HospitalInspections.org

Based on interview and record review it was determined the hospital failed to ensure that patient safety requirements were met for 1 of 1 patient (Patient #1) who sustained injuries during a fall at the hospital and was scheduled for transport to another facility for additional care. (Patient #1) was diagnosed with dementia and psychosis and was allowed to be picked up by a transport van without hospital personnel in attendance.

Findings included:

(Patient #1's) ED (Emergency Department) note dated 07/12/12 timed at 19:09 PM reflected, "Mode of arrival ambulance...fall...complaints of left hip pain and right face pain...20:42 PM...patient fell off of bed while in ED, sustaining new injuries, swelling...right side of face...abrasion over the nose...22:28 PM...admit the patient for observation...diagnosis...dementia with psychosis, nasal bone fracture..."

The nursing note dated 07/12/12 timed at 22:14 PM reflected, "Patient is a fall risk...cognitive limitations...side rails up times two..."

The nursing note dated 07/13/12 timed at 00:06 AM reflected, "Admitted to medical/surgical unit via stretcher...in posey vest with four point restraints..."

The nursing note dated 07/13/12 timed at 10:00 AM reflected, "Restraint...chest vest...confused, disoriented, wandering...at 15:00 PM...discharged going to...Hospital B." No documentation was found which indicated hospital personnel escorted (Patient #1) and stayed with (Patient #1) until safely aboard van transport to Hospital B.

The discharge assessment dated 07/13/12 timed 12:36 PM reflected, "Resource center spoke with...(Hospital B) who stated patient will transfer at 15:15 PM...house supervisor notified..."

On 02/27/13 at approximately 02:05 PM Personnel #2 was interviewed. Personnel #2 was asked whether hospital personnel were supposed to escort patients and ensure they are safely assisted to the transport vehicle. Personnel #2 stated "No not typically."

On 03/06/13 at approximately 10:35 AM Transport Staff #10 was interviewed by telephone. Transport Staff #10 stated the transport company transports patients both by ambulance and/or a transport van. Transport Staff #10 stated the van driver went to pick up (Patient #1). (Patient #1's) spouse was in attendance. Transport staff #10 stated no hospital personnel were in attendance. He stated the van driver reported (Patient #1) got out of the wheelchair and went after her spouse. Transport Staff #10 stated it is assumed the patient has been assessed adequately and is capable of riding in the transport van.