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Based on record review and interview, the facility failed to inform a patient's spouse of her transfer to another healthcare facility, per policy.

[citing Patient # 402]

Findings included:

TX 00321128

Review of facility policy titled "Transfer of Patients,"review date 06-27-19, showed the policy governed three (3) types of transfers to include non-emergency medical condition transfers. The policy read: "A Memorandum of Transfer" (MOT) must be completed by the sending hospital."

Record review of complaint intake TX 00321128 showed complainant's wife had been admitted to the facility in April 2019 for low blood sugar and subsequent seizure activity. He stated he visited her there for 2 days. He called the the hospital to check on his wife and was told she was not there. Shortly thereafter, he received a telephone call from a different hospital saying his wife was being discharged from there.

He further stated when he picked up his wife at the 2nd hospital, she had a "large knot on her right chin."

Record review of Patient # 402's medical record showed she arrived to facility ER via ambulance on 04-08-19 at 10:40 A.M. Patient 402's chief complaint was possible seizure, shortness of breath, lethargy. It was documented this patient had history of dialysis, chronic obstructive pulmonary disease (COPD) and prior myocardial infarction.

Review of ER physician notes showed : Patient # 402 was placed on oxygen, EKG done, and labs were obtained. Patient had a high potassium level and also developed a facial droop. A CAT scan was done, which was negative for findings. Patient underwent dialysis, glucose remained elevated , she was noted to have generalized shaking. Plan was for admission for further evaluation. Because no beds were available, the decision was made to transfer to another facility for admission. The transfer was discussed with the patient. There was no documentation by a physician or nursing staff that the husband of Patient # 402 was informed of her imminent transfer to another hospital.

Patient # 402 was transferred by ambulance to another acute care hospital on 04-09-19 at 0348 AM.

Review of the MOT, dated 04-09-19 showed : # 3. Next of Kin: name & telephone number of Patient's spouse was documented. The field that read " Notified : YES:___ NO: ___ " was left blank.

Interview on 09-27-19 at 1:30 PM with Registered Nurse (RN) # S495 she stated there should always be an attempt to notify the family of a patient's transfer. This was to be documented on the MOT in the space provided for notification.