HospitalInspections.org

Based on interview and record review, the facility failed to uphold the right of Patient # 1 to participate in his plan of care per facility patients' rights policy:

a. The facility failed to ensure documentation to support Patient # 1 's appropriate & safe for discharge (from emergency room [ER] ) with elevated blood sugar.

b.The facility failed to ensure assessment of Patient # 1's open hand wound by nursing or physician at time of ED visit.

(Citing Patient # 1)

Findings include:

TX 00316855

Record review of facility policy titled "Patients' Rights & Responsibilities," dated January 2017, showed patient rights included:

*The right to reasonable response to their requests and needs for treatment and services;

*The right to collaborate with the physician to make decisions in the development of the plan of care.

Appropriate/safe discharge:

a. Patient #1 : "unsafe to go home" : "Conditional Discharge "selected did not have established discharge criteria: nursing checked this criteria was "met." Discharge instructions provided to patient advised him to seek medical attention for blood sugar results lower than he had at discharge.

Review of complaint intake # TX 00 316855 showed documentation Patient # 1 told ER doctor on 05/30/19 he did not feel safe to go home with his blood sugar so high.

Review of Patient # 1's ER electronic medical record, dated 5/30/19 showed the following blood sugar results:

Time 1709:Point of Care (POC) glucose testing: 564 Mg/dl (milligrams per deciliter);
Lab results: serum glucose: 730 Mg/dl ; 10 Units Humulin insulin given
Time 1919: point of care (POC) testing showed: glucose above 600mg/dl
Time 2048: POC glucose 474 mg/dl
Time 2051: POC glucose 509 mg/dl
Time 2142: POC glucose 416 mg/dl

Further review of Patient # 11's medical record showed:

Nursing Flowsheet: Departure Condition: Thursday May 30, 2019. "Have the conditional discharge conditions been met? "YES" ("Discharge patient" )

During an an interview on 07-18-19 at 11:45 AM with Staff E, ER Manager, he said if a physician ordered "Conditional Discharge", the physician will enter free text in the "DISPO Section " to document the conditions to be met, for example: "when fluid bolus complete, etc..."

Patient # 1's electronic medical record (EMR) was reviewed with with Staff E, ER Manager. He was unable to locate any documented "discharge conditions" by physician. Review of printed ER record, dated 05/30/19 failed to show any "conditional discharge " criteria or delineated circumstances to be met prior to discharge.

Surveyor was unable to verify "safe & appropriate discharge". Under "DISPOSITION" section, physician checked "Conditional Discharge." There were no conditions documented to indicate patient criteria /circumstances for discharge. Nurse checked "yes" conditions were met; there were no discharge conditions specified by physician.

Record review of discharge instructions given to Patient #1 showed:" ... "Follow-up care:...When to see medical advice: call your healthcare provider right away if these occur: high blood sugar symptoms (symptoms listed & described); blood sugar over 300 mg/dl if you can't reach your healthcare provider, go to a hospital ER or urgent care center. .."

Patient # 1's last recorded blood sugar on 05/30/19 was at 2142 ; 416 mg/dl.

b. Open hand wound :assessment (physician & nursing) :

Review of complaint intake # TX 00 316855 showed documentation Patient # 1 told ER staff his right hand was infected.

Physician documentation 5/30/19 visit showed: "...history of open hand wound: new and requires work up. ...patient with hyperglycemia, chronic hand wound. Not currently on abx but has taken clindamycin for this in the past. He believes this is what is causing the spike in the glucose ...advised to see wound doctor ..."

5-30-19: physical exam: " .... Skin: negative for pallor; skin is warm." No assessment by physician of Patient # 1's open hand wound.

Review of Patient # 1's "After Visit Summary" dated 05/30/19 lists a wound care center and telephone number with instructions for patient to make an appointment as soon as possible, in one day. In addition, ED physician prescribed Bactrim DS antibiotic.

Review of facility policy titled" Emergency Nursing -Standards of Care and Practice", dated 04/30/2017, showed: "...the emergency nurse initiates accurate and ongoing assessment of physical concerns of patients..."

Review of all nursing flowsheets/assessments for Patient # 1's ER visit, dated 5/30/19 failed to show any documentation of assessment of patient's right hand.