HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to follow the facility grievance policy by not entering the grievance in the electronic system and by not having a belongings list on admission in the electronic health record for one (1) of five (5) Patients. (Patient # 1)

The findings include:

On March 7, 2023, a review of the Clinical Record for Patient # 1 revealed the following:

Routine Process Addendum dated October 20, 2022 at 12:30 p.m. reads in part "
Patient told the Physical therapist that [Patient] lost lower dentures, phone charger and bottle of scope mouthwash while in rehab. This writer was made aware of this and a call was placed to ARU (Acute Rehabilitation Unit). Spoke with [Staff Member] and informed that would check and call back. The patient was made aware that this writer had reached out to the ARU staff.

1:30 p.m. - Another therapist told this writer that the patient lost lower dentures, phone charger and a bottle of scope mouthwash.

3:30 p.m. - Called the ARU again and spoke with [Staff Member], at this time [Staff Member] informed this writer that would call back.

3:45 p.m. - [Staff Member] called back and said that the patient's [family] came and took personal items. Informed the patient what the ARU staff said the patient replied that [family] didn't have the items that could find.

4:00 p.m. - Security called at this time to see if there was a report on missing items for this patient. The security informed this writer that they didn't have any items reported for this patient.

4:05 p.m. - The supervisor was called concerning this matter and informed this writer to call the Patient's Advocate and leave a message with the patient's name, address and items missing.

5:00 p.m. - Nurse manager made aware of this situation.

5:30 p.m. - patient discharged and left personal cell number for patient advocate to call."

The After Visit Summary (AVS) dated October 20, 2022 at 4:57 p.m. reads in part "The following personal items are in your possession at time of discharge. Dental appliances: lowers, uppers with patient. Visual aid: Glasses Home Medications: none Jewelry: Earrings Clothing: footwear, shirt, socks Other valuables: Cell Phone, Eyeglasses."

There was no documentation of belongings on October 14, 2022; admission to acute rehab unit.

On March 7, 2022 at 2:00 p.m., an interview with Staff Member # 7 revealed "There is no record of a complaint from this patient."

On March 7, 2022 at 2:10 p.m., an interview with Staff Member # 2 revealed "The nurse manager for the unit is no longer here; left in November. I am covering and have no knowledge of the [Patient # 1] complaint."

Staff Members # 2 and # 7 agreed the process for lost items was to report to Patient Advocate. Patient Advocate would reach out to Nurse Manager to do a search. Patient Advocate would follow up with Patient.

On March 8, 2023, a review of the facility policy titled "Patient complaint and grievance" reads in part "Upon receiving a complaint from a patient or duly authorized representative, every effort will be made to resolve the issue at the time of the complaint.
Grievances submitted in writing, verbally, email, fax or website shall be entered into the electronic event reporting system.
The investigation of the grievance shall be conducted by the manager or director of the area involved in collaboration with the patient advocate/delegee.
Grievant must receive a written response which shall promptly be made within the average time frame of seven (7) days."
The policy titled "Patient Belongings/Valuable in Non-behavioral Health Areas" reads in part "Staff will document belongings in the electronic health record (EHR).

On March 8, 2022, the findings were discussed with Staff Members # 2, # 3 and # 11 during the exit interview.

Based on document review and interview, it was determined that the facility failed to provide care and services to prevent over sedation for one (1) of five (5) Patients. (Patient # 1)

The findings include:

On March 7, 2023, a review of the Clinical Record for Patient # 1 revealed the following:

The History and Physical (H&P) dated October 15, 2022 reads in part "Admission date October 14, 2022. [Patient # 1] with history of HTN (hypertension), COPD (Chronic Obstructive Pulmonary Disease), CAD (Coronary Artery Disease), presented to [Name of facility] after onset of weakness worse in lower extremities, initially family called ambulance pt declined to go to ER (Emergency Room) however symptoms worsened overnight was not able to ambulate and so went to ER for evaluation. [Patient] was found to have acute CVA (Cardiovascular Accident). Neurology consulted and was started on aspirin, plavix and statin therapy.
The Patient had remained hemodynamically stable but due to the above events, the patient was noted to have impaired mobility and ADLs (Activities of Daily Living). Patient was felt to be a good candidate for acute inpatient rehabilitation. Upon evaluation by Physical Therapy and Occupational Therapy, the patient was recommended for acute inpatient rehabilitation. The was discharged and was subsequently admitted to [Name of Facility] for Physical Rehabilitation by intensive rehabilitation to help recover strength, function and mobility."

Home Medication list includes "Morphine 20 mg CERP (controlled release), 60 mg daily and
Baclofen, 20 mg by mouth three (3) times daily."

The Medication Administration Report reads in part "Baclofen 20 mg, 3 times daily, Morphine ER (extended release), 30 mg, 4 times daily and Morphine IR (immediate release) 15 mg, every 6 hours as needed.
On October 17, 2022 at 2:43 p.m. and 6:06 p.m. Morphine ER 30 mg, held, Pt drowsy."

Progress note dated October 17, 2022 at 10:58 p.m. reads in part:
"10:45 p.m. - Patient remains drowsy with confusion V/S (Vital Signs) Temp (Temperature) - 98.3, BP (Blood pressure) 133/80, O2 (Oxygen) sat (saturation) RA (room air) - 95 %, HR (Heart rate) - 66, BS (blood sugar) - 137. [Family] at bedside. [Physician Name] notified of patient's condition. Advised to call RRT (Rapid Response Team)
10:58 p.m. - RRT called
11:02 p.m. - RRT arrived
11::11 p.m. - Narcan 0.2 mg IV administered as ordered
11:23 p.m. - Zofran 4 mg given for c/o (complain of) nausea
11:30 p.m. - [Physician Name] spoke with resident
11:45 p.m. - Transported to ER per WC (wheelchair) with RN (Registered Nurse). Report give to the ED (Emergency Department)."

ED provider note dated October 17, 2022 at 11:55 p.m. reads in part "Give 0.4 Narcan in the Ed and became irritable, alert, oriented to person, not oriented to time no focal deficits on neuro exam. Pt resting comfortably in bed, cooperative with exam intermittently. Resting, sleeping. Pupils pinpoint, reactive.
Possible that pt was over medicated earlier today and was not exhaling CO2 (carbon dioxide) well as a cause of AMS (altered mental status).

Neurology progress note dated October 18, 2022 at 10:59 a.m. reads in part "[Patient # 1] admitted for rehab following a stroke. Had become progressively delirious during this admission and think it is quite clear that encephalopathy (brain disease that alters brain function) was most likely due to hypercarbia (increase in carbon dioxide) and hypoxia (decrease in oxygen) perhaps due to respiratory depression from narcotics. Hypercarbia will commonly cause myoclonus (muscle jerks). Also an increased WBC (white blood count) which could indicate an occult infection. Also polycythemic (high concentration of red blood cells) which can be a response to hypoxia. I have no concerns for a new stroke."

On March 7, 2023, an interview with Staff Members # 4 and # 6 revealed "[Patient # 1] received two (2) doses of Narcan. One dose on Acute Rehab Unit and One dose in the ED."

On March 8, 2023, an interview with Staff Member # 2 revealed the morphine dose was more than what [Patient # 1] was receiving at home.

On March 8, 2023, the findings were discussed with Staff Members # 2, # 3 and # 11 during the exit interview.