HospitalInspections.org

Based on record review and interviews, the facility failed to provide a safe discharge for 1(P1 (Patient)] out of 26 (P1-P26) patients. This deficient practice could likely result in harm to the patients that are discharged from the facility.

The findings are:

A. Record review of P1's medical chart under Emergency Department Record dated 03/31/2025 at 11:15 pm stated P1 lives in Lordsburg New Mexico, presented to the ER (Emergency Room) via helicopter on 03/31/2025 at 2:56 pm after passing out at a store in Lordsburg, New Mexico and had complaints of a fall and chest pain 3-4 days ago. Under physician documentation it stated that a full cardiac work-up in the emergency room, with 2 electrocardiograms (electrical activity of the heart) the first on 03/31/2025 at 3:36 pm and 6:09 pm. Under Nurses Notes dated 03/31/2025 at 2:56 pm stated that P1 was alert and oriented to person, place and time. P1's chart did not contain an address or phone number and the patient did not know them. It was noted by S (staff)4 (clinical) that EMS (emergency medical service) reported P1 lives in a hotel. Medical record review noted that P1 on 04/01/2025 at 1:52 am "patient left the ED".

B. During an interview on 04/30/2025 at 3:45 pm with S3 (clinical) confirmed there was no address listed or a phone number for P1, for the staff to use for discharge planning. S3 confirmed that EMS in the chart stated that P1 lives in a hotel. Confirmed that discharging this patient without a ride back to Lordsburg, New Mexico could cause harm and there was no documentation of a discharge plan or an attempt to come up with a safe discharge plan. S3 confirmed the emergency room staff should have found a way to get home and not left at the bus stop for hours at night and the bus does not run through the night.

C. During an interview with S1 (clinical) on 04/30/2025 at 6:20 am it was confirmed that P1 did not know where he lived or had a phone number to call for a ride and told S1 that he just moved in with a friend. S1 stated "his story sounded good". S1 confirmed that the record was not read for further information for a safe discharge.

D. During an interview with S2 (clinical) on 04/30/2025 at 7:00 am it was confirmed that S2 took care of P1 and P1 did not know his address or phone number. S2 stated the staff could have called the EMS company to find where he lived and get a possible phone number to call for a ride back to his home. S2 stated that the police came into the ER on 04/01/2025 at 7:00 am when she came on shift and stated the patient had sat at the bus stop all night.

E. During an interview with S4 (clinical) on 04/30/2025 at 10:30 am confirmed P1 was confused and did not know his address or phone number, had no money to call for transport home. S4 confirmed that the discharge of this patient was not safe.