HospitalInspections.org

Based on interview and document review, the facility failed to ensure emergency department (ED) staff provided safe and appropriate care for 1 of 1 patient (P1), who was transported by wheelchair from the emergency department (ED) to the nursing home a half mile away by ED staff, and P1 sustained injuries to his foot.

The findings include:

Review of a report provided by hospital staff, indicated the hospital had filed a report to the State Agency on 6/24/20, regarding P1 sustaining injuries during an inappropriate transport from the ED to the nursing home. The report indicated ED charge nurse registered nurse (RN)-A, and licensed practical nurse (LPN)-A, transported P1 via wheelchair from the ED across town to the nursing facility. During the transport, P1 sustained injuries to the toes on his right foot which had drug on the ground for an undetermined amount of time during the transport.

During observation on 8/7/20 at 8:00 a.m., the available route from the facility to the nursing home was observed. The route was determined to trek past a hi-way under construction, approximately 1/2 mile away from the ED. The majority of the route had no available sidewalks, resulting in P1's wheelchair being pushed on the street.

Review of the 6/13/20, ED provider notes written by physician assistant (PA)-A, identified P1 had presented to the ED via emergency medical services (EMS) for treatment of a surgical wound to the sternum at 4:21 p.m.. The notes indicated P1 had been started on antibiotics for a suspected infection prior to the ED visit. Further, it was identified there was no transportation service available when P1 was discharged from the ED so two of the ED nurses (RN-A and LPN-A), had volunteered to take P1 back to the nursing home via wheelchair indicating to the PA the nursing home was "just down the street".

An After Visit Summary note identified staff printed off P1's discharge orders at 6:22 p.m. 6/13/20, finalizing his ED visit.

Review of a 6/14/20, written grievance from P1's family member (FM)-A, identified FM-A had called he facility and spoke with the the ED nurse who stated "they weren't sure how (P1) had returned to (the nursing home) because the ambulance wouldn't bring him back and the local transit company was closed for the day." The ED staff had commented the nursing home's facility "probably just needed a respite from (P1)." Since P1's stroke, P1 yelled out and could not help it. He was "confused and scared". Two of the facility staff were given permission to walk P1 back to the nursing home. During the walk, P1's right foot fell off the pedal. P1 had no feeling in his right leg and foot at that time. "Your staff didn't even put his foot back on the pedal. They just kept walking and dragged his foot on the road. When he got back to (the nursing home), his sock had blood on it and 2 of his toes were cut up from being dragged. (P1) is a vulnerable adult due to his stroke. This is neglect and abuse".

Review of a written resolution provided to FM-A dated 6/15/20, by the quality officer (QA)-A included: "Your concerns are taken seriously and we have completed a review regarding the information you shared. We have used this information to improve our processes by implementing discharge guidelines which includes methods of transportation..."

When interviewed on 8/7/20 at 10:17 a.m., the hospital's director of nursing (DON) stated RN-A had reported on 6/13/20 after P1 had been assessed by PA-A, that P1 was agitated and wanted to leave the ED. The DON stated because FM-A had been unable to be at the facility during P1's examination and treatment that day, RN-A had asked if it was o.k. to take P1 via wheelchair to the nursing home which she had eluded was across the street. The DON stated she did not live in the community so was unaware where the nursing home was located. The DON further stated she had asked RN-A if she'd checked with PA-A to determine whether it would be acceptable, and PA-A had advised RN-A to contact the DON for the final determination, but was o.k. with the transport if the DON approved. The DON clarified, PA-A was a locum (traveling) ED provider and was not familiar with the community either, and stated RN-A reported P1 had intact cognition and the only reason he was in the nursing home was to heal from his surgical wound. The DON acknowledged RN-A failed to tell her the nursing home was located 1/2 mile away, or that P1 had comorbidities of a stroke which impaired his sensation in his lower extremities. The DON stated she'd first heard of the incident from the nursing home when it had been reported to the hospital's Chief Executive Officer (CEO) the following Monday on 6/15/20. The DON stated it was an expectation staff would make good decisions based on the safety of the patient, and not for convenience. The DON was unaware the distance was more than across the street as RN-A claimed it to be. The DON stated she and the CEO drove the route to the nursing home themselves on 6/15/20, and had been unaware of the construction and lack of sidewalks prior to that time. The DON stated neither she nor the CEO identified any broken pavement in the facility parking lot of the nursing home, and verified RN-A had no disciplinary action taken after the incident. The hospital's DON confirmed the hospital had no contracts with any transportation companies. The community did have a local transport company however, they were only available during regular business hours: Monday thru Friday 8:00 a.m. to 5:00 p.m. There was no indication the nursing home had been notified by ED staff of their decision to transport P1 back to the facility by wheelchair.

During interview on 8/7/20 at 10:35 a.m., with the ED manager RN-B, she stated she was aware of the incident from 6/13/20, and had spoken with RN-A following the incident (could not recall date). RN-B stated RN-A reported to her staff were unable to find transportation back to the nursing home so RN-A decided to transport P1 via wheelchair back to the nursing home. RN-B stated RN-A has continued to work her normally scheduled shifts as charge nurse, and verified there had been no further assessment or oversight of her care to ensure she was making appropriate choices in care. RN-B also verified she had not performed any auditing of patient charts to determine whether RN-A was making critically appropriate choices when directing patient care in the ED. However, RN-A received a coaching session advising her never to transport a patient in that manner again. RN-A did not receive any re-education or monitoring to ensure any lack of safety with providing care. RN-A had also done some discharge training identified as a note in a "blog" staff could read, but was unaware what staff received those instructions or if the context was understood. RN-B acknowledged having no formal way to ensure any re-education was received or understood. Although RN-B stated she was responsible for ED staff training, she verified there was no re-training to other staff related to current discharge or safety policies.

During further interview on 8/7/20 at 11:23 a.m., the DON stated RN-A had told her staff had transported patients "that way before". Further, the DON stated there were policies related to discharge on the facility's online learning, but after review, it was determined RN-A had not received that education within the past year including after the incident. The DON also stated RN-A had a history of poor judgement and choices including incidents with other staff members and had reportedly thrown an object at a provider in the ED during her shift. It was unknown if this occurred around patients. The DON agreed RN-A's lack of judgement in dealing with others prior to the incident may indicate she did not always use sound judgement in dealing with situations of staff or patients. The DON verified RN-A was not placed with another co-worker or taken off duty as the charge nurse in the ED after the incident. The DON stated she had assigned the quality assurance (QA) staff to be in charge of the investigation.

On 8/7/20 at 12:45 p.m., interview and photographic document review were conducted with the nursing home's DON. The DON stated she had been informed of this incident by the nurse on duty at the nursing home shortly after P1's arrival back to the nursing home from the ED visit. The nursing home's DON stated P1 arrived at the facility with RN-A and LPN-A via wheelchair, knocking at the nursing home's front door, which was not currently being used due to COVID-19. The DON said a facility nursing assistant answered the door, and let P1 in, but the hospital staff did not give any other status updates. When transferred to bed from the wheelchair, the nurse on duty noticed holes and what appeared to be blood staining on P1's socks. Upon removing the socks, the nurse identified severe deep gouging in P1's first 2 toes on his right foot. The DON stated the sores appeared to have been from P1's feet dragging on the ground, so the nurse on duty took a photograph and sent it to her (the nursing home's DON). The DON said she had immediately contacted the hospital ED and had spoken to RN-C who said she was the charge nurse on duty in the ED. The DON said RN-C informed her RN-A and LPN-A had been "in a hurry to get home to their families" and had not reported the incident. The nursing home DON said she had reported the incident to the nursing home's administrator who followed up with the hospital CEO regarding the concerns on 6/15/20. When reviewed with the facility's DON at the time of the interview, photo documents showed pictures of deep tissue and or muscle injuries to toes on P1's right foot, with obvious skin missing to R1's toes.

During interview and document review on 8/7/20 with QA-A, she verified she was responsible for the investigation of events surrounding the injury P1 received during transport from the ED back to the nursing home:
1) The incident report date opened was 6/15/20. The hospital had received a call from the nursing home's DON regarding P1's injuries during transport. No other entry was made that day.
2) On 6/18/20, QA-A had interviewed RN-C regarding the incident. RN-C confirmed having received a call at approximately 7:45 p.m. on 6/13/20, from the nursing home's DON regarding P1's injuries, and was aware the nursing home would file a complaint. There was no indication QA-A had asked RN-C any other details surrounding the event.
3) On 6/24/20, QA-A stated she filed a SA report. No other entry was made that day.
4) 7/16/20, QA-A had identified the facility had developed discharge guidelines for each nursing department which included acceptable methods of transportation. A resolution letter had been mailed to FM-A. The resolution summary included acknowledgement of the incident, an apology, change in processes, notification of staff, and report to the SA. QA-A confirmed she had had not spoken to all parties involved, nor had she performed any auditing of medical records to identify any other potential inappropriate transport or care of ED patients. QA-A stated she had closed the file on 7/16/20, so other staff would not see it related to privacy. QA-A acknowledged only one other staff other than the DON and CEO had access to the file, an appropriate managerial staff who could review the investigation. QA-A agreed her investigation was neither timely nor thorough to prevent potential risk to other patients cared for by RN-A at the facility. QA-A confirmed P1 suffered injuries to his toes during the inappropriate transport.

During interview on 8/7/20 at 4:04 p.m., PA-A stated she was unaware the nursing home was 1/2 mile away from the hospital, and stated she'd advised staff to follow their policies and contact the DON for decisions about walking P1 back to the nursing home from the ED. PA-A also stated upon return to the ED, neither RN-A nor LPN-A had reported the injuries to P1's right foot to the PA-A.

Interview on 8/10/20 at 10:35 a.m. with RN-A identified she recalled the events surrounding the transfer of P1. RN-A stated there were no local transportation services available after business hours on 6/13/20, to transfer P1 back to the nursing home. RN-A stated she'd discussed the nursing home location with another nurse and PA-A, RN-A said LPN-A had stated the nursing home was "very close by". RN-A advised the DON P1 required the use of a wheelchair plus 1 additional staff to "be safe". RN-A felt the transfer was authorized so as not to have P1 stuck at the hospital. RN-A stated they'd had another patient several weeks earlier who had mental health issues, who had to stay in the ED while awaiting mental health placement. RN-A stated P1 was a "stress to staff" while in the ED. RN-A stated she was not familiar with the community as she herself lived out of town, and therefore had been unaware of the location of the nursing home. RN-A stated, "Everything was going well", however stated the nursing home had not advised her which door to bring P1 to upon arrival, and the parking lot was torn up which is probably where P1 sustained the injuries to his toes. RN-A verified she had observed P1's toe injuries and described them as "small, superficial abrasions". Further, RN-A stated she heard staff had given patient's rides in personal automobiles before and felt there was no concern pushing him back in a wheelchair to the nursing home. RN-A said it was "hard to judge [P1's] mental or physical capacity". When asked about the paperwork sent with P1 to the ED, RN-A acknowledged the nursing home had provided paperwork with his diagnoses listed upon arrival to the ED. RN-A verified she had never viewed that information to determine potential risks to P1 prior to transport. RN-A agreed she had not told the hospital's DON about P1's diagnoses or impaired mental capacity when asking for permission for the transport. RN-A stated she had reported off to the nursing home's nursing assistant when she'd arrived at the facility with LPN-A. RN-A again acknowledged she was aware P1 had dragged his foot, and felt it happened on rough pavement upon arriving to the nursing home's main entrance. RN-A was unaware, due to his stroke, P1 had no sensation in his lower extremity and would have been unable to advise staff his foot had fallen or was being injured. RN-A felt she had made the right decision at the time, but advised she would "Never do that again." RN-A verified she had received the policy on appropriate discharge and transport after the incident, and had worked as charge nurse in the ED during her subsequent shifts with no additional oversight.

Interview on 8/10/20 at 12:15 with the CEO identified he agreed staff had inappropriately transported P1 causing injury to P1's foot. The CEO also agreed staff had not performed a thorough investigation, or taken steps to prevent reoccurrence by ensuring RN-A made safe choices with regards to patient care and transport. The CEO verified the hospital had no transportation company contracts currently in place at the facility to ensure safe transportation by qualified staff. If no transportation was available, staff were to keep the patient at the facility for appropriate care and supervision.

Review of the 7/19/07 Prevention of the Maltreatment of Vulnerable Adults (VA)policy identified the hospital would evaluate physical or environmental factors that could lead to neglect of any of its patients. All staff who suspect abuse or neglect was to have reported the incident. Neglect was defined as failure on the part of the caretaker to supply the VA with necessary care and supervision.

Review of the 7/25/19, Patient Concerns/Complaint Reporting and Resolution policy identified a formal or informal verbal, written complaint received after the patient is discharged was considered a grievance and was to be forwarded to the chief quality office (QA-A). QA-A was to contact the complainant by telephone if possible. QA-A was to have obtained the facts surrounding the complaint and document the nature of the complaint and other pertinent information. The results of the investigation and resolution was to be sent to the complainant within 7 days of receipt of the complaint. All grievances which cannot be satisfactorily resolved are to be forwarded to the Grievance Committee for review and resolution.

Review of the hospital's June 2020 Discharge Guidelines- Inpatient Department, used by the ED at the time of the incident, identified patient care staff were to request a safe vehicle for pickup at discharge. The nurse was to verify there was a safe vehicle for transport with patient and family. Medical transportation was to be provided for patients with limited mobility.

Review of the hospital's July 2020, Standards of Employee Conduct or Behavior policy identified infractions of the following standards of conduct was to result in disciplinary action including verbal or written warnings, suspension, or termination if not corrected: Disregard for hospital policies, failure to use safety techniques or report injury.