HospitalInspections.org

Based on record review and interview the facility failed to meet the Condition of Participation for Patient's Rights to be free from all forms of abuse by not escorting a patient who had memory loss to the correct facility.

The findings are:

A. The facility failed to transport a patient with memory loss to the correct facility. Refer to tag A-0145.

Based on record review and interview the facility failed to transport a patient with a decline in cognition to the correct facility. Patient was left unattended at the wrong facility and should have been escorted to the memory care unit of another facility for 1(P[patient] 1) of 10 (P1-10) patients reviewed for transportation and discharge planning. This deficient practice could lead to serious harm, injury or death of the patient.
The findings are:

A. Review of the facility's policy titled, "Driver Transporter Policy" undated stated "The Driver/Transporter is responsible for picking up and transporting clients in a safe and responsible manner. He/she will maintain control of the clients at all times. The clients will be loaded from the curbside of the vehicle."

B. Record review of P1's Medical Record:
1. Titled "Physician Diagnosis Attestation" indicated, admitting diagnosis is unspecified psychosis (generalized diagnosis is given when an individual has a psychotic episode). Admission date 03/14/24 and release date 03/22/24 [From Facility 1].

2. Titled "Discharge Summary", page 2 dated 03/22/2024 stated "Discharge After Care Plan: [Facility 3] in [City] as a place of stay and treatment."

C. During an interview with P1's daughter in-law on 06/28/2024 at 1:35 PM, she explained that P1's son received a call from a staff member of facility #2. The staff member explained that the facility #2 had P1 which was not the facility that P1 was to be admitted to. P1 was confused and did not have any belongings. The daughter in-law explained that facility #1 had dropped P1 off at the incorrect facility. On 03/22/24 time unknown P1 began to wander inside the building of facility #2, where she was assisted by a staff member to call a family member. The daughter in-law explained that P1 should have been taken to facility #3. The staff member of facility #2 was able to walk P1 across the street to the correct facility, facility #3.

D. Record review of voice recording of a phone call between P1's son and staff member at facility #2 on 03/22/24 date unknown indicated that P1 had been dropped off at the front door of facility #2 and was left unattended. P1's son said she was supposed to be transported to the memory care unit (a locked unit for confused patients that require 24 hour supervision for safety) at facility #3. Facility #2's staff member walked the patient to facility #3.

E. During an interview with a staff member from facility #3 on 06/26/2024 at 5:05 PM, stated "We were waiting for transport, and we kept waiting about 45 minutes after expected time. Next thing we know staff member from facility #2 walked in the door with the patient. P1 was very upset and said that she was dropped off outside. The patient was confused and did not know where she was supposed to be. P1 was to be admitted into the memory care unit. Staff member stated "I called the daughter in law, and she said she was going to report it to the state. I was trying to get P1 to settle down and took her to have a smoke. . . . .3/22/24 at 1:12 PM it was documented in my journal that [P1] was dropped off at wrong facility."

F. During an interview with a staff member from facility #2 on 07/02/2024 at 2:53 PM, stated "woman was dropped off outside of our community literally at the very front. She walked and said I'm here to sign in . . . What was frustrating was that they literally dropped her off. We got her fed and something to drink. She kept saying she wanted to get hold of her son. She was extremely confused and had some type of cognitive decline. . . Finally, I was able to get a hold of son. He confirmed that P1 was supposed to get admitted into [name of facility #3] Memory Care Unit. P1 did not have any medical records with her, she was saying I'm scheduled to get married to a superstar. It was obvious she was confused. I personally walked her to [Facility #3] and waited. I tried reaching out to [Facility #1] administrator and left several messages."