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Based on record review and interview, the facility failed to preserve each patient's/family's right of an individual to request transfer into the care of a physician and a hospital of his own choosing for 1 of 12 patients (Patient #3), in that,

Patient #3's family asked multiple times to go back to the hospital (transfer) and the facility failed to act on their request.

Findings

~ 1/21/2022 14:24 Nutrition Initial Assessment ...son has stated that he wants to take patient AMA due to limited visitation, and nursing, case management have been working on this for several hours now. Two transporters have arrived, and both have declined the patient due to no emergent need ...able to feed himself ...

Against Medical Advice documentation:

~ 1/21/2022 AMA - patient/son decided to stay after talking to the doctor


~ 2/12/2022 AMA documentation signed

Physician Note:

~ 1/26/2022 Son came in earlier today and demaned (sp) to leave AMA and take the patient to (named acute hospital), son feels the patient is not getting better..

There is no physician note for 1/21/2022 or 2/12/2022 the describes the son wanting to leave.

Case Management:

~ 1/23/2022 8:58 spoke with pt's son Luciano on 1/21/22 at 1445 ...concerns he has about COVID visitation and his father's care ...Son has called at least 2 ambulance services to take his father out AMA (against Medical Advice) but they have all refused to do so. Son upset that they would not take him ...explained that the STACHs (Short term acute care hospital) are full and the ambulance personnel can not transport a patient to an STACH for a non-emergent reason ...

There were no case management or nurse notes regarding the 1/26/2022 complaint wanting to take the patient to (Named acute hospital).

The was no facility documentation (nursing, case management, etc) to act on the multiple requests and attempt to help the son transfer the patient.

There was no nurse documentation a physician had been notified about the patient leaving against medical advice on 1/21/2022, 1/26/2022, or 2/12/2022.

During an interview on 2/22/2022, Personnel #1 stated was asked about management of a patient who requests transfer. Personnel #1 stated there has to be a medical reason to transfer to higher care and someone has to accept him (patient). We were capable of caring for his (patient) needs.

During electronic record review and interview on 2/22/2022, Personnel #16 stated navigated the record and confirmed the findings and there were no physician notifications documented for the findings.

Personnel #3 stated the nurse should notify the Physician, take/implement any orders, and document.

Personnel #3 was asked if son asked for the patient to be transferred over and over. Personnel #3 stated yes, and agreed they had no documentation of attempts to transfer, attempts to affect a transfer, transfer denial by facilities, or other options.

During an interview on 2/22/2022 ending at 11:36 AM, Personnel #5 was asked about Patient #3's son asking for a transfer and saying the patient was not normal. Personnel #5 stated He (Son) said he wanted to take him (patient) AMA (against medical advice) in 30 minutes. He (Son) didn't ask me for a transfer.
I told him (Son) we had a full round of doctors to care for him (patient). He would say it was better over there (Named acute Hospital).

During an interview on 2/22/22 ending at 2:49 PM, Personnel #4 was asked about the 1/26/2022 incident with the son. Personnel #4 stated He (Son) wanted to take his dad to (Named acute hospital) He (Son) consistently said this through the admission.

Personnel #4 was asked if she called the facility to see if they would take him. Personnel #4 stated We may not have. We would need a doctor's order and a reason to transfer to a higher level of care. We would have told the son that. Against Medical Advice would have been discussed because he (patient) has to have a physician's order for a transfer to a higher level of care.

During an interview on 2/22/22 at 2:51 PM, Personnel #8 involved on 1/21/2022 was asked what the son complained about. Personnel #8 stated He felt dad wasn't getting care he needed. He was getting worse and wanted him to go AMA. I stepped in. Personnel #8 was asked if he wanted to take him home without oxygen or back to the hospital. Personnel #8 stated well yeah, He wants to go back to the acute hospital. He did not say the hospital name. Personnel #8 was asked if she called the doctor. Personnel #8 stated No. Personnel #8 was asked about her 1/21 - 1/23 documentation. Did you notify the MD. Personnel #8 stated No. Personnel #8 was asked if the doctor refused to transfer him. Personnel #8 stated the nurse said there was no clinical reason to transfer him. Personnel #8 was asked if she had called the hospitals to determine they were all full like her documentation stated. Personnel #8 stated No I just gave him an example of why they may not take him.

During a telephone interview on 2/23/2022 at 11:00 AM, Personnel #14 was asked about the son complaints on 1/21/2022. Personnel #14 stated He was upset and dialed 911 to have his father taken out to an ER. He (son) signed AMA papers. They (ambulance) came and told him we can't take him without a reason.
Personnel #14 was asked if she or anyone that she was aware of attempt to act on the patient request to transfer by calling a facility for acceptance. Personnel #14 stated No not to my knowledge.

During a telephone interview (214-205-1133) on 2/23/2022 at 12:00 PM, Personnel #17 was asked on 1/21/2022 you are the supervisor and the son complain. Personnel #17 stated He (son) wanted to return his - he (son) felt his father was - I can't remember - he (son) wanted to send him back to (Named acute Hospital). Personnel #17 was asked - send? - meaning transfer. Personnel #17 stated Yes.
Personnel #17 was asked if she or anyone she was aware of attempted to request to transfer by calling the facility for acceptance. Personnel #17 stated No I did not.

During a telephone interview (214-930-2147) on 2/23/2022 at 1:29 PM, Personnel #7 was asked about the son complaints on 2/12/2022 when she was the house supervisor. Personnel #7 stated I asked if he (son) was taking him AMA. He (son) said yes, I am. I asked why and he said because he (patient) is not getting rehab and getting worse here. He can't get up, could not feed himself.
Personnel #7 was asked if she went to see the patient. Personnel #7 stated Yes, I asked the patient if he (patient) was willing to leave with his son. He said oh yea.

During a telephone interview on 2/23/2022 at 4:01 PM, Personnel #6 was asked about the son wanting to transfer. Personnel #6 stated Son comes periodically. He (son) requests transfer for no reason. Not no reason, but not getting better. I told him (son) it takes time. He is stable. Not making a lot of progress daily. A few changes here and there. On Ventilator and high flow oxygen - oxygen issues every day. Improved, but not ready to discharge. I can't send him out without a reason.

It is very difficult to transfer during COVID. I told him (son) I can't prevent you from taking him. He (son) did that. Traditionally, if a patient is stable - I don't just transfer them.

Personnel #6 was asked about patient choice. Personnel #6 stated Yes, Patient choice. We did not initiate a transfer. No. I don't think so. My experience when we don't have a reason, they decline. Deny. It is considered dumping patient to other hospital.

Personnel #6 asked for my reference if it happens again, CMS core measures of quality metrics include length of stay and return to acute care. We are penalized if those numbers are too high. This is part of issue. We had no clinical reason to transfer. If we try to send back, they will decline him when there is no need, in my experience.

Based on record review and interview, the facility failed to ensure an RN supervised and evaluated patient care for 1 of 12 Patients (Patient #3), in that,

There was no wound care assessment, treatment, and follow-up for Patient #3's non-intact skin/wound related until 2/02/2022; AND

There was no nurse documentation of physician notification for Patient #3's non-intact skin/wound related; unable to place NG tube; and multiple requests to transfer/AMA (Against Medical Advice).

Findings

Patient#3's record:

The nurse documentation reflected ...skin not intact, wound related. There was no physician or wound care notification documented.

There was no wound care, wound care team assessment documented until 2/02/2022.

The 2/02/2022 Order for Normal Saline and foam dressing daily sacrum wound.

The 2/07/2022 Personnel #11 Wound Care Note ...deconditioned ...low braden score has developed sacral deep tissue injury ...partial thickness loss of epidermis. Bruising noted ...no maceration ...no drainage noted ...ordered air loss mattress ...turned on side q 2 hours ...

The attending Physician Notes did not document the non-intact skin/wound related, assessment, treatment, or consultation.

During electronic record review and interview on 2/22/2022, Personnel #16 navigated the record and confirmed the findings.

During an interview on 2/22/2022 ending at 11:36 AM, Personnel #5 was asked about being notified of the patient receiving a wound on his bottom while in care. Personnel #5 stated I don't remember a wound.

During a telephone interview on 2/23/2022 at 4:01 PM, Personnel #6 was asked if he was notified of a wound. Personnel #6 stated I don't think I was told.

Documented change of conditions for the whole stay:
~ 1/29/2022 refused 2nd NG tube placement - no physician notification documented, AND

~ 2/2/2022 desaturation documented by RT (Respiratory Therapy) - no physician notification documented

Against Medical Advice documentation:

~ 1/21/2022 AMA signed - no physician notification documented

~ 2/12/2022 AMA signed - no physician notification documented

Complaint :
1/26/2022 Patients son requested to speak to case management regarding transferring his father to (named acute Hospital)

During electronic record review and interview on 2/22/2022, Personnel #16 navigated the record and confirmed the findings.

During electronic record review and interview on 2/22/2022, Personnel #16 stated there were no physician notifications documented for the findings. Personnel #3 stated the nurse should notify the Physician, take/implement any orders, and document.

Personnel #3 was asked if the son asked for the patient to be transferred over and over. Personnel #3 stated yes, and agreed they had no documentation of attempts to transfer, attempts to affect a transfer, transfer denial by facilities, or other options.

During an interview on 2/22/22 ending at 2:49 PM, Personnel #4 was asked about the 1/26/2022 incident with the son. Personnel #4 stated He (Son) wanted to take his dad to (Named acute hospital). He (Son) consistently said this through the admission.

During a telephone interview on 2/23/2022 at 4:01 PM, Personnel #6 was asked about the son wanting to transfer. Personnel #6 stated Son comes periodically. He (son) requests transfer for no reason. Not no reason, but not getting better.