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Based on interview, record review, and personnel file review, the hospital failed to ensure the effective delivery of nursing services to provide safe, quality care for 1 of 20 sampled patients (Patient 1) when:

The hospital failed to ensure a Registered nurse (RN 1) was adequately trained and competent to provide nursing care to meet the specialized needs of a patient (Patient 1) assigned to their care, when RN 1 did not safelyly discharge Patient 1 from the Emergency Department (ED). RN 1 was on his second day post orientation and did not receive safe discharge training. Patient 1 was brought to the ED by ambulance with paperwork from his board and care residence showing he had a conservator (a legal representative that makes sure a person has adequate food, clothing, shelter, and medical/dental care). Patient 1 had a history of dementia (loss of thinking ability) and anoxic (lack of oxygen) brain injury. RN 1 discharged Patient 1 home alone, barefoot, and without transportation to his board and care. Patient 1 never made it to his board and care residence, and Patient 1 was found two days later unresponsive and covered in feces and vomit at a nearby parking lot. Patient 1 was then brought back to the ED by paramedics, suffered a heart attack, and died in the Intensive Care Unit (ICU) the next day. (Refer to A0397)

This failure adversely affected the health and safety of Patient 1 and contributed to Patient 1's death.

The cumulative effect of these failures resulted in the hospital's inability to provide effective, safe and quality nursing services in accordance with the statutorily-mandated Conditions of Participation Nursing Services.

Based on interview, record review, and personnel file review, the facility failed to ensure Registered Nurse (RN) 1 was adequately trained and competent to provide nursing care to meet the specialized needs for one of 20 sampled patients (Patient 1) assigned to their care, when RN 1 did not safely discharge Patient 1 from the Emergency Department (ED).

This failure adversely affected the health and safety of Patient 1 and contributed to Patient 1's death.

Findings:

Review of Patient 1's Physician Orders for Life-Sustaining Treatment (POLST) form dated 3/4/2022 indicated Patient 1 had a legally recognized decision maker to make medical decisions upon Patient 1's behalf.

Review of Patient 1's Physician Report For Residential Care Facilities For The Elderly (RCFE) dated 3/4/2022 indicated Patient 1 lived at a board and care residence. The report further indicated Patient 1 had a conservator.

Review of Patient 1's face sheet indicated Patient 1 was admitted to the ED on 4/16/2024 at 3:38 a.m. The document further indicated Patient 1 was disabled with a conservator (a legal representative that makes sure a person has adequate food, clothing, shelter, and medical/dental care).

Review of Patient 1's ED Physician Notes dated 4/16/2024 indicated Patient 1 was brought into the ED by ambulance with a complaint of knee pain. The note further indicated Patient 1 had a long medical history including dementia (loss of thinking abilities) and anoxic (lack of oxygen) brain injury.

Review of Patient 1's ED Discharge Note dated 4/16/2024 indicated Patient 1 was discharged home by RN 1 at 7:55 p.m. The note further indicated Patient 1 had no evident barriers to learning, communicated understanding of the discharge plan of care, and agreed to walk out to go home. Patient 1's ED medical record did not contain documented evidence of a discharge plan that included an assessment of Patient 1's mental capacity, ability to care for himself, or had access to transportation.

Review of Patient 1's ambulance report titled "Metro Fire PCR" dated 4/18/2024 at 1:48 p.m. indicated Patient 1 was found unresponsive and laying in the sun at a nearby store parking lot. The report further indicated Patient 1 was transported by paramedics immediately back to the facility's ED.

Review of Patient 1's ED Physician Notes dated 4/18/2024 at 3:07 p.m. indicated Patient 1 was brought into the ED by ambulance covered in feces and vomit, blood pressure (BP) was 62/25 millimeters of mercury (mm HG, unit of measurement with normal BP between 90/60 to 120/80), heart rate was 140 beats per minute (bpm, unit of measurement with normal between 60 to 100), respiratory rate was 18 breaths per minute (bpm, unit of measurement with normal between 12 to 18), and temperature was 40 degrees Celsius (C, unit of measurement with normal between 36 to 36.8). The note further indicated Patient 1 was intubated (a tube placed through the mouth and into the lungs for breathing) and two rounds of cardio pulmonary resuscitation (CPR, life-saving technique which includes chest compressions and breaths) were performed.

Review of Patient 1's Physician Note dated 4/19/2024 at 7:10 p.m. indicated Patient 1 was admitted to the Intensive Care Unit (ICU) with multi-organ failure. The note further indicated the ICU physician notified Patient 1's conservator of Patient 1's poor prognosis.

Review of Patient 1's face sheet dated 4/18/2024 indicated Patient 1 died on 4/19/2024 at 10:07 p.m.

Review of the facility reported incident submitted to California Department of Public Health (CDPH) on 4/22/2024 at 4:24 p.m. indicated a 51-year-old gravely (an alarming degree) disabled male (Patient 1) resided at a board and care facility. On 4/16/2024, Patient 1 was transported to the ED for leg pain and discharged. On the morning of 4/17/2024, Patient 1's caregiver called for a status update and was advised by the operator that Patient 1 was not at the facility. On the morning of 4/18/2024, the caregiver contacted the facility's ED to advise them Patient 1 had not returned to their board and care. Upon the facility's immediate review, it was found Patient 1 walked out of the ED unattended. A missing person's report was filed and an active search was initiated. Patient 1 was found by a bystander unresponsive and lying on the ground with sun exposure, and the bystander called emergency medical services to have Patient 1 transported back to the ED. Upon arrival, the patient was hyperthermic (above normal body temperature), unstable and intubated. He then had a heart attack and was in multiorgan failure. His condition worsened despite mechanical ventilation (breathing machine), blood pressure medications, intravenous (IV, within the vein) fluid resuscitation, and antibiotics (medications for infection). Patient 1 had a poor prognosis and his conservator and family opted to transition his care to comfort care, and Patient 1 died on 4/19/2024 at 10:08 p.m.

During an interview with the Director of Quality (DQ) on 4/22/24 at 1:15 p.m., the DQ stated Patient 1 did not have capacity and had the mentality of 4 year old. DQ stated Patient 1 was transported to the facility's ED from a board and care, and at the time of discharge, Patient 1's nurse removed his IV, read the discharge instructions to him, and asked what the plan for home was to which Patient 1's reply was "walk out." The nurse stated they had no idea Patient 1 was conserved and went to care for another patient, while Patient 1 walked out of the ED. DQ stated the facility video revealed Patient 1 walked throughout the facility and out of the front door barefoot. The board and care home subsequently called for an update, and the facility took action by interviewing staff and watching video footage. Patient 1 was found in the community by a bystander badly sunburned and unresponsive and was transported back to the ED by ambulance. Upon arrival to the ED, Patient 1 was noted to have a very high blood sugar level and severe muscle breakdown. Patient 1 had two episodes of cardiac arrest (heart attacks) during and after intubation, he was placed on four vasopressors (medication to increase blood pressure), and transferred to the ICU. DQ further stated Patient 1's conservator and family eventually withdrew life support, and he was taken to the operating room for organ recovery (kidney donor) after dying.

During an interview with the DQ on 5/7/2024 at 2:30 p.m., DQ stated Patient 1 came to the ED on 4/16/2024 with paperwork from the board and care home The DQ stated RN 1 should have reviewed the paperwork in Patient 1's chart, and was responsible for discharging the patient back to the board and care with transportation and not allowing the patent to walk out of the ED barefoot. DQ further stated ED nurses are provided a safe discharge checklist during new hire orientation, which is available for nurses to use to help understand the discharge process.

During an interview with RN 1 on 5/8/2024 at 3:00 p.m., RN 1 stated the physician's order was to discharge the patient home with self-care and the patient appeared appropriate to go home by himself at the time of discharge, so RN 1 discharged Patient 1 who walked out of the ED on his own. RN 1 further stated he did not receive training on safe discharges of ED patients during his new hire orientation, and he learned after the incident how Patient 1 should have been discharged safely to a board and care.

During an interview with the Clinical Educator Emergency Department (CEED) on 5/8/2024 at 3:30 p.m., CEED stated RN 1 provided care for Patient 1 on RN 1's second day off of orientation. CEED verified RN 1's orientation binder was not complete on 4/16/2024, RN 1 did not receive safe patient discharge training until 4/27/2024, and stated RN 1 was not ready to be off of orientation when providing care to Patient 1.

Review of the facility's checklist for safe discharges indicated "A safe discharge begins with an assessment of patient's baseline status and results in a discharge plan to ensure the patient has access to food, shelter, clothing, and necessary medical after care." The checklist further indicated the patient must have the mental capacity to make informed decisions, ability to care for themselves, and access to transportation.

Review of RN 1's personnel file training document titled "MSJ-Tip Safe Discharge" indicated the discharge planning process begins as soon as the patient arrives in the ED. The file further indicated a safe discharge is planned using information from assessment information, run sheet (paramedic notes) information, prior admission information, and any discharge history such as a patient's memory problem. RN 1 acknowledged by signature the training, understanding, and agreement to follow the guidelines on 4/27/2024, which was 11 days after RN 1 discharged Patient 1 from the ED.