HospitalInspections.org

Based on interview and record review, the facility failed to ensure that one of six sampled patients (Patient #1) fully participated in her discharge plan of care. The facility failed to:

? Verify and discuss family contact information,
? Assess and evaluate family support options, and
? Provide safe travel arrangements to return home.

Findings include:

TX 00209790

Record review of intake # 00209790 revealed statements by Patient #1 in which she described a fall at home on 05/13/14, followed by a call to 911 and transportation to the hospital. After tests were run, she was returned home in a cab despite her protest of the discharge and request for further treatment.

Record review of Patient #1's Emergency Department (ED) record dated 05/15/14 revealed an 89 year old who arrived by ambulance at 4:15 PM with complaints of back pain and generalized weakness following a fall at home.

Record review of Patient #1's x-ray of pelvis and bilateral hips and computed tomography of the left hip dated 05/15/14 showed degenerative changes with no fracture.

Record review of the Nursing Notes dated 05/15/14 at 7:30 PM revealed that Patient #1 was discharged home in a cab. Further review of the Nursing Notes failed to reveal documentation that staff attempted to contact her family at any time during this ED visit.

Interview on 02/11/15 at 03:00 PM with the Chief Nursing Officer (#52) revealed acknowledgements that Patient #1's disposition home should have been handled differently. There should have been family involvement in the discharge plan and a different mode of transportation should have been provided for her.

Interviews on 02/11/15 at 10:55 AM with ED Registered Nurses (#53, #54 and #61): all three stated that in this situation, Patient #1's family should have been contacted and the patient should not have been sent home alone in a cab.

Review of the facility policy titled "Patient Rights and Responsibilities/Provisions for the Disabled" dated 08/2012 reads, "1. The Patient has the right to: ... (b) Reasonable safety insofar as the hospital practices ... are concerned ... (f) Be involved in care planning and treatment ... (j) Have a family member or representative of his choice ... notified promptly of his admission to the hospital."