HospitalInspections.org

Based on record review, interview and policy review, the facility failed to ensure a patient's responsible party was notified of a change in condition and subsequent transfer to an outside hospital. This affected one (Patient #1) of ten records reviewed. The census was 45.

Findings include:

Record review revealed Patient #1 was admitted on 08/04/24 as a direct admit from a nursing home. The progress note documented Patient #1 had physical combativeness towards caregivers and has recently escalated to physical aggression. Patient #1 was on hospice for end stage dementia.

Review of a medical progress note dated 08/07/24 documented the nurse practitioner (NP) saw Patient #1 due to a rapid decline, not eating or drinking. Patient #1 was lying in bed with his legs hanging over the side and was not able to tell the NP his name, where he was, year or why he is here. He reported bilateral foot pain and had an episode of bladder incontinence. Patient #1 appeared to be uncomfortable and restless.

Review of a general progress note dated 08/07/24 for 12:56 PM revealed the NP wrote an order for Patient #1 to be sent to the hospital for failure to thrive.

Review of a general progress note dated 08/08/24 for 5:00 PM documented the nurse was able to reach the staff at an outside hospital emergency department and Patient #1 was admitted for delirium. There was no documentation Patient #1's responsible party was notified of his change in condition or subsequent transfer to an outside hospital.

During an interview on 11/19/24 at 1:51 PM, Staff C verified there was no documentation that Patient #1's responsible party was notified of his change in condition or transfer to an outside hospital.

Review of the policy titled "Change in Condition Chain of Command Notification:l dated February 2024, stated at the time of admission, the patient and their family (if present) will be informed of how to seek assistance when they have concerns about the patient condition. The nurse assigned to a patient/client or supervising the care of a patient is responsible for notification of and communication to the medical staff regarding significant changes or significant deterioration in the patient condition and for assuring that there is provider response. Changes in the condition of the patient are determined by assessments utilizing defined parameters, current and past medical condition, medical orders, and or patient safety factors. Examples of change of condition may include patient transfer.