HospitalInspections.org

Based on review of medical record and documentation, the facility failed to ensure a patient's change in condition was recognized at the time of discharge from the hospital. This affected one patient of 10 patient records reviewed. The census was 390 patients.

Findings include:

Patient #1's medical record was reviewed and revealed the patient was discharged from the facility on 12/19/16 and transported by wheelchair off the floor at 4:00 PM toward the ED entrance for pick up by the patient's husband. The medical record contained an order to discharge the patient on 12/19/16 at 1:14 PM. The medical record revealed the patient received discharge instructions on 12/19/16 at 3:00 PM. Review of the medical record revealed vital signs on 12/19/16 at 3:35 PM were temperature of 98.1, heart rate 85, respiratory rate 18, blood pressure 132/84 and pulse oximetry of 98%. The patient became unresponsive during the transport to the ED entrance and no one recognized the change in the patient's condition until the patient's husband asked Staff H what was wrong with his wife.

Review of the facility's documentation revealed an interview with Staff J dated 12/20/16. The nurse and Staff H assisted Patient #1 to the wheelchair and Staff H proceeded off the unit. When Staff H was asked about the patient's appearance and behavior he/she stated that Patient #1 was leaning to his/her right side, which was a common position for Patient #1 to assume. Staff H also stated that the patient was quiet and did not respond to conversation, which was also his/her baseline. When asked about the last conversation Staff H had with Patient #1, Staff H stated "Prior to getting on the elevator." Once Staff H arrived to the Emergency Department entrance, he/she parked Patient #1 in the wheelchair near the inner-most glass doors and walked to the outer-most doors to look for Patient #1's husband's truck. Once the husband's truck came into view, Staff H wheeled Patient #1 toward the exit. At this time, the husband asked Staff H what was wrong with his wife, her head was back and her mouth was open. In response, Staff H wheeled Patient #1 back inside the inner-most glass doors and asked a nearby woman for help (who was later determined to be a nurse). Staff H and the woman checked Patient #1's pulse and his/her breathing and determined there was no pulse and Patient #1 was not breathing. Staff H and the woman then wheeled Patient #1 to the Emergency Department.

Staff J expressed to Staff H the importance of communicating with patients throughout the transportation process, for which she responded that Patient #1 did not like to talk, often, and this is why he/she did not pursue further conversation with him/her.

The Job Description of the Staff H, a Customer Care Partner, was reviewed. The job description stated the customer care partner contributes to patient safety by providing a safe environment for patients. The customer care partner observes patients throughout tour of duty and reporting unusual conditions to proper personnel. The job description included transporting and/or accompanying patients as needed.