HospitalInspections.org

Based on record review and interview, facility #1 (a rehabilitation hospital) failed to provide care in a safe setting for 1 (P#1) of 3 (P#1-3) patients sampled by transporting P#1 to facility #2 (an acute care hospital) for a provider visit. Facility #1 failed to have a mechanism in place to ensure transfer of information and documentation for the patient was available before and after the visit to facility #2. This failed practice places the patient at risk of being unaccounted for during transportation to and from appointments to another provider.
The findings are:

A. Record review of complaint received on 09/04/19 reveals P#1 arrived at facility #2 on 05/07/19 with open pressure ulcers to the coccyx, bilateral buttock and red area to the right heel. P#1 had a catheter replaced earlier in the day [05/06/19] and had bleeding which seemed to come from the urethra but subsequently had vaginal bleeding with large clots. The patient is postmenopausal and has no history of postmenopausal bleeding.

B. Record review of P#1's chart reveals no evidence of transfer documentation from facility #1 to facility #2 ER on 05/06/19.

C. On 09/04/19 at 11:00 am during interview, the CCO stated the patient was admitted to facility #1 on the evening of 04/30/19. She stated, "this is the only time she [P#1] transferred to [name of facility #2 for a provider appointment]. She went to [name of facility #2 for provider appointment] on 05/06/19 with vaginal bleeding and came right back [to facility #1]. It wasn't a transfer because she was never admitted [as a patient to the ER at facility #2]. It was a visit, an appointment. It's like a mini-consult. It's only doctor to doctor. We schedule the ambulance for appointments such as these."

D. On 09/04/19 at 11:15 am during interview, the CCO stated, "there is no 'transfer documentation' since it's a visit not an admission. We send the most recent progress note, the prescription list, h&p. The packet has a big, bright, green sticker with information to contact [name of facility] if there are any issues. We don't save that copy."

E. On 09/04/19 at 11:40 am during interview, the DCM stated, "There is nothing signed-off that the patient actually made it [to the appointment]."

F. On 09/04/19 at 11:40 am during interview, the CCO stated, "This process was established before I started 2 years ago. It pre-dates me."