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Based on document review and interview, the facility failed to ensure all complaint allegations were addressed for 1 of 10 patient (Patient 4) medical records reviewed.

Findings include:

1. Facility policy titled, Patient/Parent Rights and Responsibilities, Complaints, and Grievances, publication date 05/27/2025, indicated under IV. Definitions, Patient Grievance: 1. Any patient complaint that cannot be resolved promptly on the spot, by the patient care team members after escalating through immediate supervisor, their delegate, or clinical leadership. 2. Situations were patients call or write regarding concerns related to care or services that could not have been resolved during their stay. Under VI. Procedures, 3. If the complaint cannot be solved by team members immediately present, team members should contact their immediate supervisor, their delegate, or clinical leadership to address the patient/family concern and reach resolution. Unresolved complaints may become grievances, and the following procedures may apply if resolution is not achieved.

2. Review of Complaint and Grievances from 01/01/2025 to 07/27/2025 indicated there was a complaint filed on 05/29/2025 regarding patient 4's care during the current and previous hospitalization. Report indicated concerns during previous hospitalization which included a medication error and an identified nurse making inappropriate comments; report lacked documentation regarding an allegation and no follow up was documented.

3. Interview with A3 (Accreditation and Regulatory Consultant) on 07/28/2025 at approximately 3:05 p.m. confirmed that Patient Advocacy indicated they did not send a formal response to the complaint filed on 05/29/2025 as it was considered a complaint as the patient was a current inpatient. A3 confirmed that the complaint had an allegation that lacked documentation of response and allegations were from previous hospitalization.

4. Interview C1 (Complainant) on 07/31/2025 at approximately 2:42 p.m. indicated that they did notify the Patient Advocacy line of concerns which included concerns from patient 4's first hospitalization on 05/29/2025; C1 indicated all concerns in the formal complaint were not addressed and did not receive any documentation regarding the complaints.

Based on document review and interview, nursing services failed to administer medication as ordered for 1 of 10 (Patient 4) medical records reviewed.

Findings include:

1. Facility policy titled, Medication Administration and Management, publication date 05/08/2023, indicated under IV. Procedures, under B. The team member administering the medications must perform the 5 rights plus 4 checks (9 rights) on all medications prior to administering them to a patient. This includes right patient, right medication, right dose, right time, right route, right documentation, right action, right form, and right response.

2. Review of Patient 4's medical record indicated the following:
a. The patient was admitted on 04/04/2025.
b. Medical record indicated on 04/08/2025 at 1:12 p.m. provider ordered Geodon 5 mg (milligrams) IV (intravenous) push one time dose. Medication administration record indicated the patient was administered Geodon 20 mg IV push at 2:49 p.m. Medical record indicated the patient became hypoxic and hypertensive.
c. Patient was discharged on 05/07/2025 in stable condition.

3. Review of Incidents Reports from 01/01/2025 to 07/27/2025 indicated there was an incident report related to Patient 4 and a medication error on 04/08/2025. Report indicated that the N1 scanned the medication, nurse looked up to see how to dilute the medication and how to administer it. N1 indicated they diluted the medication and drew it up; administered the medication over 3 minutes as ordered. When N1 went to sign off the medication, they realized the dose needed to be entered and that the vial had more than ordered dose.

4. Interview with A8 (Executive Director of Pharmacy) on 07/28/2025 at approximately 3:02 p.m. confirmed that Geodon is packaged in a vial that is 20 mg/ml and that N1 administered the entire vial to the patient.

Based on observation and interview, facility failed to maintain a clean environment for 4 of 20 patient rooms (B487, B489, B492, and B496) observed.

Findings include:

1. Facility policy titled, ES Environmental Cleaning, published 01/09/2025, indicated under VI. Procedures, A. Cleaning Principles, 9. High dust horizontal surfaces and fixtures above shoulder height, including vents. Use an extension with the appropriate equipment such as a high duster or HEPA filtered vacuum. Replace microfiber high district cloth at the end of the day, when dirty and after each isolation room. Do not high dust over a patient area in an occupied room.

2. Observation on 07/28/2025 at approximately 3:10 p.m. observed visible, copious, and hanging dust from the ceiling vents which were located directly above the patient's bed in the following rooms: B487, B489, B492, and B496 on the 4B unit.

3. Interview with A3 (Accreditation and Regulatory Consultant) and A10 (Manager of Environmental Services) on 07/28/2025 at approximately 3:30 p.m. confirmed the following rooms had visible copious hanging dust in the ceiling vents in patient rooms B487, B489, B492, and B496.