| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670031 | (X3) Date Survey Completed 10/27/2011 |
| Name of Provider or Supplier St Luke's Patients Medical Center | Street Address, City, State 4600 East Sam Houston Parkway South, Pasadena, TX | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| A0799 | DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that applies to all patients. The hospital's policies and procedures must be specified in writing. This CONDITION is not met as evidenced by: Based on record review and interview, facility failed to operationalize it's policy and procedure to ensure 1/1 unstable patients from a sample of of 10 patients was transferred from the facility to a hospital with appropriate specialized equipment and support measures which were medically appropriate to stabilize the patient and to sustain the patient during transfer. Finding : Review of patient #'1's clinical record ( Memorandum of Transfer) revealed the patient was transferred from hospital (A) to hospital (B) on 10/08/2011. Review of the patient's clinical record revealed no evidence of an assessment of the patient's condition immediately prior to transfer by the registered nurse or a physician. Review of the patient's clinical record revealed, the Memorandum of Transfer was not signed by a physician at the transferring hospital. There was no order in the patient's clinical record as to specialized equipment and support measures which are medically appropriate to stabilize the patient and to sustain the patient during transfer. Review of physician's progress ( from receiving hospital B) notes dated 10/08/2011 at 8:20 p.m. revealed the following assessment of the patient: "When patient came to the unit , obtunded, not following the command , tachypnic, very cyanotic, no peripherals pulse (+) cyanosis , dilated pupils not reactive." The progress notes further indicated that the patient had fixed pupils, not able to follow commands and the patient was intubated immediately. The patient was maintained on ventilator with vasopressors medications. Physician's progress notes at hospital (B) dated 10/10/2011 indicated that the patient had no spontaneous breathing, pupils were fixed and dilated and the patient was declared dead at 9:11 a.m. Cross reference A-0837 |