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Based on review of medical records, staff interviews, policy titled "Discharge of Patients," and discharge protocol, it was determined that the nursing staff failed to be readily available to remove the peripheral Intravenous (IV) line (a thin, flexible tube used to administer fluids, medications, and blood products directly into a patient's bloodstream) when one patient (P) (P#1) of six sampled patients was discharged from the Emergency Department with a peripheral IV in place.


Findings included:


Review of medical record revealed P#1 was brought into the emergency department (ED) by ambulance on 7/15/2025 at 7:37 p.m. with a chief complaint of Shortness of Breath on and off for one week.


Upon triage, P#1 was assigned an ESI (emergency severity index) of 3. Provider orders were placed at 7:48 p.m. for Albuterol 2.5mg nebulizer (a respiratory treatment to allow the patient to breathe easier), and blood drawn for lab. These labs were for Troponin I and BNP (a marker for heart attack), Atrovent nebulizer solution and Solumedrol (a steroid medication) Intravenously (IV), Chest Xray (imaging to see if there was fluid in the lungs), and EKG (heart study tracing). At 11:39 p.m. the provider entered a discharge order for P #1. At 11:47 p.m. P#1 was reassessed and was stable. At 12:12 a.m. Registered Nurse (RN) GG administered a medication to P#1. At 12:46 a.m. ED personnel requested ambulance transport for P#1. At 6:03 a.m. RN GG documented vital signs for P#1. At 6:36 a.m. RN GG described P#1's condition at departure as stable. P#1 was transported by stretcher to the ambulance. Continue review of nursing flowsheets included an IV removal date and time as 7/16/25 at 6:37 a.m. and the "Removal Reason" stated: Removed by patient.


An interview with the ED Nurse Educator (RN AA) took place on 8/4/25 at 2:50 p.m. in the conference room. RN AA said she was aware that the family of P#1 called the ED in relation to the patient that went home without belongings. RN AA said she understood that the Nurse Manager back then referred the call to Charge Nurse BB to handle as the family was very angry. RN AA said Charge Nurse BB showed her P#1's clothes packed in a bag and the clothes appeared wet and soiled. RN AA said she believed based on the appearance of the patient's clothes that staff did not change her but rather allowed P#1 to go home in the hospital gown. RN AA said that was not uncommon for patients to get discharged from the ED in hospital gowns instead of their own clothes and usually these patients were elderly patients, and nursing home patients. RN AA explained in case patients left without their belongings, the facility would call and arrange with the patient's family to have the items delivered, or some families would come to the ED to get the items. RN AA said the items were kept in a safe or locker with security until returned.


An interview with the ED Charge Nurse BB took place on 8/4/25 at 3:10 p.m. in the conference room. Charge RN BB said he never met the patient (P#1) but spoke with the patient's daughter on the phone that morning. He said the family called the ED and the Nurse Manager (no longer worked at the facility) transferred the call to him. RN BB said the family was very upset that P#1 came back from the facility not in her own clothes. RN BB said he was trying to explain to the daughter that possibly the patient was sleepy since she was being transferred early but she did not want to hear it. Charge Nurse BB said P#1's daughter called a second time approximately two hours later and this time she reported that she just found 'needle' stuck in her mother's arm and it was a hospital IV. Charge Nurse BB said that never happened in a patient being transported by ambulance. Charge Nurse BB said he immediately reported the incident to the then Nurse Manager. RN BB said he was aware that the Nurse Manager dispatched two nurses from the ED to P#1's home to deliver the clothes and to remove the IV. RN BB said he was working in the ED since 2018, and that was the first time he knew of such an incident. Patients are usually called and asked to return to the ED to pick up any left belongings.


An interview with RN CC took place on 8/4/25 at 3:45 p.m. in the conference room. RN CC recalled that she came in to work on the morning P#1 was discharged. RN CC said the Charge Nurse at the time asked her to go to a patient's home to remove an IV that was left in the patients arm and to take the patient her clothes because the patient was discharged in hospital gown. RN CC said because it was a private home, the Nurse Manager sent a male nurse with her. RN CC said when they got to the doorstep, P#1's daughter showed them the IV and said P#1 just removed it. RN CC said they still went inside the house to inspect the IV site, cleaned it and covered it with gauze. RN CC said there was no blood, no leaking of any kind. RN CC recalled that the daughter was very upset. RN CC collected the IV catheter and disposed of it in the ED sharps container.


An interview with RN DD took place on 8/4/25 at 3:55 p.m. in the conference room. RN DD explained the discharge process and stated that first and foremost, the staff must know the patient had a safe place to go at the moment of discharge. He further indicated that once the provider and case worker cleared the patient, the nurse should make sure all devices were removed, in particular IV devices, indwelling catheter unless these devices were ordered permanently (i.e. Port for dialysis). RN DD said that was standard practice to also make sure patients had their belongings at discharge. RN DD said he did not take care of P#1; he had never met her before. RN DD recalled that the Nurse Manager (who no longer worked for the organization) approached him the morning that P#1 was discharged and asked him to go with RN CC to the patient's home to remove the IV. The Nurse Manager told him that the patient had been discharged home earlier in the morning with her IV intact. RN DD recalled that when he and RN CC arrived to the home, the patient had already removed the IV. RN DD and RN CC assessed the patient to make sure the IV site was clean; they wiped it with alcohol and covered it with gauze. RN DD said he remained skeptical because the site did not look fresh at all, he said he could even see the needle mark in the patient's arm. RN DD said the patient's daughter was more upset because the ambulance did not return the patient's clothes and P#1 was discharged in the hospital gown.


An interview with ED Nurse Director/RN FF took place on 8/5/25 at 10:45 a.m. in the conference room. Director FF said he was aware of the incident with P#1. He said it was reported to him the same day. Director FF said he asked the nurse for an explanation as to how the patient was allowed to go home with the IV. Director FF said the nurse (RN GG) said he was busy with two other very critical patients that night. He said they called for transport sometime before midnight and the ambulance did not come until 6:30 a.m. or so. He was not in the room when EMS removed the patient from the room. Director FF said the facility had a policy and protocol that includes safe body inspection when patients were being discharged. Director FF said they were able to dispatch two nurses to the patient's home to remove the IV without delay. Director FF said he also became aware that the patient was discharged in hospital gown and the family was very upset about that. Staff delivered her clothes to the family.


A phone interview with RN GG took place on 8/6/25 at 11:15 a.m. RN GG stated he was the nurse assigned to P#1 when she presented in the ED. RN GG said he was a night shift nurse. RN GG said P#1 came for respiratory distress and was stable after a couple respiratory therapy interventions. RN GG explained that he was busy with two patients that were intubated when he had P#1. RN GG said after the doctor put the order to discharge P#1; they requested an ambulance to take the patient home. He said it could take some time before an ambulance arrived especially if the system was getting calls for more critical patients. He said because he was busy with two critical patients, another nurse was keeping eye on P#1 for him. He said P#1 went to sleep and he put the discharge papers in the room waiting for the ambulance to arrive before he disconnected the peripheral IV. RN GG said the ambulance arrived around 6:30 a.m. and they went to the patient's room and initiated transport without notifying him. RN GG said P#1 was covered with a blanket and EMS did not uncover her; and as a result, she was discharged with the IV. RN GG said the EMS staff did not take the patient's clothes with them. He said it was later when he went to the room, he realized they had already taken the patient home. He said he returned the patient's bag where they kept her clothes to the Nurse Manager. RN GG said he did not remove the IV because he had not been notified that EMS had arrived to transport the patient. He explained that should not happen because they had protocol to do a final assessment and remove any peripheral IV unless the doctor ordered to keep the IV for medication administration at home.


Review of policy titled " Discharge of Patients," effective date 05/17/2023 revealed the purpose was to ensure a smooth and safe discharge process for patients, minimize risks, prevent unplanned readmissions, and maintain compliance with regulatory guidelines. The policy stated that patients in an admitted or observation status were to be discharged on the order of a physician or authorized practitioner. Further review of the procedures indicated the following:
1. The attending physician or designee was responsible for discharging the patient, performing a medication reconciliation, and providing a summary of the patient's medical condition and care plan.
2. All patients received written and verbal post-discharge care instructions, including prescriptions, supplies, and follow up appointment details, through the EeMR After Visit Summary (AVS).
3. Patients who were driving themselves to their destination after discharge should not have narcotic medications administered within 4 hours of discharge.
4. Responsibilities of the nursing staff at discharge included:
a. Inventory and pack personal belongings and retrieve any valuables from public safety and/or personal medications stored in the pharmacy or on the unit.
b. Review and complete the discharge navigator checklist and finalize all care plan statuses
i. In the event the patient needed to be discharged with IV access, an MD order was required with the appropriate indication.
c. Provide and explain discharge instructions, including discharge prescriptions and supplies/DME and any follow up appointment details.
d. Return hospital issued medications, supplies, and equipment for credit.
e. Complete all required documentation, both electronic and on paper as applicable and discharge the patient from EeMR once the patient was physically out of the unit. A manual discharge required the completion of the date, time, and discharge disposition.
i. If transport was requested at discharge, the discharge disposition must be entered prior to requesting transport.
f. Prepare any paper documents to be included in the patient's medical record for pick-up by medical records personnel.
5. The necessary means of transportation (wheelchair, caddy, or stretcher) will be provided.
6. All patients were escorted to the hospital exit or to their personal vehicle and assisted into the vehicle which will take the patient to their destination.
Discharge Criteria:
1. Patients discharged from the facilities had to meet the following criteria:
a. Blood pressure stable for patient per baseline within 4 hours prior to discharge.
b. Temperature less than 38 degrees centigrade within 4 hours prior to discharge.
c. Heart rate stable or within baseline within 4 hours prior to discharge.
d. No complaints of shortness of breath exceeding baseline.
e. No significant wound drainage if applicable.
f. Pain and nausea were controlled to patient's level of satisfaction.
g. SpO2 or respiratory rate at patient's baseline.
The policy revealed if the patient demonstrated variation from the above criteria, the physician must be notified prior to patient discharge and response noted in the patient's medical record.
If a patient was discharged by ambulance, the ambulance personnel was to come to the patient's room to transport the patient.


Review of facility document titled "Discharge Protocol," revised date: 5/19/2025 indicated staff were to retrieve patient's valuables from facility's safe and review each item with the patient. Then obtain the patient's signature indicating that the patient's belongings were returned to the patient.
The protocol indicated that the nurse was to go over the discharge paperwork with the patient and/or family member and allowed opportunities to ask questions. Then the nurse was to perform hand hygiene, put on the necessary PPE such as gloves, perform a physical assessment and obtain vital signs. The document stated that the nurse was to ensure the removal of all devices discontinued by the practitioner and such devices included IV catheters, indwelling urinary catheters and drains to avoid potential complications. The protocol further indicated that the nurse helped the patient dress as needed.