Memorialcare Saddleback Medical Center

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure one of eight sampled patients (Patient 1) was discharged in accordance with the physician’s discharge order and to an appropriate post-hospital level of care. Patient 1 was transferred from Hospital 2 to Hospital 1 for medical treatment. Following medical clearance, the physician ordered discharge back to Hospital 2. However, there was no bed hold in place, a new intake evaluation was required for readmission, and Social Worker 1 did not complete the intake process or notify the physician that the patient could not return as ordered. Despite the absence of an accepting psychiatric facility and without notifying the physician that the ordered discharge disposition could not be carried out, Patient 1 was discharged to self-care and transported by ridesharing to Hospital 2 to retrieve their personal belongings. Upon arrival at Hospital 2, the staff reported that Patient 1 appeared disheveled, confused, disorganized, had slurred speech and difficulty keeping their eyes open, and reported that they had been rushed out of the hospital. Due to concerns regarding the patient’s condition, Hospital 2 staff contacted 911, and Patient 1 was transported to the emergency department for further evaluation. These failures resulted in Patient 1 not being discharged as ordered, interruption of the patient’s ongoing care needs, and an emergency transfer for further medical evaluation. The failures had the potential to delay access to appropriate follow-up services, worsen the patient’s condition, and place the patient at risk for harm. Findings: During a review of the hospital’s P&P titled “Admission/Discharge/Transfer,” dated 1/31/24, the P&P showed the following: - Discharge is the formal release by the hospital, upon a physician order, of an inpatient/outpatient. This can be to the following facilities: psychiatric hospital, acute rehabilitation, or home. - Discharge planning begins on admission and is a continuous process utilizing an interdisciplinary approach to facilitate and ensure an appropriate, timely, and safe discharge plan, in accordance with the patient needs and preferences. - Prior to discharge, the Care Manager/Discharge Planner ensures that the appropriate facility has accepted the patient and needed resources can be provided. Facility referrals, requests for procurement of services and supplies, and communication of pertinent clinical information are sent. - Patients are discharged when the physician determines that the patient has met the predetermined criteria for discharge or transfer from acute care (and prior appropriate arrangements have been made to continue care at home, long-term care, skilled nursing facility, or acute care facility). - Upon determination that a patient requires acute psychiatric care, the RN/case manager ensures physician order for discharge. The RN/case manager/social worker verifies with the Psychiatric Evaluation Team transportation arrangements and/or arranges as necessary. During a review of Patient 1’s medical record on 6/9/26, the medical record showed Patient 1 was admitted to Hospital 1 on 4/15/26 and discharged on 4/17/26 at 1739 hours. During a review of the ED Provider Notes dated 4/15/26 at 1722 hours, the ED Provider Notes showed Patient 1 was brought to the emergency department by ambulance from Hospital 2 for altered mental status. During a review of Patient 1’s H&P examination dated 4/15/26 at 2254 hours, the H&P showed Patient 1 presented to Hospital 1 with a chief complaint of altered level of consciousness. The patient was brought from Hospital 2 where the patient had been voluntarily admitted for suicidal ideation with a plan to slit their wrists. During a review of the Hospitalist Medicine Progress Note dated 4/17/26 at 1455 hours, the Hospitalist Medicine Progress Note showed Patient 1 had been voluntarily admitted to Hospital 2 for suicidal ideation with a plan to slit their wrists. The note showed Patient 1 was found with altered mental status and demonstrated mild improvement following Narcan (a medication used to quickly reverse effects of opioids [pain relievers] administration). The physician documented that Patient 1 was medically cleared and planned for discharge back to Hospital 2. During a review of Patient 1’s physician order dated 4/17/26 at 1515 hours, the physician’s order showed Patient 1 was to be discharged back to Hospital 2, from which he had been transferred. During a review of Patient 1’s Social Work progress note dated 4/17/26 at 1122 hours, the Social Work progress note showed Social Worker 1 spoke with the staff at Hospital 2 and was informed that Patient 1 did not have a bed hold and a new intake evaluation was required for readmission once Patient 1 was medically cleared for discharge. During a review of Patient 1’s Interdisciplinary Discharge Plan Report dated the Interdisciplinary Discharge Plan Report showed the patient’s discharge goals were to return to Hospital 2 to continue inpatient therapy. During a review of Patient 1’s Social Work progress note dated 4/17/26 at 1645 hours, the Social Work progress note showed Social Worker 1 met with Patient 1 and discussed that Hospital 2 did not hold a bed for the patient but the patient was ready for discharge and Hospital 1 would arrange for transportation for them to retrieve their belongings at Hospital 2. During a review of Patient 1’s medical record, the medical records failed to show documentation that the physician was notified that Patient 1 could not return to Hospital 2 as ordered due to the absence of a bed hold and the need for a new intake evaluation. Additionally, Patient 1’s medical record failed to show evidence that Hospital 2 had accepted Patient 1 for readmission prior to discharge. During a review of Patient 1’s nursing discharge note dated 4/17/26 at 1740 hours, Patient 1’s nursing discharge note showed the discharge disposition was documented as Hospital 2 per the physician. However, the note also showed Patient 1 was transported by ridesharing service to Hospital 2 to retrieve personal belongings, rather than being transferred to an accepting psychiatric facility as ordered. During a concurrent interview and Patient 1’s medical record review on 6/10/26 at 1111 hours, with the Executive Director of Acute Care Services, Director of Emergency Services, and Social Worker 2, who verified the findings. They stated Patient 1 had a physician order to discharge back to Hospital 2; however, Social Worker 1 discharged the patient to self-care, contrary to the physician’s discharge order. They stated Social Worker 1 had been informed that no bed hold was in place and that a new intake evaluation was required for the patient to return to Hospital 2. They confirmed Patient 1’s medical record contained no evidence that the physician was notified that Patient 1 could not return to Hospital 2, as ordered. They stated the appropriate action would have been to notify the physician and initiate the intake evaluation process. During a telephone interview on 6/10/26 at 1212 hours, with staff at Hospital 2 who reported that Patient 1 was dropped off by a ridesharing service. Staff reported that Patient 1 appeared disheveled, confused, disorganized, had slurred speech and difficulty keeping their eyes open, and reported that they had been rushed out of the hospital. The psychiatric hospital staff stated that due to concerns regarding Patient 1’s condition, they contacted 911 and Patient 1 was transported to the emergency department for further evaluation. During a review of the ED Care Timeline, the ED Care Timeline showed Patient 1 was brought by ambulance to a different hospital’s emergency department on 4/17/26 at 1912 hours, for altered mental status and weakness. Documentation showed the patient was falling asleep during triage and was disoriented to place.”