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Based on medical record review and staff interview it was determined the facility failed to provide patient care in a safe setting for one (#2) of four patients sampled.

Findings included:

Review of the medical record for patient #2 revealed the patient arrived to the facility's ER (Emergency Room) on 10/16/2020 at 7:05 pm. Review of the ER physician's evaluation on 10/16/2020 at 7:20 pm revealed the patient presented for intentional ingestion of a foreign body. The patient stated she swallowed a soap dispenser straw in an attempt to harm herself. The ER physician documented the patient resided at a group home and this type of behavior was frequent.

The patient was admitted for removal of the foreign body and was placed under a Baker Act. Review of the History & Physical, performed on 10/17/2020 at 4:11 am, revealed the patient had a history of PICA (psychological eating disorder characterized by a tendency to eat non-food items), anxiety, lived in a group home, and had a history of eating objects both outpatient and while in the hospital. Review of the patient's history revealed the patient had previous upper endoscopy procedures performed on 4/30/2020, 5/04/2020, 5/16/2020, 5/22/2020, 8/18/2020, and 9/21/2020 all for removal of intentionally ingested foreign bodies. The patient was placed under a Baker Act and observed 1:1 at all times. Review of the record revealed on 10/17/2020 the foreign body was successfully removed by the Gastrointestinal (GI) physician.

Review of the case management documentation on 10/17/2020 revealed the patient was medically cleared and approval for admission to a psychiatric facility was in progress. On 10/18/2020 the case management documentation revealed the psychiatric did not have capability to admit the patient. On 10/18/20 at 2:45 pm the patient was assessed by a psychiatrist who determined the patient did not meet the criteria to be held under the Baker Act and therefore rescinded the Baker Act. The patient's primary care physician and legal guardian were informed. The physician ordered the patient to be transferred back to her group home and would follow up with her psychiatrist.

Review of the nursing note, dated 10/18/2020 at 5:41 pm revealed the patient swallowed a plastic knife from her dinner tray. Review of the record revealed the patient was on 1:1 observation at the time of the incident and according to the primary care physician note the patient was again placed under the Baker Act. The record revealed the patient underwent a second upper endoscopy procedure for removal of the plastic knife on 10/19/2020.

On 11/6/2020 at 9:25 am an interview was conducted with the Director of Risk Management. She confirmed the above findings and stated the facility is in the process of reviewing the event.

On 11/6/2020 at 2:15 pm the sitter at the time of the event on 10/19/2020 was interviewed. She stated the patient became upset when she was informed she would be returning to the group home. She stated her dinner tray was delivered to the room and as she was observing the patient took the plastic knife from the tray, broke it in half, and quickly swallowed it. The sitter stated she quickly intercepted the patient's hand which held the other half of the knife and removed it from the patient. Review of the record revealed the nurse and physician were immediately made aware. The sitter stated she remained with the patient. The interview revealed the sitter stayed with the patient and she stated the patient was looking for other items to swallow. The sitter stated she removed the gloves from the room and also observed the patient beginning to rip a face mask up that she was given to wear during transport to radiology. The sitter stated she was able to remove the ripped pieces of the mask before the patient had a chance to swallow them. Review of the record revealed the facility failed to provide care to the patient in a safe setting.

Based on medical record review, review of policy and procedures, and staff interview it was determined the facility failed to discharge the patient to the appropriate post-acute care provider and according to physician orders for one (#2) of four patients sampled.

Findings included:

Review of the facility policy, "Patient Discharge Procedure", #8-008, under the guidelines section the policy stated the hospital arranges services required by the patient after discharge in order to meet his/her ongoing needs for care and services; and a physician order is required for patient discharge. The procedure states the Physician places the order in the electronic record with discharge instructions and the RN (Registered Nurse) verifies the discharge order.

Review of the medical record for patient #2 revealed the patient arrived to the facility's ER (Emergency Room) on 10/16/2020 at 7:05 pm. Review of the ER physician's evaluation on 10/16/2020 at 7:20 pm revealed the patient presented for intentional ingestion of a foreign body. The patient stated she swallowed a soap dispenser straw in an attempt to harm herself. The ER physician documented the patient resided at a group home and this type of behavior was frequent. The patient was admitted for removal of the foreign body and was placed under a Baker Act and observed 1:1 at all times. Review of the record revealed on 10/17/2020 the foreign body was successfully removed by the Gastrointestinal (GI) physician.

Review of the case management documentation on 10/17/2020 revealed the patient was medically cleared and approval for admission to a psychiatric facility was in progress. On 10/18/2020 the case management documentation revealed the psychiatric facility did not have capability to admit the patient. On 10/18/20 at 2:45 pm the patient was assessed by a psychiatrist who determined the patient did not meet the criteria to be held under the Baker Act and therefore rescinded the Baker Act. The patient's primary care physician and legal guardian were informed. The physician ordered the patient to be transferred back to her group home and would follow up with her psychiatrist.

Review of the nursing note, dated 10/18/2020 at 5:41 pm revealed the patient swallowed a plastic knife from her dinner tray. Review of the record revealed the patient was on 1:1 observation at the time of the incident and according to the primary care physician note the patient was again placed under the Baker Act. The record revealed the patient underwent a second upper endoscopy procedure for removal of the plastic knife on 10/19/2020.

Review of the physician documentation revealed on 10/19/2020 the patient was medically cleared. At 5:15 pm the psychiatrist evaluated the patient and determined the patient did not meet the criteria to be held under the Baker Act. The primary care physician was informed and ordered the patient to be discharged back to her group home.

Review of the nursing note, dated 10/19/2020 at 8:31 pm, revealed case management was unable to make arrangements for patient to discharge back to group home this evening. The patient informed the nurse she was not staying and the Baker Act had been rescinded and they could no longer keep her. The nurse spoke with the midlevel provider whom assessed the patient and determined she was alert and oriented with capacity to make her own decisions. The patient was informed of the risks of leaving against medical advice and signed the form confirming she understood the risks and the patient was discharged.

Review of the discharge summary addendum, dated 10/20/2020 at 8:32 am, by the primary care provider revealed the physician was informed by the midlevel provider the patient had left against medical advice. Documentation stated the physician discussed with the midlevel that the patient lacked capacity, she lived in a group home, and his order stated she was to be discharged back to that location. Review of the record revealed the patient was readmitted to the hospital on 10/20/2020. The patient was discharged back to the group home on 10/24/2020.

On 11/6/2020 at 9:25 am an interview was conducted with the Director of Risk Management. She confirmed the above findings and stated the facility is in the process of reviewing the event.