HospitalInspections.org

This CONDITION is not met as evidenced by:

Based on policy review, document review, medical record review, and interview, it was determined that the facility failed to meet the emergency needs of patients in accordance with acceptable standards of practice as evidence by:
Emergency department staff failed to verify the discharge location and/or contact the skilled nursing facility prior to the discharge of Patient #1. This resulted in the discharge of Patient #1 to their home/community residence instead of the rehabilitation facility (TAG-A1104).

Cross Reference:
482.55(a)(3)- Emergency Services Policies

Based on policy review, medical record review, and interview, emergency department staff failed to verify the discharge location and/or contact the skilled nursing facility prior to the discharge of Patient #1. This resulted in the discharge of Patient #1 to their home/community residence instead of the rehabilitation facility.

Findings include:

Review on 05/30/24 of the policy "Transfer/Discharge Transportation from the Emergency Department to Another Facility," last revised 02/13/23, indicated if a patient is returning to a care facility, the registered nurse will call report to the appropriate facility, copy any required data (lab results, radiology reports), and seal the information in an envelope. (The policy did not include guidance on nursing staff verification of the correct discharge location/address of a patient).

Review on 05/30/24 of emergency department medical record and ambulance documentation for Patient #1 dated 05/17/24 revealed the following:
-At 03:24 PM, Patient #1 arrived via ambulance to the emergency department for right hip pain.
-At 03:26 PM, the pre-arrival summary (from the rehabilitation facility) revealed Patient #1 was sent to the emergency department from the rehabilitation facility due to a right hip dislocation. Patient #1 was alert but not oriented. The daughter (health care proxy) was aware of the transfer to the emergency department but would not be going to the hospital.
-At 03:31 PM, a medical screen examination note by Staff (E), Physician documented Patient #1 had a right hip dislocation. Patient #1 had several dislocations during the past few weeks. The plan was for Patient #1 to have a hip revision completed at another hospital; however, Patient #1 does not have an appointment yet. Patient #1 was currently staying at a rehabilitation facility. Past medical history included dementia and was prescribed Donepezil (used to treat confusion (dementia) related to Alzheimer's disease). The neurological examination revealed Patient #1 was alert, oriented, and cooperative.
-At 03:40 PM, the physician ordered a right hip and pelvic x-ray for deformity.
-At 03:44 PM, a triage note by Staff (D), Registered Nurse, indicated Patient #1 ' s chief complaint was right hip dislocation that occurred from physical therapy in the rehabilitation facility. Patient #1 was confused at baseline.
-At 04:10 PM, radiological results revealed the right hip was found to be dislocated.
-At 04:38 PM, Staff (E), Physician, performed a reduction of the right hip dislocation.
-At 04:53 PM, radiological results revealed the right hip and hardware was in alignment.
-At 05:18 PM, Staff (E), Physician, documented that an orthopedic surgeon from another hospital was consulted and stated Patient #1 would not benefit from a transfer. The orthopedic surgeon recommended Patient #1 should go back to their current living arrangement and call the office on Monday to see if appointment can be moved to a sooner date. Patient #1 was stable for discharge.
-At 06:50 PM, the discharge note by Staff (D), Registered Nurse, indicated at 06:44 PM, Patient #1 was discharged via ambulance stretcher to the rehabilitation facility. The medical record face sheet indicated that Patient #1 ' s home address as primary residence. No secondary address was listed (rehabilitation facility). (There is no documentation that the registered nurse contacted the rehabilitation facility prior to the discharge of Patient #1).
The ambulance transfer form indicated Patient #1 was transported via wheelchair ambulance. The destination location listed on the form is "home" (Patient #1's home address in the community).

Review on 05/30/24 of emergency department medical record for Patient #1 dated 05/18/24 revealed the following:
-At 09:29 AM, a medical screen examination note by Staff (E), Physician, indicated Patient #1 arrived by ambulance for a medical evaluation due to accidently being discharged to their home on 05/17/24, instead of back to the rehabilitation facility. Patient #1 was found in their home that morning by their child. The rehabilitation facility requested that Patient #1 be evaluated to ensure the right hip was still in a normal position and to have blood work completed.
-At 10:56 AM, Staff (E), Physician documented that Patient #1 was at baseline. Patient #1 was stable for discharge back to the nursing home and to follow-up with the orthopedic surgeon.
-At 12:28 PM, a discharge note by Staff (F), Registered Nurse, indicated that Patient #1 was stable. The ambulance staff were at the bedside to transfer back to the rehabilitation facility. The rehabilitation facility was contacted and made aware that Patient #1 was returning. The medical record face sheet indicated that Patient #1 ' s home address as primary residence.

Interview on 05/30/24 at 10:25 AM with Staff (C), Charge Nurse in the emergency department on 05/17/24, indicated that Patient #1 was in the emergency department a few times for hip issues. Patient #1 was temporarily living at a rehabilitation facility until they could have hip surgery. On 05/17/24, Patient #1 arrived by ambulance for a dislocated hip which was realigned. Prior to Patient #1's arrival, the rehabilitation facility called to alert the emergency department staff that Patient #1 needed to be evaluated giving a brief description of what was going on. Patient #1 was alert and oriented, and wanted to go back home, not back to the rehabilitation facility. Patient #1 was discharged back to the rehabilitation facility, however, the ambulance transported Patient #1 back to their home in the community.

Interview on 05/30/24 at 12:55 PM with Staff (D), Registered Nurse who cared for Patient #1 on 05/17/24 indicated that once Patient #1 was ready to be discharged, Staff (D) told Staff (K), Health Unit Coordinator, to "send Patient #1 back." Staff (D) did not recall where they told Staff (K), Health Unit Coordinator to send Patient #1 back to. Staff (D) stated that they were busy when the ambulance crew arrived to transport Patient #1 back to the rehabilitation facility. Staff (D) gave the ambulance crew a brief report but did not remember if they told the ambulance crew Patient #1 was going back to the rehabilitation facility. Staff (D) forgot to call the rehabilitation facility to give report and discharge instructions prior to Patient #1 being discharged.

Interview on 05/31/24 at 10:30 AM, Staff (K), Health Unit Coordinator, revealed they arranged Patient #1's transport for discharge. Staff (D), Registered Nurse, came up to the desk and told Staff (K) that Patient #1 was ready to go home and to arrange transportation via wheelchair transport. Staff (K) checked for paperwork at Patient #1's bedside but there was not any. Staff (K) stated they also checked for pre-arrival note in Patient #1's medical record, but there was not a note in Patient #1's medical record. Staff (K) verbally confirmed Patient #1's discharge location with Patient #1 and registration. There were no incoming calls from a rehabilitation facility to check on Patient #1's anticipated discharge. Staff (K) call the ambulance company and gave Patient #1's home address as the destination location. Staff (K) gave the discharge paperwork to the ambulance crew transporting Patient #1, who confirmed the address (home/community) with Staff (K) and Patient #1.

Interview on 05/31/24 at 11:30 AM with Staff (A), Vice President of Patient Care, confirmed these findings.