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Based on interviews and record review, the facility failed to ensure coordination of a safe discharge plan for Patient ID #2, who was a cognitively impaired group home patient, intended to return to a residential group home facility at discharge from the ED, but was allowed to leave unaccompanied, in an ambulatory fashion, from the ED lobby. This failed practice could result in serious harm or death to a patient.

Refer to tag 1104.

Based on medical record reviews, document reviews, and interviews, the facility failed to ensure a safe discharge for 1 of 24 patients reviewed (Patient #2). The facility failed to have a comprehensive Emergency Department (ED) policy and procedure, which included visual identification and/or communication of patients who arrived from group home and post-acute settings. The facility failed to ensure coordination of a safe discharge plan for Patient ID #2 who was a cognitively impaired group home patient, who was intended to be returning to residential group home facility, but allowed to leave unaccompanied, in an ambulatory fashion, from the ED lobby.

Findings included:

Telephone interview on 9/24/2024 at 09:35 am with Group Home Manager Staff ID #100. She stated that Patient ID #2 was a 70 year old genleman who had limited cognitive aptitude and psychiatric impairment, who required assistance to meet all activities of daily living, largely due to his cognitive and psychiatric impairments. She confirmed that Patient ID #2 had been brought to Facility's ED department via EMS for syncopal episode on 08/20/2024. She stated the facility never contacted the facility and that no transportation arrangements had been made to ensure his safe return to his residential group home. She stated there had been no contact with facility staff regarding his ED visit, care provided and discharge/follow-up plans.

Medical Record Review of Patient ID #2 with ED Nurse Manager Staff ID #55 on 10/1/2024 at 10:45 AM showed patient ID#2 arrived in the ED 8/20/2024 at 14:44 via ambulance for "syncopal episode." The medical record reflected the patient had altered mental status. Patient left ambulatory from the ED unaccompanied with a disposition of Discharge 8/20/2024 at 7:53 PM. There was no evidence of communication with the group home or any responsible party at discharge.

Medical Record Review of Patient ID#2 with ED Nurse Manager Staff ID #55 on 10/1/2024 at 10:45 AM showed patient ID#2 returned to the ED on 8/21/2024 via ambulance at 19:00 with chief complaint of "never was picked up by group home." The record stated "patient here for heat exposure and dehydration. Patient was seen here yesterday for syncopal episode, left the hospital and spent the day in the parking lot with limited amount of water. Patient denies fever, chest pain, vomiting, diarrhea." Patient ID #2 was admitted to the hospital from the ED on 8/22/2024 with acute kidney injury, rhabdomyolysis and dehydration. Record revealed he was ultimately discharged to the group home facility on 8/24/2024.

Policy Review of Facility Policy titled "Care Coordination Discharge Planning", effective 11/2022, stated "Roles & Responsibilities. Nursing - The bedside nurse is responsible for completing the discharge planning screening of all patients upon admission, ensuring that all necessary patient or caregiver/representative teaching has occurred, completing dishcarge instructions, providing written discharge instructions (including post-acute follow up) and reconciled medication list, and documenting discharge in the medical record. The bedside nurse will collaborate with other members of the multidisciplinary team as needed to ensure patient discharges. The discharging nurse will notify the patient's designated caregiver/representative of the patient's discharge or transfer to another facility as soon as possible, but at a minimum upon issuance of a discharge order by an attending physician. The discharging nurse will provide handoff communication to receiving facilities." The policy stated "4. Documentation. All activities related to discharge planning, patient choice, and referrals are documented in the medical record including screenings, assessments/reassessments, evaluations, and arrangements made for implementation of the discharge plan...."

Interview with ED Nurse Manager Staff ID #55 on 10/1/2024 at 11:15 AM confirmed that Patient ID #2 arrived via EMS from a group home, where he resided after a syncopal episode. Staff ID #55 confirmed there was no documentation or evidence that any coordination of care or communication occurred between group home and facility ED staff when the decision to discharge disposition occurred on 8/20/2024. He confirmed that the ED nursing staff are responsible for this coordination and communication for ED patients. He confirmed there was no electornic medical record identifier of patients who arrived from group home or post-acute settings. He confirmed there was not a specific policy and procedure for ED nurses for ensuring coordination of care and communication for group home patients as a component of a safe discharge plan.