The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on interview and record review, the hospital failed to meet the needs of 1 of 4 sampled patients released from the emergency department (ED) who had altered mental status (#4). The total sampled was 20 patients.


Cross Refer to A1103 - Based on interview and record review, the hospital failed to ensure staff provided a physician requested discharge planning assessment and a safe discharge for 1 of 4 sampled emergency department (ED) patients with altered mental status (#4).

Based on interview and record review, the facility failed to ensure staff provided a physician requested discharge planning assessment and a safe discharge for 1 of 4 sampled emergency department (ED) patients with altered mental status (#4). The total sampled was 20 patients.


Review of the medical record for patient #4, [AGE], showed he was admitted on [DATE] for altered mental status and discharged to an assisted living facility (ALF) on 6/03/2014.

The history and physical (H&P) examination dated 5/09/2014 documented patient #4 was Baker Acted from a nursing home for aggressive and abusive behavior toward staff. The H&P read, "The patient does not know where he is or what happened." The psychiatric consultation, written by physician #A on 5/09/2014 read, "The patient appears frail, disorganized. Speech is slow, soft, and monotone. Insight and judgment is poor...."

The second psychiatric consultation by physician #B on 5/09/2014 read, "The patient reported having a history of decline in cognition and diagnosis of dementia. Had been Baker Acted....Impaired insight. Impaired ability for abstract thinking and processing of information...."

The third consultation written on 5/27/2014 to determine capacity of the patient to make decisions by physician #B read, "At this time, given the patient's current presentation, the patient does not have the ability to make decisions regarding safe discharge planning. The patient requires assistance with activities of daily living and instrumental activities of daily living...."

Case management notes on 5/12/2014 read, "Met with patient and he was unable to participate with assessment at this time."

The patient was not accepted for admission by multiple long-term care facilities and finally accepted by a local ALF. The Healthcare Surrogate was notified on 6/03/2014 at 4:51 p.m. and agreed to admission to the ALF. The patient was discharged by medical transportation, ambulette, on 6/03/2014. The nurse's notes revealed on 6/03/2014 at 5:45 p.m., the patient was picked up by the medical transportation company.

Patient #4 returned to the ED on 6/06/2014 at 10:40 a.m., treated for altered mental status and released on 6/06/2014 at 1:53 p.m. The patient was found wandering on the street earlier on 6/06/2014, trying to cash a check at an automated teller machine (ATM) to get a cup of coffee. By-standers called 911, and the patient was picked up by emergency medical services and brought to the ED. The patient was seen in the ED, assessed by ED physician #C, and approximately 3 hours later, physician #C ordered the patient released back to the ALF. The ED T-sheet, used by the ED physician to document, showed the patient had similar symptoms previously, and was disoriented and confused. The 6/06/2014 ED T-sheet documented ED physician #C reviewed patient #4's previous hospital inpatient admission from 5/09/2014 to 6/03/2014.

The 6/06/2014 ED physician #C's progress note read, "Spoke with case manager concerning (patient #4). Contacted the ALF which noted that the patient wandered away from facility today. Patient is noted to have dementia. Patient will receive a cab ride back to the ALF, patient in no acute distress, conversing, drinking coffee, in no acute distress." The ED physician documented the clinical impression as "confusion and dementia", and counseled the patient regarding lab reports, radiology reports, and diagnosis. The clinical impression upon release from the ED on 6/06/2014 was "confusion and dementia". As of the survey dates of 7/10/2014, 7/11/2014 and 7/14/2014, ED physician #C remained on staff, working in the ED.

On 6/06/2014 at 10:18 p.m., ED case manager #G wrote, "Discharge Plan - Request by ER physician to assist with discharge plan as patient was just discharged on [DATE]. Called (ALF administrator) where patient had been staying....Patient welcome back to residence. Yellow cab called for transport, discharged to (ALF).

Review of the ED notes showed the patient was released from the ED at 1:43 p.m. The discharge instructions were signed by the patient at 1:47 p.m. and included ED specific instructions for confusion, "Confusion is a change in a person's ability to think clearly. There may be trouble recognizing familiar people and places, or knowing what day it is. Memory, judgment and decision-making may also be affected....Home care: Be sure someone is with the confused person at all times. He/she should not be left alone or unsupervised." ED registered nurse (RN) #H, who worked on 6/06/2014 during this time frame, documented patient #4 was escorted to the transport area by an un-named security employee at 1:53 p.m., and the time he was picked up by the cab company was at 3:53 p.m. However, review of the cab company invoice provided by the facility on 7/11/14, showed the cab company documented the patient was a no-show at 1:45 p.m. Therefore, the patient never got into the cab and never returned to the ALF. Patient #4 remains missing as of the exit date, 7/14/2014.

The ED clinical summary documented under "Transport to Location: Vehicle for discharge home" as accompanied by "security".

During a telephone interview on 7/10/2014 at 9:30 a.m., the Department of Children and Families (DCF) investigator said she was closing cases, and had one open for patient #4. She said she found out patient #4 was discharged from the nursing home, sent to the hospital, and from there discharged to an ALF. She said she called the ALF and found out patient #4 had wandered away, returned to the hospital, and had not returned to the ALF. She said she called the hospital on [DATE] at 4:50 p.m. to notify them patient #4 was missing from the ALF. She said she called the hospital again on 7/02/14 at 2:25 p.m. The hospital case manager informed her that an alert was placed in the hospital system to notify case management if the patient returned to the hospital. On 7/11/2013 at approximately 8:30 a.m., the DCF investigator was called again and said patient #4 has been missing since 6/06/2014. During another call at approximately 3 p.m. on 7/11/2014, she said a missing person report was filed with the Orange County Sheriff's department on 6/05/2014 by the ALF. She said that the ALF allowed the resident to sign out of the facility on 6/04/2014. She said the staff member at the ALF tried to convince the patient #4 not to leave that day but he had insisted. When he didn't return on 6/05/2014, she said the ALF called the Orange County Sheriff's Department to file a missing person report.

During an interview on 7/10/2014 at 1:45 p.m., case manager #F and the director of case management, #E, both said the facility practice is not to discharge a patient with known lack of capacity home in a cab, unless approved by the health care surrogate. She confirmed there was no documentation in the second record from the ED visit on 6/06/2014 of any contact with the health care surrogate. She also said the case manager should have reviewed the patient's previous admission, and must have reviewed the prior record in order to obtain the name of the ALF where the patient lived.

During an interview on 7/11/2014 at 11:45 a.m., staff #D, RN manager for the ED said when a patient is discharged and they are alert and oriented, they are discharged , receive instructions, stop by the registration desk, and then leave the ED. She said if the patient has orientation problems, they show the patient the driveway/valet area and instruct them to sit and wait for the cab. She said the cab will not wait. She reviewed patient #4's record and said the documentation showed security was with the patient but she said there was no documentation of the identity of the security officer and if the security officer stayed with the patient.

During an interview on 7/11/2014 at 12 p.m., the risk manager (RM) was asked which security staff worked on 6/06/2014 at the time of the ED release for patient #4. She said she asked security staff who was working and which security staff would have escorted the patient to the waiting/valet area, and security staff said there is no log kept and none of the security staff remembered patient #4 or taking him to the valet/waiting area for cab pick up.

During a telephone interview on 7/11/2014 12:10 p.m., physician #C said he remembered patient #4. He said when the patient came to the ED, the patient was not sure of what day it was, but did answer other questions, like the name of the president correctly. Physician #C said the patient was close in his answer for the day of the week. He said he remembered that case management (CM) was now available in the ED and requested CM to see this patient. The CM identified the patient was from a ALF. He said he reviewed the medical record from the prior discharge, but did not remember if he saw the patient lacked capacity for discharge planning. He said he does not remember if the patient knew where he lived. Physician #C said when he found out the patient was from a ALF, he felt it was an appropriate discharge to send the patient back to the ALF and the CM got transport for a cab for the patient to return back to the ALF."

During a phone interview on 7/11/2014 at 12:50 p.m., case manager #G said she remembered calling the ALF where patient #4 lived, and asked if the patient could return. At that time, she said no one at the ALF told her that patient #4 had been reported missing. She said the ED physician and nurse are responsible for discharge plan for ED patients. She said she was only responsible for obtaining the transportation and if he could return to the ALF. She said she did not do a discharge plan and did just what the ED physician requested.

Review of the hospital policy "Discharge Planning", dated as last reviewed 2/28/2014, read: "Scope - This policy applies to all patients receiving services in a Florida Hospital health care setting. Areas responsible for adhering to this policy include Advanced License Practice Nurses (ALPN); Case Mangers (CM), including Registered Nurse (RN) and social worker (SW) Case Mangers and Case Management Assistants (CMA); Health Unit Coordinators (HUC), Patient Access, and Registered Nurse (RN)."
"B. Discharge Assessment:....d. Referrals for discharge planning assessment by case management may be requested by the physician, nursing, rehabilitation therapy, patients/families, and community resources.
C. Discharge Plan of Care includes: #1 Discharge planning shall be an interdisciplinary effort requiring coordination by the physician, health care team, patient/LAP (legally authorized person), and community services liaison or resources.
D. Case Management Responsibilities for Discharge Planning: #3 The registered nurse, social worker, or other appropriately qualified personnel (as defined in the job description) conducts and coordinates discharge planning evaluations and high risk screenings on patients identified by their physician, families, healthcare team, or community resources. a. Patients shall be re-assessed throughout their hospitalization to confirm that the discharge plan meets the needs of the patient. b. Patients/LAPs shall be actively involved in the discharge planning process and their choices are encouraged and supported.
E. Documentation of Discharge Planning: Assessment and subsequent re-assessments are documented in the patient's medical record and include the following discharge options: 2 Discharge instructions given and 3 Hands off communication and provision of application medical records to the next level of care facility or community agency, as applicable."

Review of the policy "Follow-up Care Instructions-Emergency Department", dated as last reviewed on 5/09/2013, read in part, "#1 Advise patient of follow-up instructions; and #6 Assess the patient's understanding of instructions given and clarify misunderstandings as necessary." There was no indication in the ED record that this policy was followed.