HospitalInspections.org

Based on review of documentation and interviews with staff, the facility failed to ensure timely referral of concerns expressed by a family member of 1 of 1 patient whose record was reviewed. Patient #1's family informed staff on at least 2 occasions about difficulty contacting the patient and the patient's hospital caregivers; however this issue was never reported as required by facility policy.

Findings were:

Facility policy RIS-625, entitled, Patient and Customer Complaint or Grievance, last reviewed by the facility on 9/16/11, states under section 2(a), that the facility defines a complaint as an issue that cannot be immediately resolved to the customer's satisfaction by the staff. Section 2(c) continues the definition of a grievance as an issue in which the customer is not satisfied with previous actions taken.

Facility policy CM-101, entitled, Case Management Services, last reviewed by the facility in October of 2008, states under section D(c)(2) and D(c)(3) that the hospital identifies possible barriers to implementing a plan of care for patients, including barriers to patient and family education and involvement and participation in the plan of care. The policy indicates that barriers can impede progress to obtain goals.

Review of the medical record of Patient #1 revealed that the patient was admitted to Healthsouth Plano Rehabilitation Hospital on 9/28/2011 at 5 pm. Upon admission, the admitting physician dictated a History and Physical report (H&P). In this report was a plan for the care of Patient #1, including a referral to case management for patient/family supportive counseling. The Patient/Care Giver Education Record includes each therapist and discipline's record of instructions to patients and families. On 9/29/11, the physical therapist documented that the goals of treatment, schedule of treatment, role of discipline, and safety/precautions were "understood by the patient." The patient was documented as "confused" and/or "forgetful" during the inpatient stay; however, the therapists indicated that the patient understood the goals for therapy. The areas that indicate the family demonstrated understanding, are either marked "No" or "NA" (not applicable). Additionally, the therapists' marked the area "Needs Family Contact" as "NA."

According to the family member's written complaint to the TX Department of State Health Services (DSHS), attempts were made to contact the patient and nursing staff several times during the inpatient stay. The patient was admitted the evening of 9/28/11, and family contact information, including telephone number, was in the admission documentation; however, no staff member notified the family of the admission on 9/28/11. The complainant stated that contact was not made until the evening of 9/29/11. It was also reported that daily calls were attempted, both to the nursing station, nursing supervisor and patient, but the family member was unable to gain information; the patient was lethargic and unresponsive to the phone calls. In the written complaint, the family member describes talking to nursing staff in tears while explaining that contact couldn't be made with the patient or caregivers regarding the patient's condition. These grievances were not reported to administrative staff per facility policy and procedure.

An in-person interview was conducted with the Director of Care Management, Staff #3 at 2:30 pm, 2/1/12, in a facility conference room. Staff #3 stated that no grievance had been filed on behalf of Patient #1's family regarding concerns voiced to nursing staff about contact with and obtaining information about Patient #1.

An interview was conducted with the CNO, Staff #2, at 4:15 pm on 2/1/12. Regarding the hospital's complaint and grievance process, the CNO agreed that at least 2 staff members were aware of Patient #1's family member's frustrations, and did not report the issues to the correct staff members who could have handled the problems per facility grievance policy.

Based on review of documentation and interview with staff, the facility failed to provide evidence that necessary medical information accompanied 1 of 1 patient to an off-site appointment. Patient #1 was transported to an appointment and subsequently admitted to another acute care facility, and it cannot be determined if pertinent clinical information from Healthsouth was communicated to that facility.

Findings were:

An interview was conducted with the CNO, Staff #2, at 3 pm on 2/1/12. Regarding the issue of transport to the VA clinic, Staff #2 stated that Patient #1 had a long-standing appointment and didn't want to miss the appointment. The CNO indicated that often the patients in the rehab hospital have other appointments outside the facility and they are taken to the appointments with a packet of clinical information from Healthsouth. Staff #2 stated that it depends on the appointment what is sent with the patient, but usually is history and physical, vital signs, and other pertinent information that the clinic may need. These patients are brought back to Healthsouth after their appointments. The CNO indicated that a packet is always sent, but there is no documentation that one was sent with Patient #1, or what the packet contained. It was unknown for certain if the VA had clinical information from Healthsouth when they decided to admit Patient #1 directly from the clinic appointment. There was no documentation in the record that the VA attempted to contact the facility to obtain records or that Healthsouth contacted the VA with clinical report.

According to the family member's written complaint to the TX Department of State Health Services (DSHS), Patient #1 had an appointment with an outpatient clinic at a VA Hospital. The complainant stated that when patient #1 arrived on 10/6/2011, there was no accompanying paperwork with clinical information from Healthsouth. Patient #1 had been a patient of Healthsouth since 9/28/11 and had not yet been discharged from the facility. The patient was subsequently admitted to the VA hospital.

A review of the medical record revealed that nursing notes written on 10/6/11 state at 6:10 am, the patient was "picked up for transportation to VA in Dallas for an appointment ..." There is no documentation that a packet of clinical information accompanied the patient. The medical record does not document that efforts were made to contact VA in order to give clinical report.