HospitalInspections.org

Based on medical record review, policy review , grievance review, and staff interviews, it was determined the hospital failed to ensure care in a safe setting for 1 of 10 patients (Patient # 14 ) whose records were reviewed and were seen in the ED. This had the poteintial to affect all patients seen in the ED.
Findings include:

A hospital policy titled, "Safe Patient Handling and Mobility (SPHM), PE031 SLHS," last revised 1/29/24, was reviewed. The policy stated, "Assessment for Safe Patient Handling and Mobility (SPHM): performed by a licensed clinician to examine and evaluate the physicial, mental, cognitive, medical, and/or environmental conditions of a healthcare recipient to determine appropriate SPHM methods, technology, and equipment or assistive devices used during patient care."
The policy also stated, under compliance, "Healthcare workers will use best practice methods for patient handling and mobility tasks including the use of mechanical lifting devices and/or other approved safe patient handling aids and techniques for patient handling and mobility tasks."
The policy also stated, under SPHM Injury Prevention: "Examples of controls for patient handling injury prevention: 1. Eliminiate: Remove the hazard by not manually lifting patient." This policy was not followed.

A hospital policy titled, "Patient Rights and Responsibilities Policy, PA014 SLHS, last revised 8/27/25, was reviewed. The policy stated, "All patients of [hospital] have the following rights:...Respect, consideration and dignity...to be actively involved in consenting to treatment and in development and implementing of their plan of care." This policy was not followed. Example includes:

Patient #14 was a 66 year old female who presented with her caregiver to the ED on 7/24/25 with a chief complaint of increased pain due to parasites. Patient #14 had comorbidities which included quadriplegia and autonomic dysreflexia. Patient #14 had a CT abdomen and pelvis with unremarkable results. Patient was discharged to home with specific instructions to return with worsening symptoms.

Patient and caregiver requested a hoyer lift to assist with transfer from gurney to wheelchair upon discharge. Patient was informed there was no hoyer lift available in the ED. A nurse apprentice attempted to transfer patient from gurney to wheelchair at which time patient slid onto the floor. The nurse apprentice picked up patient #14 from the floor and put patient into her wheelchair.

The nurse apprentice was interviewed on 9/9/25 beginning at 1:20 PM. He stated he was familiar with Patient #14. He was asked if Patient #14 requested a hoyer lift when she was discharged. He stated that she did, but that they rarely use hoyer lifts as there are none in the ED. He could call for transport to assist but that "he has lifted thousands of patients himself." He was asked if Patient #14 complained of pain after the fall and he stated that she did not complain of pain any greater than when she came in and that she and her caregiver were "just in a hurry to get out of there."

The ED nurse manager was interviewed on 9/9/25 beginning at 1:20 PM. She stated that the nurse apprentice did notify her of the incident after the occurrence. When asked about using a hoyer lift, she stated they were rarely used in the ED. When asked if a hoyer lift could be used in the ED, she stated that yes, they could call transport to bring a hoyer lift down to the ED. She stated that they have lift sheets and manpower to typically transfer patients.

Patient #14 returned to the ED at a sister hospital the following day, 7/25/25, with a complaint of bilateral leg pain after she was dropped in the ED on 7/24/25. X-Rays of bilateral legs and ankles were completed and showed no indication of fractures. She was discharged with instructions to return to the ED with further concerns.

Patient #14 was brought in by ambulance on 7/26/25 to the ED again. Patient #14 complained of pain to her pelvis after the fall in the ED on 7/24/25. A CT pelvis was completed with no indications of further fractures or injuries. Patient #14 was returned home via nonemergency medical transport. Patient #14 again requested a hoyer lift to assist with transfer from gurney to medical transport gurney but was told none was available. Patient #14 was successfully transferred with a 4 person assist and transported to home.

The hospital failed to ensure all patients were cared for in a safe environment and also failed to ensure Patient #14 was treated with respect and dignity and allowed to be actively involved in her plan of care.