Cleveland Clinic Rehabilitation Hospitals LLC

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45753 Based on record review, interview and policy review, the facility failed to ensure a patient was sent to an appointment with assistance and proper transportation for return to the facility. This affected one (Patient #6) of ten patients reviewed. Findings include: Record review revealed Patient #6 was admitted on 09/18/24 and discharged on 10/04/24. Patient #6’s active problem list was traumatic spinal cord injury and status post right knee fluid removal. Review of the fall risk assessment revealed Patient #6 was at high risk for falls. Patient #6 was incontinent of bowel and bladder. Review of the activities of daily living evaluation dated 09/18/24 revealed Patient #6 was alert and oriented, mobilized with wheelchair and required assistance for all transfers and toileting. Patient #6 was high risk for falls. Review of the nurse practitioner orders dated 09/18/24 at 3:00 PM revealed Patient #6 was to be scheduled for a urology appointment on 09/25/24. Review of the physician orders dated 09/19/24 at 8:12 AM revealed transportation was to be scheduled for appointments at the main campus outpatient facility. Review of the Physical Therapy (PT) evaluation dated 09/19/24 revealed Patient #6 required moderate assistance of one for standard wheelchair mobility and transfers. Review of the Occupational Therapy (OT) evaluation dated 09/19/24 revealed Patient #6 required maximum assistance of 76 percent or more for toileting and moderate assist of 51 percent or more for transfers. Review of the outside appointment questionnaire completed on 09/24/24 and reviewed by nursing supervisor documented the patient was leaving the facility for a doctor appointment, mobilized with wheelchair and transported by medical van. Patient #6’s safety considerations were documented as requiring a seat belt for safety. The questionnaire documented that monitoring or observation of staff or family was not required. Safety considerations present on checklist included impulsive, high fall risk, unable to make own decisions, restraints, and other; no other safety considerations was documented as part of the assessment. Review of the therapy notes documented on 09/24/24 that moderate assistance was required to transfer Patient #6 from wheelchair to toilet using grab bar and moderate assistance was required for hygiene. Review of the pain assessment dated 09/24/24 at 3:45 PM revealed pain was rated eight out of ten on a one to ten scale. Patient #6 described pain orientation to the right knee as ongoing, constant, and continuous. Review of the patient tracking log dated 09/25/24 revealed Patient #6 signed out at 9:00 AM and signed back into the facility at 4:53 PM. During an interview on 11/18/24 at 12:05 PM, Case Management Director Staff E stated Patient #6 was to attend a urology appointment on 09/25/24 for frequent incontinence and had reached out to the nurse practitioner for a definitive answer about Patient #6 attending the urology and cardiology appointments. Staff E stated Patient #6’s caregiver had attended a care partner meeting on 09/23/24 and family training on management of Patient #6’s personal care needs with the treating physical therapist. Staff E stated the caregiver was to cancel the second out patient appointment for cardiology on 09/25/24; however Staff E confirmed she did not document this or follow up with the caregiver regarding cancellation of the outside appointment. Staff E confirmed she did not cancel the appointment and arranged transportation to and from the urology appointment only. Staff E confirmed no food or hydration was provided nor was education provided in regard to the operation of chair alarm, and confirmed she did not follow up with the transportation company. Staff E confirmed she did not cancel the cardiology appointment. Staff E stated a “red coat”, a hospital volunteer, wheeled Patient #6 from the urology appointment to the cardiology appointment in another building. Patient #6 self-propelled wheelchair back to main lobby where she was unable to call transportation company for pick-up. During an interview on 11/18/24 at 2:10 PM, Nurse Practitioner Staff C revealed Patient #6 had a urology appointment for neurogenic bladder and left the hospital with a seat belt and chair alarm in place to the wheelchair. Staff C confirmed orders were placed for appointments and to schedule round trip transportation. During an interview on 11/18/24 at 2:32 PM, Patient #6’s caregiver stated he attended the care conference and verified being aware of physician appointments on 09/25/24 with the urologist and cardiology. Patient #6’s caregiver stated he there was a mix up with the transportation and he then traveled to main campus to pick up Patient #6, however he was unable to deactivate the wheelchair alarm. He did not know what to do and Patient #6 had to wait for transport to come back and pick her up. He stated Patient #6 was unable to transfer on her own and was unable to use the bathroom while out of the facility. Patient #6 did not eat or drink while out of the facility. Patient #6 called her adult child for transportation because Patient #6 did not have a phone number to the transportation services or the rehabilitation facility. During an interview on 11/18/24 at 2:35 PM, Physical Therapist Staff G stated the therapy care partner meeting was focused on functional status and was not focused on the outpatient appointments. Staff G confirmed Patient #6 was a high fall risk and required assistance of another for transfer and mobility. Review of the “Guidelines for the Management of Outside Appointments/Diagnostics”, undated, documented during Team Conference, the clinical and case management team will discuss outside appointments for impact on the patient’s plan of care. If an appointment is deemed necessary, the physician will be notified to enter the order. A physician’s order is required for all outside appointments and diagnostic testing. Transportation type and level of monitoring are dependent on patient mobility, safety and clinical risk factors. Family transport and monitoring should be considered an exceptional event that is limited to a small subset of patients. Because of the risk of injury associated with a fall, dislodgement, elopement, these patients should be considered for observation/monitoring at outside appointments. Impulsive, poor safety awareness, sitter in place for safety or suicide precautions, restraints, unable to make own decisions. Prior to transport, clinical staff should consider the needs of the patients during the outside appointment (i.e. snack for diabetic patients, Roho cushion for at risk patients, etc.). Clinical judgement is required to determine the level of monitoring required during an outside appointment. This decision is made with the collaboration of the physician, nursing supervisor, and clinical staff (including but not limited to nursing, therapy, RT). Prior to the appointment, the nurse should document the following information in a nursing note: Patient assessment, person receiving handoff, transport type/company, mode of transportation (wheelchair, stretcher), and time patient left the hospital. After the appointment, the nurse should document the following information in a nursing note: Time patient returned, information received from the outside facility, and brief assessment of patient’s condition upon return.”