HospitalInspections.org

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Based on interview and record review it was determined the hospital failed to inform the representative of 1 of 5 sampled patients (Patient 5) of their health status following a change in condition. Findings include:


According to facility records Patient 5 had been admitted to the hospital on multiple occasions with a constellation of symptoms from a chronic complex medical condition. Records indicate Patient 5 had initially been admitted on 10/25/09 with diagnosis that included Blindness, Loss of Hearing, COPD, Pulmonary Fibrosis, Diabetes Mellitus, Retinopathy, Peripheral Vascular Disease, Peripheral neuropathy, Cellulitis, Hypothyroidism, Hypertension, Aortic Valve Disease, Benign Prostatic Hypertrophy, Hypercholesterolemia, Bi-lateral Below Knee Amputation, Anxiety, Mild Dementia and Pneumoconiosis.

Following discharge on 11/6/09 Patient 5 had been readmitted to the hospital on 11/9/09 with acute pneumonia, tachycardia and declining respiratory status. Patient 5 remained a patient at the hospital on 2/9/10 at the time of this survey.

Review of facility records revealed that while in the hospital on 1/1/10 at approximately 7:00 am Patient 5 experienced an unobserved fall with injury. Noted injuries included lacerations and bruising of the head and left arm.

According to hospital policy, patients or their representative will be provided information regarding their care needs and condition. Hospital policy "Communicating Outcomes to Patients" indicates that "appropriate guardian or representative will be provided relevant information of all outcomes of care in a timely manner." Interview and record review determined the hospital failed to implement that policy as planned. The facility failed to inform Patient 5's representative of the fall in a timely manner.


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