HospitalInspections.org

Based on document review, medical record review, and interview, the hospital failed to ensure patients' rights to receive care in a safe setting was implemented for 1 of 15 (Patient #2) patients transferred to the Emergency Department (ED) from a Nursing Facility, and discharged to the care of an unauthorized adult male without notifying the Nursing Facility or the patient's Durable Power of Attorney for Healthcare that the patient was being discharged. Patient #2 was a vulnerable female in the care of the unauthorized adult male for a total of 4 days before being returned to the Nursing Facility.

The findings included:

1. Review of the facility policy titled, "Advanced Directives" effective 2/23/2022, revealed, "...Purpose...to comply with the Patient Self-Determination Act (PSDA). The purpose of the PSDA is to protect all adult patients (age 18 and older) rights to participate in health care decision making to the maximum extent of their ability and to prevent discrimination based on whether or not patients have executed an Advance Directive for health care..."Durable Power of Attorney [DPOA] for Healthcare" specifies: 1. A trusted person to make decisions for another if the person is unable to speak for himself...goes into effect only when the patient is unable to speak for himself..".Descending Preference of Surrogates" means relatives are able to give permission for treatment in the following order: The patient's spouse, unless legally separated Patient's adult children...An adult who has exhibited special care and concern for the patient..."

2. Review of the facility policy titled, "Emergency Department Patient Discharge" effective 12/17/2020 revealed, "...The purpose of this policy is to establish guidelines for a safe discharge from the Emergency Department...Procedure...The Emergency Department physician determines the applicable discharge instructions, home care, and follow-up and appropriately documents this information in the Medical Record...Nursing staff documents from the "Depart" tab the appropriate disposition, mode of discharge, and patient condition...All patients will be provided with verbal and written discharge instructions specific and individualized for their illness, injury, and continuing care needs by utilizing the discharge instructions...The patient/family acknowledges instructions by signature or verbal consent..."

3. Patient #2 was transferred to Hospital #1's emergency department (ED) from Nursing Facility #1 via ambulance on 6/25/2022 after falling out of a wheelchair and sustaining a laceration to the head. The patient was cognitively impaired and unable to make decisions for herself. An unauthorized adult male arrived to the ED shortly after the patient arrived and informed hospital staff he was the patient's husband. The hospital did not verify with the transferring Nursing Facility the identification of the adult male or if the adult male had DPOA. The patient was evaluated, treated and medically cleared for discharge at the hospital's ED. The patient was discharged "home". There was no documentation who the patient was discharged with, and no documentation of discharge instructions. Three days after Patient #2 was discharged from the hospital's ED, the Nursing Facility contacted the hospital to inquire of the status of Patient #2. The Nursing Facility was informed by the hospital that the patient had been discharged 3 days prior however could not provide the name or place the patient was discharged to. The Nursing Facility contacted Adult Protective Services (APS) who located the patient at the adult male's home. The adult male was a cousin of the patient, not the patient's husband and did not have DPOA. Upon APS instructions, the adult male took Patient #2 back to the Nursing Facility on the fourth day of being discharged from the hospital's ED.

The hospital staff failed to notify the Nursing Facility and the patient's POA that the patient had been discharged. Patient #2 was with the unauthorized adult male a total of four days before she was taken back to the Nursing Facility.

Refer to A144.

Based on document review, medical record review, and interview, the hospital failed to ensure patients' rights to receive care in a safe setting was implemented for 1 of 15 (Patient #2) patients transferred to the hospital's Emergency Department (ED) from a nursing facility, and the hospital discharged the patient, who was a vulnerable female adult, to the care of an unauthorized adult male without notifying the Nursing Facility or the patient's Durable Power of Attorney (DPOA) for Healthcare. Patient #2 was in the care of the unauthorized male for a total of four days before being returned to the Nursing Facility.

The findings included:

1. Review of the hospital policy titled, "Advanced Directives" effective 2/23/2022, revealed, "...Purpose...to comply with the Patient Self-Determination Act (PSDA). The purpose of the PSDA is to protect all adult patients (age 18 and older) rights to participate in health care decision making to the maximum extent of their ability and to prevent discrimination based on whether or not patients have executed an Advance Directive for health care..."Durable Power of Attorney for Healthcare" specifies: 1. A trusted person to make decisions for another if the person is unable to speak for himself...goes into effect only when the patient is unable to speak for himself..".Descending Preference of Surrogates" means relatives are able to give permission for treatment in the following order: The patient's spouse, unless legally separated Patient's adult children...An adult who has exhibited special care and concern for the patient..."

2. Review of the hospital policy titled, "Emergency Department Patient Discharge" effective 12/17/2020 revealed, "...The purpose of this policy is to establish guidelines for a safe discharge from the Emergency Department...Procedure...The Emergency Department physician determines the applicable discharge instructions, home care, and follow-up and appropriately documents this information in the Medical Record...Nursing staff documents from the "Depart" tab the appropriate disposition, mode of discharge, and patient condition...All patients will be provided with verbal and written discharge instructions specific and individualized for their illness, injury, and continuing care needs by utilizing the discharge instructions...The patient/family acknowledges instructions by signature or verbal consent..."

3. Review of the "Prior to Arrival/EMTALA Form" dated 6/25/2022 at 8:32 AM revealed Emergency Medical Services (EMS) were in route to the facility with Patient #2, a 71 year old nursing home resident who had fallen and sustained a laceration and hematoma to the head. The document further revealed, "...unknown blood thinners..." and the patient was "Awake/Alert x 1 - Pt's NL [patient's normal limit]..."

4. Review of the hospital's medical record for Patient #2 revealed the patient was a wheelchair bound 71 year old resident from Nursing Facility #1 who presented to the hospital's ED via ambulance on 6/25/2022 at 8:43 AM after falling out of a wheelchair.

A triage assessment was completed by Registered Nurse (RN) #1 at 8:49 AM. The patient presented with a laceration to the forehead. RN #1 documented Patient #2 was "unable to effectively communicate pain or any other area of injury. Oriented to self, pt's normal..." The patient was placed in an ED room and was evaluated by RN #2 at 8:50 AM. RN #2 documented the ED screening information was given by "Family member [an adult male who had identified himself as the pt's husband]...No evidence of abuse/neglect...Advance Directive Additional Information: Unable to answer..." There was no documentation the hospital contacted the nursing facility to inquire about Patient #1's Advanced Directive or DPOA status since this was not sent to the hospital when transferred there.

A Nursing Note written by RN #1 on 6/25/2022 at 8:54 AM revealed, "Attempted to call [Nursing Facility #1] to get confirmation of allergies and medication list..." There was no documentation to indicate the information was ever received from the nursing facility.

A Medical Screening Examination (MSE) was initiated at 9:01 AM by Physician #1. The physician documented, "...71 year old...with a forehead laceration, after a fall today...Husband [a male companion who had identified himself as the husband] reports that the patient has been in a nursing home for 2 months...Also reports that at baseline...is wheelchair bound...two 3 cm [centimeters] lacerations with dressing on forehead..." Physician #1 ordered a Tetanus Diphtheria, and Pertussis (TDAP) vaccine injection, Comprehensive Metabolic Panel (CMP), a Complete Blood Count (CBC), Toponin 1, Urinalysis with Microscopic Exam if indicated, a Urine Barbiturate and Benzodiazepine Screen, an Electrocardiogram (EKG) a Computerized tomography (CT) scan of the Head and Cervical Spine, and a Chest X-ray. All diagnostic studies were within desired parameters. Physician #1 closed the patient's forehead laceration with 9 sutures. The patient received the TDAP vaccine injection at 12:04 PM.

On 6/25/2022 at 12:32 PM, Physician #1 documented the patient was medically cleared and stable to discharge "Home" with diagnoses which included Fall, Facial Laceration, and Forehead Contusion. The physician further documented, "Patient Education: Facial or Scalp Contusion...Laceration Care, Adult...Head Injury..." There was no documentation who received the instructions.

On 6/25/2022 at 2:19 PM, RN #2 documented Patient #2 was discharged "Home" with instructions for "Facial or Scalp Contusion...Laceration Care...Head Injury...Med Leaflet Information..." There was no documentation who received the instructions. There was no documentation Nursing Facility #1 was notified the patient had been discharged. There was no documentation how or with whom the patient was discharged. The hospital was unable to provide a signed copy of the discharge paperwork.

On 6/28/2022 Nursing Facility #1 contacted the hospital to ask about the care that Patient #2 was receiving in the hospital. The hospital notified the nursing facility that the patient had been discharged on 6/25/2022.

Review of Nursing Facility #1's progress note dated 6/28/2022 at 10:28 AM for Patient #1 revealed, "advised that [an adult male who had identified himself as the patient's husband] picked up resident [Patient #2] from hospital and took her home with him. APS [Adult Protective Services] was notified immediately..."

A Nursing Facility #1 progress note dated 6/29/2022 at 1:46 PM revealed, "Resident [Patient #2] arrived via personal vehicle accompanied by [adult male who had identified himself as the patient's husband]...he was not allowed entry into the building..."

Review of a progress note written by Nursing Facility #1's Director of Nursing (DON) dated "6/29/2022 at 5:12 PM", revealed, "Resident [Patient #2] was sent to [Hospital #1] for post fall workup. The resident was discharged to the care of [an adult male] who told the hospital he was her husband. The resident spent almost 4 days with [the adult male] until...dropped the resident to [Nursing Facility #1]...Interim DON received the resident at the door and told [the adult male] he was not to wait here. DON spoke to NP [nurse practitioner] about the situation and NP wanted Resident to go to the hospital for testing and evaluation of any drugs, rape, or injuries that could have occurred while the resident was out...911 was called and Resident was transported via ambulance to [Hospital #1]. Report was given over the phone to ER manager...who was made aware of the situation with [the adult male] and who the POA on record is..." There was no documentation the patient was assessed by the nursing facility prior to her transfer back to the hospital.

On 6/29/2022 at 4:14 PM, Patient #2 returned to the hospital's ED with the chief complaint of possible assault. A triage assessment was completed by RN #3 at 4:26 PM. RN #3 documented, "transfer from [Nursing Facility #1] for nurse concerned of pt being raped. pt was dropped off at their facility by cousin [the adult male who had identified himself as the patient's husband]. hx [history] dementia, schizo [schizophrenia], bipolar. pt aaox 1 [awake, alert, oriented]..."

A MSE was initiated at 4:28 PM by Physician #2. The physician documented, "...transfer from [Nursing Facility #1] for nurse concerned of pt being raped...was discharged from the ED on the 25th. She was dropped off at [Nursing Facility #1] by cousin where she was possibly raped...No out word signs of trauma on the pelvic or abd [abdomen.=]..." There was no documentation an internal pelvic examination was performed and no documentation a rape kit was utilized to collect any potential evidence of rape.

A nursing note written by the ED Nurse Manager on 6/29/2022 at 6:51 PM, revealed, "...spoke with...nurse at [Nursing Facility #1]...there is no injuries or physical indications that pt has been raped...requested a copy of pt POA to be faxed to facility as it was not included in original paperwork..."

A nursing note written by RN #4 on 6/29/2022 at 9:08 PM revealed, "...handed off report from day charge RN that this pt could have been raped...Pt came from [Nursing Facility #1], checked into ER on 06/25 [6/25/2022] for a fall, then was discharged to caregiver [the adult male who had identified himself as the patient's husband]. [Nursing Facility #1] was contacted at 1931 [7:31 PM] to get report and was informed that pt needed to be changed and could have been sore in the genital area and need to be sent to hospital for evaluation of possible physical and/or sexual assault by [the adult male who had identified himself as the patient's husband]...This RN spoke to and examined [Patient #2], Pt denied any injury or assault but pt's mentation status can't testify for her statement...called...POA...Was informed [the adult male who had identified himself as the patient's husband] was a distant cousin and caregiver for [Patient #2] for 7 years..."

Patient #2 was discharged back to Nursing Facility #1 via ambulance on 6/29/2022 at 10:37 PM.

5. In a telephone interview on 7/13/2022 at 8:45 AM, Nursing Facility #1's Administrator stated that the adult male was not Patient #2's POA, but he was the person the nursing facility notified when the patient went to the ED on 6/25/2022 because they were unable to reach the patient's POA. The Administrator stated the nursing facility called the hospital to check on Patient #2 on 6/28/2022, 3 days after the patient had been sent to the hospital, and was informed the patient had been discharged on 6/25/2022 and left the hospital with the adult male who had told the hospital he was the patient's husband. The Administrator stated APS was immediately notified of the incident. The Administrator stated that Patient #2 was "dropped off" at the nursing facility on 6/29/2022 after APS contacted the adult male and informed him he had to take the patient back to the nursing facility. The Administrator stated the nursing facility had the patient sent back to the ED to be evaluated "to make sure she was safe..." on 6/29/2022. The Administrator verified Patient #2 had been gone from the nursing facility and hospital in the care of adult male for a total of 4 days (6/25/2022 through 6/29/2022) without consent from the patient's POA. The Administrator further verified the hospital failed to notify the facility of the patient's discharge and failed to provide any discharge instructions.

In an interview on 7/13/2022 at 10:05 AM, RN #3 verified she completed the triage assessment on Patient #2 during the ED visit on 6/29/2022. The nurse stated the patient was sent to the hospital by Nursing Facility #1 to "see if she was raped." The RN stated she contacted the ED Nurse Manager who informed her Patient #2 had been discharged with her cousin, who had claimed to be the patient's husband, on 6/25/2022 and had been dropped off at the nursing facility on 6/29/2022. The patient's whereabouts were unknown by the hospital and nursing facility for a total of 4 days. RN #3 was asked to explain the normal process followed when a patient presented to the ED from a nursing home. The RN stated, "Call the nursing home and give report..." The RN verified she was not present on 6/25/2022 when the patient was discharged with the adult male.

In an interview on 7/13/2022 at 10:25 AM, the ED Director of Nursing (EDDON) stated patients who presented to the ED from a nursing facility were usually evaluated, treated, and sent back to the nursing facility, however, "In this case, we sent her [Patient #2] with who we thought was the husband."
The EDDON was asked if someone should have called report to the nursing facility. The EDDON stated, "If we didn't know there was a POA, we would have assumed the spouse would assume responsibility and not necessarily call the nursing home and give report. In hind sight, that's a good question as to why not."
The EDDON was asked if the adult male signed any discharge paperwork for the patient. The EDDON stated, "I don't see the signed discharge papers."
The EDDON was asked what measures had been put in place to prevent future occurrences. The EDDON stated, "I see in the future when someone from a nursing home comes to us, we will call nursing home to see if there's a POA." The EDDON was again asked what measures the hospital had put in place to prevent future occurrence. The EDDON stated, "Nothing has been put in place at this time to address it. We've been looking to see how it happened but we haven't put anything in place right now to address it."

In an interview on 7/13/2022 at 12:55 PM, Physician #2, the Medical Director of the ED, stated patients who presented to the ED from a nursing facility were usually sent back to the nursing facility. The physician continued and stated occasionally, if the patient is not stretcher bound, the patient might be transported back by a family member.
Physician #2 stated, "I reviewed the chart [Patient #2's visit on 6/25/2022] on her second visit [6/29/2022] and she was discharged not to [Nursing Facility #1] but in the care of somebody else. She came back in [6/29/2022] because the person who took her home [the adult male] dropped her off at the nursing home and they sent her back here to have her checked for possible assault...somebody that was not family had taken here home."
Physician #2 was asked what measures had been put in place to prevent future occurrences. The physician stated, "Great question...There will have to be a double check; in this case [Patient #2] it was just a horrible event. In the future is to determine who the POA is and notify the POA before disposition."
Physician #2 was asked if a pelvic examination had been performed on Patient #2 to screen for possible sexual assault. The physician stated, "As I recall there were no obvious signs of trauma. From an ED standpoint, we actually called 3 - 4 police agencies to help us determine what to do and we could not find anyone to bring us a rape kit. There were no rape kits here; that's a legal problem. I did look at her pelvic area and there were no obvious external signs. I would not do a speculum because it could possibly contaminate if actual assault...Police would be the ones to order a rape kit done. Clinicians are trained to do them but we don't keep them here because the reagents expire. Police could possibly bring in a kit and request it, but they [police] usually send them to the Rape Crisis Center. Our job is to notify the authorities and do what they advise." The physician was asked if a urine drug screen had been performed on the patient. The physician stated, "I wouldn't have done one based on her presentation. She was at there baseline and there was no reason to believe drugs were involved.

In an interview on 7/13/2022 at 2:10 PM, Physician #1 verified he was the medical provider for Patient #2 on 6/25/2022. The physician stated, "There was guy [the adult male] with her the whole time I saw her. He said he was her husband. He wasn't inappropriate...At the end, we went over instructions and he said he would take her back...I don't recall getting any paperwork from the nursing home...We did call to get records but did not receive any..." The physician was asked what the usual process was when patients presented to the ED from a nursing facility. Physician #1 stated, "Clearly, if they come from someplace we try to get them back to that place. If stable, family can take them back. Again, the assumption is that's their family." The physician was asked what measures had been put in place to prevent future occurrences. Physician #1 verified no measures had been put in place to prevent future occurrences then stated, "Obviously you're here because you want safeguards put in place so this doesn't happen again."

In a telephone interview via conference call on 7/13/2022 at 5:00 PM, RN #4 verified she was the primary nurse on duty on 6/29/2022 when Patient #2 returned to the ED. The RN stated Patient #2 was already present in the ED when she arrived for her shift. The RN continued and stated the patient had been sent by Nursing Facility #1 to be evaluated for possible sexual assault because she had been out of the nursing home with her distant cousin for 4 days. The RN verified she was not present on 6/25/2022 when Patient #2 was discharged with an adult male. RN #4 was asked where patients from a nursing facility were usually discharged to. RN #4 stated, "They go back to the nursing home unless the nursing home instructs us differently." RN #4 was asked if report is called to a nursing facility before a patient is discharged from the ED. The RN stated, "We always call report to the nursing home before the patient is discharged."

In a telephone interview via conference call on 7/15/2022 at 9:44 AM, RN #1 verified she completed the triage assessment on Patient #2 on 6/25/2022. The RN stated the patient came in by Emergency Medical Services (EMS) and the only paperwork from the nursing facility was the patient's face sheet. The RN stated she called the nursing facility and requested medical records because the patient had a head injury and she didn't know if the patient was on any blood thinners. RN #1 then stated she was unaware if the nursing facility ever forwarded the patient's medical records. RN #1 was asked the normal discharge process for patients that presented to the ED from a nursing facility. The RN stated, "Normally, the majority travel back by ambulance." The RN was asked if report should be called to the nursing facility before the patient is discharged. RN #1 stated, "Yes."

In a telephone interview via conference call on 7/15/2022 at 9:52 AM, the ED Nurse Manager (EDNM) stated she was not present on 6/25/2022 but had been informed later that the Patient #2 "was sent home with someone that wasn't the husband." The EDNM stated patients that presented to the ED via ambulance from a nursing facility were normally sent back to the nursing facility via ambulance and report is called to the facility. The EDNM continued and stated if the patients didn't meet medical necessity for ambulance transport, they could be taken back to the facility by a family member. The EDNM was asked if report was called to the nursing facility when a patient was transported by a family member. The EDNM stated, "No, we do discharge instructions with the family." The EDNM was asked what measures the hospital had put in place to prevent future occurrences. The EDNM stated, "We're educating our nurses to contact the facilities before discharging as to how coming back and with whom." The EDNM stated education was being presented in the daily huddles in the ED and was started, "3 or 4 days" after they were informed Patient #2 had been discharged with someone who wasn't her husband and was not the POA. The EDNM was asked to provide documentation of the education that had been provided.

Review of an email received on 7/15/2022 at 11:49 AM, revealed an "Emergency Department [Hospital #1's initials] Huddle Notes/Safety Briefing" dated 7/4/2022, "Upon pt discharge back to a nursing home/facility ensure facility is being notified/given report whether pt is dc/d by ambulance, family member, etc. Ensure with facility staff that person transporting is an appropriate/safe dc. ie. POA, conservator..." There was no documentation to indicate which staff members reviewed the information.

The email also contained a document which read, "July 13 2022 Effective Immediately Emergency Department Discharge Process for patients that have arrived from any facility where the patient resides; Skilled Nursing Home, Rehab, Long Term Care, etc. The Primary RN must call report to the facility, informing them that the pt has been dispositioned, whether admitted or DCed [discharged]. The discussion will include how the pt will be returning to the facility. This conversation must be documented...Please note the name of the person taking the report." The EDDON and the EDNM were 2 of the RNs who had signed the document. The memo was dated 7/13/2022, 2 days after this surveyor entered the facility to investigate the complaint.