HospitalInspections.org

Based on policy review, record review, and staff interview, it has been determined that the hospital failed to follow its policy titled, "Patient Discharge/Transfer Policy (Adult)-Inpatient and Outpatient Settings," by discharging a patient home from the Post Anesthesia Care Unit (PACU), without a physician's order for 1 of 6 patients reviewed, Patient ID #1.

Findings are as follows:

A community reported complaint submitted to the Rhode Island Department of Health on 1/3/2025, indicated that a patient was discharged home from the Post Anesthesia Care Unit, prematurely and was contacted by the hospital, the next day to return to the Emergency Room for blood work and further evaluation.

Review of the hospital policy titled, "Patient Discharge/Transfer Policy (Adult)-Inpatient and Outpatient Settings" last reviewed 11/2023 states in part...
" ...Procedure 1. All discharges/transfers from the inpatient setting require a written order by the attending provider or designee ..."

Review of Patient ID #1's medical record revealed that the 27 year old, presented to the hospital's emergency room (ED) on 10/27/2024, for heavy vaginal bleeding. It was also identified that the patient was currently 17 weeks pregnant. While in the ED, the patient continued with heavy bleeding. After physician evaluations and discussion with the patient and their family, it was determined that the only safe option was for the patient to undergo a dilation and evacuation (D&E), a procedure used to terminate a pregnancy in the second trimester (between 13 and 24 weeks).

Review of the patient's Operative Report, dated 10/27/2024 at 4:05 PM, documented that the patient was administered general anesthesia and a ultrasound guided, standard D&E was performed.

Review of the patient's Operating Room PACU Nursing Documentation, completed by Staff A, per diem Registered Nurse, on 10/27/2024, revealed that the patient entered the PACU at 3:50 PM and was discharged home from the PACU at 5:29 PM.

Review of the patient's Physician orders documented a physician order, entered at 4:04 PM by Staff B, 4th year Obstetrical (OB) Medical Resident, to admit the patient to the medical/surgical unit.

Patient ID #1's medical record failed to reveal any evidence of a physician order for the patient to be discharged home.

During a surveyor interview on 1/30/2025 at 2:25 PM with Registered Nurse, Staff A, who discharged the patient home, she indicated that she not aware that the patient was going to be admitted to the hospital. She acknowledged that she did not see a discharge to home order.

During a surveyor interview with the OB Physician, Staff B, on 1/30/2025, at 1:30 PM, he explained that he wrote an order for Patient ID #1, requesting an inpatient admission to the hospital's medical surgical unit. Staff B indicated that he enters the admission order into the computer and the nurse is responsible to check the orders.

During a surveyor interview with the PACU Anesthesia Physician, Staff C on 1/30/2025, at 2:00PM, he indicated that the PACU Physician is responsible for writing an order documenting that the patient may be discharged from the PACU level of care after they meet the Post Anesthesia Units discharge criteria. He then explained that each physician service is responsible to determine the patient's next level of care, either an admission to the hospital, or to discharge home, entering an order into the patient's medical record indicating the patient's disposition when leaving the PACU.

During a surveyor interview with the Assistant Nurse Manager of the PACU, Staff D, on 1/30/2025 at 2:45 PM she acknowledged that Staff A discharged Patient ID #1 from the PACU to home without a discharge order from the OB physician per the hospital's policy.