HospitalInspections.org

Based on policy review, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20(l) and §489.24.

Findings included:

1. The hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 28 sampled patients (Patient #2).

~cross refer to 489.24 (a) & 489.24 (c), Appropriate Medical Screening Exam - Tag A2406

2. The hospital failed to ensure necessary stabilizing treatment was provided as required to stabilize an emergency medical condition for 1 of 28 sampled patients (Patient #2).

~cross refer to 489.24 (d)(3), Stabilizing Treatment - Tag A2407

Based on policy and procedure review, medical record reviews, and staff interviews, the hospital failed to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of transfer for 1 of 28 sampled patients (Patient #2).

Findings included:

Review of the hospital policy titled, "Emergency Medical Treatment and Labor Act" (EMTALA) last revised on 10/2020, revealed, "...EMTALA ...1 ...federal law that addressed how hospitals deliver emergency services to the public ...A ...I. Maintain medical and other records related to individuals transferred to and from the hospital, as required by the regulations ...K. Maintain a central log of individuals who come to the Dedicated Emergency Department seeking treatment and indicate whether these individuals refused treatment, were denied treatment, were treated, admitted, stabilized and/or transferred or were discharged ..."

1. Review on 09/15/2021 of the 2nd DED record for Patient #2, revealed the 82-year-old female returned to the hospital's DED via ambulance on 08/31/2021 at 1130 (20 hours and 40 minutes after discharge) with a chief complaint of "Fall." Review of the EMS (Emergency Medical Services) Run Sheet revealed, "...Dispatch advises the patient rolled down her driveway and overturned in the weeds. Law enforcement on scene ...Upon arrival found female patient seated on the ground in the kudzu on the side of her driveway ...Patient appears very confused ...Patient was found by the meals on wheels driver ...Spouse is also wheelchair bound. Patient does not recall what happened...noted to have minor scrapes and bruises on her face ...Full report given to ER staff including DSS having been involved with patient due to her being unable to care for herself and her spouse being unable to care for her. Patient care transferred to RN (Registered Nurse) at bedside ..." Review of the ED Patient Care Timeline revealed NP (nurse practitioner) #2 began the MSE (medical screening exam) at 1134. Review of the ED Physician Documentation started by NP #2 at 1155 revealed, "...MDM (medical decision making) - Multiple Trauma Minor ...Spoke with (named Case Manager)...she has thoroughly investigated the home situation of patient...suggest patient is okay to be discharged home today...Plan to Discharge ...Time of Decision: 1302. MDM Comments...Discharge Diagnosis: (1) Fall from wheelchair...Condition: Good..." Review of the DED Timeline revealed Patient #2 departed the ED at 1940, however, the record review failed to reveal documentation of the EMS Transfer back to Patient #2's home.

Interview with the CNO on 09/16/2021 at 0942 revealed, "We were unable to find the EMS record...may have been misfiled, I don't know..."

2. Review on 09/15/2021 of several of Case Management Notes revealed Patient #2 returned to the DED on 08/31/2021 (unknown time) after being discharged and transported home via EMS at 1940. Review of the DED Central Logs failed to reveal a 3rd DED visit for Patient #2. Review revealed a Case Management Note signed by Case Manager (CM) #1 on 09/01/2021 at 0946 that stated, "Today I was informed that yesterday Pt's (sic) family refused to allow Pt to stay at home and had EMS bring her back to the ER (emergency room) last night." Review of another Case Management Note signed on 09/02/2021 at 1313 revealed, "(Named Skilled Nursing Facility) agreed to accept (Patient #2) even after I informed them of her acting out this morning and ...report that Pt (sic) would wonder (sic). ER Unit Clerk is making packet ...(Named Skilled Nursing Facility) to transport...this afternoon..." Review revealed no documentation of Patient #2's EMS Transfer back to the named hospital on 08/31/2021. Review further failed to reveal any documentation of Patient #2's care between 08/31/2021 and 09/02/2021, when CM Notes revealed Patient #2 was being transferred to a SNF (Skilled Nursing Facility). Review revealed Patient #2 was not registered and logged in as a patient when she was brought back to the DED on this third visit.

Interview on 09/15/2021 at 0855 with the CNO (Chief Nursing Officer) revealed EMS transported Patient #2 back to the hospital when her spouse refused to let her in. The CNO stated, "She was not a patient at that point." When asked what Patient #2 was, if not a patient, the CNO replied, "That's a good question." Follow-up interview with the CNO on 09/16/2021 at 0942 revealed, "We were unable to find the EMS record...may have been misfiled, I don't know..." The CNO stated that Patient #2 had been discharged and there was no way to document those things in the record because the record was closed. Interview revealed CM was able to document notes because those were able to be amended. Interview revealed, "We dropped the ball, we should've opened the record back up and logged her in as a patient." Interview revealed the hospital failed to comply with its own policy and federal regulations.

In summary, Patient #2 was discharged and transported home by EMS on 08/31/2021 at 1940. A review of case management notes dated 09/01/2021 revealed Patient #2 was transported back to the DED a short time (exact time not documented) after her discharge. Review of the Central Logs revealed no documentation that Patient #2 returned to the hospital and failed to reveal documentation of Patient #2's EMS Transfer from and back to the DED on 08/31/2021. Review further revealed Patient #2 was not acknowledged as a patient upon her presentation back to the DED, as evidenced by no documentation of her registration, triage or medical screening exam. Review revealed no medical record of Patient #2's third DED visit was available.

Based on policy and procedure review, medical record reviews, staff and physician interviews, the hospital failed to maintain a central log on each individual who came to the Dedicated Emergency Department (DED), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 of 28 sampled patients (Patient #2).

Findings included:

Review of the hospital policy titled, "Emergency Medical Treatment and Labor Act" (EMTALA) last revised on 10/2020, revealed, "...EMTALA ...1 ...federal law that addressed how hospitals deliver emergency services to the public...A...I. Maintain medical and other records related to individuals transferred to and from the hospital, as required by the regulations...K. Maintain a central log of individuals who come to the Dedicated Emergency Department seeking treatment and indicate whether these individuals refused treatment, were denied treatment, were treated, admitted, stabilized and/or transferred or were discharged ...5. MEDICAL RECORDS / DOCUMENTATION REQUIREMENTS: A. Patient Logs: The Hospital will maintain a central log on each individual who comes to the emergency department ...The minimum elements each log should contain are the date, time of presentation, name, age, sex, presenting complaint, diagnosis, disposition and time of discharge. Registration staff will maintain patient logs, directly or by reference ..."

1. Review on 09/15/2021 of the 2nd DED record for Patient #2, revealed the 82-year-old female returned to the hospital's DED via ambulance on 08/31/2021 at 1130 (20 hours and 40 minutes after discharge) with a chief complaint of "Fall." Review of the EMS (emergency medical services) Run Sheet revealed, "...Dispatch advises the patient rolled down her driveway and overturned in the weeds. Law enforcement on scene ...Upon arrival found female patient seated on the ground in the kudzu on the side of her driveway ...Patient appears very confused ...Patient was found by the meals on wheels driver ...Spouse is also wheelchair bound. Patient does not recall what happened...noted to have minor scrapes and bruises on her face ...Full report given to ER staff including DSS having been involved with patient due to her being unable to care for herself and her spouse being unable to care for her. Patient care transferred to Registered Nurse (RN) at bedside ..." Review of the ED Patient Care Timeline revealed NP (nurse practitioner) #2 began the MSE (medical screening exam) at 1134. Review of the ED Physician Documentation started by NP #2 at 1155 revealed, "...MDM (medical decision making) - Multiple Trauma Minor ...Spoke with (named Case Manager)...she has thoroughly investigated the home situation of patient...suggest patient is okay to be discharged home today...Plan to Discharge ...Time of Decision: 1302. MDM Comments...Discharge Diagnosis: (1) Fall from wheelchair...Condition: Good..." Review of the ED Timeline revealed Patient #2 departed the ED at 1940, however, the record review failed to reveal documentation of the EMS Transfer back to Patient #2's home.

2. Review on 09/15/2021 of several of Case Management Notes revealed Patient #2 returned to the named ED on 08/31/2021 (unknown time) after being discharged and transported home via EMS at 1940. Review of the ED Logs failed to reveal a 3rd DED visit for Patient #2. Review revealed a Case Management Note signed by Case Manager (CM) #1 on 09/01/2021 at 0946 that stated, "Today I was informed that yesterday Pt's (sic) family refused to allow Pt to stay at home and had EMS bring her back to the ER (emergency room) last night." Review of another Case Management Note signed on 09/02/2021 at 1313 revealed, "(Named Skilled Nursing Facility) agreed to accept (Patient #2) even after I informed them of her acting out this morning and ...report that Pt (sic) would wonder (sic). ER Unit Clerk is making packet ...(Named Skilled Nursing Facility) to transport...this afternoon..." Review revealed no documentation of Patient #2's EMS Transfer back to the named hospital. Review further failed to reveal any documentation of Patient #2's care between 08/31/2021 and 09/02/2021, when CM Notes revealed Patient #2 was being transferred to a SNF (Skilled Nursing Facility). Review revealed Patient #2 was not registered and logged in as a patient when she was brought back to the DED on this third visit.

Interview on 09/15/2021 at 0855 with the CNO (Chief Nursing Officer) revealed EMS transported Patient #2 back to the hospital when her spouse refused to let her in. The CNO stated, "She was not a patient at that point." When asked what Patient #2 was, if not a patient, the CNO replied, "That's a good question." Follow-up interview with the CNO on 09/16/2021 at 0942 revealed, "We were unable to find the EMS record...may have been misfiled, I don't know..." Interview revealed, "We dropped the ball, we should've opened the record back up and logged her in as a patient." Interview revealed the hospital failed to comply with its own policy and federal regulations.

Interview on 09/16/2021 at 1415 with MD (Medical Doctor) #1, the ED Provider on 08/31/2021, revealed he remembered that Patient #2 was seen in the ED earlier on 08/31/2021 and was discharged home. Interview revealed the CN (charge nurse) asked MD #1 if the patient needed to be seen again and MD #1 responded, "No, because nothing new happened." MD #1 stated that he did not see a need to do a new MSE and charge Patient #2 for another visit. Interview further revealed that MD #1 felt it was best to just take care of her since she was already discharged.
MD #1 stated that he did not review Patient #2's medical record from visit #2 and relied on the information received from RN #3. Interview revealed the hospital failed to comply with its own policy and federal regulations.

Interview on 09/16/2021 at 1536 with the RN (Registered Nurse) #3, the Charge Nurse on 08/31/2021, revealed she was contacted by the EMS Supervisor on the evening of 08/31/2021 and was informed that Patient #2's husband refused to let her come back home. Interview further revealed that she believed one of the registration staff asked Patient #2 if she needed to be seen and Patient #2 said 'no'. Interview revealed RN #3 was unaware that Patient #2 had dementia because that information had not been relayed to her. RN #3 stated, "I thought about pulling her chart back up because I wanted to document my conversation with her daughter, but she had already been discharged and so, I didn't know what to do." Interview revealed the hospital failed to comply with its own policy and federal regulations.

In summary, Patient #2 was discharged and transported home by EMS on 08/31/2021 at 1940. A review of case management notes dated 09/01/2021 revealed Patient #2 was transported back to the named DED a short time (exact time unknown) after her discharge. Review of the Central Logs revealed no documentation that Patient #2 presented back to the DED between the time of her discharge on 08/31/2021 and the time of her placement and transport to a SNF on 09/02/2021 (2 days). Review further revealed Patient #2 was not acknowledged as a patient upon her presentation back to the DED, as evidenced by the lack of documentation that she was registered, triaged or received a medical screening exam.

Based on policy and procedure review, medical record reviews, staff and physician interviews, the hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 28 sampled patients (Patient #2).

Findings included:

Review of the hospital policy titled, "Emergency Medical Treatment and Labor Act" (EMTALA) last revised on 10/2020, revealed PURPOSE: ...Patients are not denied evaluation, screening, testing, treatment or stabilization on the basis of ...actual or perceived disability, nor on their presenting complaint ...EMTALA ...1 ...federal law that addressed how hospitals deliver emergency services to the public ...A. Provide an appropriate Medical Screening Exam (MSE) to any individual who comes to the emergency department ...PROCEDURE: 1. Medical Screening Exam (MSE) ...A. Any individual who presents to the Emergency Department (ED) ...and requests examination or treatment (request is made by or on behalf of the individual) will undergo a MSE ..."

1. Review on 09/14/2021 of the 1st DED record for Patient #2, revealed the 82-year-old female arrived at the hospital's DED via ambulance on 08/30/2021 at 1450 with a chief complaint of "Possible Arm Fracture." Review of the EMS (emergency medical services) Run Sheet revealed, "...it is decided that the best option is for the patient to be seen in the ER...Full report is given and care is transferred to nursing staff at bedside with the patient in no visible distress..." Review of the DED Patient Care Timeline revealed Patient #2 received a MSE (medical screening exam) at 1458 and the ED Physician Documentation further revealed, "...Plan to Discharge...Time of Decision: 1745...MDM (medical decision making) Comments: ...DX BILATERAL HUMERUS (upper arm x-rays) 2 views ...IMPRESSION: Transverse fracture left humeral neck with slight angulation and fragmentation. No fracture right humerus...Disposition Type: Discharge ...Condition: Stable...sling to left arm ...Return to emergency room if worsening ..." Review revealed Patient #2 was discharged home via private vehicle at 2200. The patient did not receive an appropriate medical screening examination, as the safety of her living situation was not assessed. The patient was not stabilized prior to discharge, as she was not capable of taking care of herself at home, and the ability of other family members to take care of her was not assessed.

2. Review on 09/15/2021 of the 2nd DED record for Patient #2, revealed the 82-year-old female returned to the hospital's DED via ambulance on 08/31/2021 at 1130 (20 hours and 40 minutes after discharge) with a chief complaint of "Fall." Review of the EMS (emergency medical services) Run Sheet revealed, "...Dispatch advises the patient rolled down her driveway and overturned in the weeds. Law enforcement on scene ...Upon arrival found female patient seated on the ground in the kudzu on the side of her driveway ...Patient appears very confused ...Patient was found by the meals on wheels driver ...Spouse is also wheelchair bound. Patient does not recall what happened...noted to have minor scrapes and bruises on her face ...Full report given to ER staff including DSS having been involved with patient due to her being unable to care for herself and her spouse being unable to care for her. Patient care transferred to Registered Nurse (RN) at bedside ..." Review of the DED Patient Care Timeline revealed NP (nurse practitioner) #2 began the MSE (medical screening exam) at 1134. Review of the DED Physician Documentation started by NP #2 at 1155 revealed, "...MDM (medical decision making) - Multiple Trauma Minor ...Spoke with (named Case Manager)...she has thoroughly investigated the home situation of patient...suggest patient is okay to be discharged home today...Plan to Discharge ...Time of Decision: 1302. MDM Comments...Discharge Diagnosis: (1) Fall from wheelchair...Condition: Good..." Review of the ED Timeline revealed Patient #2 departed the DED at 1940, however, the record review failed to reveal documentation of the EMS Transfer back to Patient #2's home. The patient did not receive an appropriate medical screening examination, as the safety of her living situation was not assessed. The patient was not stabilized prior to discharge, as she was not capable of taking care of herself at home, and the ability of other family members to take care of her was not assessed.


3. Review on 09/15/2021 of several of Case Management Notes revealed Patient #2 returned to the hospital's DED on 08/31/2021 (unknown time) after being discharged and transported home via EMS at 1940. Review of the DED Central Logs failed to reveal a 3rd DED visit for Patient #2. Review revealed a Case Management Note signed by Case Manager (CM) #1 on 09/01/2021 at 0946 that stated, "Today I was informed that yesterday Pt's (sic) family refused to allow Pt to stay at home and had EMS bring her back to the ER (emergency room) last night." Review of another Case Management Note signed on 09/02/2021 at 1313 revealed, "(Named Skilled Nursing Facility) agreed to accept ( Patient #2) even after I informed them of her acting out this morning and ...report that Pt (sic) would wonder (sic). ER Unit Clerk is making packet...(Skilled Nursing Facility) to transport...this afternoon..." Review revealed no documentation of Patient #2's EMS Transfer back to the DED on 08/31/2021. Review further failed to reveal any documentation of Patient #2's care between 08/31/2021 and 09/02/2021 (2 days), when CM Notes revealed Patient #2 was being transferred to a SNF (Skilled Nursing Facility). Review revealed Patient #2 was not registered and logged in as a patient when she was brought back to the DED on this third visit. Review revealed no evidence of a Medical Screening Examination for Patient #2 on this third visit. The patient did not receive an appropriate medical screening examination by a qualified medical provider. There was no indication that a qualified medical provider assessed and stabilized the patient as there was no new documentation generated.

Interview on 09/15/2021 at 0855 with the CNO (Chief Nursing Officer) revealed EMS transported Patient #2 back to the hospital when her spouse refused to let her in. The CNO stated, "She was not a patient at that point." When asked what Patient #2 was, if not a patient, the CNO replied, "That's a good question." Follow-up interview with the CNO on 09/16/2021 at 0942 revealed, "We were unable to find the EMS record...may have been misfiled, I don't know..." The CNO stated that Patient #2 had been discharged and there was no way to document patient care in the record because the record was closed. Interview revealed CM was able to document notes because those were able to be amended. Interview revealed, "We dropped the ball, we should've opened the record back up and logged her in as a patient." Interview revealed no medical screening examination was completed as Patient #2 was not considered a patient. Interview revealed the hospital failed to comply with its own policy and federal regulations.

Interview on 09/16/2021 at 1415 with MD (Medical Doctor) #1, the ED Provider on 08/31/2021, revealed he remembered that Patient #2 was seen in the ED earlier on 08/31/2021 and was discharged home. Interview revealed the CN (Charge Nurse) asked MD #1 if the patient needed to be seen again and MD #1 responded, "No, because nothing new happened." MD #1 stated that he did not see a need to do a new MSE and charge Patient #2 for another visit. Interview further revealed that MD #1 felt it was best to just take care of her since she was already discharged.
MD #1 stated that he did not review Patient #2's medical record from visit #2 and relied on the information received from RN #3. Interview revealed the hospital failed to comply with its own policy and federal regulations.

Interview on 09/16/2021 at 1536 with the RN (Registered Nurse) #3, the Charge Nurse on 08/31/2021, revealed she was contacted by the EMS Supervisor on the evening of 08/31/2021 and was informed that Patient #2's husband refused to let her come back home. Interview further revealed that she believed one of the registration staff asked Patient #2 if she needed to be seen and Patient #2 said 'no'. Interview revealed RN #3 was unaware that Patient #2 had dementia because that information had not been relayed to her. RN #3 stated, "I thought about pulling her chart back up because I wanted to document my conversation with her daughter, but she had already been discharged and so, I didn't know what to do."Interview revealed the hospital failed to comply with its own policy and federal regulations.

In summary, Patient #2 did not receive an appropriate medical screening exam. Although Patient #2 was discharged earlier on 08/31/2021, there is no documentation of her EMS Transfer home, or the EMS Transfer back to the named DED. Therefore, the hospital had no way of knowing if a change had occurred between the time of Patient #2's discharge and the time she returned. Record review from the 1st and 2nd DED visits further revealed Patient #2 had symptoms consistent with dementia and may not have been able to communicate her desire to be seen when asked by registration staff (as stated by RN #3). MD #1 made the determination that Patient #2 did not require a new MSE based on the information received from RN #3. MD #1 stated that he did not review Patient #2's DED record from visit #2 and was not aware of Patient #2's medical history, medication needs or previous treatments.

Based on policy and procedure review, medical record reviews, staff and physician interviews, the hospital failed to ensure necessary stabilizing treatment was provided as required to stabilize an emergency medical condition for 1 of 28 sampled patients (Patient #2).

Findings included:

Review of the hospital policy titled, "Emergency Medical Treatment and Labor Act" (EMTALA) last revised on 10/2020, revealed, "...EMTALA...1...federal law that addressed how hospitals deliver emergency services to the public...B. Provide necessary stabilizing treatment to an individual with an EMC [emergency medical condition]...within a hospitals capability and capacity...G...If an EMC is present initially but resolves while the patient is in the DED, the resolution of the EMC must be documented in the medical record prior to discharge...2. STABILIZATION...C...is achieved when the patients EMC has resolved to the point within reasonable clinical confidence, where the patients continued care, where appropriate, including further diagnostic work-up and/or treatment could be performed as an outpatient ..."

1. Review on 09/14/2021 of the 1st DED record for Patient #2, revealed the 82-year-old female arrived at the named hospital via ambulance on 08/30/2021 at 1450 with a chief complaint of "Possible Arm Fracture." Review of the EMS (emergency medical services) Run Sheet revealed, " ...Upon arrival found DSS (department of social services) worker speaking with (named city) Police Officer ...Patient is stating that her husband hit her ...Patient swaps rapidly from speaking about one subject to an entirely different subject ...Husband is present in the residence in a wheelchair ...patient fell and was diagnosed with a fracture to her left arm on 08/21/2021 at (named hospital #2)...daughter is out of town and did not appear concerned with the allegations Patient's husband seems surprised about the allegations but does not appear angry ...Patient is noted to be naked ...With the patient making accusations of abuse, having obvious bruising to her upper arm...it is decided that the best option is for the patient to be seen in the ER....for a proper exam to insure (sic) that the injury is old and that a secondary injury has not occurred ...Full report is given and care is transferred to nursing staff at bedside with the patient in no visible distress ..." Review of the Provider Progress Note written by NP #3 (Mental Health Service) at 1743 revealed, " ...Patient currently denies any suicidal or homicidal ideation and was not always sure of what occurred at her home that resulted in her being brought to the hospital. It is possible that the patient has dementia and currently does not meet inpatient criteria for the BHU. Patient is clear psychiatrically." The ED Physician Documentation further revealed, "Plan for Disposition of Patient: Plan to Discharge ...Time of Decision: 1745 ...MDM Comments: DX BILATERAL HUMERUS (upper arm x-rays) 2 views...IMPRESSION: Transverse fracture left humeral neck with slight angulation and fragmentation. No fracture right humerus...Disposition Type: Discharge...Condition: Stable...sling to left arm...Return to emergency room if worsening..." Police officer who initially went to the house returned to the DED...reports the husband is wheelchair bound, patient fell out of bed and broke her arm. Daughters are trying to get placement of the patient as she is suffering from dementia...Case management here to eval, trying to find contacts for daughters, attempting to find placement within her family for this patient to go to ..." Review revealed Patient #2 was discharged home at 2200. The patient did not receive an appropriate medical screening examination, as the safety of her living situation was not assessed. The patient was not stabilized prior to discharge, as she was not capable of taking care of herself at home, and the ability of other family members to take care of her was not assessed.

2. Review on 09/15/2021 of the 2nd DED record for Patient #2, revealed the 82-year-old female returned to the named hospital via ambulance on 08/31/2021 at 1130 with a chief complaint of "Fall." Review of the EMS (emergency medical services) Run Sheet revealed, "...Dispatch advises the patient rolled down her driveway and overturned in the weeds. Law enforcement on scene ...Upon arrival found female patient seated on the ground in the kudzu on the side of her driveway. According to first responders patient rolled approximately 40 yards down her steep driveway in her wheelchair ...Patient appears very confused ...has history of confusion but it is unknown as to whether it is related to dementia ...Patient has sling on her left upper arm...Her left arm was fractured on 08/21/21 when she fell out of bed ...Patient was found by the meals on wheels driver...Spouse is also wheelchair bound. Patient does not recall what happened ...noted to have minor scrapes and bruises on her face...Upon arrival at (named hospital)...Full report given to ER staff including DSS having been involved with patient due to her being unable to care for herself and her spouse being unable to care for her. Patient care transferred to RN at bedside..." Review of the DED Patient Care Timeline revealed Patient #2 was triaged 1130 and assigned an ESI (emergency severity index) Level 3, urgent. The DED Timeline revealed NP (Nurse Practitioner) #2 began the MSE (medical screening exam) at 1134. Review of the ED Physician Documentation started by NP #2 at 1155 revealed, " ...Other History...Patient was seen in this emergency department yesterday and diagnosed with a humeral fracture. Patient has an appointment with (named orthopedic physician) in 1 week...has abrasions to her forehead and nose. Patient is a poor historian as she does not know where this happened or circumstances surrounding it. Patient is also unable to tell me if she has a primary care provider...Physical Exam Findings: Constitutional: Alert, Well nourished, Moderate Distress...Cardiovascular: Regular Rhythm, Tachycardia. Respiratory: Normal Rate, Lung Sounds Clear ...Musculoskeletal ...Normal C/T/L [cervical, thoracic, lumbar] Spine ROM [range of motion] ...Tenderness (Left arm and left hip)...Integumentary...Abrasions (Forehead and nose). Neurological: Speech WNL (within normal limits) ...Answering Questions WNL (Patient unable to tell me where the incident happened), Oriented ...(Alert and oriented x 1, to self) ...MDM (medical decision making) - Multiple Trauma Minor...Consultation: Other (Case management)...Spoke with (named Case Manager)...she has thoroughly investigated the home situation of patient ...states that patient is demented and today was able to make it outside of her home in her own wheelchair and rolled down a hill ...has investigated the home situation as well as spoken to law enforcement...has also spoken with patient's daughters and the home health agency...suggest patient is okay to be discharged home today...Plan to Discharge ...Time of Decision: 1302. MDM Comments: 1252 Left Hip X-ray. IMPRESSION: No acute fracture or dislocation ...CT Head. IMPRESSION: 1. No acute intracranial findings. 2. Mild volume loss and chronic microvascular change. CT C-Spine (cervical spine). IMPRESSION: 1. No acute fracture or malalignment. 2. Moderate degenerative disc disease...Patient Education/Counseling-Information given to: Patient...Regarding: Diagnosis, Treatment, Prognosis, Need for follow-up." Discharge Diagnosis: (1) Fall from wheelchair...Condition: Good..." Review of the Home Medication List revealed, "Flexeril (muscle relaxer) 5-10 mg PO TID (three times daily) PRN (as needed), Docusate Sodium (stool softener) 100 mg PO daily, Insulin Lispro Sliding Scale (amount taken based on blood sugar levels), Levothyroxine (treats hypothyroidism) 50 mcg (micrograms) PO QAM (every morning), Oxycodone (narcotic pain medicine) 10 mg PO BID (twice daily) PRN and Miralax (laxative) 1 packet PO daily. The Home Medications List further revealed the list had not been updated and was last recorded and confirmed on 05/14/21. Review of a SW (social worker) Note signed by SW #1 at 1438 revealed, "Spoke with Pt's (sic) husband ...He reports that he is having a hard time taking care of her at home and that (named home health agency) nurse told him to tell the hospital that he can not (sic) take care of her. He asked why Pt (sic) is not being admitted and SW explained that has no reason to be admitted. SW inquired if there is family that can help or somewhere she can stay until she is placed. He reported that he will have to do the best that he can with her. SW agreed to send referrals to SNF and that the facilities can take her from home. An ED Nurses Note signed by RN (Registered Nurse) #2 at 1440 revealed, "Currently awaiting SW to assist with pt's (sic) D/C [discharge] d/t [due to] pt's (sic) daughter and niece refusing to take pt home. Record review further revealed another SW Note signed by SW #2 at 1507 that read, " ...Per (named CM Director), Pt is D/C and the family will need to take her home and work on placement from home. Referrals sent to (11 named facilities). Spoke with the husband and explained to him that Pt will need to D/C home and if the facilities can take her, they will contact him. He agreed to pick up Pt." A note by CM #1 at 1156 further revealed, "Per (named ED Provider, NP #2) ...Case Management consult to rule out elder abuse. I notified (named NP #2) that the police were at Pt's (sic) home yesterday and reported Pt (sic) has altered mental status. (Named home health agency staff) reported Pt is current with them and Pt does have dementia and they were working with the family on placement ...(Named home health agency staff) reported Pt's (sic) Dtrs [daughters] ...told her they want Pt cared for at home ...1559 ...The ER RN reported the Pt's Dtr (named) reported they can't take Pt. home. I called (named daughter) and her voicemail is full. Pt's niece (named) reported they can't care for Pt at home and she lives 2 hours away. I informed (named niece) that Pt has been discharged and it is not safe due to Covid + cases in this hospital or Pt to stay here. (Named niece) reported she will try to get her cousin to come pick up the Pt (sic). Record review further revealed a Pharmacy Note documented at 1612 that stated, "contacted patient's pharmacy and primary care physician for current home med list. Review revealed no response from Patient #2's pharmacy or PCP was received prior to her discharge. Record review revealed Patient #2 departed the named ED at 1940 via ambulance transport.

Review of "Scanned Documents" revealed an ER Report received from Hospital #2 (unknown time) that revealed Patient #2 was seen and evaluated at the outside hospital (Hospital #2) on 08/21/2021 and stated, "...History of Present Illness: 82-year-old female presents with left shoulder pain after a fall. Occurred this morning when she was trying to get out of bed, she tripped...landed on her left shoulder...Social History...Alcohol...Current...1-2 times per month...Feels unsafe at home: No...Lives with Self, Spouse. Married...Living situation: Home/Independent...Sleeping concerns; Yes. Feels highly stressed: No...Problem List/Past Medical History...At risk for violence...Carpal tunnel syndrome, Chronic pain syndrome (pseudogout, fibromyalgia, cervical DDD [degenerative disc disease]...History of total Left/Right Knee replacement...Hypothyroid...Opioid dependence...Type 2 Diabetes Mellitus ...Physical Exam...Musculoskeletal... Tenderness without deformity to left shoulder...Left anterior and posterior chest wall is tender without any crepitus or deformity. Neurological: AAO [awake, alert, oriented] x3. No gross motor or sensory deficit observed ...Assessment/Plan; X-ray shows left proximal humerus fracture. She was placed in a sling and given pain medicine here. Advised on sling use at home...Outpatient follow-up with orthopedics instructed her return precautions discussed. Stable for discharge. Diagnosis/Disposition: 1. Fracture of proximal end of left humerus ...Patient Instructions ...Tylenol and Motrin for pain. You can take stronger pain medicine as prescribed if you need to. Apply ice for pain and swelling. Follow-up with orthopedics as soon as possible. Return to the ER for worsening symptoms." Review of hospital #2's ER Report revealed no details about the circumstances surrounding Patient #2's fall, no mention of a dementia diagnosis and had no documentation of how Patient #2 returned home upon discharge.

Interview on 09/15/2021 at 0855 with the CNO (Chief Nursing Officer) revealed Patient #2's spouse accepted her back home before she was discharged on 08/31/2021. The CNO stated, "but then something changed and when she got there, he refused to let her in." Interview revealed EMS transported Patient #2 back to the DED when her spouse refused to let her in and the CNO stated, "She was not a patient at that point." When asked what Patient #2 was, if not a patient, the CNO replied, "That's a good question." A follow-up interview on 09/16/2021 at 0942 revealed, "We thought it was a transportation issue..We dropped the ball, we should've opened the record back up and logged her in as a patient."

Interview on 09/15/2021 at 0945 with the Director of CM revealed, Patient #2 was brought back to the DED after her spouse refused to let EMS in on 08/31/2021. Interview further revealed the Director contacted Patient #2's spouse herself the next day (09/01/2021) and told him that he had to let her in because that's where she lived. The Director stated that Patient #2's husband never told her that he could not care for her and when she spoke with him the next day, he told her that they could send her back home. Interview revealed that the Director contacted CM #1 and instructed her to contact the police department for their assistance in case Patient #2's spouse refused to let her in again. Interview revealed that at some point CM #1 had a conversation with Patient #2's family members and they were concerned that her husband could not take care of her, but they were going to work on picking her up. The Director stated, "At that point it was just a transportation issue, a social issue."

Interview on 09/15/2021 at 1031 with CM #1 revealed she was not aware of the home health agency involvement during Patient #2's first visit, but stated that the agency reached out to her at during the second visit and told her they were working on placement for Patient #2. CM #1 was unsure of the services Patient #2's home health agency were providing or the frequency of their visits. Interview revealed the ED was full of Covid patients on 08/31/2021 and stated, "We needed (named patient, #2) to get home safely. Interview revealed no conversation occurred with Patient #2's husband about his ability to care for her. CM #1 stated that she did speak with Patient #2's family and "they did at some point say they were not coming to get her." CM #1 did not remember when that conversation occurred. Interview revealed she had a conversation with the ED Provider as well to let him know what was going on. Interview further revealed that CM #1 contacted the police department to see if they could help with transporting Patient #2 back home, but stated, "they were unable to help ...we were forced to work on placement simultaneously with the home health agency."

Interview on 09/15/2021 at 1442 with NP #2, the ED Provider on the 2nd visit, revealed, "All I remember is that she (Patient #2) had been in the ER a time or two before. She had gone home and was under the care of someone." NP #2 recalled that Patient #2 had rolled down a hill in a wheelchair, fell and had a fracture of her shoulder. Interview revealed NP #2 remembered Patient #2 had some confusion, but he was unable to remember the extent of the confusion. Interview further revealed NP #2 did not recall a direct conversation with Patient #2's daughters. NP #2 stated that he recalled allegations of abuse on Patient #2's first visit, but also recalled that law enforcement was involved and ultimately determined that Patient #2's spouse was not capable of that. NP #2 was unable to remember if CM was consulted on the second visit or not. NP #2 further stated that he was not aware Patient #2 returned to the ED after her discharge on 08/31/2021. Interview revealed NP #2 was "under the impression she had a caregiver at home and not in danger." NP #2 stated that he had no knowledge of Patient #2's husband not being able to care for her. NP #2 stated, "Typically if family makes that kind of statement about not being able to take a patient back home, we get case management involved."

Interview on 09/16/2021 at 1115 with hospital SW (Social Worker) #1 revealed she had a conversation with Patient #2's husband prior to her discharge on 08/31/2021. The SW stated that Patient #2's husband told he that he had a "hard time taking care of her" but did not say he "could not" take care of her. The SW stated she was aware he was handicapped himself, but Patient #2's husband did not give her any further details about his difficulty with her and she did not attempt to obtain additional information either. The SW stated Patient #2's husband "did not have any barriers that I was aware of." When asked how the SW interpreted what Patient #2's husband meant by the statement that he would 'do the best he could', the SW stated she "thought he would do that." Interview revealed she did not perceive his statement as him saying he could not care for Patient #2. Interview revealed the SW did not have any direct contact with Patient #2 and only knew what she read in the chart about her.

Interview with Detective #1 on 09/16/2021 at 1325 revealed he responded to the second call to Patient #2's home when she was found lying in the Kudzu at the end of her driveway by the meals on wheels driver. Detective #1 stated that he became aggravated this time because it was clear to him that Patient #2's husband was not able to keep her safe. Interview revealed that Detective #1 had a conversation with Patient #2's husband at that time and stated that he did not even know she had gotten out of the house. Detective #1 recalled that Patient #2's husband commented that he could not take care of Patient #2 during their conversation. Interview further revealed, "You could tell she [Patient #2] could not take care of herself...I'm not a doctor, but to me it's just common sense." Interview revealed Detective #1 did not speak directly with anyone at the hospital about his conversation with Patient #2's husband on 08/31/2021. Detective #1 stated, "...normally EMS does...It won't happen again." Interview revealed that he spoke with the Police Chief about the situation the next day (09/01/2021) though and the Chief reached out to the CEO but got her voicemail. Detective #1 stated that he also reached out to DSS because he had received a text that morning from the DSS SW making him aware that Patient #2's husband had been contacted by the hospital and was in tears because they were telling him he had to pick up Patient #2. Interview further revealed the hospital CNO returned the Chief's call, "presumably after being notified by the CEO." Detective #1 stated that he and the Chief put the CNO on speaker phone and they both spoke with him together about the situation. Detective #1 stated, "They wanted us to come get her...I'm pretty sure I made the comment that he [Patient #2's husband] was not capable of taking care of her at that point...I told them she could not even dial a phone, if something happened to her husband...she could not call for help."

3. Review on 09/15/2021 of several of Case Management Notes revealed Patient #2 returned to the hospital's DED on 08/31/2021 (unknown time) after being discharged and transported home via EMS at 1940. Review of the ED Central Logs failed to reveal a 3rd DED visit for Patient #2. Review revealed a Case Management Note signed by CM #1 on 09/01/2021 at 0946 that stated, "Today I was informed that yesterday Pt's (sic) family refused to allow Pt to stay at home and had EMS bring her back to the ER (emergency room) last night." Review of another Case Management Note signed on 09/02/2021 at 1313 revealed, "(Skilled Nursing Facility) agreed to accept (Patient #2) even after I informed them of her acting out this morning and...report that Pt (sic) would wonder (sic). ER Unit Clerk is making packet...(Skilled Nursing Facility) to transport...this afternoon..." Review revealed no documentation of Patient #2's EMS Transfer back to the hospital's DED on 08/31/2021. Review further failed to reveal any documentation of Patient #2's care between 08/31/2021 and 09/02/2021 (2 days), when CM Notes revealed Patient #2 was being transferred to a SNF (Skilled Nursing Facility). Review revealed Patient #2 was not registered and logged in as a patient when she was brought back to the named DED on this third visit.

In summary, the hospital staff was aware Patient #2's daughters lived out of town and were attempting to find placement for Patient #2 due to her dementia. The RARF (Regional Assessment and Referral Form - Psychiatric Screening) completed during visit #1, along with the Progress Note by the Mental Health NP revealed Patient #2 was exhibiting behaviors consistent with dementia. The EMS Run Sheet for DED visit #2 stated DSS was involved because Patient #2 was unable to care for herself and her husband was unable to care for her. The conversation between Patient #2's husband and the hospital SW revealed he was having a hard time taking care of her and the hospital's SW did not attempt to obtain additional information about the difficulties he was having. The hospital staff received records from hospital #2 during visit #2 that revealed Patient #2 had a previous fall 9 days prior; resulting in a fractured humerus. Upon Patient #2's return to the DED on 08/31/2021, it was known that she fell from her wheelchair (2nd fall) and was found lying naked, outside in a kudzu patch by a meals on wheels driver. Patient #2's husband refused to take her back home when she was discharged the 2nd time and the hospital staff continued to believe it was a "transportation issue." This resulted in Patient #2 being boarded in the DED for 2 days. During her time in the DED from 08/31/2021 to 09/02/2021, Patient #2 was not registered as a patient and had no medical record to document in. Patient #2 did not receive a medical screening exam, there was no documentation her blood sugar was checked, or she received her home medications. Based on a review of Patient #2's three DED visits, she was not stabilized for discharge. This resulsted in additional ED visits. As a result of Patient #2 not being acknowledged as a patient during visit #3, she failed to receive medical care necessary and required prior to her SNF placement. There was no indication that a qualified medical provider assessed and stabilized the patient as there was no new documentation generated.