HospitalInspections.org

Based on staff interview, review of facility documents, and review of three of three medical records (Patient (P)1, P4, and P5) of patients transferred from the ASC (Ambulatory Surgical Center) building to the hospital, it was determined that the facility failed to ensure patients are transferred from the surgery center to the hospital in an emotionally and physically safe environment in non-emergency situations.

Findings include:

On 1/27/25 at 9:45 AM, upon entrance to the ASC, the hospital and ASC was observed to be separated by a parking area.

At 10:12 AM, a tour was conducted of the pre-operative area in the presence of Staff (S)1, Director of Surgical Services, and S3, Patient Safety Director. During an interview at 10:15 AM, S10, a Pre-operative Nurse, stated that if a patient needed to be brought over to the hospital from the surgery center, "if the patient isn't dressed yet, we could wheelchair them to the emergency department or have their ride bring them there."

During medical record review, the following was revealed:

The Nursing note in Patient (P) 1's medical record, entered on 12/10/2024 at 2:18 PM, by Registered Nurse (S9), stated " ... it was determined that due to patients [sic] recent history of TIA [transient ischemic attack] [he/she] is not a suitable candidate for the ASC. [anesthesiologist (S13)] at bedside with patient explanation given to patient ... issue presented to [S14, nurse manager] and [S1], it is their decision to place patient in wheel chair and [S14] will push [him/her] in the wheel chair over to the hospital [for surgery]. Patient and wife informed and each are agreeable to plan [sic]."

The Nursing note in P1's medical record, entered on 12/10/2024 at 2:30 PM, by pre-op nurse (S10), stated "... Patient was considered by anesthesia to be too high risk to be done at the ASC [ambulatory surgery center], so [he/she] was transported via wheelchair by [nurse manager (S14)] and [S1] [for surgery]..."

The "OP [operative] Note" in P1's medical record, entered on 12/10/2024 at 3:49 PM, by Podiatrist (S15), stated "... we elected to bring [him/her] into the main hospital rather than the surgery center for [his/her] safety ..."

The "SDS [same day surgery] Post Procedure Assessment" note in P4's medical record, entered on 6/24/2024 at 1:16 PM, by Registered Nurse (S16), stated "... pt [patient] denies nausea, or dizziness. Pt states pain is tolerable. Pt ambulated to BR [bathroom] with assist of writer, voided... [P4's sister] brought to pt's side for instructions. IV D/C'd [discontinued]... pt got dressed independently without difficulty. Pt escorted to hospital via wheelchair by staff members... for post MRI port insertion chest x-ray at 12:50pm..."

The "Multidisciplinary Notes" in P5's medical record, entered on 6/19/2024 at 11:24 AM, by Registered Nurse (S17), stated "... Pt was given discharge instructions and changed into her street clothes VSS [vital signs stable] and pain fully under control. Our portable XRAY machine was found to not be working properly... communicated with the Radiologist who was reading said XRAY, he was not pleased with the quality of the XRAY. He asked us to take the patient to the hosspital [sic] where [he/she] could get another one done. Two OR staff, one RN and also an anesthesia tech accompanied the patient to the hospital with [him/her] in a wheelchair..."

At 2:13 PM, S1 and S3 confirmed that there is no policy in place that defines the procedure of transporting patients across the parking lot to the hospital.

These findings were reviewed with S1 at 2:30 PM.