HospitalInspections.org

Based on record review, staff interview, and policy review, the facility failed to ensure the patient representative was informed of health changes for one (#2) of 10 patients reviewed for notification. The facility census was 128.

Findings include:

Review of medical record for Patient #1 revealed the patient was admitted on 02/11/25 for mania and symptomatic anemia to the medical floor. On 02/14/25 the patient was transferred from the medical floor to the Behavioral Unit. On 02/17/25 the patient was febrile and tachycardic. Blood cultures and chest x-rays were obtained. On 02/18/25 the patient was observed with a change in condition which included intermittent catatonia, drooling, and tachycardia. The physician was notified and order was obtained to send the patient to the Emergency Room (ER) as there were no beds available in the Intensive Care Unit (ICU) at the time. Patient #1 was transferred to the ER on 02/18/25 2:15 A.M. On 02/18/25 at 4:05 A.M. the patient was intubated to protect the airway. On 02/18/25 discharge paperwork from the Behavioral Unit to the ER revealed no documentation Patient #1's family was notified of the transfer or the change in health status of the patient.

Interview on 04/22/25 at 3:03 P.M. with Registered Nurse (RN) A revealed they took over care for Patient #1 at 11:00 P.M. on 02/18/25. RN A stated the patient had a change in condition and required the transfer to the ER. RN A verified she did not call the family to inform them of the transfer as she thought the ER would.

Review of facility policy titled "Transfers,for " reviewed 09/19/22, revealed transfers within the hospital the family, the physician, and the consultants are to be notified when patients are transferred to a higher level of care.