HospitalInspections.org

Based on record review and interview the hospital failed to provide care in a safe setting in that the hospital transferred 1 of 1 (Patient #7) minor patients to an outside hospital without a sitter and without calling report to the receiving facility.

Findings included:

Patient #7 was a 16. year-old minor patient that had been admitted on 04/20/22 with high risk behavior and a history of running away from foster homes. The patient was assaulted by another patient on 04/21/22 and transferred to an outside medical hospital for treatment. The facility failed to call report to the outside hospital and failed to send a sitter with the patient.

During an interview on 05/05/22 ending at 1235 Personnel #1 stated the facility did not have a policy related to the transfer of a minor, but the minor should have been accompanied by a sitter. Personnel #1 verified there was no documentation the facility had called a report to the outside facility until 04/22/22. During a follow up telephone interview on 05/09/22 at 1010 Personnel #1 stated the House Supervisor on duty verified the patient was transferred without a sitter.

Based on record review and interview the hospital failed to maintain an accurately written medical record in that 1 of 1 (Patient #7) patient's medical record did not evidence the patient was admitted to an outside facility for injuries related to an assault. The facility failed to initiate a new medical record when the patient was returned to the facility 26 hours later.

Findings included:

Patient #7 was a 16-year-old female that was admitted on 04/20/22 for risky behavior, suicide attempt and a history of running away from foster homes. The patient was assaulted by another patient on 04/21/22 and transferred to an outside hospital for treatment at 2135 on 04/21/22. The patient was returned to the facility on 04/23/22 at 0000. The Physician Daily Progress Note from 04/23/22 through 04/28/22 when the patient was discharged did not evidence the patient had been assaulted and transferred to outside facility for medical care. The Medical Progress Note did not evidence the patient had been assaulted and sent to an outside facility for care.

During an interview with 05/05/22 ending at 1235 Personnel #1 verified the medical record did not contain documentation of the patient's assault and transfer. Personnel #1 stated this patient was admitted to the outside facility and this patient should have been discharged from the facility and a new chart started when the patient was returned to the facility.

The Policy titled Patient Transfer/Medical Emergency revised 01/2020 reflected..."Section 4...f. Documentation...a. Progress Notes are to include time, details of incident...d. If admitted to another hospital, patient is discharged..."