HospitalInspections.org

Based on security camera review, record review and interviews with staff, the facility failed to protect a patient's right to a safe treatment environment that ensures protection from harm when Patient A, a patient with a known heart history and Alzheimer's disease, was left unattended outside the facility on a hot day, placing the patient at risk of elopement, heat exhaustion and heat stroke.

A) Staff #5 left Patient A, an Alzheimer's and heart patient, outside alone on a hot day to wait for her ride home on 08/08/2024 at noon. A review of www.wunderground.com reflected the temperature for Irving, Texas on 08/08/2024 at noon to be about 98 degrees Fahrenheit. This failure places patients being placed outside, alone to wait for their ride at risk of elopement, heat exhaustion, and heat stroke.

B) The facility staff was not monitoring Patient A to ensure her safety. This placed the patient, an Alzheimer's patient noted to be confused and a poor historian at times, an opportunity for elopement thus risking her physical and emotional safety.

Findings include:

1) Review of The Patient Rights and Responsibilities brochure (revised 07/2019) given to patients. This document reflected that patients have the right to ...receive ethical, high-quality, safe and professional care.."

a) An observation made during a review of the facility provided security camera recordings of 08/08/2024 at approximately 11:50 am to 12:30 pm revealed Patient A was left outside alone to wait for her ride for about twenty minutes. There was no staff in the recording observed to be monitoring her. During the twenty minute she sat on a bench. Staff #5 did not return. Patient A got in the vehicle without assistance when it arrived.

b) A review of www.wunderground.com reflected the temperature for Irving, Texas on 08/08/2024 at noon to be about 98 degrees Fahrenheit.

c) Staff #5 was asked by Staff #2 to get a wheelchair and take Patient A downstairs for discharge as Patient A told her the ride was there. During an interview with Staff #5, a patient care technician, at 2:31pm on 08/21/2024 ,the following exchange was made.

Surveyor: Did you receive report on your patients that morning?
Staff #5: Yes. I'm not sure from who.
Surveyor: Were you helping another PCT or was Patient A in your patient assignment that morning?
Staff #5: Yes. She was in my hall.
Surveyor: So, you received report on her at shift change?
Staff #5: Yes.
Surveyor: What information is shared during report?
Staff #5: General info is shared. Habits, medications, restrictions on food.
Surveyor: Is the patient's mental status something that is typically shared in report?
Staff #5: Yes, but I do not recall if it was mentioned she had Alzheimer's or dementia.
Surveyor: If you have known that Patient A had Alzheimer's dementia, would you have done things differently?
Staff #5: If I had known that, things would have been different.

Staff #2 told this surveyor that when she asked Staff #5 what took so long when taking Patient A down for discharge, Staff #5 stated that the ride wasn't there at the time he took Patient A down, but Patient A had gotten in the car before he came back upstairs.

d) A review of Patient A's medical records revealed the following:
1. was "a poor historian and has difficulty answering simple questions" and exhibit
"impaired...safety awareness." Documented by a Speech Therapist.
2. exhibited "impaired...safety awareness" and was "very confused." Documented by an Occupational Therapist.
3. "... has difficulty complying outside of home due to her dementia." Documented by a Social Worker as a statement from Patient A's daughter.
4. exhibited "impaired...safety awareness." Documented by a Physical Therapist.