HospitalInspections.org

Based on interview and record review, it was determined the facility failed to ensure the patient's representative was contacted prior to an out-of-facility appointment for one (1) of ten (10) sampled patients. Patient #1 had an appointment to see an Orthopedic Surgeon at a walk-in clinic on 08/05/16; however, this information was not communicated to Patient #1's representative.

The findings include:

Review of facility policy on Transfer Procedure, dated 04/99 revealed the policy did not have any information regarding contact with a patients responsible party.

Review of Patient #1's medical record revealed he/she was admitted to the facility on 07/25/16 with complaint of Fractured Femur Status Post Fall which required surrgery prior to entering the facility, and Late Effect Cerebrovascular Accident. On page two (2) of a Case Management Addendum, completed upon admission, Patient #1's legal representative was identified, along with a contact number. This same contact person was also documented on an Interdisciplinary Assessment, dated 07/25/16, as an emergency contact for Patient #1. Continued review of the medical record revealed no documentation to support Patient #1's responsible party had been contacted prior to an appointment on 08/05/16.

Interview with the Wound Care Nurse, on 09/21/16 at 9:47 AM, revealed she assessed Patient #1's incision site on his/her right thigh on the morning of 08/05/16. She revealed observation of exudate coming from the wound, and stated she contacted Patient #1's Orthopedic Surgeon at 11:25 AM to alert him. She went on to reveal he was working at a walk-in clinic near the facility, and wanted Patient #1 to come in for an appointment at 1:00 PM.

Interview with the Charge Nurse, on 09/21/16 at 2:05 PM, revealed she instructed another nurse to contact Patient #1's responsible party and inform them of Patient #1's appointment after speaking with the Wound Care Nurse on the morning of 08/05/16. She revealed she was not aware until after the fact, the nurse in question had provided incorrect information to Patient #1's responsible party, and did not inform them he/she had an appointment that day at 1:00 PM. The Charge Nurse was unable to recall which nurse she had instructed to contact the responsible party.

Interview with the Patient #1's responsible party, on 09/22/16 at 9:30 AM, revealed she was the power of attorney for the patient. She went on to reveal she was not contacted prior to Patient #1 being sent out to an appointment on 08/05/16 at 1:00 PM, and was not aware of the appointment until she was contacted by the walk-in clinic staff while Patient #1 was at the appointment.

Interview with the Director of Nursing, on 09/21/16 at 2:52 PM, revealed it was her expectation that the nurse assigned to a patient would be responsible for contacting a patient's responsible party and informing them of any changes or upcoming appointments to provide them the opportunity to attend. She went on to reveal this information should be documented in patient progress notes, along with the name of the person receiving the information and the time of the communication. She was unaware Patient #1's responsible party had not been contacted prior to the appointment on 08/05/16.