (RAPM)-A stated P1's legal information had been in P1's medical record; however, it had been misplaced under a Media tab. RAPM-A stated she did not know why P1's demographic sheet had not been changed when his legal information was entered into his medical record.

MD-A was unavailable for interview.

The facility policy Discharge Planning effective date 10/23/20, directed hospital staff to provide timely, safe discharge services to all patients as they move to the next level of care or home.

The facility policy Surrogate Decision-makers for Patients Who Lack Decision-making Capacity effective date 11/6/20, directed hospital staff that when the care team is unable to identify anyone who has authority for decision-making, or who knows the patient, or who knows the patient's wishes, or who cares to be involved with decision-making, or who is making decisions in the best interest of the patient a care conference may be convened to help determine next steps, and could include representatives from Risk Management, Ethics, and Administration. The policy further directed staff decision maker information including general guidance, names and contact information, and scanned documents are to be visible in the Epic Code/ACP tab. Additionally this information can be accessed by clicking on the code status (IE: Full, DNR) in the patient header bar. Registration staff will see the status of Legal Guardianship within the Patient Headers. (Registration staff can hover over the yellow highlighted Legal Guardian area within the header for the Guardian's name to display). If a person claims to be the patient's guardian and the Epic Code/ACP tab indicates we have not received a guardianship document, the person must be requested to submit the court order for review and entry into the medical record. Surrogate Decision Makers are also listed in the Additional Information tab of Demographics in EPIC.

The IJ was removed on 3/6/23, at 2:01 p.m. when it could be verified the hospital had submitted and implemented an acceptable removal plan which included appropriate education and training of all nursing and hospital staff included in patient discharges, including registration staff. This was verified through interview and policy review.