HospitalInspections.org

Based on interviews and record review, the facility failed to ensure patients' discharge plans were re-evaluated and updated to reflect occurrences at the facility, which could have augmented patient's post-discharge care and follow-up needs. As a result, the patients were not provided comprehensive follow-up instructions post-discharge (Patient ID #1 and 2).

Findings included:

Record review of HHSC intake submitted via email 8/29/23 by complainant for patient ID #1 stated "at some point (Patient ID #1) became unconscious (unattended in the bathroom) ... and awoke on the bathroom floor on the right side of (her) face .... The procedure occurred as scheduled .... (Patient ID #1) was not referred to any other medical care for follow-up for any complications that might result from the fall ... in the bathroom."

Record Review of Patient ID #1 medical record for date of service 8/18/23 performed with Clinical Director Staff ID #58. The entry dated 8/18/23 07:59 am by Staff RN ID # 69 record for Patient ID #1 stated "Pt went to restroom prior to getting dressed. She reports sitting on toilet, dry heaving and says she woke up laying on the floor. VS obtained in bed and WNL. States feeling better but still nauseous. Pt remains alert and oriented without contusion. Notified anesthesia who assessed patient at bedside. IV started and fluids." Patient ID #1 Discharge Instructions with date of service 8/18/23 revealed focused discharge instructions prepared by physician Staff ID #70 which related specifically to the post-colonoscopy care. These instructions failed to instruct patients to follow up with their primary care physician, emergency department, the facility or any other health care entity should new signs and symptoms occur.

Record review of Patient ID #2 medical record and quality records with Performance Improvement Specialist Staff ID #59. She confirmed facility quality records showed Patient ID #2 sustained a fall while in the facility for outpatient surgery care. There were no fall precautions, return to care or facility follow-up care or information provided at discharge.

Interview 10/12/2023 2:15 pm with Chief Nursing Officer Staff ID #52 revealed the facility did not have a discharge policy and procedure which applied to the outpatient surgery/procedure area. She confirmed that she would expect discharge instructions for patients who received anesthesia, at a minimum, to include fall precautions, general post-anesthesia teaching and general instructions for return to care.