HospitalInspections.org

Based upon record review and interviews, the facility failed to ensure patients received care in an environment that provided safety.
a) The facility failed to ensure that a policy or procedure was implemented for transportation of patients outside the facility who are unattended by staff.
b) The facility failed to ensure that patients received an assessment, prior to transportation and an assessment upon return, while unattended by staff outside the facility and failed to document the pre and post-transportation assessment in 4/4 patients reviewed (Patient ID #2, 14, 15 and 16).

Findings Included:

Record Review:
HHSC Intake received via telephone on 9/23/2020. The complainant stated "the facility neglected (Patient ID #2) by failing to provide adequate care and by not sending a healthcare professional to accompany her to a scheduled doctor's appointment. She was transferred on a van. She and the driver were the only individuals on the van. The driver left the patient at the doctor's appointment ..."

Record review of facility's "Patient's Rights and Responsibilities" policy, last reviewed 11/1/2022, stated "2. All patient care and patient related functions shall be delivered in a manner consistent with the 'Patients' Rights and Responsibilities'."

Record review of facility's "Acknowledgement of Receipt of Patient Rights and Responsibilities", revised on 11/7/2018, stated "As our patient, you have the right to safe, respectful and dignified care at all times." It further stated "Care Delivery: You have the right to: Receive care in a safe setting ... Receive kind, respectful, safe, quality care delivered with the highest quality of service."

Record review of facility contract provided by Controller Staff ID #57 on 7/13/2023 at 09:20 am. The contract is labeled Non-Emergency medical transportation service agreement". It stated that the "Provider shall provide properly staffed and equipped vehicles necessary to accommodate patients needs for transportation. Both parties recognize that the responsible physician must determine that it is safe and appropriate for patient to travel to and from the Hospital in Provider's vehicle."

Record review of "Midnight Census Report" with DON Staff ID #51 and Nurse Manager Staff ID #54 completed on 7/13/2023 at 2:00 pm. They confirmed:
a) Patient ID #14 left the facility via wheelchair transportation service on 6/29/2023 at 09:31am for an orthopedic appointment and returned on 6/29/2023 at 12:30pm.
b) Patient ID #15 left the facility via wheelchair transportation service on 6/6/2023 at 09:21 am for an orthopedic appointment and returned on 6/29/2023 at 2:15 pm.
c) Patient ID #16 left the facility via wheelchair transportation service on 6/26/2023 at 2:25 pm for an "appointment" and returned on 6/29/2023 at 6:30 pm.

Record review of electronic medical records with DON Staff ID #51 and Nurse Manager Staff ID #54 completed on 7/13/2023 at 2:10 pm. They confirmed that patient ID #2, 15 and 16 did not have adequate nursing assessments performed/documented prior to leaving the facility and upon return. They confirmed that patient ID # 14 had left the facility for 2 hours and 59 minutes and did not have pain reassessment performed upon return. The physical therapist staff ID #63 note entered 6/29/23 at 1:36 pm (approximately one hour after her return) documented a pain assessment of "6" and need for pain medication administration.

Interview 7/13/23 at 11:55 with DON Staff ID #51. She confirmed the facility had no specific policy or procedure regarding transportation of patients outside the facility for appointments or testing. She confirmed it was the expectation of facility leadership that patients receive a nursing assessment, prior to leaving the facility and upon return to the facility. She stated she would expect this assessment to be documented in the medical record.

Interview 7/13/23 at 09:45 am Case Manager Staff ID # 53. She explained the case management process for arranging appointments. She stated when an appointment time is obtained that the case managers coordinate with the medical team the most appropriate transfer method. She stated for wheelchair bound patients, they currently use "Delta Wheelchair" transportation company. She stated the family/next of kin are notified of the appointment time and invited to attend. She stated that they could ride with patient on transportation van, meet patient at the appointment or sometimes the patient goes alone. She confirmed there is no facility staff accompanying patients to appointments.

Interview 7/13/2023 at 10:25 am Staff RN ID # 67. She was interviewed regarding process for patients going to physician appointments. She stated that case management arranges appointment time, transportation method and provides a packet to the unit secretary. She stated the van driver comes onto the unit and retrieves packet of papers from unit secretary that go with patient to appointment (face sheet, medication list, history and physical and labs). She stated we will "tell them if they're confused or if they can't eat something." She confirmed no official report is provided to them or anyone else. She stated the nurses do a "quick focused assessment" before patient leaves and when they return. She confirmed there were no staff members or facility personnel accompanying patients to appointments.