HospitalInspections.org

Based on interview and record review, the facility failed to fully investigate a grievance regarding discharge care coordination issues involving lack of access to pain medications. (Patient ID# 1).

Findings included:
HHSC Intake received 10/23/23 via hotline telephone. Complainant stated the facility negligently discharged patient from hospital to a personal care home and they were unable to provide the care he needed. She stated 13 hours after arrival she picked him up and he was brought to another acute care hospital where he was admitted. The intake stated "complainant filed a complaint with the patient advocate."

Telephone Interview with Complainant for HHSC Intake TX on 10/30/23 at 10:00 am. She re-stated that Patient ID#1 had been "very ill" and she felt the facility "rushed to discharge patient." She stated the personal care home did not have medicines needed to manage patient's pain. She stated when she arrived the following morning, she took him from the facility to another acute care hospital and he was admitted.

Record review of electronic grievance and complaint log dated April 1, 2023 to 11/14/2023 revealed Patient ID#1 with grievance entered 10/23/2023 Patient Relations Manager Staff ID #63. The electronic log classified event type "Discharge - Service Coordination ..."

Record review of electronic grievance and complaint entry related to Patient ID #1 revealed:
10/23/23 at 03:29 pm grievance received by Patient Relations Staff ID #63 via a telephone call from complainant for Patient ID#1. The grievance log record stated " ....caller felt that the discharge was not a safe discharge because the hospital discharged patient knowing that he would not have access to any pain medication until Monday (3 days from discharge)."

Grievance records show a letter dated 10/23/2023 by Staff ID # 63, Patient Relations Representative. The letter was a grievance acknowledgment letter mailed to patient via certified mail. The letter stated the hospital had "received your concerns" and "would conduct a review on his behalf." It further stated they would communicate findings in writing within 30 calendar days.
Grievance investigation records prepared by case management department on 10/23/23 stated "Description of complaint ... Caller felt that the discharge was not safe because the hospital discharged patient knowing he would not have access to any pain medication until Monday." There were "results of chart review" and "Interviews conducted."

Grievance closure occurred 11/02/2023 by Patient Relations staff ID #63 and certified letter was mailed to patient. The grievance was categorized "closed, able to satisfy."

Record review of facility "Patient Rights and Responsibilities" policy, last reviewed 06/2022, stated "Patient Rights: Patients have the right to ... effective communication with all who are involved in the patients care ..." It further stated "Register complaints about your care or treatment, and receive a timely response to those complaints ...."

Record Review of facility's "Patient Complaints and Grievances Procedure", last reviewed 6/3/2022, stated "Action: 5. Document grievances in the hospital approved electronic tracking tool.. and refer to appropriate personnel to review and investigate ... 7. Department leadership will investigate the grievance including, as appropriate, clinical reviews and staff interviews."

Interview 11/14/2023 1:35 pm, Case Management Director, Staff ID #55, confirmed the facility was aware that the patient was discharged on a Friday afternoon and that the initial hospice visit would not occur until Monday. She confirmed the patient had been on morphine 10 mg per PEG tube scheduled round the clock for pain. She stated that the morphine elixir had been sent to the pharmacy and would be "picked up by personal care home staff."

Interview 11/14/2023 1:45 pm with Case Management Medical Director, Staff ID #69, she stated that the medical record reflected the hospital medicine physician had continued all admission medications, including a muscle relaxant and nerve pain medicine, and sent a new prescription for morphine elixir to a local pharmacy. She stated that it would be patient and or family responsibility to provide prior home medications to the new facility to avoid duplicating medications and cost. She stated that the physician would have determined this prior to discharge. She stated the medical record stated the patient had full "capacity" and would have been decision-maker for care. She confirmed she could not locate documentation in the medical record that this had been coordinated.

Telephone Interview 11/14/2023 2:15 pm with Personal Care Home owner, Staff ID #70, she stated that the morphine elixir had been sent late on 10/22/2023 (Friday) to a local pharmacy (Bemaj) that delivers to them. She stated that the medicine was delivered at 9am on 10/23/2023 (Saturday morning). She stated she had provided over the counter Tylenol for pain in the interim. She stated that after the patient was discharged from the hospital, the personal care home would use the discharge instructions to provide care for the patient until hospice assumed care.
Interview 11/14/23 at 2:30 pm with Patient Relations Manager Staff ID #63, she confirmed that there had not been analysis or response related to the lack of pain medication availability/discharge care coordination of medications prior to grievance closure.