HospitalInspections.org

Based on interviews and record reviews, the facility failed to comply with the Condition of Participation by failing to provide care in a safe setting by failing to secure the safety of patient #1, a vulnerable adult, who was transferred to the Emergency Department (ED) for care of a foot wound, from a local Assisted Living Facility, (ALF) and was not identified as a vulnerable adult by the ED staff, and subsequently was allowed to leave the hospital 7/25/25 without the hospital notifying the ALF facility or the patient's legal court appointed guardian, for 1 of 3 patients reviewed for emergency care which resulted in Patient #1 being reported as missing by the ALF/Guardian on 7/28/25 and subsequently found by Emergency Medical Services (EMS) on the railroad tracks, 0.8 miles from the hospital, unresponsive and septic three days later (Refer to A0144).

Based on interviews, patient medical record reviews and reviews of the hospital's policies and procedures, the facility failed to provide care in a safe setting by failing to secure the safety of patient #1, a vulnerable adult, who was transferred to the Emergency Department (ED) for care of a foot wound, from a local Assisted Living Facility, (ALF). The ED staff failed to identify the patient as a vulnerable adult and subsequently allowed the patient to leave the hospital without the hospital notifying the ALF facility or the patient's legal court appointed guardian, for 1 of 3 patients reviewed for emergency care. (Patient #1)

This standard is not met as evidenced by:

The findings include:

On 8/6/25, a review of patient #1's electronic medical record was conducted. The electronic record revealed a consent for treatment form signed by patient #1 on 7/25/25 at 3:25 PM. A Physician assessment conducted on 7/25/25 at 3:38 PM, and physician orders were placed for a venous doppler study on left foot, laboratory testing and intravenous (IV) insertion. Vital signs were last recorded on 7/26/25 at 1:41 AM. A form titled ED Release and Refusal of Screening/treatment indicating the patient left the ED without notifying staff was dated 7/26/25 at 5:40 AM. There was no further clinical documentation for this visit after this time. A review of the ED log revealed Patient #1 arrived on 7/25/25 at 3:25 PM, via Emergency Medical Services (EMS), ambulance.
Further review of the electronic medical record revealed the patient returned (a second time) to the ED on 7/26/25 at 5:55 PM, per the ED log. Patient #1 was not assessed during this visit as patient #1 walked out of the ED.
Interview with Staff A, Risk Manager Director, who was assisting with the electronic record review, indicated by ED protocol, staff would have called Patient #1's name three times, and if there is "no show" for assessment after three calls, the patient would be removed from the list.

Review of the ED log revealed Patient #1 arrived (a third time) at the ED on 7/26/25 at 7:04 PM. Patient #1 was triaged at 7:26 PM. Documentation signed by Staff Q, Advanced Practice Registered Nurse (APRN) revealed he was evaluated for possible left foot infection. Documentation by Staff Q, ARNP, indicated Patient #1 lived alone and that he was currently working in the area. On this visit, Patient #1 had a wound on the left foot that had clear drainage and a foul odor. IV antibiotics were given. Wound care was performed. Documentation further identified Patient#1 was discharged home.


On 8/6/25 at approximately 12:35 PM an interview was conducted with Staff Registered Nurse (RN) C, Executive Director of Emergency Services. Staff RN C indicated that patient #1 came into the ED via EMS transport. Staff RN C further stated that the ED did not receive any documentation from EMS indicating that the patient was from a long-term care facility or an ALF.

On 8/6/25 at approximately 12:38 PM an interview was conducted with Staff Member D, RN and ED Director, who indicated that Patient #1 came into the ED on Friday (7/25/25) and that the hospital received a telephone call from the ALF on Monday (7/28/25) asking about patient #1's status. Staff RN D further stated that this was the moment that the hospital became aware that Patient #1 was a vulnerable adult and was "missing." The Director of Risk Management indicated that the ALF notified the Police department and was not sure when the Guardian was notified that the patient was missing. The Police department arrived at the hospital requesting video footage which was released to them for viewing on the 28th at 2:57 PM.

The patient was located, 3 days later, on 7/31/25 at 10:54 PM by EMS, on the railroad tracks at the corner of Sycamore Street and St. Johns Street. (Distance from the hospital was clocked by this surveyor's odometer as being 0.8 tenths of a mile. The patient was unresponsive and septic, and emergency transported to Baptist Hospital.

On 8/6/25 at approximately 12:44 PM, Staff L, the Lutheran Services program manager supervisor, was interviewed. She stated Lutheran Services had legal guardianship of Patient #1. She stated that the hospital did not contact Lutheran Services about Patient #1's status. She further stated the (Assisted Living Facility) called Lutheran Services on Monday (7/28/25) to inform them that Patient #1 had been sent to the hospital on Friday (7/25/25) and that he was missing. The Hospital called Lutheran Services on 7/31/25 reporting Patient #1 had been found.

On 8/6/25, a review of patient #1's Letter of Plenary was conducted. This document was dated and signed on 3/4/2023 in the Circuit Court in and for Escambia County, Florida Probate division. The document indicated Lutheran Services Florida, INC. was declared plenary guardian (Absolute Control over all matters) for patient #1.

On 8/6/25 at approximately 4:00 PM an in-person interview was conducted with the ALF's Resident Care Coordinator (RCC) Licensed Practical Nurse (LPN). The RCC indicated that on 7/25/25 she was notified by therapy staff of patient #1-foot wounds. The RCC stated she went to look at the wound and called 911; printed out his transfer packet and gave it to EMS along with a verbal report at the transfer to the hospital. The transfer packet included his face sheet and medication list. The RCC further indicated that she documented in the patients record that she called and left a message on the guardian's voice mail to return her call and sent an EMAIL to the Guardian notifying her of the patient's transfer to the hospital. The RCC indicated that she had called on Monday to the hospital to follow up on his status and learned that he had been discharged, she then proceeded to notify his Guardian, who notified the police department, and when the police arrived here, I gave my statement to them of what occurred. Department of Children and Family was also notified.

On 8/7/25 at approximately 1:15 PM a telephone interview was conducted with the paramedic, for Escambia County EMS. The Paramedic indicated that he remembered picking up Patient #1 from the ALF and stated that he did receive a report from the facility along with a transfer packet. The Paramedic indicated that they always give the packets to the ED during transfer of the patient and a rundown of where they are from and what happened and any information from the transfer trip. The Paramedic stated he did not remember who they gave hand off to, it was either the triage nurse or the paramedic in the lobby, however, did remember giving them the packet from the facility. The Paramedic indicated that patient #1 was very hard of hearing and remembered having to write the questions down on paper for the patient to read. The patient could read the questions and then answered appropriately.

On 8/7/25 at approximately 2:05 PM a telephone interview was conducted with the Escambia County Emergency Medical Technician (EMT). The EMT indicated that she did remember transporting the patient from the ALF to the hospital's ED and giving report that the patient was from an ALF to the charge nurse. The EMT further indicated that the patient was very hard of hearing.

On 8/7/25 at 1:12 PM, an interview was conducted with Staff I, RN. She recalled pulling Patient #1 from the ED lobby area. She could not recall who gave her report. Staff I, RN stated Patient #1 answered all questions appropriately. She further stated she did not get any information indicating Patient #1 came from a facility (Assisted Living facility). She stated, remembering the paramedic telling her that he wrote down questions for him [the resident] and he could answer them.


On 8/7/25 at 3:00 PM, Patients #1's hard copy chart was requested for review. The following forms (4 pages) were a part of the hard copy record and had not yet been uploaded into the electronic record:
1. Yellow-colored EMS form dated 7/25/25 nature of call as dispatched: interfacility location of call 4916 Mobile Hwy apt 4. Chief complaint: foot edema/pain. Past medical history COPD, HOH. Alert. Left foot was swollen, skin appeared to be sloughing off toes and plantar side of foot. Foot appeared saturated, no bleeding noted, patient complaint pain 3/10. Staff stated left shoe was soaked.
2. Emergency Department Release and Refusal of Screening/treatment form dated 7/26/25 at 0540. The form was checked under "patient left the Emergency Department without notifying staff.
3. Face sheet for patient #1 identifying [the name of the Assisted Living Facility] with the address and telephone number listed. Under personal contacts noted Lutheran Services with a telephone number, duties: responsible party. Under care team read: left foot edema and weeping, several small areas open on toes. Surrounding skin white in color. Shoe was saturated. Resident stated that they had some pain and stiffness while ambulating.
4. The current Physician's orders as of 25 July 2025 with the resident's ALF admission date, full code status, the patient's date of birth and list of current medications. Another order dated October 29, 2024, under treatment indicates that the Guardian or family should be notified of medication refusals.
These 4 forms contained Patient #1 hospital medical record labels containing patient #1's name, date of birth, medical record, and other coding.
On the back of medication list form were hand-written questions: "What hospital? Does it hurt" "How bad 1-10?" "How did your foot get wet?" "What year is it now?" "How long has your foot been like that?" On this same page on right top is written "N/A and 0154". The back contains the patient's label on right upper side.

Review of the following hospital's policies and procedures revealed:

"Discharge Planning", effective date June 2025. Bullet 8. Discharge instructions shall be given to the patient/family in a manner that the patient/family can understand. 17. All discharge plans shall be reviewed with the patient and/or family member before the patient is discharged from the hospital to ensure that the discharge plan meets the needs of the patient.

"Treating a Personal Representative of the Individual as the Individual", effective date December 2024. Statement of purpose: to give standards on dealing with a personal representative of an individual to ensure BHC is compliance with applicable laws and regulations. Policy states 1. If, under applicable law, a person has authority to act on behalf of an individual who is an adult or an Emancipated Minor in making decisions related to health care, BHC will treat such person as a personal representative with respect to protected health information (PHI) relevant to such personal representative.

"Triage and Emergency Medical Screening for the Non-Psychiatric Patient", effective date May 2025. After the Medical Screening Evaluation (MSE) is completed: the Qualified Medical Personnel (QMP) will inform the patient and /or family that the patient doesn't not have an Emergency Medical Condition.

Based on interviews and record reviews the facility failed to ensure the safe welfare of patient #1 of 3 sampled for Emergency Care Services. Patient #1, a vulnerable adult, who was transferred to the Emergency Department (ED) for care of a foot wound, from a local Assisted Living Facility, (ALF) was not identified as a vulnerable adult by the ED staff, and subsequently was allowed to leave the hospital 7/25/25 without the hospital notifying the ALF facility or the patient's legal court appointed guardian, which resulted in Patient #1 being reported as missing by the ALF/Guardian on 7/28/25 and subsequently found by Emergency Medical Services (EMS) on the railroad tracks, 0.8 miles from the hospital, unresponsive and septic three days later.

The findings include:

On 8/6/25, a review of patient #1's electronic medical record was conducted. The electronic record revealed a consent for treatment form signed by patient #1 on 7/25/25 at 3:25 PM. A Physician assessment conducted on 7/25/25 at 3:38 PM, and physician orders were placed for a venous doppler study on left foot, laboratory testing and intravenous (IV) insertion. Vital signs were last recorded on 7/26/25 at 1:41 AM. A form titled ED Release and Refusal of Screening/treatment indicating the patient left the ED without notifying staff was dated 7/26/25 at 5:40 AM. There was no further clinical documentation for this visit after this time. A review of the ED log revealed Patient #1 arrived on 7/25/25 at 3:25 PM, via Emergency Medical Services (EMS), ambulance.
Further review of the electronic medical record revealed the patient returned (a second time) to the ED on 7/26/25 at 5:55 PM, per the ED log. Patient #1 was not assessed during this visit as patient #1 walked out of the ED.
Interview with Staff A, Risk Manager Director, who was assisting with the electronic record review, indicated by ED protocol, staff would have called Patient #1's name three times, and if there is "no show" for assessment after three calls, the patient would be removed from the list.

Review of the ED log revealed Patient #1 arrived (a third time) at the ED on 7/26/25 at 7:04 PM. Patient #1 was triaged at 7:26 PM. Documentation signed by Staff Q, Advanced Practice Registered Nurse (APRN) revealed he was evaluated for possible left foot infection. Documentation by Staff Q, ARNP, indicated Patient #1 lived alone and that he was currently working in the area. On this visit, Patient #1 had a wound on the left foot that had clear drainage and a foul odor. IV antibiotics were given. Wound care was performed. Documentation further identified Patient#1 was discharged home.


On 8/6/25 at approximately 12:35 PM an interview was conducted with Staff Registered Nurse (RN) C, Executive Director of Emergency Services. Staff RN C indicated that patient #1 came into the ED via EMS transport. Staff RN C further stated that the ED did not receive any documentation from EMS indicating that the patient was from a long-term care facility or an ALF.

On 8/6/25 at approximately 12:38 PM an interview was conducted with Staff Member D, RN and ED Director, who indicated that Patient #1 came into the ED on Friday (7/25/25) and that the hospital received a telephone call from the ALF on Monday (7/28/25) asking about patient #1's status. Staff RN D further stated that this was the moment that the hospital became aware that Patient #1 was a vulnerable adult and was "missing." The Director of Risk Management indicated that the ALF notified the Police department and was not sure when the Guardian was notified that the patient was missing. The Police department arrived at the hospital requesting video footage which was released to them for viewing on the 28th at 2:57 PM.

The patient was located, 3 days later, on 7/31/25 at 10:54 PM by EMS, on the railroad tracks at the corner of Sycamore Street and St. Johns Street. (Distance from the hospital was clocked by this surveyor's odometer as being 0.8 tenths of a mile. The patient was unresponsive and septic, and emergency transported to Baptist Hospital.

On 8/6/25 at approximately 12:44 PM, Staff L, the Lutheran Services program manager supervisor, was interviewed. She stated Lutheran Services had legal guardianship of Patient #1. She stated that the hospital did not contact Lutheran Services about Patient #1's status. She further stated the (Assisted Living Facility) called Lutheran Services on Monday (7/28/25) to inform them that Patient #1 had been sent to the hospital on Friday (7/25/25) and that he was missing. The Hospital called Lutheran Services on 7/31/25 reporting Patient #1 had been found.

On 8/6/25, a review of patient #1's Letter of Plenary was conducted. This document was dated and signed on 3/4/2023 in the Circuit Court in and for Escambia County, Florida Probate division. The document indicated Lutheran Services Florida, INC. was declared plenary guardian (Absolute Control over all matters) for patient #1.

On 8/6/25 at approximately 4:00 PM an in-person interview was conducted with the ALF's Resident Care Coordinator (RCC) Licensed Practical Nurse (LPN). The RCC indicated that on 7/25/25 she was notified by therapy staff of patient #1-foot wounds. The RCC stated she went to look at the wound and called 911; printed out his transfer packet and gave it to EMS along with a verbal report at the transfer to the hospital. The transfer packet included his face sheet and medication list. The RCC further indicated that she documented in the patients record that she called and left a message on the guardian's voice mail to return her call and sent an EMAIL to the Guardian notifying her of the patient's transfer to the hospital. The RCC indicated that she had called on Monday to the hospital to follow up on his status and learned that he had been discharged, she then proceeded to notify his Guardian, who notified the police department, and when the police arrived here, I gave my statement to them of what occurred. Department of Children and Family was also notified.

On 8/7/25 at approximately 1:15 PM a telephone interview was conducted with the paramedic, for Escambia County EMS. The Paramedic indicated that he remembered picking up Patient #1 from the ALF and stated that he did receive a report from the facility along with a transfer packet. The Paramedic indicated that they always give the packets to the ED during transfer of the patient and a rundown of where they are from and what happened and any information from the transfer trip. The Paramedic stated he did not remember who they gave hand off to, it was either the triage nurse or the paramedic in the lobby, however, did remember giving them the packet from the facility. The Paramedic indicated that patient #1 was very hard of hearing and remembered having to write the questions down on paper for the patient to read. The patient could read the questions and then answered appropriately.

On 8/7/25 at approximately 2:05 PM a telephone interview was conducted with the Escambia County Emergency Medical Technician (EMT). The EMT indicated that she did remember transporting the patient from the ALF to the hospital's ED and giving report that the patient was from an ALF to the charge nurse. The EMT further indicated that the patient was very hard of hearing.

On 8/7/25 at 1:12 PM, an interview was conducted with Staff I, RN. She recalled pulling Patient #1 from the ED lobby area. She could not recall who gave her report. Staff I, RN stated Patient #1 answered all questions appropriately. She further stated she did not get any information indicating Patient #1 came from a facility (Assisted Living facility). She stated, remembering the paramedic telling her that he wrote down questions for him [the resident] and he could answer them.


On 8/7/25 at 3:00 PM, Patients #1's hard copy chart was requested for review. The following forms (4 pages) were a part of the hard copy record and had not yet been uploaded into the electronic record:
1. Yellow-colored EMS form dated 7/25/25 nature of call as dispatched: interfacility location of call 4916 Mobile Hwy apt 4. Chief complaint: foot edema/pain. Past medical history COPD, HOH. Alert. Left foot was swollen, skin appeared to be sloughing off toes and plantar side of foot. Foot appeared saturated, no bleeding noted, patient complaint pain 3/10. Staff stated left shoe was soaked.
2. Emergency Department Release and Refusal of Screening/treatment form dated 7/26/25 at 0540. The form was checked under "patient left the Emergency Department without notifying staff.
3. Face sheet for patient #1 identifying [the name of the Assisted Living Facility] with the address and telephone number listed. Under personal contacts noted Lutheran Services with a telephone number, duties: responsible party. Under care team read: left foot edema and weeping, several small areas open on toes. Surrounding skin white in color. Shoe was saturated. Resident stated that they had some pain and stiffness while ambulating.
4. The current Physician's orders as of 25 July 2025 with the resident's ALF admission date, full code status, the patient's date of birth and list of current medications. Another order dated October 29, 2024, under treatment indicates that the Guardian or family should be notified of medication refusals.
These 4 forms contained Patient #1 hospital medical record labels containing patient #1's name, date of birth, medical record, and other coding.
On the back of medication list form were hand-written questions: "What hospital? Does it hurt" "How bad 1-10?" "How did your foot get wet?" "What year is it now?" "How long has your foot been like that?" On this same page on right top is written "N/A and 0154". The back contains the patient's label on right upper side.

Review of the following hospital's policies and procedures revealed:

"Discharge Planning", effective date June 2025. Bullet 8. Discharge instructions shall be given to the patient/family in a manner that the patient/family can understand. 17. All discharge plans shall be reviewed with the patient and/or family member before the patient is discharged from the hospital to ensure that the discharge plan meets the needs of the patient.

"Treating a Personal Representative of the Individual as the Individual", effective date December 2024. Statement of purpose: to give standards on dealing with a personal representative of an individual to ensure BHC is compliance with applicable laws and regulations. Policy states 1. If, under applicable law, a person has authority to act on behalf of an individual who is an adult or an Emancipated Minor in making decisions related to health care, BHC will treat such person as a personal representative with respect to protected health information (PHI) relevant to such personal representative.

"Triage and Emergency Medical Screening for the Non-Psychiatric Patient", effective date May 2025. After the Medical Screening Evaluation (MSE) is completed: the Qualified Medical Personnel (QMP) will inform the patient and /or family that the patient doesn't not have an Emergency Medical Condition.

Based on interviews, patient medical record reviews and reviews of the hospital's policies and procedures, the facility failed to provide care in a safe setting by failing to secure the safety of patient #1, a vulnerable adult, who was transferred to the Emergency Department (ED) for care of a foot wound, from a local Assisted Living Facility, (ALF). The ED staff failed to identify the patient as a vulnerable adult and subsequently allowed the patient to leave the hospital without the hospital notifying the ALF facility or the patient's legal court appointed guardian, for 1 of 3 patients reviewed for emergency care. (Patient #1)

The findings include:

On 8/6/25, a review of patient #1's electronic medical record was conducted. The electronic record revealed a consent for treatment form signed by patient #1 on 7/25/25 at 3:25 PM. A Physician assessment conducted on 7/25/25 at 3:38 PM, and physician orders were placed for a venous doppler study on left foot, laboratory testing and intravenous (IV) insertion. Vital signs were last recorded on 7/26/25 at 1:41 AM. A form titled ED Release and Refusal of Screening/treatment indicating the patient left the ED without notifying staff was dated 7/26/25 at 5:40 AM. There was no further clinical documentation for this visit after this time. A review of the ED log revealed Patient #1 arrived on 7/25/25 at 3:25 PM, via Emergency Medical Services (EMS), ambulance.
Further review of the electronic medical record revealed the patient returned (a second time) to the ED on 7/26/25 at 5:55 PM, per the ED log. Patient #1 was not assessed during this visit as patient #1 walked out of the ED.
Interview with Staff A, Risk Manager Director, who was assisting with the electronic record review, indicated by ED protocol, staff would have called Patient #1's name three times, and if there is "no show" for assessment after three calls, the patient would be removed from the list.

Review of the ED log revealed Patient #1 arrived (a third time) at the ED on 7/26/25 at 7:04 PM. Patient #1 was triaged at 7:26 PM. Documentation signed by Staff Q, Advanced Practice Registered Nurse (APRN) revealed he was evaluated for possible left foot infection. Documentation by Staff Q, ARNP, indicated Patient #1 lived alone and that he was currently working in the area. On this visit, Patient #1 had a wound on the left foot that had clear drainage and a foul odor. IV antibiotics were given. Wound care was performed. Documentation further identified Patient#1 was discharged home.

On 8/6/25 at approximately 12:35 PM an interview was conducted with Staff Registered Nurse (RN) C, Executive Director of Emergency Services. Staff RN C indicated that patient #1 came into the ED via EMS transport. Staff RN C further stated that the ED did not receive any documentation from EMS indicating that the patient was from a long-term care facility or an ALF.

On 8/6/25 at approximately 12:38 PM an interview was conducted with Staff Member D, RN and ED Director, who indicated that Patient #1 came into the ED on Friday (7/25/25) and that the hospital received a telephone call from the ALF on Monday (7/28/25) asking about patient #1's status. Staff RN D further stated that this was the moment that the hospital became aware that Patient #1 was a vulnerable adult and was "missing." The Director of Risk Management indicated that the ALF notified the Police department and was not sure when the Guardian was notified that the patient was missing. The Police department arrived at the hospital requesting video footage which was released to them for viewing on the 28th at 2:57 PM.

The patient was located, 3 days later, on 7/31/25 at 10:54 PM by EMS, on the railroad tracks at the corner of Sycamore Street and St. Johns Street. (Distance from the hospital was clocked by this surveyor's odometer as being 0.8 tenths of a mile. The patient was unresponsive and septic, and emergency transported to Baptist Hospital.

On 8/6/25 at approximately 12:44 PM, Staff L, the Lutheran Services program manager supervisor, was interviewed. She stated Lutheran Services had legal guardianship of Patient #1. She stated that the hospital did not contact Lutheran Services about Patient #1's status. She further stated the (Assisted Living Facility) called Lutheran Services on Monday (7/28/25) to inform them that Patient #1 had been sent to the hospital on Friday (7/25/25) and that he was missing. The Hospital called Lutheran Services on 7/31/25 reporting Patient #1 had been found.

On 8/6/25, a review of patient #1's Letter of Plenary was conducted. This document was dated and signed on 3/4/2023 in the Circuit Court in and for Escambia County, Florida Probate division. The document indicated Lutheran Services Florida, INC. was declared plenary guardian (Absolute Control over all matters) for patient #1.

On 8/6/25 at approximately 4:00 PM an in-person interview was conducted with the ALF's Resident Care Coordinator (RCC) Licensed Practical Nurse (LPN). The RCC indicated that on 7/25/25 she was notified by therapy staff of patient #1-foot wounds. The RCC stated she went to look at the wound and called 911; printed out his transfer packet and gave it to EMS along with a verbal report at the transfer to the hospital. The transfer packet included his face sheet and medication list. The RCC further indicated that she documented in the patients record that she called and left a message on the guardian's voice mail to return her call and sent an EMAIL to the Guardian notifying her of the patient's transfer to the hospital. The RCC indicated that she had called on Monday to the hospital to follow up on his status and learned that he had been discharged, she then proceeded to notify his Guardian, who notified the police department, and when the police arrived here, I gave my statement to them of what occurred. Department of Children and Family was also notified.

On 8/7/25 at approximately 1:15 PM a telephone interview was conducted with the paramedic, for Escambia County EMS. The Paramedic indicated that he remembered picking up Patient #1 from the ALF and stated that he did receive a report from the facility along with a transfer packet. The Paramedic indicated that they always give the packets to the ED during transfer of the patient and a rundown of where they are from and what happened and any information from the transfer trip. The Paramedic stated he did not remember who they gave hand off to, it was either the triage nurse or the paramedic in the lobby, however, did remember giving them the packet from the facility. The Paramedic indicated that patient #1 was very hard of hearing and remembered having to write the questions down on paper for the patient to read. The patient could read the questions and then answered appropriately.

On 8/7/25 at approximately 2:05 PM a telephone interview was conducted with the Escambia County Emergency Medical Technician (EMT). The EMT indicated that she did remember transporting the patient from the ALF to the hospital's ED and giving report that the patient was from an ALF to the charge nurse. The EMT further indicated that the patient was very hard of hearing.

On 8/7/25 at 1:12 PM, an interview was conducted with Staff I, RN. She recalled pulling Patient #1 from the ED lobby area. She could not recall who gave her report. Staff I, RN stated Patient #1 answered all questions appropriately. She further stated she did not get any information indicating Patient #1 came from a facility (Assisted Living facility). She stated, remembering the paramedic telling her that he wrote down questions for him [the resident] and he could answer them.


On 8/7/25 at 3:00 PM, Patients #1's hard copy chart was requested for review. The following forms (4 pages) were a part of the hard copy record and had not yet been uploaded into the electronic record:
1. Yellow-colored EMS form dated 7/25/25 nature of call as dispatched: interfacility location of call 4916 Mobile Hwy apt 4. Chief complaint: foot edema/pain. Past medical history COPD, HOH. Alert. Left foot was swollen, skin appeared to be sloughing off toes and plantar side of foot. Foot appeared saturated, no bleeding noted, patient complaint pain 3/10. Staff stated left shoe was soaked.
2. Emergency Department Release and Refusal of Screening/treatment form dated 7/26/25 at 0540. The form was checked under "patient left the Emergency Department without notifying staff.
3. Face sheet for patient #1 identifying [the name of the Assisted Living Facility] with the address and telephone number listed. Under personal contacts noted Lutheran Services with a telephone number, duties: responsible party. Under care team read: left foot edema and weeping, several small areas open on toes. Surrounding skin white in color. Shoe was saturated. Resident stated that they had some pain and stiffness while ambulating.
4. The current Physician's orders as of 25 July 2025 with the resident's ALF admission date, full code status, the patient's date of birth and list of current medications. Another order dated October 29, 2024, under treatment indicates that the Guardian or family should be notified of medication refusals.
These 4 forms contained Patient #1 hospital medical record labels containing patient #1's name, date of birth, medical record, and other coding.
On the back of medication list form were hand-written questions: "What hospital? Does it hurt" "How bad 1-10?" "How did your foot get wet?" "What year is it now?" "How long has your foot been like that?" On this same page on right top is written "N/A and 0154". The back contains the patient's label on right upper side.

Review of the following hospital's policies and procedures revealed:

"Discharge Planning", effective date June 2025. Bullet 8. Discharge instructions shall be given to the patient/family in a manner that the patient/family can understand. 17. All discharge plans shall be reviewed with the patient and/or family member before the patient is discharged from the hospital to ensure that the discharge plan meets the needs of the patient.

"Treating a Personal Representative of the Individual as the Individual", effective date December 2024. Statement of purpose: to give standards on dealing with a personal representative of an individual to ensure BHC is compliance with applicable laws and regulations. Policy states 1. If, under applicable law, a person has authority to act on behalf of an individual who is an adult or an Emancipated Minor in making decisions related to health care, BHC will treat such person as a personal representative with respect to protected health information (PHI) relevant to such personal representative.

"Triage and Emergency Medical Screening for the Non-Psychiatric Patient", effective date May 2025. After the Medical Screening Evaluation (MSE) is completed: the Qualified Medical Personnel (QMP) will inform the patient and /or family that the patient doesn't not have an Emergency Medical Condition.