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Based on document review and staff interviews it was determined the hospital failed to ensure an incompetent patient was delivered to their healthcare surrogate in one (1) of thirty (30) medical records reviewed (patient #2). This failure to provide a safe setting could possibly lead to harm or possible death of an incompetent patient.

Findings include:

1. A review of the medical record for patient #2 reveals a thirty-six (36) year old male that presented to the emergency room on 7/14/20 with a self-inflicted gun shot wound below the chin. The patient was admitted to the Surgical Trauma Intensive Care Unit (STICU). During the time in the STICU he received multiple antibiotics and tested positive for clostridium difficile colitis (C-Diff). The record indicates contact precautions were put in place for the C-Diff diagnosis. The patient was admitted to the trauma step-down unit and placed in the isolation room where contact precautions continued. The patient was declared incompetent by the physician and his sister was appointed his health care surrogate. The patient was to be discharged home to his sister's care on 8/3/20. The sister was unable to pick the patient up and arrangements were made by the staff for the patient to be transported to his sister's home by Logisticare. The health care surrogate agreed to the arrangements. He was dropped off by the Logisticare driver at the wrong location, leaving the incompetent patient with no supervision.

2. A review of the hospital document, signed by the physician, entitled 'Surrogate Appointment' dated 7/23/20 at 8:36 a.m. names patient #2's sister as his healthcare surrogate.

3. A review of the hospital document, signed by the physician, entitled 'Physician Determination of Capacity' dated 7/23/20 at 9:30 a.m. states "patient #2 demonstrates INCAPACITY to make medical decisions."

4. An interview was conducted with the Charge Nurse on 5 South on 8/24/20 at approximately 1:25 p.m. During the interview she stated that patient #2 was declared incompetent by the physician. She stated on the date of discharge she had spoken with the healthcare surrogate of the patient and informed her of the patient's pending discharge She stated, "The MPOA was unable to pick the patient up that day and I informed her where he had Medicaid that he could be transported home by Logisticare and she agreed to that. She gave me the address where she wanted him transported to. If the address is different than the address on the patient's Medicaid card, we have to call a supervisor at Logisticare and get approval for the patient to go to a different address other than what is on the card. So, I did. We discharged him into the care of the driver to take him home."

5. A review of the hospital document entitled 'Nursing Narrative Note' dated 8/3/20 at 1647 (4:47 p.m.) states, "Spoke with sister on phone. Unable to transport patient home today. States she will be at home for patient to arrive if MTM set up. Attempting to set up MTM ride currently."

6. A review of the hospital document entitled 'Nursing Narrative Note' dated 8/3/20 at 1825 (6:25 p.m.) states, "Pt to lobby with NE. Assisted into Logisticare transport. Sister notified is waiting at home for arrival."

7. A telephone interview was conducted with the Director of Corporate Compliance on 8/26/20 at approximately 3:20 p.m. She concurred the hospital failed to ensure that patient #2 was transported to the care of his health care surrogate.

Based on document review and staff interviews it was determined the hospital failed to provide outpatient lab services as ordered by the physician in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to negatively impact any patient that needs the services of the outpatient lab.

Findings include:

1. Patient #1 is a fifty-two (52) year old female that came to the hospital for pre-admission testing on 7/23/20. She presented with a power-port catheter and was directed by the pre-admission nurse (RN #2) to go to lab to have lab work obtained. Upon arrival to lab she was told lab employees were not allowed to access her power-port catheter. RN #2 was notified and called Short Stay Surgery to see if someone there could access her port. The patient was escorted to the Emergency Room (ER) in an attempt to have her port accessed, however the patient would have had to be registered as an ER patient and she refused. The patient came back to outpatient lab and continued to wait for someone to access her port. Patient #1 left the hospital without having her lab work obtained as ordered by the physician.

2. A review of the hospital document entitled 'Physician's Orders-Pre-Operative' dated 7/23/20 at 10:00 a.m. reveals under the box checked Pre-Admission Testing (PAT) an order for a Chest X-Ray, EKG, CBC, Comprehensive Metabolic Panel and Type and Screen. The order also states, "Okay to access powerport!"

3. A telephone interview was conducted with RN #1 on 8/25/20 at approximately 8:55 a.m. During the interview she stated she remembered RN #2 calling her to ask for someone to come and access the port of patient #1. She said, "I remember we were really busy. I had two (2) nurses in pre-op and two (2) in post-op. I didn't have anyone available to go access her port at that time. Plus, we needed an order for a heparin flush to flush the port before we de-accessed the port. I tried to call the physician to get an order but couldn't get the physician, so I got our coordinator to work on getting an order for the flush and the physician said we could wait until the day of the surgery to obtain the lab work. I called the lab to tell them I had the order and they told me the patient had already left."

4. A review of the hospital document entitled 'Physicians' Orders' reveals an order was received on 7/23/20 at 1530 (3:30 p.m.). The order was for '3 ml Heparin flush to power port after blood draw morning of surgery (8/12/20 0600) VORB (Verbal Order Read Back).'

5. A telephone interview was conducted with RN #2 on 8/25/20 at approximately 9:15 a.m. She stated, "The patient came in for Pre-Admission Testing. I told the lab I had a patient with a power-port. I sent her to the lab and the lab called to say they could not access power-port and patient refused to be stuck for labs. I am not competent to draw from port so I called Short Stay Surgery and asked them to draw from port. They said they were busy and didn't have anyone available. In the mean time I guess she had called someone in administration. She eventually decided to let someone in the lab stick her, but the phlebotomist didn't feel comfortable to stick her."

6. A telephone interview was conducted with the phlebotomist on 8/25/20 at approximately 9:25 a.m. She stated, "The Pre-Admission Testing (PAT) nurse called to say they were sending a patient with a power-port down for lab. I told them that we were not allowed to stick ports but she sent the patient anyway. When the patient got there I told her we were not allowed to access her power-port. She was very adamant about not being stuck peripherally. She said that she had medical conditions that had come about because she had been stuck so many times. We called and told the PAT nurse that we could not help the patient. The nurse called Short-Stay Surgery to see if they had one available. I know at some point the patient was taken to the ER to see if someone there could draw her labs and I know she called someone in administration as well. We are not allowed to draw from a patient's port. It is not in our scope of practice. She eventually agreed to let us stick her but I didn't feel comfortable enough to stick her. I know by the time Short-Stay Surgery got the order from the physician the patient had already left the hospital without getting her lab work."

7. A telephone interview was conducted with the Director of Corporate Compliance on 8/26/20 at approximately 3:15 p.m. She concurred that the hospital failed to ensure staff were available to have labs drawn on patient #1 as ordered by the physician.