HospitalInspections.org

Based on document review and interview the hospital failed to ensure patient rights for informed consent and involvement in care related to discharge were implemented as per policy for 1 of 10 patients (P2).

Findings include:

1. Review of hospital policies indicated the following:
PolicyStat ID: 3809950, titled Patient Rights and Responsibilities, IPC.SUP.001; Reviewed 11/2017, indicated the following:
Policy: (The hospital) maintains that individuals hold basic rights for independence of expression and decision...
Procedure: 1.P. A patient may not be transferred to another facility or organization unless he/she has received a complete explanation of the need for the transfer... The patient or surrogate has the right to be informed by the practitioner responsible for care of any requirements following discharge from the medical center. A completed and signed consent for the transfer is necessary prior to the transfer being initiated.

2. Review of the medical record (MR) for patient P2 indicated the physician had planned for the patient to be transferred to hospital H2 in the city of C1. The MR indicated, however; that the patient was transferred to another hospital in the city of C2 without the informed consent of the patient's POA.
MR documentation indicated the following:
The patient arrived in the ED on 11/30/19 at 1932 hours and was admitted to a medical/surgical unit on 11/30/19 2207 hours. The Admission Health History, entered 11/30/19 at 23:01 hours, indicated that the family/support person to contact/notify was F2. Case management/discharge planning notes dated 12/2/19 indicated the patients' family member F2 was the patients' POA. Hospitalist Progress note dated 12/3/19 at 1309 hours indicated the following: May need transfer to (Hospital 2) for the neuropsychiatric unit where Psych (psychiatry) and Neurology can see him/her. The Discharge Summary, dated 12/6/19 at 1927 hours indicated the following: In the past I have transferred patients to H2 in C1. I discussed with the (family member) F2 the possibility of transfer to H2 in Indianapolis if unable to improved (sic) his/her symptoms. He/she (F2) was agreeable to this... After no clinical improvement with discontinuing his/her antipsychotic and depakote, and treating his/her UTI for 5 day with meropenam, I decided to reach out to the transfer center and request transfer to H2 in C1. See the clinical note dated 12/7/19 for further details so as not to be redundant. I talked to F2... he/she was agreeable...I called the transfer center to make this happen specifically to the Neuropsych Unit at H2 in C1. He/she (the patient) ended up going somewhere else. See clinical note when I found out this had occurred... The Clinical Note by MD2 dated 12/7/19 at 2135 hours indicated the following: I have been made aware that my attempt to transfer this patient to the Neuropsychiatric facility at H2 was not completed properly. Nurses Notes dated 12/6/19 at 2152 hours indicated the following: Patient discharged to neuro psych facility in city C2... Nurses Notes dated 12/7/19 at 1906 hours indicated the following: Patients' (family) arrived at unit to visit patient - notified that patient was transferred the previous evening. Patient family was "not notified" according to present family members. The MR lacked documentation of the patient and/or POA having been included in the decision making of transferring the patient to a hospital in city C2, lacked documentation of notification to the POA that the patient was transferred out of the hospital and lacked documentation of a completed and signed consent for transfer.

3. The following was indicated in interview:
On 1/6/20, between approximately 12:15pm and 2:45pm, A9, Director of Advanced Clinicals, verified that the MR of P2 lacked documentation of the family/POA having been notified of the transfer out of the hospital and lacked documentation of the POA having been included in the decision making to transfer to a facility other than that previously discussed.
On 1/7/19, between approximately 10:45am and 11:00am, MD2, Hospitalist, indicated that he/she was the hospitalist for patient P2 during the 11/30/19 to 12/6/19 visit. MD2 indicated that F2 was unable to make an informed decision for transfer on behalf of patient P2 due to lack of information. MD2 indicated that he/she had not discussed with the patient's POA (F2), that the patient would need to be transferred to anywhere other than the neuropsych unit at hospital H2 in C1.

Based on document review and interview, the hospital failed to ensure nursing care for transfer of 1 of 10 patients (P2) was provided in accordance with policies.

Findings include:

1. Review of hospital policies indicated the following:
PolicyStat ID: 3809950, titled Patient Rights and Responsibilities, IPC.SUP.001; Reviewed 11/2017, indicated the following: Procedure: 1.P. A completed and signed consent for the transfer is necessary prior to the transfer being initiated.
PolicyStat ID: 5902828, titled Discharge Procedure, IPC.NUR.011; Last revised 01/2019, indicated the following: Policy: The Discharge Summary/Instructions must be completed on all patients, except those transferring to another facility for higher level of acute care in which a transfer form is utilized.
Medical and Dental Staff Rules and Regulations, approved August 2019, indicated the following:
I.n. Patient transfers: No patient will be transferred unless such transfer has been approved by a responsible practitioner.

2. Review of the medical record (MR) of patient P2 indicated the following: The Admission Health History, entered 11/30/19 at 23:01 hours, indicated that the family/support person to contact/notify was F2. Case management/discharge planning notes dated 12/2/19 indicated the patients' family member F2 was the patients' POA. The Discharge Summary, dated 12/6/19 at 1927 hours indicated the following: I decided to reach out to the transfer center and request transfer to H2 in C1... I called the transfer center to make this happen specifically to the Neuropsych Unit at H2 in C1. He/she (the patient) ended up going somewhere else. Nurses Notes dated 12/6/19 at 2152 hours indicated the following: Patient discharged to neuro psych facility in city C2... The MR lacked documentation of a completed and signed consent for the transfer, lacked documentation of a transfer form and lacked documentation of a responsible practitioner having approved the transfer to a facility in city C2.

3. The following was indicated in interview:
On 1/6/20, between approximately 12:15pm and 2:45pm, A9, Director of Advanced Clinicals, verified that the MR lacked documentation of signed consent for transfer and/or a transfer form.
On 1/7/19, between approximately 10:45am and 11:00am, MD2, Hospitalist, verified that he/she was the hospitalist for patient P2 during the 11/30/19 to 12/6/19 visit. MD2 indicated that he/she was not aware of and did not approve of such a transfer to a facility in C2.