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Based on interview, record review, and review of facility policies and procedures, it was determined the facility failed to establish and implement policies and procedures to ensure that the needs and concerns of the hospital were given due consideration, and that the unified and integrated QAPI program had mechanisms in place to ensure that localized issues were duly considered and addressed. Concerns had been identified regarding security assisted escort of patients involuntarily leaving the facility, with practices put into place to include presence of a clinical staff member for security assisted escorts. However, there was no mechanism put into place to monitor this practice to ensure it was being followed.

The findings include:

1. Review of the "University of Louisville Medical Staff Bylaws," approved by the board of directors on 01/24/2023, revealed the responsibilities of medical staff include reviewing and evaluating the quality of patient care through a valid and reliable patient care monitoring procedure, including identification and resolution of important problems in patient care and treatment. The bylaws identify the chief of staff as a member of the hospital Clinical Quality and Patient Safety Committee and a conduit between medical staff and the governing body on quality improvement of the medical staff related to its responsibility to provide high quality and safe patient care.

Review of the "Quality and Patient Safety Committee U of L Health-U of L Hospital CHARTER," not dated, revealed one of the primary duties of the Quality and Patient Safety Committee (QPSC) was making recommendations for changes in clinical practice to ensure that care was provided with the highest degree of quality in a safe environment. Two of the guiding principles identified in the QPSC Charter included: 1. A fully engaged QPSC working collaboratively leads to successful clinical outcomes and improvements in the quality and safety of care delivery, and 2. Service excellence and accountability were standards for the delivery of care and resolution of operational issues.

2. Interview with the System Director of Security (SDS) on 07/25/2023 at 2:02 PM revealed the facility received contact from a local televised news report alleging patient dumping (https://www.wave3.com/2023/06/29/its-like-im-worthless-troubleshooters-investigate-patient-dumping-allegations/), prior to report airing on 06/29/2023. Surveyor review of televised report revealed a patient (later identified as Patient #22) with a walker being escorted off facility property by two security staff. Continued review of televised report revealed patient (later identified as Patient #22) alleging medical conditions and stating he/she had unmet medical care needs despite being discharged from the facility Emergency Department (ED). SDS revealed facility staff were unable to identify any patients present in the news report, however, as a result, changes were made to the discharge procedures.

Review of an email sent by the facility SDS to security management and personnel as well as the Manager Security ULH Campus on 06/15/2023 with the subject of immediate change to patient discharge procedures by security, revealed whenever a request was made by clinical staff for security assistance with patients being discharged, both security and house supervisor were notified. The email revealed security staff would not remove a patient from hospital property, house supervisor or clinical designee would accompany security during the process, security would complete a Helias report [Helias was the software program used by security] to document the incident, and house supervisor or their designee would complete an RL Solutions report [RL Solutions was the software program used by clinical staff to document incidents] to document incident.

Review of "Weekly ED Leadership News" dated 06/16/2023 to 06/23/2023 included information regarding Assisted Discharges - "There will be a new process for patients that are getting escorted out by security for discharge. If your patient needs a security escort, please notify the charge nurse and house supervisor prior to security escorting them. There also needs to be a clinical person that walks with security to the street. This is effective immediately. We are meeting about this next week so there should be more information to come."

Review of a 06/20/2023 "Discharge Assist Meeting" attended by nursing leadership, SDS, MD emergency psych, VP of Operations, Director of Critical Care, and Associate Chief Nursing Officer, emphasized the house supervisor or the clinical nurse designee must be available for security assisted discharges, and the discharging nurse was responsible for completing an RL Solutions report regarding the security assisted discharge.

Review of U of L Emergency Department staff meetings dated 06/27/2023, 06/29/2023, and 07/11/2023 revealed ED staff were educated on notifying both the house manager and security supervisor when the need for discharge assist occurs, and of the need for clinical staff to accompany security staff during security assisted discharges.

Review of a second Discharge Assist Meeting held on 08/02/2023 noted that discrepancies between HELIAS and RL Solutions reports were identified. A plan was established for comparative review of programs, continued staff education on changes, and development of policy. One of the identified problems was clinical staff were documenting incidents under various headings in the RL Solutions system, which made tracking incidents difficult. A reminder was added to the RL Solutions program home screen, and a new prompt was added for a drop-down box for security discharge assist. Also identified, security staff may not have documented cases in which there was no interaction and patient(s) walked out without incident, instead focusing on documenting verbally or physically aggressive patients.

3. Review of facility documentation comparing dates provided in televised report enabled survey staff to pinpoint Patient #22 as one of three potential patients on televised report alleging patient dumping. Documentation was reviewed from Multiple ED visits as well as nine (9) inpatient hospitalizations of Patient #22 from 11/16/2022 through 07/27/2023.

Review of thirty-eight (38) Helias reports between the period of 06/15/2023 and 07/27/2023 revealed a total of thirty-six (36) were situations involving security assisted discharge of patients from either inpatient or the ED. Of the thirty-six (36) Helias reports, seven (7) were unclear whether or not a house supervisor or clinical staff were present at the time of the security assisted discharge. Although time and location of incidents were documented, patient identifying information was not included in the reports.

Review of information provided regarding RL Solutions reports during this same time period revealed the two reporting systems did not match up, with information provided on the RL Solutions reports not documenting the time of the incident or patient identifying information. Comparison of reports indicating potentially ten (10) RL Solutions reports that should have had a corresponding Helias report, with corresponding Helias report located.

Interview with the Director of Patient Safety and Peer Review (DPSPR) on 08/01/2023 at 3:03 PM and again on 08/03/2023 at 9:00 AM revealed, in review of Helias reports and comparison with RL Solutions data from the period of 06/15/2023 through 07/27/2023 she was unable to confirm in four (4) of the seven (7) security assisted discharge incidents that clinical staff were present. She confirmed a second Discharge Assist meeting was held on 08/02/2023 at noon, and as a result a drop down was added to the RL Solutions report for "security discharge assist" in order to better organize and account for clinical staff involvement in security assisted discharges. She stated this was a newer process, and through audits of the process, concerns identified would guide the final process. DPSPR went on to state the new procedure would be reviewed in the QPSC to be held on 08/15/2023, with information presented by the Director of Psychiatric Nursing Services (DPNS). DPSPR stated the Discharge Assist committee were working on a policy to replace the email which currently covered the new procedure on security assisted discharges.

Interview with the Vice President of Quality and Safety (VPQS) on 08/01/2023 at 3:09 PM revealed if the new procedure for security assisted discharges was not being monitored, it would be monitored. She stated it was a newer process, and staff had identified areas to revise, and the final process, once determined, would be audited.

Interview with the SDS on 08/03/2023 at 10:01 AM stated the security assisted discharge process was a pilot program created weeks ago, and was not yet finalized. The SDS went on to state "security assisted discharge" had been added as a category for the RL Solutions reports, as prior to that staff were putting reports under other headings such as security incident, disorderly patient, and threats. He revealed the Helias reports were security based reports, while the RL Solutions reports were more clinically based, and he found having duplicate reports for security assisted discharges was a good system, for both tracking and for information obtained through differing standpoints. He acknowledged there were currently gaps, with both security and nursing needing to do a better job of completing reports. The SDS stated he was currently reviewing shift reports, but there was currently no tracking process to ensure Helias reports and RL Solutions reports regarding security assisted discharges were being completed. SDS stated security had been trained on the new procedure, now it was just a matter of getting in the routine of completing reports. SDS stated security had walked patients out, with or without nursing staff, prior to this, but were now having to document it. SDS concluded by stating this was not required, but we were going a step above to make sure we were doing everything possible to take care of patients.

Interview with the Director of Nursing Psychiatric Services (DNPS) on 08/03/2023 at 10:41 AM stated staff had an informal meeting prior to the Discharge Assist meeting on 06/20/2023, and originally planned to meet monthly, but that got pushed back so they had a second meeting on 08/02/2023. She stated security and house supervisors were now partnering up to develop a policy, which would be reviewed in the next Discharge Assist meeting to be held in September. She stated for the foreseeable future, the Discharge Assist meetings would be held monthly, and data obtained each month would be reviewed in the following monthly meeting. She stated tracking and trending of reports was important, to determine if there were ways to improve on patient care, or if there were specific times or events that contributed to situations requiring security assisted discharges. She stated the procedure was still in the development phase, but once formalized it would be consistent across the board. She stated the SDS would be tracking to ensure reports were coming both from security and from ED. The DNPS concluded by stating having a clinical presence with security during assisted discharges would not only reinforce the perception that the patient had been properly treated and did not require hospitalization, but also in case a patient's condition changed clinical staff would be on hand.

Interview with the Associate Chief Medical Officer (Associate CMO) on 08/03/2023 at 11:14 AM stated he was responsible for overseeing the quality patient safety aspects of the hospital. He stated he obtains information from the QPSC which he chaired and oversaw, and was scheduled for 08/15/2023. He stated the assisted discharge procedure was new, and he did not have data to assess on it, but anything that helped ensure patients moving through their system were safe and getting where they needed to go was a good thing.