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Based on record review and interviews with facility staff, the facility failed to ensure 1 of 20 patients (Patient #1) was discharged safely. Patient #1 was discharged home under the influence of medications which caused drowsiness (prochlorperazine (Compazine) and diphenhydramine (Benadryl)) prior to observing the patient to reduce risk of harm or injury.

(Cross Refer A1112).

Based on record review and interviews with facility staff, the facility failed to ensure 1 of 20 patients (Patient #1) was discharged safely. Patient #1 was discharged home under the influence of medications which caused drowsiness (prochlorperazine (Compazine) and diphenhydramine (Benadryl)) prior to observing the patient to reduce risk of harm or injury. The deficient practices identified were determined to pose a severe risk to patient health and safety. This placed the patient at risk for the likelihood of harm, serious injury, and possibly subsequent death.

The findings are as follows:

Record review:

The Medical Record Review for Patient #1 revealed that Patient #1, a 61-year-old female, arrived at the facility on 05/23/2024 at 0528 AM with a chief complaint of headache and abdominal pain. The triage note completed at 0532 revealed the patient arrived alone. Patient #1 was given 10 mg intravenous Compazine at 0626 AM and intravenous 50 mg Benadryl at 0629 AM. The facility's consent forms were electronically signed by Patient #1 at 0723 AM after Patient #1 was given the two medications. At discharge, the patient was considered "stable" and allowed to go home. The medical record did not indicate if Patient #1 was able to ambulate without assistance. The discharge disposition was contradictory and indicated the patient had a ride home, and the method of transportation was, "walk."

Discharge paperwork under the section "Pain Medication After Care Information" indicated the patient was given, "pain/sedating medicine during the Emergency Department visit." The discharge paperwork informs the patient that the medication "might change the way you think and you might not be able to do some things safely." Discharge paperwork indicated the patient was given acetaminophen, aspirin, diphenhydramine (Benadryl), famotidine (Pepcid), normal saline, and prochlorperazine (Compazine). Patient #1 was discharged home to use their private vehicle at 0857 AM, 2 hours 28 minutes after being given the medications, which included two medications known to cause sedation, Benadryl and Compazine.

National Institute of Medicine, last updated 8/14/2023, indicated prochlorperazine (Compazine) is a first generation antipsychotic which treats nausea and vomiting. Antihistaminic side effects (blockage of H1 receptor) include sedation.

National Institute of Medicine, last updated 7/10/2023, indicated diphenhydramine (Benadryl) is a first-generation antihistamine that is used in a variety of conditions to treat and prevent dystonias, insomnia, pruritis, urticaria, vertigo, and motion sickness. The medication is also used as a sedative when administered at 25mg-50mg every 4 to 6 hours. This medication is considered high-risk medication for elderly patients because of increased fall risk from dizziness, sedation, and hypotension.

Interviews:

In an interview with Patient #1, on 7/8/2024 at 12:46 PM, Patient #1 indicated they could not remember details surrounding discharge due to being very drowsy. Patient #1 indicated they did not have anyone with them to drive them home and drove 5 minutes home independently.

In an interview with ED RN Staff#5, RN discharge nurse, on 07/08/2024 at 0345 PM, Staff #5 indicated they did not recall Patient #1 driving themselves to the ER and intending to drive home. Staff #5 stated they will typically give 4 hours gap after the administration any sedative medications, including Benadryl. Furthermore, staff #5 stated patients are typically only discharged with family members.

In an interview with Staff#2 ED Medical Director on 07/09/2024 at 2:34 PM, Staff #2 indicated the standard protocol for discharging a patient who has received sedative medications is to wait at least 4 hours. Staff #2 stated the patients must be able to walk a few steps and answer questions appropriately before being discharged.