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.

CAPE FEAR VALLEY MEDICAL CENTER 1638 OWEN DRIVE P O BOX 2000 FAYETTEVILLE, NC 28302 Nov. 30, 2011
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of hospital policy, job descriptions, closed medical record review, hospital document review and staff, physician, medical examiner and contracted transportation staff interview, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights by providing care in a safe setting and failed to ensure an organized nursing service.

Findings include:

A. The hospital failed to promote and protect patients' rights by failing to ensure a safe setting for patient care.

~ cross refer to 482.13 Patient Rights' Condition Tag 0115.

B. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care.

~cross refer to 482.23 Nursing Services Condition Tag A0385.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of the hospital failed to promote and protect patients' rights by failing to ensure a safe setting for patient care.

Findings include:

~ cross refer to 482.13(c)(2) Patient Rights' Standard: Tag 0144.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, job descriptions, closed medical record review, hospital document review and staff, physician, medical examiner and contracted transportation staff interview, the hospital failed to ensure care in a safe setting by failing to ensure hospital staff evaluated a patient's response to pain medication, failed to reassess a patient once notified of a change in the patient's condition, and failed to initiate the hospital's rapid response team for 1 of 1 inpatient discharge reviewed (#1).


The findings include:

Review of the hospital's policy, "Pain Management", revised 07/26/2010, revealed, "POLICY: (Name of hospital), through its care providers, assesses, intervenes and reassesses the patient's pain on an ongoing basis. ...GUIDELINES: Each patient has the right to expect his/her report of pain to be accepted, to have the pain assessed and reassessed...6. ...Patients are reassessed and effectiveness (including pain scale) is documented by providers after administration of oral pain medication after 60 minutes to 120 minutes. ...".

Review of the hospital's policy, "Discharging a Patient", revised 02/19/2009, revealed, "...REQUISITES: RNs/LPNs are responsible for completion of Patient Discharge Instruction...Nursing Assistants may assist by taking vital signs...".

Review of the hospital's policy, "Assessment and Reassessment", revised 11/16/2010, revealed, "..Procedure: ...3. Assessment and reassessment are completed as patient's condition warrants... 6. Reassessment is any assessment completed after the initial shift assessment. ...The timing,scope and intensity of reassessment is based on the patient's diagnosis, response to any previous care, change in condition and/or diagnosis, as requested by patient or at discretion of the RN. ... A. Reassessment includes: a. Response to medications...b. Response to pain medications and interventions...f. Discharge planning...".

Review of the hospital's policy, "Rapid Response Guidelines", revised 04/25/2011, revealed, "POLICY: The Rapid Response Team (RRT) responds to situations where patients at (Hospital Name) are experiencing acute clinical changes or are in a pre-code status. The RRT responds to emergent and pre-emergent situations in all areas...PURPOSE: To provide early intervention for patients who experience acute clinical changes in an effort to stabilize, monitor and transfer to a higher level of care if needed, thereby preventing the progression to cardiopulmonary arrest. ...GUIDELINES: Rapid Response Team Members: 1. RRT member responds within 5 minutes to requests for patient assistance or requests that fall within the following established guidelines for response: a. Staff member concerned about the medical condition of a patient...".

Review of the hospital's job description for a Registered Nurse, revised 11/2011, revealed, "...Job Summary: Plans and implements professional nursing care for patients in accordance with hospital policies. ... Major Job Functions: 1. Assesses the patient and identifies patient needs. ...3. Plans, organizes, implements and evaluates patient care. ...".

Closed record review of Patient #1 revealed a [AGE] year-old admitted to the hospital 11/15/2011 after presenting to the hospital's emergency department on 11/14/2011 with chief complaint of right-sided chest pain. Review of the admitting physician's dictated history and physical, dated 11/15/2011 at 1858 revealed, "Chief Complaint Right-sided chest pain. History of Present Illness This is a [AGE]-year-old African American male who recently discharged 2 weeks ago. He was actually admitted for sepsis, rule out meningitis, but his meningitis was ruled out, cachetic, anorexia nervosa, malnutrition, worsening chronic pai[DIAGNOSES REDACTED], polysubstance abuse. The patient has history of non-Hodgkin's [DIAGNOSES REDACTED], currently in remission...The patient is complaining of mild shortness of breath...The patient has a cough on and off. ...In the emergency department he was evaluated by the ED physicians who did cardiac enzymes which were negative. He had a chest x-ray that was consistent with volume loss. There is an infiltrate within the right upper lobe which is increasing in appearance and early stage of cavitary formation and gradually increasing in density and shape since 10/27/2011. ...Plan The patient will be admitted ...in isolation room. The patient will be isolated, droplet and airborne precaution. ...".

Review of the physician's discharge summary for Patient #1, dictated 11/22/2011 at 1630 revealed, "...Hospital Course The patient was admitted as a case of right-sided chest pain, cavitary lung lesions, and also query pneumonia, as well as hypokalemia, failure to thrive, malnutrition, and a history of non-Hodgkin's [DIAGNOSES REDACTED]. The patient was placed on telemetry monitoring. The patient was placed on droplet precautions and contact isolation. Sputum was sent for acid-fast bacilli, which was negative times two. The patient was also seen by the pulmonary consult. The patient had a bronchoscopy done, without any complications. Cultures from the bronchoscopy and the pathology report just showed mild, chronic inflammation of the bronchial mucosa in the right upper lobe. There was no evidence of any malignant cells. ...Bronchial washing cultures grew fungal elements. The patient received Avelox (antibiotic) for seven days and also Zosyn (antibiotic). This was subsequently discontinued, and the patient was started on Diflucan (anti-fungal), as per infectious disease...He is awake, without altered mentation. He is able to respond appropriately to questions. He is generally weak...the patient is stable and afebrile...He is going to be discharged home...Condition on Discharge Stable...Followup Care The patient is to follow up with the primary MD, as scheduled on an outpatient basis...The plan was communicated to the patient, who verbalized understanding".

Further record review for Patient #1 revealed a physician's order dated 11/22/2011 at 0902 for discharge to home. Record review revealed admission orders dated 11/14/2011 at 1910 for vital signs every 4 hours. Record review revealed documentation of vital signs on 11/22/2011 at 0800. Record review revealed no documentation of vital signs at 1200 on 11/22/2011. Record review revealed no documentation of vital signs taken prior to or at the time of discharge on 11/22/2011 at 1404 (6 hours after last vital signs taken). Record review further revealed RN #1 administered Percocet (narcotic pain medication) on 11/22/2011 at 1005 for generalized pain with pain rated at 10, with 10 being the most severe pain on a scale of 1 to 10. Record review revealed no documentation that the patient's pain was reassessed after administration of the pain medication. Further record review revealed nursing documentation completed by RN #1 on 11/22/2011 at 1000, "Pt refusing morning meds, requests pain meds only, refused breakfast as well, no complaints and no distress noted...monitoring continues". Further record review revealed nursing documentation completed by RN #2 on 11/22/2011 at 1230, "Pt. awake with intermittent spont (spontaneous) eye movement, told of MD order to discharge. Pt. nodded head yes to understanding of order & nodded head yes to transporter on the way". Further record review revealed nursing documentation by RN #2 on 11/22/2011 at 1347, "Pt lying in bed, discharge instructions given, pt refusing to talk or move, transport in to take pt to front lobby, explained to pt that taxi would be coming to pick him up, still would not move, security called to escort pt to front lobby, no distress noted".

Review of the hospital's "Event Response Team Checklist" revealed, "Date ERT met: 11-23-11 ERT Members Present: (names of members) Issue discussed: Pt expired after d/c (discharge) on way home...Immediate Issues to be disseminated to staff: Continue to follow policies & procedures...Pt of (MD #1) . Taxi cab owner called (RN #2) , told her the pt has 'flatlined'. Driver was relaying info to owner (of taxi contract service) who was telling (RN #2). Pt d/c 1347, phone call at 1455. Pt was uncooperative at d/c, was alert. Stopped talking when found out was being d/c, wouldn't make eye contact. Cousin, NA (nursing assistant) who works here, went into room with (RN #2), said he does this everytime it's time for him to be d/c. Transport and security took him downstairs. (MD #1) said he is stable, it's time for him to go. This was minutes before d/c. Does not appear nor does any staff mention inappropriate discharge. Not a sentinel event, with pt's history, death is not unexpected. Will continue to interview to discern more information...".

Interview on 11/30/2011 at 0925 with RN #2 revealed the nurse was the charge nurse on 8 South 11/22/2011 (the unit from where Patient #1 was discharged ). Interview further revealed, "He (Patient #1) had mood swings. One minute he was upbeat and talkative. The next time he was quiet, wouldn't make eye contact and wouldn't talk. He was withdrawn, especially when he didn't get his way. When his IV pain medication was discontinued, he got upset. He would only eat when he was getting his pain medicine". Interview further revealed, "I went in (to his room) at 1230 because (RN #1) told me that when she told him he was being discharged , he shut down. I had developed rapport with him. I went in and he made eye contact. He nodded yes when I told him he was going home". Interview further revealed, "he has a cousin that works on our floor. She talked with his mother and the mother gave the address to take him to. I saw him in the wheelchair as he was leaving. He seemed fine to me. He was alert". Interview further revealed, "once a patient has discharge orders, we don't do vital signs again unless the condition warrants. His monitor (EKG) stayed on until right before discharge".

Interview on 11/30/2011 at 1020 with RN #1 revealed the nurse had been assigned primary care to Patient #1 on previous hospital admissions. Interview revealed 11/22/2011 (the day Patient #1 was discharged ) was RN#1's first assignment to Patient #1 for the current hospital admission. Interview revealed, "I assessed him between 7:30 and 8:00. He was in bed, in no distress. He answered all my questions. When I told him he was being discharged , I tried to call his Mom but the phone was disconnected. I told him he had a taxi voucher to go home and was being discharged . He just stopped talking. He was already upset that he didn't have IV pain medication ordered. He had a cough. I brought him his cough medicine and he knocked it out of my hand so I just wasted it and didn't give it to him. I called the taxi service first, then called the transporter. He wasn't being cooperative for us, so I called security to assist with getting him in the wheelchair. I saw him in the wheelchair prior to him getting on the elevator. He was sitting up, alert and in no distress". Interview further revealed, "I got a phone call from (Transporter #2). He said he was slouched down in the wheelchair in the lobby. I told him he was just being uncooperative. They didn't tell me he was in any kind of distress. I figured he was just being uncooperative".

Further interview with RN #1 on 11/22/2011 at 1445 revealed, "I did not reassess him after giving him his pain medicine at 1005. He should have been reassessed within an hour". Interview further revealed, " I received a call from (Transporter #2) when he (Patient #1) was in the lobby. He told me the patient was slouched down in the chair. I didn't ask him any questions about his color or was he breathing". Interview further revealed, "I didn't go down to assess him because he had been discharged and I had five other patients to look after". Interview further revealed, "the transporter should have recognized a problem and called the rapid response team". Interview further revealed, "I should have called rapid response".

Interview on 11/30/2011 at 1000 with Transporter #1 revealed the transporter remembered Patient #1. Interview revealed he went to 8 South at approximately 1330 on 11/22/2011 to transport Patient #1 to the lobby for discharge. Interview revealed, "he was alert but non-communicative. When we talked to him, he turned away from us. Security helped me get him in the wheelchair. Security had been called by nursing because he had refused to get in the wheelchair". Interview further revealed, "the taxi van didn't arrive until about 2:05. We waited down there about 15 minutes. He was sitting up straight and then he slouched down in the wheelchair, like he was giving up, he was going home".

Interview on 11/30/2011 at 1125 with Transporter #2 revealed the transporter worked in the front lobby discharge area and was working on 11/22/2011. Interview revealed, "when (Transporter #1) brought (Patient #1) down, I asked him, 'Is this guy ok? He doesn't look good. He was sitting, slouched in the wheelchair. I called the nurse on 8 South and asked her was this patient ok. She said, 'he's ok. He just doesn't want to go home. He just wants his meds". Interview further revealed, "(Transporter #1) and I helped him into the van. He would not stand up. We lifted him up and put him in the van. We put his seat belt on him. I think he was breathing. His eyes were open".

Further interview with Transporter #1 on 11/30/2011 at 1145 revealed, "we had to lift him up and put him in the van. We had to put his legs into the van. When we put him in the van, the (taxi) driver asked that the nurse be called because he (Patient #1) didn't look right to him. (Transporter #2) called the nurse and he told the driver exactly what the nurse upstairs told me, that this was normal for him". Interview revealed the only call made concerning the change in condition for Patient #1 was the call made by Transporter #2 to nursing on 8 South at the request of the taxi driver. Interview further revealed, "I thought it was a good idea to call the nurse. I thought the nurse should have come down and reassessed him before he drove off".

Interview via telephone on 11/30/2011 at 1300 with Taxi Driver #1 revealed the taxi/transport company has a contract with named hospital. Interview revealed, "I was taught to observe the whole patient. Our contract says the patient should be able to board/unboard by himself. When I pulled up, (Patient #1) was slumped over in the wheelchair. He didn't look normal to me. I told the transporter, (Transporter #2) that he didn't look right. He (Transporter #2) called the nurse and the nurse said he was ok. He just didn't want to go home. I told him the patient needed to be able to talk to me because I didn't know exactly where his house was. I got a phone number to his house". Interview further revealed, "He never stood up. Those two men (Transporters #1 and #2) lifted him into the van". Interview further revealed, "I tried to talk to him while in the taxi. I asked him was he ok and did he need assistance. He was non-responsive. I contacted (name of supervisor) and told her he didn't look right. When I arrived at his house, he had closed his eyes. He looked like he was sleeping. I called his house and his mother came out. She called his name. She said, 'he's not acting right'. She called 911. When EMS arrived, they put the monitor on him. He was flatlined, dead. We couldn't move him. It was about 5 hours before they finally got him out of the van. They said because he had died on the way home from the hospital, they had to treat it like a criminal scene". Interview further revealed it was a 45 minute drive from the hospital to Patient #1's house.

Interview via telephone on 11/30/2011 at 1315 with the owner of the transport/taxi service revealed she received a call from RN #1 on 11/22/2011 at 1312 for a patient to be transported home. Interview further revealed she received a call at 1352 from Transporter #2 that patient was in the lobby, ready to be picked up. Interview further revealed she received a call from Taxi Driver #1 at 1353 that he was at the hospital and that the patient didn't look right. Interview revealed, "He told me they picked him up and put him in the van and the patient was not saying a word". Interview further revealed, "I called 8 South and spoke to (RN #1). She told me he was ok, he just didn't want to go home". Interview further revealed, "(Taxi Driver #1) called 911 at 2:46 (pm). At 2:51 (pm), I called 8 South and talked to (RN #2) and told her that (Patient #1) had died ". Interview further revealed, "we have been told by the ER staff not to take patients to the ER (emergency room ). (Taxi Driver #1) did that (took a discharged patient to the ER) some time ago and he got fussed out".

Interview via telephone on 11/30/2011 at 1400 with the medical examiner in the county where Patient #1 died revealed he had received preliminary autopsy results from the pathologists at UNC. Interview revealed the autopsy results showed that Patient #1 died from pneumonia secondary to complications related to non-Hodgkin's [DIAGNOSES REDACTED].

Interview on 11/30/2011 at 1430 with the Chief Medical Officer revealed, "the nurse should have responded to a call that a patient didn't look right".

Interview on 11/30/2011 at 1425 with the Interim Chief Nursing Officer revealed Patient #1's record had been reviewed. Interview revealed there were no issues discovered from the hospital's management review of the incident of the discharge of Patient #1 related to policies/procedures being followed. Interview further revealed there were no issues discovered related to reassessment of the patient by the nursing staff.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of hospital policy, job descriptions, closed medical record review, hospital document review and staff, physician, medical examiner and contracted transportation staff interview, the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care.

The findings include:

The hospital failed to ensure nursing staff supervised and evaluated patient care by failing to ensure nursing staff evaluated a patient's response to pain medication and reassess a patient once notified of a change in the patient's condition for 1 of 1 inpatient discharges reviewed (#1).

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, job descriptions, closed medical record review, hospital document review and staff, physician, medical examiner and contracted transportation staff interview, the hospital failed to ensure nursing staff supervised and evaluated patient care by failing to ensure nursing staff evaluated a patient's response to pain medication and reassess a patient once notified of a change in the patient's condition for 1 of 1 inpatient discharges reviewed (#1).

The findings include:

Review of the hospital's policy, "Pain Management", revised 07/26/2010, revealed, "POLICY: (Name of hospital), through its care providers, assesses, intervenes and reassesses the patient's pain on an ongoing basis. ...GUIDELINES: Each patient has the right to expect his/her report of pain to be accepted, to have the pain assessed and reassessed...6. ...Patients are reassessed and effectiveness (including pain scale) is documented by providers after administration of oral pain medication after 60 minutes to 120 minutes. ...".

Review of the hospital's policy, "Discharging a Patient", revised 02/19/2009, revealed, "...REQUISITES: RNs/LPNs are responsible for completion of Patient Discharge Instruction...Nursing Assistants may assist by taking vital signs...".

Review of the hospital's policy, "Assessment and Reassessment", revised 11/16/2010, revealed, "..Procedure: ...3. Assessment and reassessment are completed as patient's condition warrants... 6. Reassessment is any assessment completed after the initial shift assessment. ...The timing,scope and intensity of reassessment is based on the patient's diagnosis, response to any previous care, change in condition and/or diagnosis, as requested by patient or at discretion of the RN. ... A. Reassessment includes: a. Response to medications...b. Response to pain medications and interventions...f. Discharge planning...".

Review of the hospital's policy, "Rapid Response Guidelines", revised 04/25/2011, revealed, "POLICY: The Rapid Response Team (RRT) responds to situations where patients at (Hospital Name) are experiencing acute clinical changes or are in a pre-code status. The RRT responds to emergent and pre-emergent situations in all areas...PURPOSE: To provide early intervention for patients who experience acute clinical changes in an effort to stabilize, monitor and transfer to a higher level of care if needed, thereby preventing the progression to cardiopulmonary arrest. ...GUIDELINES: Rapid Response Team Members: 1. RRT member responds within 5 minutes to requests for patient assistance or requests that fall within the following established guidelines for response: a. Staff member concerned about the medical condition of a patient...".

Review of the hospital's job description for a Registered Nurse, revised 11/2011, revealed, "...Job Summary: Plans and implements professional nursing care for patients in accordance with hospital policies. ... Major Job Functions: 1. Assesses the patient and identifies patient needs. ...3. Plans, organizes, implements and evaluates patient care. ...".

Closed record review of Patient #1 revealed a [AGE] year-old admitted to the hospital 11/15/2011 after presenting to the hospital's emergency department on 11/14/2011 with chief complaint of right-sided chest pain. Review of the admitting physician's dictated history and physical, dated 11/15/2011 at 1858 revealed, "Chief Complaint Right-sided chest pain. History of Present Illness This is a [AGE]-year-old African American male who recently discharged 2 weeks ago. He was actually admitted for sepsis, rule out meningitis, but his meningitis was ruled out, cachetic, anorexia nervosa, malnutrition, worsening chronic pai[DIAGNOSES REDACTED], polysubstance abuse. The patient has history of non-Hodgkin's [DIAGNOSES REDACTED], currently in remission...The patient is complaining of mild shortness of breath...The patient has a cough on and off. ...In the emergency department he was evaluated by the ED physicians who did cardiac enzymes which were negative. He had a chest x-ray that was consistent with volume loss. There is an infiltrate within the right upper lobe which is increasing in appearance and early stage of cavitary formation and gradually increasing in density and shape since 10/27/2011. ...Plan The patient will be admitted ...in isolation room. The patient will be isolated, droplet and airborne precaution. ...".

Review of the physician's discharge summary for Patient #1, dictated 11/22/2011 at 1630 revealed, "...Hospital Course The patient was admitted as a case of right-sided chest pain, cavitary lung lesions, and also query pneumonia, as well as hypokalemia, failure to thrive, malnutrition, and a history of non-Hodgkin's [DIAGNOSES REDACTED]. The patient was placed on telemetry monitoring. The patient was placed on droplet precautions and contact isolation. Sputum was sent for acid-fast bacilli, which was negative times two. The patient was also seen by the pulmonary consult. The patient had a bronchoscopy done, without any complications. Cultures from the bronchoscopy and the pathology report just showed mild, chronic inflammation of the bronchial mucosa in the right upper lobe. There was no evidence of any malignant cells. ...Bronchial washing cultures grew fungal elements. The patient received Avelox (antibiotic) for seven days and also Zosyn (antibiotic). This was subsequently discontinued, and the patient was started on Diflucan (anti-fungal), as per infectious disease...He is awake, without altered mentation. He is able to respond appropriately to questions. He is generally weak...the patient is stable and afebrile...He is going to be discharged home...Condition on Discharge Stable...Followup Care The patient is to follow up with the primary MD, as scheduled on an outpatient basis...The plan was communicated to the patient, who verbalized understanding".

Further record review for Patient #1 revealed a physician's order dated 11/22/2011 at 0902 for discharge to home. Record review revealed admission orders dated 11/14/2011 at 1910 for vital signs every 4 hours. Record review revealed documentation of vital signs on 11/22/2011 at 0800. Record review revealed no documentation of vital signs at 1200 on 11/22/2011. Record review revealed no documentation of vital signs taken prior to or at the time of discharge on 11/22/2011 at 1404 (6 hours after last vital signs taken). Record review further revealed RN #1 administered Percocet (narcotic pain medication) on 11/22/2011 at 1005 for generalized pain with pain rated at 10, with 10 being the most severe pain on a scale of 1 to 10. Record review revealed no documentation that the patient's pain was reassessed after administration of the pain medication. Further record review revealed nursing documentation completed by RN #1 on 11/22/2011 at 1000, "Pt refusing morning meds, requests pain meds only, refused breakfast as well, no complaints and no distress noted...monitoring continues". Further record review revealed nursing documentation completed by RN #2 on 11/22/2011 at 1230, "Pt. awake with intermittent spont (spontaneous) eye movement, told of MD order to discharge. Pt. nodded head yes to understanding of order & nodded head yes to transporter on the way". Further record review revealed nursing documentation by RN #2 on 11/22/2011 at 1347, "Pt lying in bed, discharge instructions given, pt refusing to talk or move, transport in to take pt to front lobby, explained to pt that taxi would be coming to pick him up, still would not move, security called to escort pt to front lobby, no distress noted".

Review of the hospital's "Event Response Team Checklist" revealed, "Date ERT met: 11-23-11 ERT Members Present: (names of members) Issue discussed: Pt expired after d/c (discharge) on way home...Immediate Issues to be disseminated to staff: Continue to follow policies & procedures...Pt of (MD #1) . Taxi cab owner called (RN #2) , told her the pt has 'flatlined'. Driver was relaying info to owner (of taxi contract service) who was telling (RN #2). Pt d/c 1347, phone call at 1455. Pt was uncooperative at d/c, was alert. Stopped talking when found out was being d/c, wouldn't make eye contact. Cousin, NA (nursing assistant) who works here, went into room with (RN #2), said he does this everytime it's time for him to be d/c. Transport and security took him downstairs. (MD #1) said he is stable, it's time for him to go. This was minutes before d/c. Does not appear nor does any staff mention inappropriate discharge. Not a sentinel event, with pt's history, death is not unexpected. Will continue to interview to discern more information...".

Interview on 11/30/2011 at 0925 with RN #2 revealed the nurse was the charge nurse on 8 South 11/22/2011. Interview further revealed, "He (Patient #1) had mood swings. One minute he was upbeat and talkative. The next time he was quiet, wouldn't make eye contact and wouldn't talk. He was withdrawn, especially when he didn't get his way. When his IV pain medication was discontinued, he got upset. He would only eat when he was getting his pain medicine". Interview further revealed, "I went in (to his room) at 1230 because (RN #1) told me that when she told him he was being discharged , he shut down. I had developed rapport with him. I went in and he made eye contact. He nodded yes when I told him he was going home". Interview further revealed, "he has a cousin that works on our floor. She talked with his mother and the mother gave the address to take him to. I saw him in the wheelchair as he was leaving. He seemed fine to me. He was alert". Interview further revealed, "once a patient has discharge orders, we don't do vital signs again unless the condition warrants. His monitor (EKG) stayed on until right before discharge".

Interview on 11/30/2011 at 1020 with RN #1 revealed the nurse had been assigned primary care to Patient #1 on previous hospital admissions. Interview revealed 11/22/2011 (the day Patient #1 was discharged ) was RN#1's first assignment to Patient #1 for the current hospital admission. Interview revealed, "I assessed him between 7:30 and 8:00. He was in bed, in no distress. He answered all my questions. When I told him he was being discharged , I tried to call his Mom but the phone was disconnected. I told him he had a taxi voucher to go home and was being discharged . He just stopped talking. He was already upset that he didn't have IV pain medication ordered. He had a cough. I brought him his cough medicine and he knocked it out of my hand so I just wasted it and didn't give it to him. I called the taxi service first, then called the transporter. He wasn't being cooperative for us, so I called security to assist with getting him in the wheelchair. I saw him in the wheelchair prior to him getting on the elevator. He was sitting up, alert and in no distress". Interview further revealed, "I got a phone call from (Transporter #2). He said he was slouched down in the wheelchair in the lobby. I told him he was just being uncooperative. They didn't tell me he was in any kind of distress. I figured he was just being uncooperative".

Further interview with RN #1 on 11/22/2011 at 1445 revealed, "I did not reassess him after giving him his pain medicine at 1005. He should have been reassessed within an hour". Interview further revealed, " I received a call from (Transporter #2) when he (Patient #1) was in the lobby. He told me the patient was slouched down in the chair. I didn't ask him any questions about his color or was he breathing". Interview further revealed, "I didn't go down to assess him because he had been discharged and I had five other patients to look after". Interview further revealed, "the transporter should have recognized a problem and called the rapid response team". Interview further revealed, "I should have called rapid response".

Interview on 11/30/2011 at 1000 with Transporter #1 revealed the transporter remembered Patient #1. Interview revealed he went to 8 South at approximately 1330 on 11/22/2011 to transport Patient #1 to the lobby for discharge. Interview revealed, "he was alert but non-communicative. When we talked to him, he turned away from us. Security helped me get him in the wheelchair. Security had been called by nursing because he had refused to get in the wheelchair". Interview further revealed, "the taxi van didn't arrive until about 2:05. We waited down there about 15 minutes. He was sitting up straight and then he slouched down in the wheelchair, like he was giving up, he was going home".

Interview on 11/30/2011 at 1125 with Transporter #2 revealed the transporter worked in the front lobby discharge area and was working on 11/22/2011. Interview revealed, "when (Transporter #1) brought (Patient #1) down, I asked him, 'Is this guy ok? He doesn't look good. He was sitting, slouched in the wheelchair. I called the nurse on 8 South and asked her was this patient ok. She said, 'he's ok. He just doesn't want to go home. He just wants his meds". Interview further revealed, "(Transporter #1) and I helped him into the van. He would not stand up. We lifted him up and put him in the van. We put his seat belt on him. I think he was breathing. His eyes were open".

Further interview with Transporter #1 on 11/30/2011 at 1145 revealed, "we had to lift him up and put him in the van. We had to put his legs into the van. When we put him in the van, the (taxi) driver asked that the nurse be called because he (Patient #1) didn't look right to him. (Transporter #2) called the nurse and he told the driver exactly what the nurse upstairs told me, that this was normal for him". Interview revealed the only call made concerning the change in condition for Patient #1 was the call made by Transporter #2 to nursing on 8 South at the request of the taxi driver. Interview further revealed, "I thought it was a good idea to call the nurse. I thought the nurse should have come down and reassessed him before he drove off".

Interview via telephone on 11/30/2011 at 1300 with Taxi Driver #1 revealed the taxi/transport company has a contract with named hospital. Interview revealed, "I was taught to observe the whole patient. Our contract says the patient should be able to board/unboard by himself. When I pulled up, (Patient #1) was slumped over in the wheelchair. He didn't look normal to me. I told the transporter, (Transporter #2) that he didn't look right. He (Transporter #2) called the nurse and the nurse said he was ok. He just didn't want to go home. I told him the patient needed to be able to talk to me because I didn't know exactly where his house was. I got a phone number to his house". Interview further revealed, "He never stood up. Those two men (Transporters #1 and #2) lifted him into the van". Interview further revealed, "I tried to talk to him while in the taxi. I asked him was he ok and did he need assistance. He was non-responsive. I contacted (name of supervisor) and told her he didn't look right. When I arrived at his house, he had closed his eyes. He looked like he was sleeping. I called his house and his mother came out. She called his name. She said, 'he's not acting right'. She called 911. When EMS arrived, they put the monitor on him. He was flatlined, dead. We couldn't move him. It was about 5 hours before they finally got him out of the van. They said because he had died on the way home from the hospital, they had to treat it like a criminal scene". Interview further revealed it was a 45 minute drive from the hospital to Patient #1's house.

Interview via telephone on 11/30/2011 at 1315 with the owner of the transport/taxi service revealed she received a call from RN #1 on 11/22/2011 at 1312 for a patient to be transported home. Interview further revealed she received a call at 1352 from Transporter #2 that patient was in the lobby, ready to be picked up. Interview further revealed she received a call from Taxi Driver #1 at 1353 that he was at the hospital and that the patient didn't look right. Interview revealed, "He told me they picked him up and put him in the van and the patient was not saying a word". Interview further revealed, "I called 8 South and spoke to (RN #1). She told me he was ok, he just didn't want to go home". Interview further revealed, "(Taxi Driver #1) called 911 at 2:46 (pm). At 2:51 (pm), I called 8 South and talked to (RN #2) and told her that (Patient #1) had died ". Interview further revealed, "we have been told by the ER staff not to take patients to the ER (emergency room ). (Taxi Driver #1) did that (took a discharged patient to the ER) some time ago and he got fussed out".

Interview via telephone on 11/30/2011 at 1400 with the medical examiner in the county where Patient #1 died revealed he had received preliminary autopsy results from the pathologists at UNC. Interview revealed the autopsy results showed that Patient #1 died from pneumonia secondary to complications related to non-Hodgkin's [DIAGNOSES REDACTED].

Interview on 11/30/2011 at 1430 with the Chief Medical Officer revealed, "the nurse should have responded to a call that a patient didn't look right".

Interview on 11/30/2011 at 1425 with the Interim Chief Nursing Officer revealed Patient #1's record had been reviewed. Interview revealed there were no issues discovered from the hospital's management review of the incident of the discharge of Patient #1 related to policies/procedures being followed. Interview further revealed there were no issues discovered related to reassessment of the patient by the nursing staff.

NC 942