HospitalInspections.org

Based on facility policy review, medical record review and interview, the hospital failed to provide Registered Nurse (RN) supervision and oversight to discharge patients from the Hospital's Emergency Department (ED) to an unsafe discharge for 1 of 4 (Patient #6) sampled patients review for discharge.

The findings included:

1. Review of the facility's policy titled "Discharge Transportation Services Program," dated 2/1/2025 revealed "...PURPOSE...To ensure, through the implementation of prudent and reasonable controls, that Facilities may provide or facilitate the provision of complimentary Discharge Transportation Services to eligible Discharged Patients in a manner that complies with federal law and regulation...The Facility may provide or facilitate Discharge Transportation Services to transport such a Discharge Patient to their residence or Alternate Location if the Discharge Patient lacks reliable transportation to leave the Facility Following discharge...A Facility may designate one or more individuals to assist in facilitating Discharge Transportation Services, including but not limited to Case Managers, Emergency Department [ED] staff, and Nursing personnel...The Facility may provide Discharge Transportation Services by facilitating transport through...(Lyft/Uber or equivalent ride share services with which the Facility may contract)...or public transportation..."

Review of the facility's policy titled "Patient Rights and Responsibilities," dated 1/2025 revealed "...Patient have a fundamental right to considerate care and treatment that safeguard their personal dignity...The patient has the right to expect reasonable safety as the hospital practices and environment are concerned..."

2. Review of the medical record revealed Patient #6 was admitted to Hospital #1's ED on 3/13/2024 with diagnoses of Diabetes, Hypertension, and Right Foot Infection.

Review of the "EMERGENCY PROVIDER REPORT," dated 3/13/2024 at 1:46 AM, by Medical Doctor (MD) #1's revealed "...Patient is a very nice 71-year-old female with history of diet controlled diabetes, diabetic neuropathy presents to the ER [Emergency Room] for evaluation of foot wound on right foot. States that she 1st noticed this about 3 weeks ago and states that the wound has been getting progressively larger and more painful, she stated that she has been followed by her PCP [Primary Care Physician] and was last seen on Monday, she stated that has been hurting more...has notice some foul-smelling discharge from this wound...admits that she has poor sensation in her feet at baseline..."

Review of the "ED Course," dated 3/14/2024 at 1:46 AM, by MD #1's revealed "...I performed local debridement of the foot wound, removing the surrounding dead, callus skin to better expose the wound itself, wound is mildly erythematous [abnormal redness of the skin] and no associated discharge, no odor, no crepitus [grinding, creaking, cracking, grating, crunching, or popping that occurs when moving a joint ], no foreign body. There is a small amount of local granulation [tissue often appears as red, bumpy tissue, new connective tissue and microscopic blood vessels that develop on a wound Surface during healing] tissue..."

Review of the "DISCHARGE ASSESSMENT," dated 3/14/2024 at 6:06 AM, by Registered Nurse (RN) #3, revealed, "...Patient left to... Home... Patient left with...Unaccompanied...Mode patient left... Ambulatory... Patient left via [by]...Private vehicle..."

Review of EMS #1's "...EMS (Emergency Medical Services) Physician Certification Statement," dated 3/13/2024, revealed "...Origin...[Named Assisted Living Facility (ALF) #1]...AMS [Acute Mental Status is a change in mental function caused by brain issues]...wound on R [right] foot had odor...pt is Diabetic..."

Review of "[Named EMS (Emergency Medical Services)] #1's Run Sheet," dated 3/13/2024 at 7:06 PM, revealed "...dispatched for mental status change, immediately proceeded to location emergent...has had foot pain for 2 weeks increasing worsened over the last 2 x days...When asked about mental status change staff reported pt [patient] had not been able to get around as well today and that she "hasn't been able to do her own laundry"...Pt was found sitting on a couch in the lobby...Transported To...[Named Hospital #1]...Emergency Room..."

Review of EMS#1's "Run Sheet," dated 3/14/2024 at 2:44 AM, revealed "...Primary Impression...Suicidal Ideation...3:00 AM...dispatched to [Named Assisted Living Facility #3]...immediately proceeded to location emergent...Pt was brought to [Named Hospital #1] from The [Named Assisted Living Facility#1]...earlier in the evening for a foot wound. Pt was apparently dropped off at the wrong location upon discharge from the ER [Emergency Room] and was found sitting outside the [Named Assisted Living Facility #3] where pt is not a resident...When asked what pt is doing outside The [Named Assisted Living Facility #3] and not the [Named Assisted Living Facility #1] pt reported she was dropped off by an Uber at this location. Pt was questioned why she didn't just tell the Uber driver he [she] was dropped her off at the wrong location and pt said, "I just want to end it all and figured I would just sit out here and freeze to death"...she called her daughter to explain why she was in the ER earlier and the daughter was rude to her and dismissive of her...Pt's [patient's] previous RN [Registered Nurse] was placed on the phone and reported they had the wrong address in their system which is why pt was sent to the wrong location upon discharge. RN denied calling facility and giving verbal report prior to discharge..."

Review of the "Ride Services #1 (is a new class of ambulance service provider)," dated 3/14/2024, revealed "Time of call...1:10 AM...From...[Named Hospital #1]...To...[Named ALF #2]..."

Review of the "Timeanddate.com," revealed the temperature on 3/14/2024 at 12:00 AM was a high of 48 degrees and low of 45 degrees.

Review of the medical records dated 3/14/2024, revealed Patient #6 was readmitted to Hospital #1's ED at 3:08 AM.

Review of the "EMERGENCY PROVIDER REPORT," dated 3/14/2024 at 4:20 AM, revealed "...Pt was just seen in this ER for suspected foot infection but was cleared...discharged back to her assisted living facility...She reportedly gave the wrong name and therefore the uber [Uber] that was ordered FOR HER took her to the wrong facility where she sat out in the cold for an hour...Patient Addendum dated 3/14/2025 at 3:43 PM, by MD #2...Psychiatry recommends inpatient however per the family they did not speak with family and only spoke with the pt, who has dementia...She is requesting to go back to her nursing facility, the [Named ALF #1]...I will rescind the 6404 [a certificate of need...a legal document used in the involuntary commitment process for individuals posing an immediate substantial likelihood of serous harm due to mental illness] and discharge her back to the [Named ALF #1]..."

3. During a telephone interview on 6/16/2025 at 10:56 AM with Family Member #1 was asked about her concerns with Patient #6's admission to the Hospital #1's ED. Family Member #1 stated, "...she resides at the [Named ALF #1]...she recently had an infection in her foot...the nurse called...she [Patient #6] was taken by ambulance...the nurse at the [Named ALF #1] stated she gave the EMT [Emergency Medical Technician]...information like a folder with all of her health insurance...health information where she lives...they put my mom in an [Ride Services #1]... I don't know if she told them the wrong place...which is possible... they didn't call the facility [ALF #1]...it was in the middle of the night...it was cold outside...the [Ride Services #1] literally dropped her off...they dropped her off at in the front of the building [ALF #2]...they [Ride Services #1] did not get the nurse...they did no go into the building...it was the middle of the night...the doors were locked and it was freezing outside...so those people [staff of the ALF #2] called the police...she got taken back to [Named Hospital #1]...mom was feeling very cold...she was saying I'm cold and I no longer want to live...the police interpreted that as suicidal..." The Family Member #1 was asked if she filed a complaint with the hospital. The Family Member #1 stated, "...I was told this is what we needed to do...I filed in March 2024 with the state of [Named State Complaint Line]..."

During an interview on 6/17/2025 at 3:38 PM, with the Director of Patient Safety and the former ED Director was asked to tell me how Patient #6 was discharged to the wrong ALF. The Patient Safety Director stated, "...we [Emergency Room Staff Member] talked to the patient...we got the address and then based off of that...we call ambulance services [Ride Services #1] to set up the medical Uber...did we just hear the address wrong...was it communicated inappropriately...somewhere along those lines that can happen...to tell you exactly how that happened...there was a breakdown..." The Patient Safety Director was asked when transferred by EMS they normally have the address where the patient is picked up from, the face sheet, and current medications. The Patient Safety Director stated, "...we don't really ever see those run sheets...if we ever need them typically, we would have to ask for them from quality or somebody along those lines..." The Patient Safety Director was asked should the discharging nurse call the facility and give them report on the patient's status and inform then the patient is returning. The Patient Safety Director stated, "...I would think so...I would..." The Patient Safety Director was asked the EMS documented that the nurse did not call the facility at the (Named ALF #1). The Patient Safety Director stated, "...I guess when he talked to the nurse in the ER[Emergency Room], she must admitted that she didn't call them [ALF #1]...I would call as the nurse...personally in my process anytime I send a patient back to a facility I attempt to call report...if I can't usually I'm going to make a note to say unable to discuss with anyone...I thought that the nurse should at least call report...that is the standard of practice, that you call them and let them know that their patient's coming back...especially if they come back at night time where you know it may be a shift change...different staff members there that wasn't there when she actually left...so they can be informed and prepare for her return...it's the same way each direction...I feels like we should also get report from the nursing home when they're sending somebody in...that doesn't happen always, that's not an excuse I'm not saying one should negate the other...there is definitely a challenge in communication...when we receive patients...from skilled nursing facilities...I was not here for this event..." The Patient Safety Director was asked if the hospital completed an incident report. The Patient Safety Director stated, "...I can say that, I would expect there would be an incident report...there was not one with this event..."

During a Teams Call on 6/24/2025 at 4:00 PM, with the Vice President (VP) of Quality was asked if the facility had identified anything in Quality Assurance (QA) with the ride share discharges. The VP of Quality stated, "...No, I was not aware of the issue until you informed me...we did not have a good tracking system in place if something like this happened...we need to do an investigation...we want to make sure the patients are safe...we did not know anything about it...the nurse is no longer working here...the patient was sent to the wrong place and incorrect address...the expectation has been clearly made to validate the address...not with the patient...make sure sending people to the right place and the right way...she was sent by the [Ride Services #1] we are contracted with...that is not an excuse...we take accountability..." The VP of Quality was asked if an incident report was completed. The VP of Quality stated, "...There was not...that the next piece to roll out to the team...it has to be reported... clearly the process needs to be reconciled...there had been some event to be rolled out with the tracking of the patients at discharge in a safe manner...with the new policy and spread sheet make sure that patients are safe and have a safe discharge plan..."

4. The facility failed to ensure Patient #6 had a safe discharge from the Emergency Department (ED) when the Patient #6 was sent by Uber in the night to ALF #2 and left unsafe and unattended outside the facility. Named ALF #2 was unaware of Patient #6's arrival.