HospitalInspections.org

Based on policy review, document review, medical record review and interview, the nursing staff did not document medication error incidents in the medical record per facility policy for 2 of 3 patients(Patient #6 and #7).

Findings Include:

Review on 07/24/18 of policy "Incident Reports and Investigations" last revised 03/18 indicates that medical record documentation should include a factual account of the incident, date and time that the provider/supervisor/family were notified, follow up care, observations and response to treatment.

Review on 07/24/18 of the Facility Quality Assurance Event Log from 12/23/17 to 05/20/17 revealed 25 medication events. Three of these events were randomly selected and tracked through quality assurance process.

Medical record review on 07/24/18 revealed no documentation of the medication error incidents that occurred on 05/14/18 for Patient #6 and on 12/26/17 for Patient #7.

Interview on 07/24/18 at 01:00 PM with Staff (E), Directotr of Quality Assurance, verified the lack of medical record documentation of the medication error incidents.

Based on medical record review and interview, the facility did not provide a written copy of Resident Rights to the patient when their status changed from hospital inpatient to swing bed status in 2 of 2 patients (Patient #3 & 4).

Findings Include:

Concurrent medical record review for Patient #3 and Patient #4 revealed no evidence that either patient received a copy of the "Residents Bill of Rights" when their status changed from hospital inpatient to a swing bed admission.

Interview on 07/24/18 at 01:00 PM with Staff (E), Director of Quality Assurance revealed swing bed patients receive the "Hospital Patient Bill of Rights". "The Resident Bill of Rights" is not provided to patients when their status changes from hospital inpatient to "swing bed" patient. The facility was unaware that there are "Resident Bill of Rights" for swing bed patients.