HospitalInspections.org

Based on document review and interview, the facility failed to implement its policy related to the written response letter after investigation of a complaint or grievance, for 2 of 2 patients (Patients #6, and #10).

Findings Include:
1. Review of the policy Patient Complaint and Grievance Process, policy number I-A.30, issued 5/2015:
A. Indicated on page 3: That the patient will receive a written notice of grievance determination.
B. Indicated on page 4: All verbal or written complaints regarding abuse, neglect, patient harm...are to be considered a grievance that requires immediate redress.
C. Indicated on page 5: The patient will be provided with written notice of: The name of the Chief Compliance Officer or designee, The steps taken to investigate and resolve the grievance, The final result of the complaint and grievance process, and The date of completion of the complaint and grievance process.

2. Review of facility complaint/grievance logs/reports indicated 2 patients had complaints, or grievances, made by family members, related to patient harm, including, but not limited to fractures sustained by a fall or due to the actions of another patient, filed with the facility.

3. Review of the letters sent to the family of patient #6, dated 12/21/15, and for patient #10, dated 12/22/15, lacked the information required by facility policy related to: the steps taken to investigate and resolve the grievance, the final result of the complaint and grievance process, and the date of completion of the complaint and grievance process.

4. At 8:45 AM on 1/13/16, interview with staff member #58, the interim chief executive officer, confirmed that the letters sent to the family of patients #6 and #10 lacked the required elements listed in the complaint and grievance policy, as stated in 1. above.

Based on document review and interview, the facility failed to ensure the safety of patients for 2 of 3 patients who fell, or were pushed to the floor by another patient, and sustained fractures while at the facility (Patients #6 and #10).

Findings Include:
1. Review of the policy Patient Rights And Responsibilities, policy number I - A.9, issued on 5/2015, indicated in item 19 that the patient had a right to: Receive care in a safe setting free from verbal or physical abuse or harassment.

2. Review of medical records indicated:
A. Pt. #6 was a 76 year old admitted with severe neurocognitive impairment related to dementia, alzheimer's type. The patient fell, after being pushed by another patient, on 11/26/15 at 8:30 AM with T12 compression fracture and a hand fracture occurring. The patient was transferred to, and remained at, the local acute care hospital with re admission to this facility on 11/28/15, and a final discharge from the facility on 12/9/15.
B. Pt. #10 was an 86 year old admitted on 12/4/15 from home after the family found the patient face down in the shower. The patient was admitted with diagnoses of moderate neurocognitive disorder related to dementia of alzheimer's type, with behaviors.
(i) The patient scored 3 (low risk) for falls on admission.
(ii) The patient fell at 5:15 AM on 12/8/15 having walked alone to the bathroom in the AM. At that time, an x-ray of the humerus showed an old, healed left humerus fracture. And, an x-ray of the left shoulder showed mild degenerative joint disease.
(iii) The patient complained of chest pain after the fall on 12/8/15 and pain medications given.
(iv) Per the discharge summary, on the day of discharge, 12/15/15, some chest pain was noted with a call to the on call practitioner giving an order for transport to the local ED (emergency department) for evaluation. Per an incident report for this patient, rib fractures were found upon x-ray in the ED. Pt. #10's MR lacked documentation of addressing the patient's complaint of chest pain from 12/8/15 to 12/15/15.

3. At 12:20 PM on 1/13/16, interview with staff member #54, the compliance officer, confirmed:
A. The current fall scoring system does not indicate fall precautions need to be implemented until a patient scores at 4 or higher.
B. That patients #6 and #10 all sustained fractures while at the facility.
C. The delay in finding rib fractures for pt. #10 was due to the patient's having complained of chest pain prior to their fall. The patient had x-rays after the fall for shoulder and arm pain, but not for ribs at that time.

Based on document review and interview, the facility failed to ensure the implementation of its policy, related to time limits for seclusion orders, for 1 of 1 patient who was secluded (Patient #7).

Findings Include:
1. Review of the policy Restraints and Seclusion, policy number II.C.8, issued 5/2015, indicated under Violent, Self-Destructive Behavioral Restraints: Application of restraints or seclusion for behavior reasons/modification require written order by LIP (licensed independent practitioner) (MD - medical doctor, PA - physician's assistant, DO - doctor of osteopathy, NP - nurse practitioner) on initiation and every 4 hours thereafter.

2. Review of the medical record for patient #7 indicated:
A. A NP wrote an order at 9:40 AM on 11/22/15 for: "Haldol 5 mg (milligrams) and 2 mg Ativan in same syringe now for aggression monitor vital signs every hr. (hour) put patient in seclusion for safety".
B. An order was written by a MD on 11/23/15 at 10:00 AM for: Seclusion for safety of self and others Haldol 5 mgm (milligrams) IM (intramuscular) with Ativan 2 mgm IM stat (now)".
C. An order was written by a NP on 11/27/15 at 4:25 PM to: "Put patient in seclusion and follow seclusion protocol".

Based on document review and interview, the facility failed ensure that 1 of 3 RNs (registered nurses) lacked competency in CPR (cardio pulmonary resuscitation). (RN P4).

Findings Include:
1. Review of the nursing file for RN P4 indicated the nurse was hired 10/12/15 and had no documentation of competency in CPR in their file. The nurse left employment on 11/30/15.

2. Review of medical records indicated that Pt. #7 was secluded two times after admission 11/21/15 (11/23/15 and 11/27/15).

3. Interview with staff member #54, the compliance officer, on 1/13/16 at 12:20 PM confirmed that:
A. The nurses' job description indicates that CPR is only required within 180 days of hire and staff member P4 left within that time frame without having completed CPR certification.
B. Pt. #7 was on the nursing unit, and was secluded, within the time frame of RN P4's working time on the unit.
C. Patient safety is compromised if nursing staff are not CPR certified while patients may be restrained or secluded.
No further documentation for staff RN P4 was provided prior to exit.

Based on document review and interview, the nursing staff failed to implement the facility policy, related to medication administration documentation, for 5 of 10 patients (Patients #2, #3, #4, #7, #8).

Findings Include:
1. Review of the policy Standardized Medication Administration, policy number II-C.65, issued 5/2015, indicated:
A. On page one: All medications administered will be recorded in the patient's medication administration record (MAR) along with the date given, time given, and the initials of the person administering the medication. Documentation on the MAR should follow the procedure guidelines below.
B. On page 3, in item #9: Administer the prescribed medication and record the administration on the MAR by documenting initial by the time on the MAR.
C. On page 3, in item #11: If the medication is refused or contraindicated, return the unused medication...and circle Initials on the MAR to indicate refusal/not given.

2. Review of patient medical records indicated:
A. Patient #2 lacked documentation on the MAR on 1/8/16 for the 9 PM Quetapine Fumanate 100 mg (milligram) tab (Seroquel 100 mg) daily at bedtime; for the Trazadone 50 mg at bedtime; and for the Miconazole 1% vaginal cream two times/day (for the 9 PM dose).The MAR was blank for these medications.
B. Patient #3 lacked documentation on the MAR on 1/8/16, 1/9/16, 1/10/16 and 1/11/16 for the Ensure plus 1 can TID (three times/day) for all three supplements for the 4 days, and lacked documentation for the 9 AM Depakote 250 mg BID (two times/day) for 1/8/16 and 1/10/16. The MAR was blank for all of these medications.
C. Patient #4 lacked documentation on the MAR for the 6 AM (1/2/16) Synthroid to be given daily; for the 2 PM Ensure Plus to be given 2 times/day on 1/8/16; and for the 1/9/16 Lorazepam 0.5 mg to be given at 9 AM and 2 PM (ordered tid and given at 9 PM).
D. Patient #7 lacked documentation on the MAR for the 9 PM Depakote syrup 250 mg on 11/22/15; on 11/25/15 for the 9 AM doses of Paronetine 20 mg (daily), Depakote syrup, and Ativan 0.5 mg; for the 2 PM Ativan 0.5 mg; and for the 9 PM Depakote syrup and Ativan 0.5 mg.; on 12/8/15 for the 9 PM meds: Clonidine 0.1 mg, Diazepam 5 mg, Quietapine 400 mg, and Valproic Acid 25 mg.
E. Patient #8 lacked documentation on the MAR for the 12/7/15 9 AM doses of Augmentin 875 mg and Cyanocobalamin 1000 mg; the 12/12/15 9 PM dose of Docusate 100 mg; and the 12/12/15 9 PM dose of Pantoprazole 40 mg.

3. At 2:30 PM on 1/12/16, interview with staff member #54, the compliance officer, confirmed that medications were not documented on the MAR, per facility policy, for pts. #2, #3, and #4, current/open medical records.

4. At 12:20 PM on 1/13/16, interview with staff member #54, confirmed that medications for the closed records (patients #7 and #8) were not documented per facility policy, as listed in 2. above.

Based on document review and interview, the infection control practitioner failed to ensure that lab results were received and reviewed timely for 1 of 1 patients with an untreated UTI (urinary tract infection), Patient #1.

Findings Include:
1. Review of the policy Laboratory Process & Procedures, policy number II.C.99, issued on 5/2015, indicated in item #11: Nurse review results, updates Clinician as needed and place lab on chart under "Lab" and notates "Results on Chart" on the patient lab sheet on the unit.

2. Review of the open medical record for patient #1 indicated:
A. An order was written on 1/6/16 at 9:30 AM for a UA/C&S (urinalysis for culture and sensitivity) for dysuria.
B. On 1/12/16 at 1:30 PM, there was no UA result in the patient's medical record.

3. Review of the UA report faxed 1/12/16 at 12:59 PM indicated the specimen was received at the lab on 1/7/16 and resulted in: "Greater than 100,000..Escherichia coli", with antibiotics that were susceptible listed below. (A preliminary report was dated 1/8/16 at 10:06 AM that showed a gram negative bacilli greater than 100,000 was isolated, with susceptibilities to follow, but was also not on the patient's chart.)

4. At 1:30 PM on 1/12/16, interview with staff member #54, the compliance officer, it was confirmed that:
A. The medical record for patient #1 lacked a copy of the UA report.
B. Nursing staff was requested to get the results of the UA specimen ordered on 1/6/16.
C. It was found that patient #1 had a UTI that had gone untreated due to staff failing to follow up on the UA specimen sent out on 1/7/16.
D. The policy, listed in 1. above, lacked parameters and expectations for lab report receipt, or nursing's timeline in procuring lab results for follow up with the Clinicians.