HospitalInspections.org

Based on review of documentation and interview, it was determined that Patient # 1 was not provided care in a safe setting.

Findings were:

Patients' Rights Handbook stated in part "You have the right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs, and promotes respect and dignity for each patient. You also have the right to appropriate treatment in the least restrictive appropriate setting available consistent with the protection of the patient and the protection of the community ...You have the right to be free from mistreatment, abuse, neglect, and exploitation."

Facility policy entitled "Fall Assessment/Re-Assessment and Precautions" stated in part "All patients will be assessed and identified for the potential of being at risk for falls within the first 8 hours of admission at the time of their initial nursing assessment, immediately after a fall and every 7 days if identified as a moderate or high risk. In the event of a fall occurrence, patients will be re-assessed and moved to a higher fall risk, and secondary fall preventions interventions will be implemented. The RN, utilizing the Fall Risk criteria on the At Risk for Falls Score Sheet form, will assess/re-assess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated ...An incident report will be completed in its entirety and forwarded to the DON after every fall."

Patient # 1was admitted to the facility on 12/12/19 after being aggressive in the nursing home where he lived. Upon admission, the patient was found to be alert and oriented X1, non-verbal and agitated. He had documented falls on 12/16/19 and 12/22/19 and a report of a skin tear on 12/14/19. Patient was discharged from the facility on 12/24/19 and admitted to a medical hospital on 12/25/19 suffering from a dislocated shoulder and extreme dehydration and kidney failure.

In interviews with the Facility Administrator and the Director of Nurses on 2/26/2020, Patient # 1's post hospitalization physical condition was acknowledged.

Based on review of documentation and interview, it was determined that patient's Medical Power of Attorneys were not always notified in the event of patient injury.

Findings were:

Facility policy entitled "Management of Information" stated in part "A patient may appoint another person as his or her power of attorney for health care purposes ...Oceans generally may disclose a patient's PHI to a person holding a power of attorney for the patient if the power of attorney meets the following criteria:
1. In writing and signed
2. Witnesses or Notarization Required
3. Validity
4. Power of Attorney-Right to Access PHI: Unless otherwise stated in the power of attorney, a person appointed as a power of attorney is considered a designated personal representative of the patient and has the same rights of access to the patient's PHI as the patient."

Patient # 1 had documented falls on 12/16/19 and 12/22/19 and a report of a skin tear on 12/14/19. The patient's Medical Power of Attorney was not notified of any of the above incidents. This was acknowledged by the Director of Nurses on February 26, 2020.