HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the contracted services were provided in a safe manner when 1 (Patieent #1) of 4 (#1,#2, #3 and #4) discharged patients reviewed was transported via the hospital's contracted transportation vendor who left Patient #1 on her porch without a means to enter the residence.
Findings:

Review of the policy/procedure titled, "Hospital Transportation Services" revealed, in part, the hospital provides transportation services to meet a variety of needs of behavioral health patients. Further review revealed the hospital may provide transportation services, including, but not limited to the following: Discharge to a specific location. Further review revealed an active transportation contract for patients who were deemed physically fit for travel.

Patient #1 was admitted to the facility on 03/29/2022 with diagnoses, in part, Major Depressive Disorder, Recurrent Severe without Psychotic Features, Suicidal ideations, and Unspecified Dementia without Behavioral Disturbance.

Review of an electronic mail sent from R1FamilyMember to S2PLCP dated 04/11/2022 at 4:08 p.m. and forwarded to S1Administrator on 04/11/2022 at 4:41 p.m. revealed a judgment of temporary interdiction issued by the 19th Judicial District Court of East Baton Rouge Parish appointing R1FamilyMember curator to Patient #1.

Review of the medical record documentation revealed Patient #1 was discharged from the hospital on 04/11/2022 at 7:10 p.m. Further review revealed Patient #1 arrived to her residence on 04/11/2022 at 7:21 p.m.

In interview on 4/18/22 at 2:20 p.m., S4Contractor indicated their services under the contract included curb to curb transportation only. S4Contractor further indicated he reviewed surveillance video and found that on 04/11/2022 at 7:21p.m., Patient #1 was escorted to the porch of her residence, had no key to enter and the driver left Patient #1 on the porch.

Review of the Committee of the Whole minutes for 12/28/2021 revealed, in part, an agenda item which included review of the 2021 contract with the transportation service to continue services for 2022. Further review revealed documentation that there were 'no issues' with the contract.

In interview on 4/19/22 at 10:05 a.m., S1Administrator indicated the governing body approved the transportation contract for 2022, but she was not familiar with the specific details regarding when the transporter should contact the facility staff. S1Administrator further indicated she had no communication from the transport company that Patient #1 did not have a key to her home. S1Administrator indicated if the driver knew the patient could not get into the house, she should have been called. S1Administrator acknowledged that, "it's not appropriate" to leave a patient outside and not ensure their safety.

In interview on 4/19/22 at 10:43 a.m., S1Administrator indicated she reviewed the transportation contract and found no language to ensure the patient arrived safely to their destination. S1Administrator further indicated she would expect a phone call if the patient had no way to get in the house.

Based on record review and interview, the hospital's discharge planning process failed to ensure adequate discharge planning for a patient who was likely to suffer adverse health consequences upon discharge when 1 (#1) of 4 discharged patients (#1, #2, #3 and #4) reviewed was transported via the hospital's contracted transportation vendor, who left Patient #1 on her porch without a means to enter the residence.
Findings:

Patient #1 was admitted to the facility on 03/29/2022 with diagnoses, in part, Major Depressive Disorder, Recurrent Severe without Psychotic Features, Suicidal ideations, and Unspecified Dementia without Behavioral Disturbance.

Review of the policy and procedure titled, "SS (Social Service) Discharge Planning" revealed, in part, the purpose of Discharge Planning is to identify the patient's continuing physical, emotional, social, transportation and safety needs, and to arrange services to meet those identified needs.

Review of the policy and procedure titled, "Administrative, Nursing, Leadership and Psychiatric Call" revealed, in part, the hospital ensures that administrative staff, nursing leadership, and psychiatrists are available 24 hours a day to receive notifications, provide guidance, make decisions, and direct hospital staff, as needed for all inpatient programs. This is accomplished by ensuring that, when not available on-site, designated staff is available on call.

Review of the policy/procedure titled, "Patient Rights" revealed, in part, the patient has a right to receive assistance from the physician and appropriate hospital staff in arranging for required follow-up care after discharge, and receive care in a safe setting.

Review of the policy/procedure titled, "Hospital Transportation Services" revealed, in part, the hospital provides transportation services to meet a variety of needs of behavioral health patients. Further review revealed the hospital may provide transportation services, including, but no limited to the following: Discharge to a specific location. Further review revealed an active transportation contract for patients where were deemed physically fit for travel.

In interview on 4/18/22 at 12:50 p.m., S1Administrator indicated Patient #1 was no longer meeting criteria to be in acute care and the plan was to discharge home to her own residence.

In interview on 4/18/2022 at 3:50 p.m., S3MD indicated in his professional opinion, Patient #1 was safe to be discharged home.

In interview on 4/18/22 at 1:10 p.m., S2PLPC assigned to coordinate a safe discharge plan for Patient #1 indicated on 04/11/2022 R1FamilyMember communicated to her via email notification that Patient #1 had no key to her residence. S2PLPC indicated she spoke to Patient #1 on 04/11/2022 and made her "promise" there was a key available on the patio of the residence prior to the transport home.

Review of the electronic mail communication provided by S2PLPC revealed, in part, on 4/11/22 at 2:16 p.m. an electronic mail communication note from S2PLPC to R1FamilyMember informing him of the planned discharge. Further review revealed on 04/11/2022 at 2:44 p.m., R1FamilyMember responded, "Wow. Guess she will stay outside".

Review of an electronic mail sent from R1FamilyMember to S2PLCP dated 04/11/2022 at 4:08 p.m. and forwarded to S1Administrator on 04/11/2022 at 4:41 p.m. revealed a judgment of temporary interdiction issued by the 19th Judicial District Court of East Baton Rouge Parish appointing R1FamilyMember curator to Patient #1.

In interview on 4/18/22 at 2:20 p.m., S4Contractor indicated on 04/11/2022 at 7:10 p.m., Patient #1 was picked up from the facility and transported to her residence at 7:21p.m. S4Contractor further indicated the driver walked Patient #1 to the front door where Patient #1 remained since she had no key to enter and the driver left the destination.

In interview on 4/19/22 at 10:05 a.m., S1Administrator indicated she had no communication from the transportation company that Patient #1 did not have a way to enter her home. S1Administrator indicated if the driver knew Patient #1 could not get into the house, she should have been called. S1Administrator considered this situation an "emergency", and that "it's not appropriate" to leave a patient outside and not ensure their safety.