Methodist Dallas Medical Center

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 33326 Based on interview and record review, the facility failed to meet the conditions of participation for discharge planning when the facility’s discharge planning process failed to identify and to provide a safe discharge back to his residence, for a known patient arriving by EMS. (emergency medical services ambulance) This failure resulted in the patient wandering out in 90+ degree Fahrenheit temperatures for 3 days and returning with heat stroke and multiple burns to his left arm, hand, and both feet. (Patient #1) Cross refer: A-800”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 33326 Based on review of documentation and interviews with facility staff, the facility failed to identify a patient who are likely to suffer adverse health consequences upon discharge and failed to provide adequate discharge planning as evidenced by a patient (Patient #1) wandering out in 90+ degree Fahrenheit temperatures for 2 days and returning with heat stroke, sunstroke, opened burn wounds, and multiple bullae (a raised fluid filled bubble) to his left arm, hand, and both feet. Findings include: Review of the facility provided document, “Discharge of the Emergency Department Patient”, (effective 12/17/2025) reflected, “POLICY: 1. It is the policy of the Emergency Department (ED) to assist patients with discharge process to ensure their understanding, safety, comfort and continued care ...8. In addition, during the discharge process, patients may be referred for discharge planning evaluation directly by the physician, various disciplines, the patient or a member of the patient’s family. If there is concern related to the patient returning to the previous environment. For homeless patients being discharged from the Emergency Department, they should be provided with appropriate clothing or paper scrubs upon discharge. Case Management should be consulted for additional resources and discharge planning. These guidelines, procedures or policies do not take the place of medical judgment in the care of the patient.” ED admission dated 7/16/2025 at 1:30 pm: Review of Patient #1’s Dallas Fire-Rescue EMS report dated 07/16/2025 at 1:03 pm reflected Patient #1 was transported from his private residence to Methodist Hospital for hyperglycemia (elevated blood sugars). The narrative reflected, “Pt is aox4 and ambulatory ...Pt has hx (history) of Alzheimer’s ...Mental Status ...” Review of Patient #1’s physician’s discharge summary, dated, 7/16/2025 and scribed at 2:35 pm and reviewed and validated by Staff #8, ED MD on 7/16/25 and electronically signed on 7/17/25 at 9:19 am reflected the following: “Review of Systems: Unable to perform ROS (Review of Systems, is a series of questions a healthcare provider asks to identify symptoms the patient may not have mentioned): Dementia Physical Exam: comments: Disheveled- appearing. Foul odor present. Homeless.” Decision-making details documented in ED course. Risk details: ...transportation challenges ...lack of health literacy. Discharge disposition: discharge. Condition: Stable.” Review of the facility provided security photo (undated and timed) revealed, Patient #1 exiting the facility wearing a blue scrub top, jeans and yellow socks. The patient was unaccompanied as he left the building. Review of the weather for the Dallas area on 7/16/25 through 7/18/25 found at “wunderground.com/history/monthly/us/tx/dallas/KDAL/date/2025-7” reflected, the outdoor reported highs of the Dallas region temperatures ranged from 93 degrees Fahrenheit to 96 degrees Fahrenheit. ED admission 7/18/2025: Review of Patient #1’s Physician’s note dated 7/18/25 reflected, “Patient #1 initially presented with a temperature of 105 degrees Fahrenheit, hypotension (low blood pressure), lactate elevated, troponin (indicative of heart muscle stress) elevated. He was disoriented on admission, unable to recall where he was prior to presentation to the ED. On exam, he had lower extremity burn wounds and bullae (a raised fluid filled bubble).” Review of Patient #1’s wound care nurse note dated 7/22/25 reflected, “This is a 69-year-old male with past medical history of A-fib who presented to the ED as he was found down at the DART (rail train terminal) station. The patient was noted to have an elevated temperature ...The patient denies prior issues with wounds and states these are new after the fall.” Review of Patient #1’s wound care nurse evaluation dated 7/22/25 (second admission) reflected, “Wound Evaluation: 1. Evaluation of the right dorsal foot and ankle into the plantar aspect demonstrates a large fluid-filled blister and blood-filled blister. There is no open wound or drainage. The great toe has some dusky purple discoloration. Toenails are overgrown. Unable to palpate pedal pulses. Limb is edematous. 2. Right hand over the first and second knuckles are fluid-filled blisters which are intact. 3. Left great toe: Plantar aspect is a deep purple blood blister. No open wound. No fluctuance, induration, or bogginess. 4. Left dorsal foot full-thickness ulceration measuring 10x7x0.1 cm. Wound base is seen with yellow-white adherent sloughing. Minimal to moderate serous drainage without odor. No tunneling or undermining. No underlying structures are exposed. No fluctuance, bogginess, or indurations. Edges are peeling. Likely this was a ruptured blister. Surrounding [sic] skin is discolored and edematous. 5. Left upper extremity from the upper arm into the hand is seen a cluster of blisters and open ulcers. Open ulcers are seen with yellow sloughing to the base. Moderate serous drainage without odor. No tunneling or undermining. No underling structures are exposed. No fluctuance, bogginess or induration, Edges are irregular but attached Surrounding skin is quite edematous.” A review of the facility provided photographs of patient #1’s wounds dated 7/22/25 revealed the following, (based on the measurements of the left dorsal foot): Right foot- A large fluid filled blister to the top of the right foot approximately 13 cm x 7 cm. The bottom of the foot has a blood and fluid filled blister approximately 10 cm x 7 cm. Left arm- At least 10 open ulcers ranging in size from approximately 4 cm x 7 cm to, 1 cm x 1 cm, from above the elbow to the top of the hand. Review of Patient#1’s previous two admissions to Methodist Dallas, (on 8/15/24 and 10/25/24) reflected the patient had been discharged and required transportation back home by ambulance. During an interview, on the morning of 9/25/25 at 11:00 am, in a facility conference room, when asked if an attempt was made to contact the family to pick up Patient #1, Staff #3, ER RN confirmed he had received the EMS report and stated, “Patient #1 came in by Dallas Fire, there was no family present. He walked from the stretcher to the bed. He didn’t want to be here. When it was time to discharge him, I asked, Do you have a ride? He answered, he did, very quickly. Typically, we ask if they have a way home. I assumed he had a way home. I don’t remember giving him a bus pass. Throughout his treatment, there wasn’t anything that would make me think he was not understanding.” During an interview on the afternoon of 9/24/25 at 1:30 pm, Staff #9, Director of Care Management, when asked about the preparations for discharging a patient from the ED, stated in part, “If the physician or nurse determines there is a need for case management, they will put in an order for us to assist the patient. We assess every admitted patient; we only do the emergency department patients if there is an order.” When asked how the facility determines if a patient is able to make decisions, Staff #9 stated, “The patient’s capacity and cognition is left up to the providers; capacity is really being reassessed by the physicians.” Staff #9 confirmed the caseworker had not been consulted to arrange Patient #1’s transportation back to his residence. During a telephone interview on 9/24/2025 at 11:20 am, when asked about the Patient #1’s ED Provider’s notes, Review of symptoms being marked as unable to determine: dementia, Staff #8. ER MD confirmed he did the assessment and stated, “That is not true, that is something my scribe must have put in, he was not demented at this time.” During an interview on 9/24/2025 at 2:00 pm, Staff #7, ED Manager stated in part, the family had called (on 7/16/2025), asking if the patient was admitted, when they (the family) were told he was discharged they informed us he didn’t come home, that’s when we (the facility) learned he was missing.”