HospitalInspections.org

Based on hospital policy review, hospital document review, medical record review and interview, the hospital failed to maintain 1 of 4 (Patient #2) patient's rights to receive care in a safe setting when Patient #2 was taken to the Discharge Lounge (DL) and left alone and unattended while waiting in the area for family to arrive to transport the patient home. Patient #2, who did not meet the hospital's criteria to be taken to the discharge lounge, was alone in this area unattended by staff for 2 hours and 45 minutes on 7/31/2023.

The findings included:

1. Review of the hospital's "Patient Bill of Rights Policy" revised 4/2022 revealed, "...You or your legally designated representative has the right to be informed about your illness, possible treatment options, and likely outcome(s), including unanticipated outcomes, and to participate and make informed decisions regarding your care...You have the right to receive care in a safe setting..."

Review of the hospital's "Assessment/Reassessment Policy" revised on 4/27/2023 revealed, "Purpose: To establish assessment/reassessment time frames and processes to help determine the care, treatment and services that will meet the patient's initial and continuing needs..."

Review of the hospital's "Documentation Policy" revised 3/2021 revealed, "...The primary purpose of patient care documentation is to communicate patient information to other health care professionals caring for the patient.

2. Review of the hospital's "Discharge Lounge Overview" document revealed, "...The Discharge Lounge was established to address capacity challenges within the hospital. The goal of the Discharge Lounge is to provide an area for patients who are medically ready for discharge and awaiting transportation out...Patient Selection Criteria Ambulatory Lounge...Alert and Oriented...Ambulatory with minimal assistance...Able to toilet with minimal PCA assistance...No behavioral issues...Able to self-administer medications - Non Isolation patients...Patient's ride must be pre-arranged and anticipated to arrive by Discharge Lounge closing time...Transporting Patient to Discharge Lounge Ambulatory Staff from sending staff transports patient to Discharge Lounge nurses station: - provides patient's name and estimated time patient's ride will arrive...Key Points...Please notify family if you are sending a patient to this discharge lounge so they are aware of patient location...Discharge Lounge Responsibilities...Every Patient must be signed in and out when they enter and leave the discharge lounge...Round hourly to check on patients Turn, Change and clean if needed...Assist to bathroom in [as] needed...Offer Drink, Water or Snack...If a patient is present during what would be meal time, offer snack pack...Prior to patient leaving, ensure patient is clean and dry...PRIOR to closing each night, the entire hall need to be checked to ensure ALL patients are gone. Log needs to be checked to ensure each patient has left. Call [phone number] and notify house supervisor you are leaving for the night..."

Review of the "Second Amendment to the Master Services Agreement Between [named Hospital #1's Health Care Corporation] and [named Ambulance Provider #1's Parent Company] Relating to Discharge Lounge Operations" document signed on 10/17/2022 and 10/11/2022 respectively revealed, "...This Second Amendment sets forth the duties and responsibilities that [named Hospital #1's Health Care Corporation]'s affiliate and [named Ambulance Provider #1] will each provide in connection with the operation of a "Discharge Lounge" (hereinafter referred to as the "Lounge")...The purpose of the Lounge is to maximize the efficiency of discharge and transportation of patients from [named Hospital #1]. Whereas the operation of the Lounge allows [named Hospital #1] to increase the availability of rooms for patients awaiting admission and provides [named Ambulance Provider #1] with a staging area for patients awaiting transport, each party agrees that the operation of the Lounge is beneficial to its operations and enhances the delivery of patient care...[named Ambulance Provider #1] will provide one (1) Emergency Medical Technician (hereinafter referred to as the "EMT") to staff the Lounge during its hours of operation. The EMT shall monitor patients in the Lounge for their personal comfort needs and changes in clinical condition and attend to them as necessary...It is intended that the EMT and the Unit Clerk shall support each other as may be necessary to ensure that patients are kept comfortable in the Lounge and that the Lounge operates as efficiently as possible with a goal that patients remain as comfortable as possible in the Lounge and that patients are conveyed from the Lounge as rapidly as possible..."

3. Medical record review revealed Patient #2 was admitted to the hospital on 7/29/2023 after having a syncopal episode and subsequent fall. (Syncope is used to describe a sudden loss of consciousness for a short period of time. It can happen when there is a sudden change in the blood flow to the brain. Syncope may also be called fainting or passing out.) The patient reported pain in the left hip and left shoulder.

Review of the Admission History and Physical completed on 7/29/2023 at 11:48 PM revealed, "...Patient presents with Syncope...pt got up to unlock the door and fell. Pt is unsure if it was mechanical fall or syncope episode...pain in her L hip and L shoulder...Of note, pt is blind. There are no other complaints at this time. No fractures noted on imaging studies...Physical Exam...Musculoskeletal...Tenderness over left elbow and hip area ROM [range of motion] OK [okay]...Alert, conversant, appropriate...Legally blind...Assessment and Plan: Syncope vs Fall...Fall precautions, PT [Physical Therapy] OT [Occupational Therapy], Ortho BP [orthostatic blood pressure] and HR [heart rate]...Hypernatremia [elevated sodium level]...Hypokalemia...Cont [contusion] left shoulder and hip, High risk falls...Diabetes mellitus Type 2: accu-checks [blood sugar checks] and SSI [sliding scale insulin] per protocol, Maintain BG [blood glucose] in acceptable range 140-180. Diabetic diet. Hypertension Adjust medications to keep BP in acceptable range. Prn antihypertensives to keep SBP [systolic blood pressure] less than 160...Updated daughter at bedside...Care Timeline 07/30 Admitted from ED 0101 [1:01 AM]..."

Review of the flowsheets dated 7/29/2023 through 7/31/2023 revealed Patient #2 required assistance with all Activities of Daily Living (ADLs), was blind, confused, at high risk for falls and required the use of bed alarms and/or tether alarms to alert staff when the patient attempted to get up on her own.

Patient #2 was considered safe for discharge on 7/31/2023 and was taken to the hospital's DL at approximately 2:30 PM to wait for her daughter to pick her up after she got off work. There was no documentation the patient was taken to the discharge lounge and no documentation the patient's daughter was informed of her location. Between 8:15-8:45 PM the same evening, Patient #2's daughter arrived at the hospital to pick up the patient; however, hospital staff were only able to determine the patient had been discharged but were not able to determine the patient's location. The House Supervisor was alerted, and subsequently found Patient #2 sitting in her wheelchair in the DL, alone and unattended. The House Supervisor reported the incident to the hospital's Risk Management staff at 11:18 PM. There was no documentation indicating the actual time Patient #2 left the hospital.

Refer to A-0144.

Based on policy review, document review, medical record review and interview, the hospital failed to ensure interventions were provided for 1 of 4 (Patient #2) sampled patients to receive care in a safe setting when an 81-year-old, blind patient, at high risk for falls, was taken to the Discharge Lounge (DL) and left alone and unattended by staff on 7/31/2023 for 2 hours and 45 minutes while awaiting family to arrive to transport the patient home after discharge from the hospital.

The findings included:

1. Review of the hospital's "Patient Bill of Rights Policy" revised 4/2022 revealed, "...You or your legally designated representative has the right to be informed about your illness, possible treatment options, and likely outcome(s), including unanticipated outcomes, and to participate and make informed decisions regarding your care...You have the right to receive care in a safe setting, free from abuse, harassment, financial and other exploitation...You have the right to expect the hospital will give you necessary health services to the best of its ability...You have the right to considerate, dignified and respectful patient care, treatment and services..."

Review of the hospital's "Assessment/Reassessment Policy" revised on 4/27/2023 revealed, "Purpose: To establish assessment/reassessment time frames and processes to help determine the care, treatment and services that will meet the patient's initial and continuing needs... The Registered Nurse [RN] creates an initial plan for care, treatment, and services appropriate to the patient's specific assessed needs... Planning for care, treatment, and services is individualized to meet the patient's unique needs and circumstances. Planning for care, treatment, and services involves using an interdisciplinary approach when warranted and involves the patient and family to the extent possible..."

Review of the hospital's "Documentation Policy" revised 3/2021 revealed, "...The primary purpose of patient care documentation is to communicate patient information to other health care professionals caring for the patient. Documentation demonstrates the patient care process, from assessment and planning care to interventions and evaluation... Electronic and paper documentation of care, treatment and service is documented at or near the time it occurs... Documentation is completed by the person delivering the care or the caregiver named in the notes..."

2. Review of the hospital's "Discharge Lounge Overview" document revealed, "...The Discharge Lounge was established to address capacity challenges within the hospital. The goal of the Discharge Lounge is to provide an area for patients who are medically ready for discharge and awaiting transportation out... The Discharge Lounge is staffed by an EMT [Emergency Medical Technician] and PCA [Patient Care Assistant] (for ambulance patients) and a PCA (for ambulatory patients). Patient Selection Criteria Ambulatory Lounge... Alert and Oriented... Ambulatory with minimal assistance... Able to toilet with minimal PCA assistance... No behavioral issues... Able to self-administer medications - Non Isolation patients... Patient's ride must be pre-arranged and anticipated to arrive by Discharge Lounge closing time... Transporting Patient to Discharge Lounge Ambulatory Staff from sending staff transports patient to Discharge Lounge nurses station: - provides patient's name and estimated time patient's ride will arrive... Key Points... Please notify family if you are sending a patient to this discharge lounge so they are aware of patient location... Discharge Lounge Responsibilities... Every Patient must be signed in and out when they enter and leave the discharge lounge... Round hourly to check on patients Turn, Change and clean if needed... Assist to bathroom in [as] needed... Offer Drink, Water or Snack... If a patient is present during what would be meal time, offer snack pack... Prior to patient leaving, ensure patient is clean and dry... PRIOR to closing each night, the entire hall need to be checked to ensure ALL patients are gone. Log needs to be checked to ensure each patient has left. Call [phone number] and notify house supervisor you are leaving for the night..."

Review of the "Second Amendment to the Master Services Agreement Between [named Hospital #1's Health Care Corporation] and [named Ambulance Provider #1's Parent Company] Relating to Discharge Lounge Operations" document signed on 10/17/2022 and 10/11/2022 respectively revealed, "...This Second Amendment sets forth the duties and responsibilities that [named Hospital #1's Health Care Corporation]'s affiliate and [named Ambulance Provider #1] will each provide in connection with the operation of a "Discharge Lounge" (hereinafter referred to as the "Lounge")... The purpose of the Lounge is to maximize the efficiency of discharge and transportation of patients from [named Hospital #1]. Whereas the operation of the Lounge allows [named Hospital #1] to increase the availability of rooms for patients awaiting admission and provides [named Ambulance Provider #1] with a staging area for patients awaiting transport, each party agrees that the operation of the Lounge is beneficial to its operations and enhances the delivery of patient care as contemplated by the Agreement. It is anticipated that the Lounge's hours of operation will be from 10:00 a.m. to 10:00 p.m., Monday through Friday. It is anticipated that the Lounge's initial patient capacity will be ten (10) patients...[named Ambulance Provider #1] will provide one (1) Emergency Medical Technician (hereinafter referred to as the "EMT") to staff the Lounge during its hours of operation. The EMT shall monitor patients in the Lounge for their personal comfort needs and changes in clinical condition and attend to them as necessary...[named Hospital #1] will provide the space in which the Lounge will operate, any equipment needed in the Lounge, and one (1) unit clerk (hereinafter referred to as the "Unit Clerk"). The Unit Clerk shall monitor patients in the Lounge for their personal comfort needs and attend to them as necessary... The Unit Clerk shall provide non-clinical assistance to the transporting ambulance crew as maybe necessary... It is intended that the EMT and the Unit Clerk shall support each other as may be necessary to ensure that patients are kept comfortable in the Lounge and that the Lounge operates as efficiently as possible with a goal that patients remain as comfortable as possible in the Lounge and that patients are conveyed from the Lounge as rapidly as possible..."

3. Medical record review revealed Patient #2 presented to the hospital's Emergency Department (ED) on 7/29/2023 with complaints of syncope resulting in a fall. (Syncope is used to describe a sudden loss of consciousness for a short period of time. It can happen when there is a sudden change in the blood flow to the brain. Syncope may also be called fainting or passing out.) The patient reported pain in the left hip and left shoulder.

Review of the ED Provider Note dated 7/29/2023 revealed Patient #2 "is a 81 y.o. [year old] Female with PMHx [past medical history] of DM [Diabetes Mellitus], HTN [Hypertension (high blood pressure)] and HLD [Hyperlipidemia, an imbalance of good and bad cholesterol] who presents to the ED complaining of syncope onset today. Pt [patient] states she was in a hotel room with her daughter when her daughter was locked out and the pt got up to unlock the door and fell. Pt is unsure if it was a mechanical fall or syncope episode. Pt is endorsing pain in her L [left] hip and L shoulder. Pt does not know if she hit her head upon the fall. Of note, pt is blind... Full workup was performed. EKG [electrocardiogram (measures electrical activity of the heart)] was reassuring... CT [computerized tomography] head CT C-spine [cervical spine] and CT abdomen pelvis were negative. Patient was found to be hypokalemic [low potassium level] and potassium was repleted. Patient was having difficulty ambulating [walking] prior to appropriate time for discharge so she will be brought in for observation to ensure hypokalemia resolves and that she has a safe disposition after appropriate physical therapy..."

Review of the flowsheet dated 7/29/2023 at 5:49 PM revealed, "... HPI [History of Present Illness]/Pre-Hospital Tx [treatment]... Reason for Visit fell today at home. denies blood thinners. later had a syncopal episode. ems [emergency medical services] did sternal rub and was unable to get patient aroused until approx [approximately] 5 min. [minutes]"

Review of the flowsheet dated 7/29/2023 at 5:50 PM revealed, "...High Fall Risk..."

Review of the Admission History and Physical completed on 7/29/2023 at 11:48 PM revealed, "...Patient [pt] presents with Syncope... pt got up to unlock the door and fell. Pt is usure if it was mechanical fall or syncope episode... pain in her L hip and L shoulder... Of note, pt is blind. There are no other complaints at this time. No fractures noted on imaging studies... Physical Exam... Musculoskeletal... Tenderness over left elbow and hip area ROM [range of motion] OK [okay]... Alert, conversant, appropriate... Legally blind... Assessment and Plan: Syncope vs Fall... Fall precautions, PT [Physical Therapy] OT [Occupational Therapy], Ortho BP [orthostatic blood pressure] and HR [heart rate]... Hypernatremia [elevated sodium level]...Hypokalemia [low potassium level in the blood]... Cont [contusion] left shoulder and hip, High risk falls... Diabetes mellitus Type 2: accu-checks [blood sugar checks] and SSI [sliding scale insulin] per protocol, Maintain BG [blood glucose] in acceptable range 140-180. Diabetic diet. Hypertension Adjust medications to keep BP in acceptable range. Prn antihypertensives to keep SBP [systolic blood pressure] less than 160... Updated daughter at bedside... Care Timeline 07/30 Admitted from ED 0101 [1:01 AM]..."

Review of the flowsheet dated 7/30/2023 at 12:52 AM revealed Patient #2 was "...chairfast" and her mobility was "slightly limited."

Review of the flowsheet dated 7/30/2023 at 1:47 AM revealed "...Anticipated Discharge Disposition/Services home or self-care; home with family..."

Review of the flowsheet dated 7/30/2023 at 1:52 AM revealed, "...Vision Management blind..."

Review of the flowsheet dated 7/30/2023 at 2:28 AM revealed, "...Safety Rounds/Standard Fall Preventions... Safety Additional... side rails raised x [times] 4 Activity Assistance Provided assistance, 1 person..."

Review of the flowsheet dated 7/30/2023 at 4:20 PM revealed, "Safety Rounds/Standard Fall Preventions... Safety Additional - upper side rails raised x 2, lower side rail raised x 1..."

Review of the flowsheet dated 7/30/2023 at 6:03 PM revealed, "Functional Screen... Ambulation 2 -assistive person... Transferring 2 - assistive person... Toileting 2 - assistive person... Bathing 2 - assistive person... Dressing 2 - assistive person..."

Review of the flowsheet dated 7/30/2023 at 6:38 PM revealed, "...Fall Risk Interventions... yellow wrist band/fall signage present; Bed alarm set... High Fall Risk Interventions... Hourly rounding conducted... Enhanced Safety Measures bed alarm set..."

Review of the flowsheet dated 7/31/2023 at 1:17 AM revealed, "Fall Risk Assessment History of fall within the last 3 months? Yes... Safety Rounds/Standard Fall Preventions Additional Safety upper side rails raised x 2, lower side rail raised x 1... Enhanced Safety Measures bed alarm set..."

Review of the Discharge Planning Note dated 7/31/2023 at 8:33 AM revealed, "...Anticipated Discharge Disposition: home with family... Additional Comments: SW [Social Worker] completed patient's assessment with her granddaughter... via phone... patient lives with her daughter... DME [Durable Medical Equipment]-wheelchair; no history of SNF [skilled nursing facility], IPR [inpatient rehabilitation], or HH [Home Health]. Patient's discharge plan is home with family..."

Review of the flowsheet dated 7/31/2023 at 8:45 AM revealed Patient #2 was provided "Perineal Care absorbent brief changed; diaper changed; perineum cleansed... Hygiene dressed/undressed; incontinence care... Bath, complete... Linen changed... Oral Care swabbed with sterile water..."

Review of the Hospitalist Discharge Summary dated 7/31/2023 at 9:26 AM revealed, "...Hospital Course: This is an 81 year-old female who got admitted for syncope. Syncope is mostly due to dehydration and hypokalemia. Started on IV [intravenous] fluids and potassium was supplemented. She is back to her baseline now. Urinalysis is positive for possible UTI [urinary tract infection]. Started on IV antibiotics. Echo [echocardiogram, a scan used to look at the heart and nearby blood vessels] done and unremarkable. EKG is unremarkable. Evaluated by PT [Physical Therapy] OT [Occupational Therapy]. Discussed with case manager to discharge home if family is agreeable... Stable for discharge..."

Review of a physician's order dated 7/31/2023 at 9:26 AM revealed, "...Discharge patient... Discharge disposition: Home..."

Review of the Occupational Therapy Evaluation completed with the Physical Therapist on 7/31/2023 from 9:27 AM through 9:44 AM revealed, "...Pt Post TX... in chair, instructed to call for assistance, call light in reach, bedside table in reach, tether alarm on... Recommended Discharge Disposition: skilled nursing facility (SNF) vs [versus] home with 24/7 assistance and HHOT/PT [Home Health Occupational Therapy/Physical Therapy]... Vision: legally blind; pt reports she can see lt/dark [light/dark]... Pt is a questionable historian, no family present during evaluation. Pt reports when her dtr [daughter] is at work she has someone that stays with her... SNF vs home with 24/7 assistance and HHOT/PT..."

Review of the Physical Therapy Evaluation completed with the Occupational Therapist on 7/31/2023 from 9:28 AM through 9:45 AM revealed, "...Recommending home with 24 hour care vs SNF... Precautions/Limitations: Fall and Blindness... Transportation: family or friends will provide... Gait: Independence level: moderate assist (50% patient effort), 1 person assist... Pt took short shuffled steps... Balance... Standing... poor... PT Diagnosis: difficulty walking, muscle weakness, impaired balance... Plan for PT: continue PT... 3-5 times per week..."

Review of the flowsheet dated 7/31/2023 at 11:46 AM revealed, "...Occupational Therapy... Pt Post Tx in chair; instructed to call for assistance; call light in reach; bedside table in reach; tether alarm on... Anticipated Discharge Disposition... home with assist; home with home health..."

Review of the flowsheet dated 7/31/2023 at 12:59 PM revealed Patient #2 was "disoriented to; time; situation" and her "Best Verbal Response... confused..."

Review of the flowsheet dated 7/31/2023 at 1:01 PM revealed Patient #2 was at "High Fall Risk."

Review of the flowsheet dated 7/31/2023 at 1:04 PM revealed Patient #2 was "...in chair; call light in reach; tether alarm on... Anticipated Discharge Disposition... home with assist; home with home health; skilled nursing facility..."

Review of the After Visit Summary dated 7/31/2023 printed at 2:07 PM revealed, "Patient to Schedule MD [Medical Doctor] Follow-Up in 1 week... Instructions from your provider Your primary diagnosis was: Fainting Your diagnoses also included: Blindness, Type 2 Diabetes Mellitus With Manifestations, High Blood Pressure, Low Blood Potassium, high Sodium Levels, At High Risk for Falls, Contusion of Elbow, Contusion of Hip..."

Review of the Summary Event Log dated 7/31/2023 at 2:15 PM revealed, "...Discharge... Discharge disposition: Home..."
There was no documentation to indicate how Patient #2 was transported to her home and no documentation the patient's family was notified she had been discharged and taken to the Discharge Lounge.

3. Review of the Discharge Lounge (DL) Log dated 7/31/2023 revealed Patient #2 was "blind" and had a "Time In" documented at 2:18 PM. A total of 4 other patients arrived in the DL after Patient #2 arrived and the last documented "Time Out" was at 8:00 PM when Patient #3 left the hospital. There was no "Time Out" documented for Patient #2.

4. Risk Manager #1 shared an email she received from the House Supervisor on 7/31/2023 at 11:18 PM regarding an incident involving Patient #2. The email indicated the House Supervisor had been called by the operator to inform her that Patient #2's daughter had arrived to pick her up and take her home, but the operator was unable to determine the patient's whereabouts because she was listed as a no publicity. The House Supervisor reviewed the patient's chart and called the 4th floor nurse's station to inform them Patient #2's daughter was there to pick her up. The person at the nurse's station informed her the patient had been discharged and there was a different patient in Patient #2's old room. The House Supervisor noted Patient #2 had signed her own discharge papers, so she called the ambulance service, but they had no record showing the patient had been picked up at the hospital and taken home. The House Supervisor indicated Patient #2's daughter was no longer waiting in the lobby area and had gone to the 5th floor looking for her mother. The email further indicated the House Supervisor found Patient #2 in a room in the DL, and documented, "There was no one on the floor but her." The House Supervisor told staff to tell the patient's daughter to drive to the discharge area and they would bring her to her car; however, someone from the 5th floor took the patient's daughter to the DL where the House Supervisor and Patient #2 were located. Patient #2's daughter became upset because she "stated that the floor was deserted, her mother had not eaten and was she was in pain." The House Supervisor requested someone follow up in the morning to call in a prescription for pain medications as the hospitalist on call would not call in the medication.
Further review of the email revealed the House Supervisor had received a call from the EMT in the DL between 8:00 PM and 8:15 PM informing the House Supervisor all patients had left the area and asked her where to send the PCA that was working that evening for the rest of the shift. The PCA was sent to work in the Emergency Room to complete her shift.

5. Review of the hospital's investigation of the incident revealed Nursing Director #1 reached out to Patient #2's daughter who thought Patient #2 was found on a deserted unit. The Nursing Director informed the patient's daughter the unit appeared to be deserted because some of the furniture had been placed in the hallway while the rooms were being painted. The Nursing Director also indicated the patient's daughter was concerned because the patient had been left alone on the unit. The Nursing Director "ensured [assured] her that we were addressing the occurrence as that was not our expectation of the care for any of our patients..."
Risk Managers #1 and 2 noted the DL Log was incomplete for Patient #2.
Risk Managers #1 and 2 interviewed EMT #1 who was on duty the night of the incident. EMT #1 verified he didn't check each room or check the DL Log to ensure all patients had been picked up before he left the unit that night.

7. In an interview conducted during a tour of the DL on 10/30/2023 beginning at 11:05 AM, Nursing Director #1 stated the DL consisted of 10 rooms on the hall and the remaining rooms at the end of the hallway were reserved for dialysis patients as needed. The director continued and stated the DL was usually staffed with an EMT and 2 PCAs or PCTs (Patient Care Technicians) and they were expected to assist patients with activities of daily living (ADLs) such as toileting, eating and drinking. They would sign the patients in and out on the log, obtain vital signs upon arrival and before they were discharged as well as check the patients at least every hour. When asked if any patients had ever been left unattended in the DL, Nursing Director #1 stated, "I'm not aware of any incidences of patients being left; there have been some conversations where the unit looked abandoned, but that has not ever been the case..." Nursing Director #1 was asked if she could recall the incident involving Patient #2. The director stated, "I do remember the patient's name. The House Supervisor got involved with the patient's daughter who didn't know her room was in the DL. That unit didn't notify the daughter where she [Patient #2] was; she [daughter] went to the unit where she [Patient #2] was discharged from. Then night shift didn't know where she [Patient #2] went because it happened on day shift. I remember talking to the daughter on the phone because she [patient's daughter] said it [DL] looked like an abandoned unit; it [DL] looked like things were being stored there. We were painting and had beds in the hallway while we were painting." When asked if Patient #2 was left alone on the unit, Nursing Director #1 stated, "The EMT wasn't on the unit at that time, he was downstairs. We looked at the logs and clarified all their [DL staff] responsibilities and expectations and retrained all staff." The Nursing Director continued and stated, "To my knowledge, the PCA was still on the unit. The House Supervisor came up and talked with the daughter..." The director then stated the EMT that was involved in the incident was no longer working at the hospital.

In an interview on 10/30/2023 at 3:35 PM, RN #1 RN #1 was asked what criteria was used to determine if a patient was appropriate to go the DL. The RN stated the patients "usually have to be alert; walky-talky." The RN was asked if she could recall caring for Patient #2, the day she was discharged. RN #1 verified she was Patient #2's nurse the day she was discharged from the hospital and stated, "She's blind. My Charge Nurse wanted the patient to go to the DL. I was busy and I told her [charge nurse] I didn't think she [Patient #2] qualified for it. She [charge nurse] told me to send her [Patient #2] anyway because they needed the room." When asked if she [RN #1] called Patient #2's daughter to inform her [daughter] the patient was going to the DL, RN #1 stated, "I tried to call her multiple times, but she never answered...I guess I didn't document it, but I did call." RN #1 continued and stated, "That night [7/31/2023] they told me the patient stayed there and nobody picked her up until late; I was told by staff the patient was there by herself because everybody [DL staff] had left."

In a telephone interview on 10/31/2023 at 8:42 AM, the House Supervisor stated she received a call from someone on the 5th floor informing her Patient #2's daughter was trying to find Patient #2. The House Supervisor continued and stated, "I looked in the computer and saw she was discharged at about 1:30 -2:30 earlier in the day. I called to the 4th floor nurses station and asked where she [Patient #2] was, but they didn't know because she left before they got there. I called the DL and there was no answer. I called back to the 5th floor and asked them to give me a moment...I physically went to the Lounge [DL], called them [5th floor staff] and told them I have her." The House Supervisor stated Patient #2's daughter "ended up on the unit [DL] with me." The House Supervisor continued and stated, "When I found her [Patient #2], I did not see any staff; there was nobody in the room with her. I went to the desk and there was no one [staff] there and no other patients." The House Supervisor was asked if Patient #2 appeared to be in distress or had any signs of incontinence. The House Supervisor stated, "She [Patient #2] was sitting there. I introduced myself then I realized she [Patient #2] was blind. I spoke with [Patient #2]. She was in a wheelchair. There was nothing visible to me as far as distress. I did ask [Patient #2] if she needed to go to the bathroom. [Patient #2] did tell me she was hungry and I got her a snack." The House Supervisor was asked if she could recall what time the patient was found. The House Supervisor was unable to verify the exact time but stated, "I reported to Risk [Risk Management] immediately after." [Note: The House Supervisor sent an email to the Risk Manager at 11:18 PM. See #4 above. ] The House Supervisor was asked if she had received any other complaints or reports of patients being left unattended in the DL. The House Supervisor stated, "No and I have an alarm set on my phone for 10:30 [PM]; I stop and call the DL and ask if there are any patients left on the unit and the estimated time of pick up as well as what types of patients are left." When asked what criteria was used to determine if a patient was appropriate to go to the DL, the House Supervisor stated, "Those going have to be able to get in and out of a car, have to be able to stand and pivot. They have to be as close to walkie-talkie as possible." When asked if Patient #2 met the criteria to go to the DL, the House Supervisor stated, "I would not have sent her there; I would have stopped with she was blind."

In a telephone interview on 10/31/2023 at 9:01 AM, PCA #1, who was scheduled in the DL on 7/31/2023, stated she did not recall Patient #2. The PCA continued and stated, "I've only worked there once or twice. The paramedic guy [EMT] just pretty much had me go in and do vital signs and when they leave, strip the bed." The PCA was asked if she made rounds every hour and checked to see if the patients needed toileting or offered them food or water. PCA #1 stated, "no ma'am. I actually only worked once; the 2nd time I went I was told to go over to the ER [emergency room]." The PCA was asked if she received any orientation or training specific to the DL before she worked there. PCA #1 stated, "No ma'am. I had a nurse take me down there because I had never been on that unit...When they told me I was going there I asked, 'what's that?'."

In a telephone interview on 10/31/2023 at 9:15 AM, RN #2 verified she was the Charge Nurse on duty when Patient #2 was discharged to the DL. When asked what criteria was used to determine if a patient was appropriate to go the DL, RN #2 stated, "Patients that won't be getting up out of bed." The RN continued and stated, "We don't send high fall risk patients." RN #2 was asked if it was appropriate to send a blind patient who needed assistance to get up to the DL. The RN stated, "They have people in the DL there to assist." RN #2 continued and stated, "When I said getting up on their own, I meant like confused patients getting up on their own; we wouldn't send those patients." The RN was asked if she had read the DL criteria. RN #2 verified she had read them in the past but was unable to recall them at this time. The RN was asked who determined if a patient met the criteria to go to the DL. RN #2 stated, "We ask the nurse and go by what the nurse says." The RN was asked if she had ever told a nurse to take a patient to the DL even when the nurse thought patient didn't meet the criteria. RN #2 stated, "No, I do not override them." RN #2 was asked if she could recall sending Patient #2 to the DL. The RN stated, "I don't remember the name." RN #2 then stated she did recall the incident and stated, "The patient [Patient #2] was blind; we took her to the DL and communicated with staff that the patient is blind and wrote it in the comments. They [DL staff] tell us what room to put the patient and we put them where they tell us." RN #2 was asked if the patient's family was notified the patient was taken to the DL. The RN stated, "No, all we did was help provide transport to the DL." This surveyor read the hospital's criteria for the DL to RN #2 and asked if Patient #2 met the criteria for the DL. The RN verified Patient #2 should not have been taken to the DL.

In an interview on 10/31/2023 at 10:47 AM, RN #3 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #3 stated, "Somebody that is able to feed themself. We don't send if they need assistance with feeding, toileting, fall risk or confused." The nurse was asked who determined if a patient met the criteria to go to the DL. RN #3 stated, "Most of the time I'm a Charge Nurse. If there is doubt, they [staff nurses] run it by me." RN #3 was asked if she ever sent patients to the DL that the staff nurse felt was not appropriate. RN #3 stated, "I'm not going to override it [staff nurse's judgement.]..."

In an interview on 10/31/2023 at 10:50 AM, RN #4 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #4 stated patients that are "waiting for Skilled Nursing Facility [SNF] but not of on [receiving] tube feedings [a tube placed into the stomach and liquid nutrition can be given if a patient has difficulty eating]. Ambulatory and waiting for a ride to pick them up...independent." The nurse was asked who determined if a patient met the criteria to go to the DL. RN #4 stated, "Usually it's a nursing judgement; if there's some question, we'll confer with a Charge Nurse." RN #4 was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient's appropriateness for the DL and had her send them anyway. RN #4 stated, "No."

In an interview on 10/31/2023 at 11:01 AM, RN #5 was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #5 stated "if they are not waiting on pain meds and waiting on their ride to arrive. Ambulatory and able to take self to bathroom with minimal assistance." As a RN, she would send the patient if eligible. If there is a need for a unit bed, the charge nurse checks with the RN to see if there is an eligible patient. RN #5 stated, "If there is a need for a bed, we will send them down no matter what." RN 5 stated, "As a charge nurse, I have never overridden a unit nurse decision [unit nurse decision on eligibility for DL.] She does not contact the patient's family member to notify them that the patient is being sent to the DL."

In an interview on 10/31/2023 at 11:00 AM, RN #6 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #6 stated patients that are alert and oriented were appropriate to go to the DL. The nurse was asked who determined if a patient met the criteria to go to the DL. RN #6 stated that she had not sent patients to the DL.

In an interview on 10/31/2023 at 11:03 AM, RN #7 was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #7 stated, "stable and ambulatory." RN #7 confirmed she had sent patients to the DL. RN #7 was asked who determines the patient's eligibility to go to the DL. RN #7 stated, "nursing judgement and doctor. If patient family is available, I notify them the patient has been sent to the DL." RN #7 stated that in her role as a charge nurse, she had never had a unit nurse question the eligibility decision regarding patient placement in the DL. RN #7 stated, "We always look for safety. Make sure they are safe."

In an interview on 10/31/2023 at 11:05 AM, RN #8 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #8 stated that they "ideally send patients that are alert and oriented times 4 [Alert and oriented times 4 means that a patient is aware of self, time, place and others]. The patients are waiting for and have an available ride to pick them up." The nurse was asked who determined if a patient met the criteria to go to the DL. RN #8 stated that is usually determined during discharge planning rounds whether or not a patient can be sent to the DL. RN #8 was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient's appropriateness for the DL and had her send them anyway. RN #8 stated, "No."

In an interview on 10/31/2023 at 11:11 AM, RN #9 was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #9 stated, "medically stable, ambulatory, can safely wait for transport without nurse intervention." RN #9 was asked who determines a patient's eligibility to go to the DL. RN #9 stated, "The doctor decides who is eligible. I would have to assume the doctor makes the decision. I certainly wouldn't want to make that call. None of my patients have ever qualified."

In an interview on 10/31/2023 at 11:14 AM, RN #10 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #10 stated she sent patients who were waiting on the ambulance for transport. The RN continued and stated she only sent patients to the DL who needed to be transported by ambulance.

In an interview on 10/31/2023 at 11:

Based on hospital policy review, document review, medical record review and interview, Nursing Services failed to provide nursing supervision and oversight to ensure nursing staff followed the patient selection criteria for the Discharge Lounge (DL) for 1 of 3 (Patient #2) discharged patients reviewed, resulting in Patient #2 , an 81 year-old confused, wheelchair dependent, blind patient being left unattended in the DL area from approximately 8:15 PM until almost 11:00 PM while she was waiting for her family to arrive and take her home.

The findings included:

1. Review of the hospital's "Assessment/Reassessment Policy" revised on 4/27/2023 revealed, "Purpose: To establish assessment/reassessment time frames and processes to help determine the care, treatment and services that will meet the patient's initial and continuing needs...The Registered Nurse [RN]creates an initial plan for care, treatment, and services appropriate to the patient's specific assessed needs..."

Review of the hospital's "Documentation Policy" revised 3/2021 revealed, "...The primary purpose of patient care documentation is to communicate patient information to other health care professionals caring for the patient. Documentation demonstrates the patient care process, from assessment and planning care to interventions and evaluation..."

2. Review of the hospital's "Discharge Lounge Overview" document revealed, "...The Discharge Lounge is staffed by an EMT [Emergency Medical Technician] and PCA [Patient Care Assistant] (for ambulance patients) and a PCA (for ambulatory patients). Patient Selection Criteria Ambulatory Lounge...Alert and Oriented...Ambulatory with minimal assistance...Able to toilet with minimal PCA assistance...No behavioral issues...Able to self-administer medications - Non Isolation patients...Key Points...Please notify family if you are sending a patient to this discharge lounge so they are aware of patient location...Discharge Lounge Responsibilities...Every Patient must be signed in and out when they enter and leave the discharge lounge...PRIOR to closing each night, the entire hall need to be checked to ensure ALL patients are gone. Log needs to be checked to ensure each patient has left. Call [phone number] and notify house supervisor you are leaving for the night..."

3. Medical record review revealed Patient #2, an 81-year-old blind female, was admitted to the hospital following a fall on 7/29/2023 with diagnoses which included Syncope versus a Fall; (Syncope is used to describe a sudden loss of consciousness for a short period of time. Syncope may also be called fainting or passing out.) Hypernatremia or (elevated blood sodium level), Hypokalemia (low blood potassium level), Diabetes mellitus Type 2, and Hypertension (high blood pressure). Patient #2 complained of pain in the left shoulder and left hip and was unsure if she sustained a head injury when she fell. Further review revealed the patient required assistance with all Activities of Daily Living (ADLs), was at high risk for falls, confused, and required supervision from another person 24 hours a day 7 days a week.

4. Review of the Discharge Lounge (DL) Log dated 7/31/2023 revealed Patient #2 was "blind" and had a "Time In" documented at 2:18 PM. A total of 4 other patients arrived in the DL after Patient #2 arrived and the last documented "Time Out" was at 8:00 PM when Patient #3 left the hospital. There was no "Time Out" documented for Patient #2.

5. Review of an email sent to Risk Manager #1 by the House Supervisor on 7/31/2023 at 11:18 PM revealed the House Supervisor
was notified by the hospital operator informing her Patient #2's daughter was at the hospital to pick the patient up and take her home. The operator was unable to tell the patient's daughter where the patient was because she was no publicity. The House Supervisor reviewed the patient's medical record and noted Patient #2's daughter had been involved in the patient's care. The House Supervisor called the 4th floor where Patient #2's room had been and was told there was another patient in that room because Patient #2 had been discharged. The House Supervisor noted Patient #2 had signed her own discharge papers, so she called the ambulance service, but they had no record showing the patient had been picked up and taken home. The House Supervisor indicated Patient #2's daughter was no longer waiting in the lobby area and had gone to the 5th floor looking for her mother. The email further indicated the House Supervisor found Patient #2 in a room in the Discharge Lounge, and documented, "There was no one on the floor but her." The email revealed Patient #2's daughter was taken to the Discharge Lounge where the House Supervisor and patient were located and the patient's daughter "stated that the floor was deserted, her mother had not eaten and was she was in pain." The email further revealed the House Supervisor had received a call from the EMT in the DL between 8:00 PM and 8:15 PM informing her that all patients had left the area and asked her where to send the PCA that was working that evening. The PCA was sent to work in the Emergency Room to complete her shift.

6. Review of the hospital's investigation of the incident revealed Nursing Director #1 reached out to Patient #2's daughter who thought Patient #2 was found on a deserted unit. The Nursing Director informed the patient's daughter the unit appeared to be deserted because some of the furniture had been placed in the hallway while the rooms were being painted. The Nursing Director also indicated the patient's daughter was concerned because the patient had been left alone on the unit. The Nursing Director "ensured [assured[ her that we were addressing the occurrence as that was not our expectation of the care for any of our patients..."
Risk Managers #1 and 2 identified the DL Log was incomplete for Patient #2.
Risk Managers #1 and 2 interviewed EMT #1 who was on duty the night of the incident and he verified he didn't check each room or check the DL Log to ensure all patients had been picked up before he left the unit that night.

Patient #2 was discharged on 7/31/2023 at 2:15 PM and was taken to the DL to wait for her daughter to arrive and pick her up. Patient #2 did not meet the hospital's criteria to be taken to the DL to await transportation to leave the hospital.

Refer to A-0395.

Based on hospital policy review, document review, medical record review and interview, the hospital failed to ensure nursing services provided adequate oversight and supervision to ensure patient's needs were met when direct care staff failed to follow the hospital's guidelines to determine if 1 of 3 (Patient #2) discharged patients reviewed met criteria to be taken to the Discharge Lounge (DL) to await transportation after discharge from inpatient care.

The findings included:

1. Review of the hospital's "Assessment/Reassessment Policy" revised on 4/27/2023 revealed, "Purpose: To establish assessment/reassessment time frames and processes to help determine the care, treatment and services that will meet the patient's initial and continuing needs... The Registered Nurse [RN] creates an initial plan for care, treatment, and services appropriate to the patient's specific assessed needs... Planning for care, treatment, and services is individualized to meet the patient's unique needs and circumstances..."

Review of the hospital's "Documentation Policy" revised 3/2021 revealed, "...The primary purpose of patient care documentation is to communicate patient information to other health care professionals caring for the patient. Documentation demonstrates the patient care process, from assessment and planning care to interventions and evaluation... Electronic and paper documentation of care, treatment and service is documented at or near the time it occurs... Documentation is completed by the person delivering the care or the caregiver named in the notes..."

2. Review of the hospital's "Discharge Lounge Overview" document revealed, "...The Discharge Lounge was established to address capacity challenges within the hospital. The goal of the Discharge Lounge is to provide an area for patients who are medically ready for discharge and awaiting transportation out. The Discharge Lounge is staffed by an EMT [Emergency Medical Technician] and PCA [Patient Care Assistant] (for ambulance patients) and a PCA (for ambulatory patients). Patient Selection Criteria Ambulatory Lounge... Alert and Oriented... Ambulatory with minimal assistance... Able to toilet with minimal PCA assistance... No behavioral issues... Able to self-administer medications - Non Isolation patients... Patient's ride must be pre-arranged and anticipated to arrive by Discharge Lounge closing time... Key Points... Please notify family if you are sending a patient to this discharge lounge so they are aware of patient location... Discharge Lounge Responsibilities... Every Patient must be signed in and out when they enter and leave the discharge lounge... PRIOR to closing each night, the entire hall need to be checked to ensure ALL patients are gone. Log needs to be checked to ensure each patient has left. Call [phone number] and notify house supervisor you are leaving for the night..."

3. Medical record review revealed Patient #2, an 81-year-old blind female, was admitted to the hospital following a fall on 7/29/2023 with diagnoses which included Syncope versus a Fall; (Syncope is used to describe a sudden loss of consciousness for a short period of time. Syncope may also be called fainting or passing out.) Hypernatremia or (elevated blood sodium level), Hypokalemia (low blood potassium level), Diabetes mellitus Type 2, and Hypertension (high blood pressure). Patient #2 complained of pain in the left shoulder and left hip and was unsure if she sustained a head injury when she fell.

Review of the Admission History and Physical completed on 7/29/2023 at 11:48 PM revealed, "...Patient presents with Syncope...pt got up to unlock the door and fell. Pt is unsure if it was mechanical fall or syncope episode... pt is blind... No fractures noted on imaging studies... Physical Exam... Alert, conversant, appropriate... Legally blind... Assessment and Plan: Syncope vs Fall... Fall precautions, PT [Physical Therapy] OT [Occupational Therapy]..."

Review of the flowsheets for Patient #2 dated 7/29/2023 through 7/31/2023 revealed the patient required assistance completing all Activities of Daily Living (ADLs), the patient was blind, alert, but confused, and was at high risk for falls. The patient required the use of a bed alarm while in the bed and a tether alarm while up in a chair to alert staff when the patient attempted to get up on her own.

Review of the Hospitalist Discharge Summary dated 7/31/2023 at 9:26 AM revealed, Patient #2 was admitted to the hospital for syncope which was likely the result of dehydration and low potassium levels. The patient was treated with Intravenous (IV) fluids and potassium, started on IV antibiotics for a possible urinary tract infection, was evaluated by Physical Therapy and Occupational Therapy and was "Stable for discharge."

Review of a physician's order dated 7/31/2023 at 9:26 AM revealed, "...Discharge patient... Discharge disposition: Home..."

Review of the Occupational Therapy Evaluation completed with the Physical Therapist on 7/31/2023 at 9:27 AM to 9:44 AM, revealed Patient #2 was legally blind but could differentiate between light and darkness. The evaluation further revealed the patient required assistance of another person 24 hours a day, 7 days a week.

Review of the Physical Therapy Evaluation completed with the Occupational Therapist on 7/31/2023 at 9:28 AM to 9:45 AM, revealed Patient #2 was at risk for falls, had functional limitations due to blindness, had poor balance and required moderate assistance to complete "short shuffled steps." The evaluation further revealed the patient required assistance of another person 24 hours a day, 7 days a week.

There was no documentation Patient #2 was taken to the DL to wait for her daughter to pick her up and take her home. There was no documentation the patient's daughter was informed the patient had been taken to the Discharge Lounge.

4. Review of the Discharge Lounge (DL) Log dated 7/31/2023 revealed Patient #2 was "blind" and had a "Time In" documented at 2:18 PM. A total of 4 other patients arrived in the DL after Patient #2 arrived and the last documented "Time Out" was at 8:00 PM when Patient #3 left the hospital. There was no "Time Out" documented for Patient #2.

5. Review of an email sent to Risk Manager #1 by the House Supervisor on 7/31/2023 at 11:18 PM revealed the House Supervisor was notified by the hospital operator informing her Patient #2's daughter was at the hospital to pick the patient up and take her home. The operator was unable to tell the patient's daughter where the patient was because she was no publicity. The House Supervisor reviewed the patient's medical record and noted Patient #2's daughter had been involved in the patient's care. The House Supervisor called the 4th floor where Patient #2's room had been and was told there was another patient in that room because Patient #2 had been discharged. The House Supervisor noted Patient #2 had signed her own discharge papers, so she (House Supervisor) called the ambulance service, but they (ambulance service) had no record showing the patient had been picked up and taken home. The House Supervisor indicated Patient #2's daughter was no longer waiting in the lobby area and had gone to the 5th floor looking for her mother. The email further indicated the House Supervisor found Patient #2 in a room in the Discharge Lounge, and documented, "There was no one on the floor but her [the patient]." The email revealed Patient #2's daughter was taken to the Discharge Lounge where the House Supervisor and patient were located and the patient's daughter "stated that the floor was deserted, her mother had not eaten and was she was in pain." The email further revealed the House Supervisor had received a call from the EMT in the DL between 8:00 PM and 8:15 PM informing her that all patients had left the area and asked her where to send the PCA that was working that evening. The PCA was sent to work in the Emergency Room to complete her shift.

6. Review of the hospital's investigation of the incident revealed Nursing Director #1 reached out to Patient #2's daughter who thought Patient #2 was found on a deserted unit. The Nursing Director informed the patient's daughter the unit appeared to be deserted because some of the furniture had been placed in the hallway while the rooms were being painted. The Nursing Director also indicated the patient's daughter was concerned because the patient had been left alone on the unit. The Nursing Director "ensured [assured] her that we were addressing the occurrence as that was not our expectation of the care for any of our patients..."
Risk Managers #1 and 2 identified the DL Log was incomplete for Patient #2.
Risk Managers #1 and 2 interviewed EMT #1 who was on duty the night of the incident and he verified he didn't check each room or check the DL Log to ensure all patients had been picked up before he left the unit that night.

7. In an interview conducted during a tour of the DL on 10/30/2023 beginning at 11:05 AM, Nursing Director #1 stated the DL was usually staffed with an EMT and 2 PCAs or PCTs (Patient Care Technicians) and they were expected to assist patients with activities of daily living (ADLs) such as toileting, eating and drinking. They would sign the patients in and out on the log, obtain vital signs upon arrival and before they were discharged as well as check the patients at least every hour. When asked if any patients had ever been left unattended in the DL, Nursing Director #1 stated, "I'm not aware of any incidences of patients being left. There have been some conversations where the unit looked abandoned, but that has not ever been the case..." Nursing Director #1 was asked if she could recall the incident involving Patient #2. The director stated, "I do remember the patient's name. The House Supervisor got involved with the patient's daughter who didn't know her room was in the DL. That unit didn't notify the daughter where she [Patient #2] was; she [patient's daughter] went to the unit where she [the patient] was discharged from. Then night shift didn't know where she [the patient] went because it happened on day shift...." When asked if Patient #2 was left alone on the unit, Nursing Director #1 stated, "The EMT wasn't on the unit at that time; he was downstairs...To my knowledge, the PCA was still on the unit." The director then stated the EMT that was involved in the incident was no longer working at the hospital.

In an interview on 10/30/2023 at 3:35 PM, RN #1 RN #1 was asked what criteria was used to determine if a patient was appropriate to go the DL. The RN stated the patients "usually have to be alert; walkie-talkie." RN #1 confirmed she was Patient #2's nurse the day she was discharged from the hospital and stated, "She's blind. My Charge Nurse wanted the patient to go to the DL...I told her [charge nurse] I didn't think she [Patient #2] qualified for it. She [charge nurse] told me to send her [the patient] anyway because they needed the room." When asked if she [RN #1] called Patient #2's daughter to inform her [the daughter] the patient was going to the DL, RN #1 stated, "I tried to call her multiple times, but she [the daughter] never answered...I guess I didn't document it, but I did call." RN #1 continued and stated, "That night [7/31/2023] they told me the patient stayed there and nobody picked her up until late. I was told by staff the patient was there by herself because everybody [DL staff] had left."

In a telephone interview on 10/31/2023 at 8:42 AM, the House Supervisor stated she received a call from someone on the 5th floor informing her Patient #2's daughter was trying to find Patient #2. The House Supervisor continued and stated, "I looked in the computer and saw she was discharged at about 1:30 -2:30 earlier in the day. I called to the 4th floor's nurses' station and asked where she [Patient #2] was, but they didn't know because she [the patient] left before they [staff] got there. I called the DL and there was no answer. I called back to the 5th floor and asked them to give me a moment...I physically went to the Lounge [DL], called them [5th floor staff] and told them I have her [the patient]." The House Supervisor stated Patient #2's daughter "ended up on the unit [DL] with me." The House Supervisor continued and stated, "When I found her [Patient #2], I did not see any staff. There was nobody in the room with her. I went to the desk and there was no one there and no other patients." The House Supervisor was asked if she could recall what time she found the patient. The House Supervisor verified she didn't know exactly when but stated, "I reported to Risk [Risk Management] immediately after." (The House Supervisor reported the incident via email to Risk Management at 11:18 PM; see #4 above.) When asked what criteria was used to determine if a patient was appropriate to go to the DL, the House Supervisor stated, "Those going have to be able to get in and out of a car, have to be able to stand and pivot. They have to be as close to walkie-talkie as possible." When asked if Patient #2 met the criteria to go to the DL, the House Supervisor stated, "I would not have sent her there; I would have stopped with she was blind."

In a telephone interview on 10/31/2023 at 9:01 AM, PCA #1, who was scheduled in the DL on 7/31/2023, stated she did not recall Patient #2. The PCA further stated she had only worked in the DL once and was sent to the ER the second time assigned to work in the DL. The PCA stated she did not receive any orientation or training specific to the DL before she was assigned to work there.

In a telephone interview on 10/31/2023 at 9:15 AM, RN #2 verified she was the Charge Nurse on duty when Patient #2 was discharged to the DL. When asked what criteria was used to determine if a patient was appropriate to go the DL, RN #2 stated, "Patients that won't be getting up out of bed." The RN continued and stated, "We don't send high fall risk patients." RN #2 was asked if it was appropriate to send a blind patient who needed assistance to get up to the DL. The RN stated, "They have people in the DL there to assist." The RN was asked if she had read the DL criteria. RN #2 verified she had read them in the past but was unable to recall them at this time. RN #2 was asked if she could recall sending Patient #2 to the DL. The RN stated, "I don't remember the name." RN #2 continued and stated she did recall the incident. The RN stated, "The patient [Patient #2] was blind; we took her to the DL and communicated with staff that the patient is blind and wrote it in the comments..." RN #2 was asked if the patient's family was notified the patient was taken to the DL. The RN stated, "No, all we did was help provide transport to the DL." This surveyor read the hospital's criteria for the DL to RN #2 and asked if Patient #2 met the criteria for the DL. The RN verified Patient #2 should not have been taken to the DL.

A total of 25 RNs (RN #3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15,16,17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27), representing every patient care unit that would possibly send patients to the DL, were interviewed regarding the criteria used to determine if a patient was appropriate to send to the DL. Of the 25 nurses interviewed, RN #10 stated only patients that were waiting on an ambulance would be taken to the DL; RN #11 was unaware the hospital had a DL; RN #12 stated the DL was staffed with "nurses;" RN #15 stated a patient was appropriate if they were able to use a call light; and RN #25 stated it was okay to send patients that were at a high risk for falls if they were able to call for help. The remaining 20 nurses interviewed verified patients at high risk for falls and/or blind patients would not meet the criteria to be taken to the DL.

In an interview conducted in the DL, on 10/31/2023 at 12:27 PM, EMT #2 stated patients that had been discharged from their room waiting on an ambulance to pick them up as well as "ambulatory" patients that were waiting on family members to pick them up were brought to the DL. The EMT was asked if patients were ever brought to the DL that he didn't feel were appropriate to be there. EMT #2 stated, "Several times... We have protocols to determine who can come. They [floor staff] call report and let us know their needs... I ask [person calling report] what type of precautions, if they're incontinent or diabetic because there's so much I can't do for the patient on this unit." The EMT was asked if he ever refused to accept a patient in the DL. EMT #2 stated, "No, but there were several I could have refused...I'm not allowed to give insulin, pain meds [medications], or do accu checks [blood glucose checks]..." The EMT stated all patient's brought to the DL were documented on the DL Log and vital signs were obtained upon arrival and prior to discharge. The EMT then walked to the computer at the nurses' station and showed the surveyors where the patient's vital signs were documented. When asked to show the surveyors the documentation of Patient #2's vital signs, the EMT pulled up the spread sheet dated 7/31/2023. There was no documentation of Patient #2's name and/or vital signs on the spread sheet.

Nursing Services failed to ensure Patient #2 met the hospital's criteria before she was taken to the DL to await family to arrive to transport home.

Refer to A-0144.

Based on hospital policy review, medical record and interview, the hospital failed to re-evaluate the discharge plan to ensure post-hospital care needs were secured after Rehabilitative Services determined home health Physical Therapy (PT) and Occupational Therapy (OT) services were recommended for 1 of 3 (Patient #2) discharged patients.

The findings included:

1. Review of the hospital's "Discharge/Transition Planning" policy revised 7/2022 revealed, "...The patient and or family and multidisciplinary team are included in the discharge planning to promote safe, effective, and a timely discharge/transition. Refinement of the initial discharge plan takes place throughout stay...The Case Managers/Social Workers evaluate current and anticipated needs of patients and document into the electronic system...The Case Manager assesses the patient and/or family's ability to safely continue post-hospital care...The Case Manager/Social Worker provides a list of SNF [skilled nursing facilities] and/or home health agencies when indicated...The Case Manager/Social Worker arranges for the post-hospital care and documents the plan in the patient record...The Case Manager and/or Social Worker update the plan every 72 hours as changes in patient's condition indicates...The discharge plan and/or patient discharge instructions include post-hospital appointments, equipment, and services arranged..."

Review of the hospital's "Assessment/Reassessment Policy" revised on 4/27/2023 revealed, "Purpose: To establish assessment/reassessment time frames and processes to help determine the care, treatment and services that will meet the patient's initial and continuing needs...Planning for care, treatment, and services involves using an interdisciplinary approach when warranted and involves the patient and family to the extent possible..."

Review of the hospital's "Documentation Policy" revised 3/2021 revealed, "...The primary purpose of patient care documentation is to communicate patient information to other health care professionals caring for the patient. Documentation demonstrates the patient care process, from assessment and planning care to interventions and evaluation..."

2. Medical record review revealed Patient #2, an 81-year-old blind female, was admitted to the hospital following a fall on 7/29/2023 with diagnoses which included Syncope versus a Fall; (Syncope is used to describe a sudden loss of consciousness for a short period of time. Syncope may also be called fainting or passing out.) Hypernatremia (elevated blood sodium level), Hypokalemia (low blood potassium level), Diabetes mellitus Type 2, and Hypertension (high blood pressure).

Review of the Admission History and Physical completed on 7/29/2023 at 11:48 PM revealed, "...Patient presents with Syncope...pt [patient] got up to unlock the door and fell. Pt is unsure if it was mechanical fall or syncope episode...pt is blind...Assessment and Plan: Syncope vs Fall...Fall precautions, PT [Physical Therapy] OT [Occupational Therapy]..."

Review of a physician's order dated 7/29/2023 at 11:56 PM revealed "...Consult to Physical Therapy...Consult to Occupational Therapy..."

Review of the Discharge Planning Note dated 7/31/2023 at 8:33 AM revealed, "...Anticipated Discharge Disposition: home with family...Additional Comments: SW [Social Worker] completed patient's assessment with her granddaughter...via phone...patient lives with her daughter...DME [Durable Medical Equipment]-wheelchair; no history of... HH [Home Health]. Patient's discharge plan is home with family..."

Review of the Hospitalist Discharge Summary dated 7/31/2023 at 9:26 AM revealed, "...Hospital Course: This is an 81-year-old female who got admitted for syncope. Syncope is mostly due to dehydration and hypokalemia. Started on IV [intravenous] fluids and potassium was supplemented. She is back to her baseline now...Evaluated by PT OT. Discussed with case manager to discharge home if family is agreeable...Stable for discharge..."

Review of a physician's order dated 7/31/2023 at 9:26 AM revealed, "...Discharge patient...Discharge disposition: Home..."

Review of the Occupational Therapy Evaluation completed with the Physical Therapist on 7/31/2023 from 9:27 AM through 9:44 AM revealed, "...Recommended Discharge Disposition: skilled nursing facility (SNF) vs [versus] home with 24/7 assistance and HHOT/PT [Home Health Occupational Therapy/Physical Therapy]...home with 24/7 assistance and HHOT/PT..."

Review of the Physical Therapy Evaluation completed with the Occupational Therapist on 7/31/2023 from 9:28 AM through 9:45 AM revealed, "...Recommending home with 24 hour care vs SNF...Precautions/Limitations: Fall and Blindness...PT Diagnosis: difficulty walking, muscle weakness, impaired balance...Plan for PT: continue PT...3-5 times per week..."

Review of the After Visit Summary dated 7/31/2023 printed at 2:07 PM revealed, "Patient to Schedule MD [Medical Doctor] Follow-Up in 1 week...Instructions from your provider Your primary diagnosis was: Fainting Your diagnoses also included: Blindness, Type 2 Diabetes Mellitus With Manifestations, High Blood Pressure, Low Blood Potassium, high Sodium Levels, At High Risk for Falls, Contusion of Elbow, Contusion of Hip..."

Review of the Summary Event Log dated 7/31/2023 at 2:15 PM revealed, "...Discharge...Discharge disposition: Home..."

There was no documentation the PT and or OT discussed their recommendations for Home Health PT and OT with the physician or the Social Worker that completed the patient's Discharge Plan.

The Hospitalist Discharge Summary was completed and the discharge orders were written after the social worker evaluated the patient and before the OT and PT evaluations were completed. There was no documentation Patient #2's need for home health OT and PT was discussed with the Hospitalist and social worker; therefore, Patient #2 was discharged home without orders for home health services.

3. In an interview on 11/6/2023 at 3:29 PM, the Director of Rehabilitative Services, after reviewing the PT and OT evaluations for Patient #2, stated "They [PT and OT] are recommending "Home Health OT/PT..." The Director was unsure if the Case Manager or physician was made aware of the recommendations for Home Health services.

In an interview on 11/6/2023 at 3:36 PM, Risk Manager #1 verified the discharge order was for "Home only" and did not contain orders for Home Health PT and/or OT.

In an interview on 11/6/2023 at 3:44 PM, Risk Manager #1 stated, "I looked in the communication log and there was nothing in there, but they are told to put it in their progress notes" regarding their recommendations for Home Health PT and OT services.

Based on hospital policy review, medical record review and interview, the hospital's rehabilitation services failed to complete ordered Physical Therapy (PT) and/or Occupational Therapy (OT) evaluations per hospital policy for 2 of 4 (Patient #2 and #4) sampled patients.

The findings included:

1. Review of the hospital's "Initiation of Therapy Services" policy revised 2/2023 revealed, "...The Rehabilitative Services Department is notified of new patient admissions...A physician's order for therapy services is obtained...PT/OT: Therapy services are initiated within the next working shift following the shift in which the order is received..."

2. Medical record review revealed Patient #2 presented to the hospital's Emergency Department (ED) on 7/29/2023 with complaints of syncope resulting in a fall. (Syncope is used to describe a sudden loss of consciousness for a short period of time. It can happen when there is a sudden change in the blood flow to the brain. Syncope may also be called fainting or passing out.) The patient reported pain in the left hip and left shoulder.

Review of the ED Provider Note dated 7/29/2023 revealed Patient #2 was "...81 y.o. [year old] Female with PMHx [past medical history] of DM [Diabetes Mellitus], HTN [Hypertension (high blood pressure)] and HLD [Hyperlipidemia, an imbalance of good and bad cholesterol] who presents to the ED complaining of syncope onset today...pt [patient] is blind...Full workup was performed...pt was found to be hypokalemic [low potassium level] and potassium was repleted. Patient was having difficulty ambulating [walking] prior to appropriate time for discharge so she will be brought in for observation to ensure hypokalemia resolves and that she has a safe disposition after appropriate physical therapy..."

Review of the Admission History and Physical completed on 7/29/2023 at 11:48 AM revealed, "...Patient presents with Syncope...pt got up to unlock the door and fell. Pt is usure if it was mechanical fall or syncope episode...pain in her L hip and L shoulder...Of note, pt is blind...Assessment and Plan: Syncope vs Fall...Fall precautions, PT, OT..."

A physician's order dated 7/29/2023 at 11:56 PM revealed, "...Consult to Physical Therapy - Eval...consult to Occupational Therapy - Eval..."

Review of the Hospitalist Daily Note dated 7/30/2023 at 12:09 PM revealed, Patient #2 "...Orders I've place in the past 24 hours...PT Eval and Treat...Disposition: TBD [to be determined] based on clinical course. Not medically stable for dc [discharge]...Discharge barriers: PT, hypokalemia..."

Review of the PT and OT evaluations revealed the evaluations were not completed until 7/31/2023 beginning at 9:27 AM, during the 2nd working shift after the order was written.

3. Medical record review Patient #4 was admitted to the hospital on 9/26/2023 with diagnoses which included Acute Metabolic Encephalopathy with Superimposed dementia, Acute Urinary Tract Infection (UTI), and Hypertension.

Review of the Admission History and Physical completed on 9/27/2023 revealed, "...The patient has dementia hypertension. Recently he sustained a change in mental status and was not really eating. Came to the emergency room. He was diagnosed with UTI sent home with oral antibiotics however is not taking the antibiotics and appetite has remained low therefore daughter brought him here...Assessment and plan...Orders I've authorized in the past 24 hours...Consult to Occupational Therapy..."

Review of the physician's orders dated 9/27/2023 at 5:24 AM revealed, "...Consult to Occupational Therapy-Eval..."

Review of the OT evaluation revealed it was not completed until 9/29/2023 beginning at 10:02 AM, during the 3rd working shift after the order was written.

4. In a telephone interview on 11/7/2023 at 11:41 AM, Risk Manager #1 verified the PT and OT evaluations should have completed within 24 hours after the order was written. The Risk Manager further stated she was informed staffing had been a contributing factor to the delays.