HospitalInspections.org

Based on document review and interview the facility failed to ensure the Power of Attorney (POA) was notified prior to the patient being transported from the facility to an Emergency Room (ER) in one (1) instance. (Patient # 10)

Findings include:

1. The hospital policy titled, "Transfer of Patient", PolicyStat ID 10623375, indicated the patient and/or personal representative shall consent to transfer. This policy was last revised in 10/2021.

2. The hospital policy titled, "Patient Rights and Responsibilities", PolicyStat ID 13517670, indicated the staff would comply with all reasonable directives. All rights apply to the person who had legal responsibility to make decisions regarding the patients medical care (POA). This policy was last revised in 09/2021.

3. Durable Power of Attorney (POA) forms dated 02/09/2022 indicated D # 1 (Family Member) was appointed as the patients healthcare representative. Intake documentation - Primary care physician letter dated 03/06/2023 indicated that the patient was unable to make or communicate informed decisions concerning his/her person and/or financial affairs. Daily Nursing Assessment dated 05/14/2023 at 7:00 am by S # 1 (Registered Nurse), indicated at 7:30 am the patient was being transferred to a wheelchair from his/her bed and hit their leg hit the metal on the wheelchair. Wound care was performed immediately. Patient had a skin tear. Provider Orders dated 05/14/2023 at 7:30 am indicated the patient was to be sent out to the Emergency Room (ER) for evaluation/treatment. The patient left and at 8:15 am the patient's POA was notified.

4. In interview on 05/31/2023 at approximately 2:45 pm with nursing staff member S # 1, confirmed I usually don't call the POA/family until the patient has left the building.