HospitalInspections.org

Based on record review and interview, the hospital's governing body failed to ensure a system was in place to evaluate the quality of the hospital's Contract Services to assure that each contracted service was provided in a safe and effective manner. This deficient practice is evidenced by failing to ensure 1 (#3) of 5 patients being transported by a contracted transportation company were protected from injury or harm.

Findings:

Record review on 10/03/17 at 8:30 a.m. revealed patient #3 had dialysis three times a week on Tuesday, Thursday and Saturday. Patient #3 was admitted to the rehabilitation hospital to improve her overall function and mobility with Occupational therapy to assist with activities of daily living, mobility, and transfer with observation precautions.

Review of the contract with transportation company "a" dated 12/04/14 revealed under Appendix "A" 4. Provider agrees to transport the patients of center in a safe and timely manner.

Review of the Incident Event Log from April 2017 to present revealed on 06/03/17 patient #3 had an injury from a fall resulting in a fracture of lower extremity.

Review of the Electronic Incident Report dated 06/03/17 revealed patient #3 had a fall at 5:40 p.m. off hospital premises while being transported to dialysis by the contracted transportation company. Dispatcher notified hospital patient #3 fell from wheel chair in van on route to dialysis. Fall not witnessed by hospital staff, and patient not present for or able to be interviewed.

Interview on 10/03/17 at 11:15 a.m. with S1Administrator verified that the hospital failed to document any formal investigation of the incident for patient #3 on 06/03/17.

Interview on 10/03/17 at 8:30 a.m. with S4RN confirmed that he remembered the situation concerning patient #3 falling in the van during transport on 6/3/17. He said at first he stated that the transportation dispatcher had stated that the patient fell in the van because the wheel chair had not been secured and locked, and an ambulance was called and transported the patient to dialysis. S4RN further stated that the contracted transportation company supervisor brought the wheel chair back to the hospital and had claimed the wheels were bent as the reason why the patient fell. S4RN remembers looking at the wheel chair and found nothing to be wrong with the wheels or the frame of the wheel chair and tagged it for maintenance. S4RN further stated he then called dialysis and discovered that the patient was not there and called the hospital and located the patient in the ED.

In an interview on 10/02/17 at 1:15 p.m. with S3Quality Director, she gave surveyor copy of hospital policy titled Transportation to Physician/Clinic Office or Special Procedures, Number 2.400, revised 02/17 that revealed in part: Provide guidelines for arranging transportation of patients to Physician/Clinic appointments or Special Procedures. S3Quality Director confirmed the policy did not reflect how the hospital maintain and protect the patient from injury or harm during transportation. S3Quality Director further stated that there was no documentation to reflect the contracted transportation services were evaluated in the hospitals Quality Assurance program to monitor the safe and timely transportation of patients.