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Based on review of the hospital's emergency room (ER) logs and review of patient medical records for 1 of 22 sampled (10) ER patients it was determined the hospital failed to comply with the provider agreement as defined in §489.20 and §489.24 by ensuring the patient had been safely discharged to a non-medical facility accompanied by an adult capable of surpervising his condition and provide care as required. Findings include:

1. Review of patient 10's ER medical record revealed he had arrived to the ER on 2/17/14 at 2:40 p.m. by ambulance after being in a motor vehicle accident (MVA). Patient 10 had sustained a scalp laceration, closed head trauma, an anterior cervical (neck) C1 fracture, loss of consciousness; and he did not remember all events of the accident. He had been discharged to a hospitality house that did not provide medical care accompanied by patient 14 (his wife). Patient 14 had also been in that same MVA, had sustained a mid-sternal chest rib fracture, had been prescribed Percocet (pain medication) as needed for her pain, and she was responsible for providing care as needed to patient 10.

Refer to A2409 finding 1.

Based on interview, record review, and policy review, the provider failed to ensure 1 of 22 sampled (10) emergency room (ER) patients was discharged to a non-medical facility accompanied by an adult capable of supervising his condition and provide care as required. Findings include:

1. Review of patient 10's medical record revealed:
*On 2/17/14 the patient was in a motor vehicle accident (MVA) and arrived at the ER by ambulance.
*He was assessed by the nurse at 2:34 p.m. and was seen by the ER physician at that same time.
*His diagnoses included scalp laceration, closed head trauma, and a nondisplaced anterior cervical (neck) fracture at vertebrate cervical 1 (C1) level.
*The scalp laceration was cleaned and repaired.

Review of the computed tomography (CT) radiology report dated 2/17/14 confirmed:
*He had a scalp laceration without a skull fracture.
*He had an anterior arch C1 cervical fracture.

Review of the ER physician consultant notes dated 2/17/14 for patient 10 confirmed:
*He arrived in the ER on a backboard with a cervical collar in place.
*He was connected to electrocardiogram (heart) monitor, blood pressure, and pulse oximetry (checks oxygen in the blood) to monitor vital signs.
*His oxygen saturation was 96 percent (%) on room air, and oxygen by nasal cannula was started at four liters.
*The patient had momentarily lost consciousness (passed out) during the accident and did not remember 100% of the events.
*He was alert and oriented to person, place, and time.
*His pupils were unequal with the left being 3 millimeters (mm) in size and the right was 2 mm; both were reactive to light.

Review of the ED physician note dated 2/17/14 for patient 10 confirmed:
*He had a transient loss of consciousness but arrived alert and oriented to person, place, and time.
*He had a laceration to the left side of his forehead and abrasions to the left hand and lower extremities.
*He denied neck pain posteriorly, weakness, sensory deficits (decreased physical and mental function), headache, and visual disturbances.
*The scalp laceration was cleansed, sutured, and antibiotic ointment with dressing was applied.
*Consultation with the neurosurgeon indicated the neck fracture was stable, and a soft cervical collar for six weeks would be appropriate until follow-up.
*He became warm, sweaty, blood pressure dropped to the 80's during the laceration repair. However he thought the patient had gotten too warm.
*Consultation with the neurosurgeon agreed discharge to the hospitality house would keep the patient close as two other family members were being admitted.
*The patient stated he understood:
-The need to keep the soft cervical collar on at all times until cleared by his physician at his follow-up appointment.
-Wound care was discussed and to watch for signs of infection.
-Head injury precautions would be followed for the next 36 to 48 hours.
*At 8:40 p.m. the patient was discharged in fair condition to the hospitality house accompanied by his wife (patient 14).

Review of patient 10's discharge instructions dated 2/17/14 revealed:
*He was to wear the soft cervical collar at all times.
*He needed to follow-up in seven to ten days with his physician.
*Follow head injury precautions the next 24-36 hours.

Review of patient 10's medical record revealed he had received and signed the discharge instructions on 2/17/14 for a minor head injury. A review of the medial record revealed a copy of those instructions was not a part of the patient's medical record.

Review of the ER log revealed on 2/17/14 at 9:43 p.m. patient 10 (approximately 63 minutes later) was readmitted to the ER with a diagnose of hypotensive (low blood pressure) episode. At 11:35 p.m. the patient was admitted into the hospital for observation.

Interview on 2/25/15 at 2:00 p.m. with the ER director and ER trauma clinical coordinator revealed:
*The discharge instructions for a head injury would have included the patient should have been woken up several times during the night to assess his alertness and his condition.
*A review of a copy of the provider's head injury discharge instructions confirmed the patient should have been woken up several times during the night.
*The patient had been discharged to the hospitality house with his wife.
*His wife would have been his caregiver during his stay at the hospitality house.
*The wife had been in the MVA with the husband.
*His wife had received Percocet (pain medication) for pain relief and was the caregiver for patient 10.
*Percocet when taken could cause drowsiness, sleep, and she might not be aware of her husband's condition and wake him up throughout the night.
*The wife was legally blind, to the extent of her blindness the hospital was not sure.
*The hospitality house had no medical staff on duty at any time.
*Patrons that stayed there must be self-care or have someone with them to oversee their needs.

Review of patient 14's medical record revealed:
*She arrived at the ER on 2/17/14 at 2:40 p.m. after a MVA.
*She had been in the MVA as her husband (patient 10).
*Her CT scan identified a non-displaced mid-sternal fracture at the 4th rib level.
*She was legally blind, could see with her glasses, but those had been lost in the MVA.
*She had a history of anxiety and took Ativan (anti-anxiety medication) at bedtime.
*At the time of her ER admission, her pain level was a ten on a zero to ten pain scale. Zero being no pain and ten being the worst.
*The following medications had been administered during her ER visit:
-At 3:34 p.m. - Ativan (antianxiety medication) one milligram for anxiety.
-At 3:34 p.m. - Fentanyl (pain medication) 50 micrograms intravenously (IV) for chest pain rated at a level four.
-At 6:28 p.m. - Percocet (pain medication) one tablet for a pain level of nine. At 7:28 p.m., she had stated her pain level had decreased to a five and was tolerable.
- At the time of her discharge her pain level was a five and tolerable.
*She was discharged with four Percocet tablets with instructions to take every four to six hours for pain as needed.
*She was discharged on 2/17/14 to the Hospitality House with her husband (patient 10) and would have been responsible for providing him care if required.

Review of the Lexi-Comp's Drug Reference Handbook, 18th Edition, 2009-2010, page 1122, revealed Percocet contained oxycodone (pain medication) and was used for moderate to severe pain relief. Oxycodone might cause impairment of an individual's physical and mental abilities and should not be used if required to perform tasks that require mental alertness.

Review of the provider's August 2012 Hospitality House policy revealed "The Hospitality House is designed to meet the overnight accommodation needs for Avera Queen of Peace patients and their caregivers. Guests must be physically able to care for themselves. No nursing care will be provided."

Review of the provider's July 2014 Emergency Medical Treatment and Active Labor Act (EMTALA) policy revealed "Stabilization should be completed before a person is discharged from the facility or transferred to another facility."