HospitalInspections.org

The Rehabilitation Hospital reported a census of 36 inpatients. Based on documentation, staff interview, and policy review the hospital failed to follow their Abuse reporting system to ensure that patients are safe and free from harm for 1 of 18 patients (patient # 4) by failing to notify the police. Failure to follow their reporting system put patients at risk for potential harm, injury, or psychological turmoil.

Findings include:

- Documentation reviewed on 10/24/2016 at 4:00 PM revealed the hospital failed to ensure staff follow their plan of reporting potential abuse that occurs inside the facility for patient # 4 by failing to notify the police.

Interview with Staff B Director of Quality/Risk Management on 10/24/2016 at 4:00 PM s/he acknowledged the hospital's Abuse reporting system was not followed. The staff are to report any abuse allegation to the police within the first 2 hours. Staff B stated she has spoken to several staff members regarding their Abuse reporting system verbally but did not document the education.

- Abuse Training Teaching Aid reviewed on 10/24/2016 directed staff: "...Reporting Abuse Inside the Facility IF YOU HAVE REASONABLE SUSPICION THAT A CRIME HAS OCCURRED AGAINST A RESIDENT OR PERSON RECEIVING CARE AT THIS FACILITY, FEDERAL LAW REQUIRES THAT YOU REPORT YOUR SUSPICION DIRECTLY TO BOTH LAW ENFORCEMENT AND THE STATE SURVEY AGENCY Meadowbrook Employees: * Notify your DON and Risk Management immediately of an allegation of abuse. * Call law enforcement within the first 2 hours of allegation and they will come to the facility and interview the resident/patient ..."

The facility staff failed to notify the police at any time during the investigation of the alleged verbal/physical abuse of patient #4.

Based on interview, document and record review, and policy and procedure review the hospital failed to transfer 1 of 15 sampled patients reviewed (patient #1) with correct discharge medications. Failure to provide the correct medications when discharging a patient to another facility had the potential to place all patient's at harm for not having symptoms managed, withdrawal, agitation, and further medical complications.

Findings include:

Interview on 10/24/16 at 4:25 PM, Director of Nursing Acute, Staff C, stated regarding a discharge to another facility, the pharmacy generates a medication discharge list, the doctor reviews the list, then the pharmacist reviews it again. The medication list is sent with the patient to the facility or to their home. Prior to discharge to a facility the social worker will fax the discharge medication list to the receiving facility. If the patient is going home they will give them a 30 day supply of the medications and make an appointment for them to follow up with their primary doctor.

Interview on 10/25/16 at 9:50 AM, Advanced Practice Registered Nurse (ARNP), Staff G, stated when a patient is discharged the social worker will get the equipment needed ordered, the pharmacy brings a medication list to the doctor or the APRN to review and make any changes. The list can be retyped by the pharmacist if there are changes made. When the list is signed by the doctor or the APRN the list goes into the social workers box. The social worker faxes the discharge medication list to the receiving facility and the patient or family takes the original with them to the facility. When the discharge medication list is reviewed by the doctor or APRN it is just looked at alone and not compared against the medication administration record (MAR). There have been no issues in 2 years. When asked how the medication list for patient # 1 had 5 missing medications upon transfer Staff G verified the medications were missing and it had their signature as complete. Staff G again stated it is not the practice upon discharge to check the discharge medications against the MAR, they let the receiving facility check the MAR with the discharge medication list. Staff G stated the medication discharge list looked complete and was signed and sent to the facility as h/she did not notice any missing medications.

Interview on 10/25/16 at 10:15 AM, Pharmacist, Staff J stated when a patient is discharged a discharge medication list is created from the patient profile in the computer. The medication discharge list is made by going to the patient profile in RX-connect, converted to an excel file to add interventions, another file adds patient information and allergies. There are a lot of computer issues and internet issues they experience throughout the day. The discharge medication list for

Patient #1's discharge medications were prepared as usual and during the process the internet connect was lost and when the list was printed a few medications were not saved and had been eliminated. As soon as Staff J noticed the problem it was corrected and an updated complete medication discharge list was faxed to the facility. Staff J immediately put into practice a check system to ensure before the discharge medication sheet is sent to the doctor or APRN to look at it is reconciled with the patient medication profile for accuracy. The pharmacist is responsible for entering all medications into the computer system and the MARs are printed and delivered to the floors daily for each 24 hour day. Staff J stated this is the first occurrence h/she has ever had with missing medications. Staff J stated the mother of patient #1 had asked for medication lists occasionally.

Interview on 10/25/16 at 11:20 AM, Director of Risk and Quality, Staff B stated a grievance was filed and followed up on by the facility. The matter was addressed and corrected as soon as possible. H/she stated the receiving facility had been contacted and stated they only use the discharge medication list and not the MAR when receiving a patient. A follow up letter was sent to the mother of patient #1.

Interview on 10/24/16 at 12:42 PM, Administrator, Staff F stated upon admission of patient #1 to their facility a discharge medication list was received that was signed by the APRN and it was sent to their pharmacy to be filled. The mother of patient #1 noticed later that there were some missing medications. The facility thought the list was complete as they go by the discharge medication list that is sent and signed by the doctor. The mother of patient #1 told the nursing staff there as the mother knew all the medications were not all there. The mother called the Ombudsman Gloria who called Melissa and Melissa contacted Meadowbrook Rehabilitation Hospital who told her that the copy machine did not print and send everything to the doctor. Staff F stated they were able to reconcile the medications.

Interview on 10/25/16 at 11:50 AM, Licensed Practical Nurse (LPN), Staff H stated upon discharge of a patient to a facility the social worker and pharmacist prepare a discharge packet with all that needs to go to the facility and the discharge medication list. The nursing staff copy the papers and put a copy in the patient chart and send the originals with the patient/family or the facility driver. H/she had called report on patient #1 to the receiving facility 3 times. On the third time h/she was able to speak with a nurse and give report. The medication list was sent and a call back was received to clarify a medication. Staff H sent upon the receiving nurse ' s request a copy of the MAR and treatment administration records (TAR) to the receiving facility and documentation was confirmed of this occurrence.

Interview on 10/25/16 at 12:00 PM, Risk and Quality Director, Staff B stated the facility does not have a form to reconcile discharge medications or a policy and procedure for medication reconciliation of medications upon patient discharge. A copy of the admission medication reconciliation policy and procedure was not available either.

Interview on 10/25/16 at 12:30 PM, House Supervisor, Staff K stated upon patient discharge to a facility the pharmacy fills out a medication list and the social worker faxes everything to the receiving facility. There is a blue envelope that everything for the patient discharge is placed in. The packet contains the doctor and nursing notes, labs and a face sheet. Report is called to the receiving facility. Sometimes the MARs and TARs are sent to the facility.

Interview on 10/25/16 at 2:30 PM, Director of Quality and Risk, Staff B, Director of Nursing Acute/TBI (total brain injury), Staff C and TBI program director Staff D verified they have not reeducated staff on medication reconciliation of discharged medications in regards to the discharge medication list and MAR. They have no policy and procedure for discharge medication reconciliation and no policy and procedure for the doctor and APRN for discharge medication reconciliation.

Interview on 10/25/16 at 3:15 PM, LPN, Staff L stated when they receive a new patient what they need is a copy of the MAR, TAR and face sheet. H/she did not remember receiving a discharge medication list.

Interview on 10/25/16 at 4:15 PM, Staff Nurse M, stated upon a patient discharge to another facility the social worker gets a blue folder that has discharge papers, pharmacy medication forms, the patients diet, nursing concerns, wound care and doctors scripts. The nursing staff calls report and then will give the discharge packet to the facility person or patient. Any discharge paperwork that is sent prior to the discharge is faxed by the social worker. The nursing staff does not unusually fax anything unless the receiving facility requests it.

- Record review on 10/25/16 at 10:10 AM revealed Doctor, Staff I documented on the doctor progress note the discharge medication list was reviewed by h/she and it was reviewed by APRN, Staff G.

Policy and procedure review on 10-24-16 at 4:00 PM policy " Discharge Planning " states ...the discharge planner/social worker will ensure that a transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies ...

TAG A0843 ADMINISTRATIVE DISCHARGE PLAN AT MEADOWBROOK REHAB
Based on interview, document and record review and policy and procedure review the facility failed to review the discharge planning process to ensure that they are responsive to discharge needs. Failure to review discharge planning and ensure discharge needs of patients are met puts patients at risk for receiving incorrect medications, treatments and care.
Findings include:
Interview on 10/25/16 at 10:15 AM, Pharmacist, Staff J stated when a patient is discharged a discharge medication list is created from the patient profile in the computer. The medication discharge list is made by going to the patient profile in RX-connect, converted to an excel file to add interventions, another file adds patient information and allergies. There are a lot of computer issues and internet issues they experience throughout the day. The discharge medication list for patient #1 was prepared as usual and during the process the internet connect was lost and when the list was printed a few medications were not saved and had been eliminated. As soon as Staff J noticed the problem it was corrected and an updated complete medication discharge list was faxed to the facility. Staff J immediately put into practice a check system to ensure before the discharge medication sheet is sent to the doctor or APRN to look at it is reconciled with the patient medication profile for accuracy. The pharmacist is responsible for entering all medications into the computer system and the MARs are printed and delivered to the floors daily for each 24 hour day. Staff J stated this is the first occurrence h/she has ever had with missing medications. Staff J stated the mother of patient #1 had asked for medication lists at various times.
Interview on 10/25/16 at 12:00 PM, Risk and Quality Director, Staff B stated the facility does not have a form to reconcile discharge medications or a policy and procedure for medication reconciliation of medications upon patient discharge. A copy of the admission medication reconciliation policy and procedure was not available either.
Interview on 10/25/16 at 2:30 PM, Director of Quality and Risk, Staff B, Director of Nursing Acute/TBI (total brain injury), Staff C and TBI program director Staff D verified they have not reeducated staff on medication reconciliation of discharged medications in regards to the discharge medication list and MAR. They have no policy and procedure for discharge medication reconciliation and no policy and procedure for the doctor and APRN discharge medication reconciliation.
Policy and procedure review on 10-24-16 at 4:00 PM policy " Discharge Planning " states ...the discharge planner/social worker will ensure that a transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies ...