HospitalInspections.org

Based on policy review, medical record review, and interview, emergency department (ED) staff did not ensure a safe mode of transport for Patient #1 following discharge back to a long term care facility.

Findings include:

Review of policy "Discharge Planning for Emergency Room Patients" effective 10/31/16 indicates if a patient is unable to safely leave, they will remain in the emergency room until appropriate arrangements have been made. Patients may be placed on observation if the physician feels the situation warrants observation. No policies specific to ED discharges back to a congregate/long-term care facility were found.

Review on 03/31/21 of the Emergency Department (ED) medical record dated 11/28/20 for Patient #1 revealed at 01:22 PM, Patient #1 arrived at the facility via ambulance from a skilled nursing facility (SNF) after sustaining a fall with a head laceration. At 01:38 PM, the ED Physician documents Patient #1 lives in a long-term care facility, is a flight risk for the nursing home, and is only able to give a limited history based on his baseline cognitive impairment. At 03:20 PM Staff (G), Licensed Practical Nurse (LPN) documents she called the SNF to report that Patient #1 is ready to return. The SNF responded that they are unable to provide transportation for Patient #1 to return to the SNF. Staff (G), LPN reviewed the discharge instructions with Patient #1 documenting his understanding. At 06:08 PM Patient #1 left the ED via cab.

Review on 03/31/21 of the Emergency Department (ED) medical record dated 11/28/20 for Patient #1 revealed a late entry nursing note dated 11/30/20 at 12:47 PM by Staff (H), Patient Care Technician (PCT) indicating that on 11/28/20, she arranged transportation with a Medicaid cab for Patient #1 to be transported to the SNF. Patient #1's former Office for People with Developmental Disabilities (OPWDD) residence staff called Staff (H), PCT to report that the Medicaid cab dropped Patient #1 off there and left. A three (3) way phone call between Staff (H), PCT, the Medicaid cab dispatcher, and the Medicaid cab driver revealed Patient #1 had requested to go to the OPWDD location. Staff (H), PCT called the SNF, who requested she cancel the Medicaid cab, indicating they would "take care of it." At 07:00 PM, Staff (H) called Staff (M), Nursing Supervisor, who reported that the SNF had transported Patient #1 from the OPWDD residence back to the SNF.

Interview on 03/30/2021 at 03:01 PM with Staff (H), Patient Care Technician (PCT) revealed she arranged transportation for a Medicaid cab for Patient #1 to the SNF. She received a call from the OPWDD residence stating that Patient #1 was left there by the cab.

Interview on 03/31/2021 at 02:34 PM with Staff (G), LPN on 11/28/20 she was assigned to care for Patient #1. After Staff (F), ED Physician wrote the discharge instructions, she called the SNF for information on discharge transportation. The SNF reported that the facility was unable to transport Patient #1. Staff (G) called the emergency contact, which reported they were unable to transport Patient #1 to the SNF. Staff (G) reported the information to Staff (M), Relief Nursing Supervisor who got on the phone and tried to get Patient #1 a ride.

Telephone interview on 03/31/21 at 03:05 PM with Staff (F), ED Physician revealed that the ED physician's role is to decide if the patient is appropriate for discharge. In his opinion, a patient needs to be cognitive enough to take care of themselves to utilize a Medicaid cab. In hindsight, Patient #1 shouldn't have been sent home in a Medicaid cab.

Interview on 03/31/2021 at 03:15 PM with Staff (A), Chief Nursing Officer and Staff (B), Director of ED Services verified the findings.