HospitalInspections.org

Based on staff interview and medical record review the facility failed to provide coordination of assessments and patient condition regarding the appropriateness of treatment and failed to evaluate the results of the treatment for 1 (Patient #2) of 4 patients sampled.

The findings include:

Medical record review for Patient #2 revealed the patient was admitted to the hospital for acute care on 6/29/10. The patient was subsequently admitted into The Rehabilitation Hospital on 7/2/10 and received rehabilitation therapy until discharged on 7/19/10. The patient was admitted after sustaining a fall onto her/his right hip. The patient was admitted with a displaced fracture of the right hip. This was non-surgically treated and orthopedic rehabilitation was initiated during this admission. The history and physical (H&P) dated 7/2/10 outlines previous medical history including a successful rehabilitation hospitalization in April after a left hip fracture with surgical hip replacement. The H&P also documents a review of the systems including the psychiatric impression and the neurological status on admission. The psychiatric assessment states "No increased nervousness, mood changes, or depression. Coping well." The neurological assessment at admission refers to the review of mental status. Mental status at admission states "The patient is awake and alert. Her/His speech is fluent. She/He has intermittent resting tremor at both extremities. There is no cogwheel tone noted (ridged muscle tension which produce jerk like motions with passive (non voluntary or assisted) muscle stretch. She/he has fairly good eye blinking but mask like facies (face). There is no psychosis."

The medical record contains the functional assessment dated 7/3/10. This facility document reveals the cognitive (mental) status documents the ability to "express complex ideas relatively clearly or with mild difficulty." The neurological assessment does not identify significant findings.

On 7/4/10 the physician order included documentation of new medication orders. The review of the occupational therapy notes dated 7/5/10 comment to the mental status of the patient at 8:38 a.m. The occupational therapy (OT) notes states "Pt (patient) not oriented this AM (morning), pt. very confused and had difficulty with following 1 (one) step commands." The afternoon OT notes document the "Pt. is very fatigued and had difficulty staying on task and keeping eyes open. A Physical Therapy (PT) note dated 7/8/10 documents the "Pt. grabbing for "the rabbits." The patient is documented as saying "Help those people -They are drowning..."

The PT note does not contain documentation communicating these behaviors to the physician nor to rehabilitation nurse. During the OT session on the same date, the OT session note documents "Pt. c/o (complains of ) 8/10 (eight out of a ten scale for pain) pain nursing (insert nurse name) notified. Pt. also hallucinating and verbalizing things things that are not appropriate."

A review of the nursing notes for 7/8/10 do not document the occurrence or follow up regarding the "hallucinations". The Team Conference Notes documented on 7/13/10 has the written entry "Hallucinations" and in a later written entry stated "Dr. explained pt. may have been reacting to infectious process not antibx (antibiotic)." The medical record does not document evaluation of an infectious process, or a psychiatric consultation.

The pharmacy records document the following antibiotic therapy:
Bactrim/septra DS 160/800 mg 1 tablet by mouth antibiotic therapy Start date 7/10/10 Stop date 7/11/10.
Cephalexin 500 mg / capsule po per day times 4 doses. Start date 7/13/10 Stop date 7/16/10.
Tetracycline 250 mg / capsule by mouth Three times a day Start date 7/12/10 Stop date 7/13/10.

Further review of the medical record revealed the patient continued to demonstrate "Hallucinations" as documented on the PT notes for 7/14/10. The OT notes of 7/14/10, 7/15/10 and 7/18/10 contain continued documentation of increased sleepiness, confusion, and hallucinations. The OT nor the PT department documented the notification of the nurse or the physician during these therapy sessions.

The rehabilitation nurse manager reviewed the medical record on 9/14/10 at 3:10 - 4:25 p.m. The rehabilitation nurse manager confirmed the facility failed to provide a coordination of care regarding the change in mental status from the baseline admission assessment by stating "The patient was confused intermittently on the floor. I do see a progression of escalating symptoms, including confusion and hallucinations during rehabilitation therapy sessions. I also see the symptoms start to decline after medications were changed. Regretfully this is late in the hospital stay." The rehabilitation nurse manager continues by stating "I can see that there was a lack of coming together as an interdisciplinary team regarding this patient. All of the departments added their pieces of assessment but they did not come together until the end." The rehabilitation nurse manager stated "There was a lack of communication here." When asked about the therapy session which documented nursing was notified of the sleepiness, hallucinations, and pain levels demonstrated by the patient, the rehabilitation nurse manager commented the nursing documentation does not include follow up to this observation in therapy, and continued by stating "I do not see any documentation which states there was follow up. Again, I would say the communication between the departments did not come together. This is unfortunate, but I agree I do not see the communication or follow up."