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Based on medical record review, staff interview, and review of facility policies, the facility failed to ensure that medical records contained evidence that patients had received Patient Rights information in advance of receiving care at the facility, whenever possible, for eight (8) of ten (10) medical records reviewed (#s 1, 2, and 5, 6, 7, 8, 9, and 10)

Findings include:

Review of ten (10) medical records (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) revealed:
Medical record #1 did not contain evidence that Patient Rights had been received.
Medical record #2 did not contain evidence that Patient Rights had been received.
Medical record #5 did not contain evidence that Patient Rights had been received.
Medical record #6 did not contain evidence that Patient Rights had been received.
Medical record #7 did not contain evidence that Patient Rights had been received.
Medical record #8 did not contain evidence that Patient Rights had been received.
Medical record #9 did not contain evidence that Patient Rights had been received.
Medical record #10 did not contain evidence that Patient Rights had been received.

The 6 North Clinical Manager and/or the Director of Risk Management acknowledged the above finding during medical record review.

Review of facility policy 1123-A, Patient Rights and Responsibilities, effective 2/18/16, revealed:
That it would be the policy of the facility system to identify patient's rights and patient's responsibilities and to inform/educate their patients and staff of those rights and responsibilities; to ensure patient safety; and identify their process to resolve conflict.
Procedure
1. Upon entering the System (at any point in the Network), the patient and/or family would be provided information, in the appropriate format, of their rights and responsibilities.

Based on medical record review, staff interview, review of facility policies, and review of employee files, the facility failed to provide care in a safe setting for Patient #1, which resulted in harm to the patient.

Findings include:

Review of ten (10) medical records (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) revealed:

Patient #1, a seventy-eight (78) year old patient was admitted to the facility on 4/9/17 at 7:36 PM.

A Consent for Treatment was signed, but not timed or dated. The record contained no evidence that Patient Rights had been received. A history and physical was performed on 4/10/17 at 10:47 AM, which noted diagnosis of sepsis, acute and chronic respiratory failure, chronic obstructive lung disease (COPD), and pneumonia.
A Treatment Plan was initiated on 4/10/17, which included falls and transfer assistance.
Physician orders included Morphine Sulfate (narcotic pain reliever) 2 mg intravenous every four (4) hours as needed for pain. The last documented dosage administered was on 4/12/2017 at 5:05 AM.
A Physical Therapist completed a Physical Therapy (PT) Evaluation on 4/15/2017 at 9:45 AM on Patient #1. The Evaluation indicated the patient's treatment diagnoses, which included; difficulty in walking, generalized muscle weakness, and unsteadiness on feet.
The physical therapist noted that the patient required maximum assistance for bed mobility, and, that the patient had not been tested on bed/chair transfer or ambulation due to medical safety concerns.
PT notes dated 4/17/2017 at 12:50 PM by the PT Assistant revealed that the patient required maximum assistance for bed mobility and bed/chair transfer; ability - two (2) person assistance.
PT notes dated 4/18/2017 at 11:46 AM by the PT Assistant revealed that the patient required maximum assistance for bed mobility and bed/chair transfer; ability - total assistance.
PT notes on 4/19/2017 at 1:07 PM by the PT Assistant contained no mention of the occurrence of an injury.
Physician Progress Note on 4/19/2017 at 1:34 PM noted the patient had slept better and denied pain at the time.
The 4/20/2017 nursing assessment which was documented at 9:00 AM, noted the patient had moderate weakness to all limbs, no pain; no injuries were noted.
4/20/2016 nursing documentation at 4:00 PM revealed the patient had no pain.
The patient was discharged to a nursing home on 4/20/2017 at 5:36 PM in good condition.
The discharge summary contained no mention of an injury.
Review of nursing notes and MD progress notes failed to reveal documentation that an injury (or assessment for such) had occurred during the patient's inpatient hospital stay.

Review of facility's Quality Log revealed an incident was reported on 5/1/17 by the patient's spouse. A quality report was documented which indicated a Physical Therapy Assistant was the staff member assisting the patient back to bed on 4/19/2017.

Interview with the PT assistant on 6/7/2017 at 11:33 AM in the conference room revealed that he/she had been employed in his/her current position since 12/23/2016, and worked on the day shift. The PT assistant recalled patient #1, stating that he/she had seen the patient two (2) times (AM and PM) the day of the incident. He/she continued on stating that at approximately 2:00 to 2:30 PM on 4/19/2017, he/she had entered the patient's room alone, discovering the patient sitting in a recliner, and the spouse in the room. The patient was wearing non-skid footwear. The room was observed to be free of spills, floor damage, and clutter. The PT assistant stated that he/she had had assistance getting the patient in the chair earlier, but the PT aide had been called to assist in another area, so was unavailable to assist with getting the patient back into bed. The PT assistant stated that he/she had not felt it necessary to request another staff member's help because he/she had transferred the patient alone on numerous occasions in the past. He/she explained that the PT evaluation on 4/15/2017 did not specify the number of persons required to assist the patient; and, noted that the patient was 80-99% impaired with a goal to decrease impairment to 20-30%. The PT assistant stated that he/she made the decision regarding the number of persons needed to assist the patient as they progressed toward their goal.
The PT assistant stated that he/she had put the chair's leg rests down, removed the patient's blankets, and had positioned the chair next to the bed. The PT assistant stated that he/she had then instructed the patient to scoot to the edge of the chair, applied a gait belt on the patient, and instructed the patient where to put his/her hands. The PT assistant stated that he/she had positioned the patient's feet closer together, and given the patient a bear hug. The PT assistant and the patient had rocked forward three (3) times, and on the count of three (3) instructed the patient to push up using the armrests. He/she further explained that in the middle of a squat-pivot to the bed, the patient had said: "ow, my foot's stuck". The PT assistant continued on stating that the patient's left foot had not pivoted correctly. Once the patient was sitting on the bed, no injuries were observed, and the PT assistant had assessed the patient's foot by moving it up/down and side to side without patient complaints of pain. He/she stated that he/she had repeatedly asked the patient if he/she was okay. The patient had said "yes, I'm fine. It just hurt a little." The PT assistant stated that he/she had placed the patient supine in bed, floated his/her heels and elbows, and assured the patient was comfortable. He/she had apologized to the patient and his/her spouse, and asked again if everything was okay- to which they answered "yes", and had thanked him/her. The PT assistant had then exited the patient's room.
The PT assistant stated that he/she had not reported or documented the event because neither the patient nor the patient's spouse had made a 'big deal' about it; the patient was not crying or moaning and had no signs of damage.

Interview with the Rehabilitation Clinical Manager on 6/7/2017 at 1:09 PM in the conference room revealed that he/she had worked in his/her current position since 12/9/2016, and had worked as an Occupational Therapist (OT) at the facility for sixteen (16) years. The manager stated that he/she was responsible for performing ninety (90) day and annual staff evaluations. The manager stated that he/she had been notified by a Patient Relations representative of an incident involving patient #1 when his/her spouse had submitted a complaint. The manager stated that he/she had conducted an investigation by interviewing the PT assistant, speaking to the patient's spouse, and completing a report in the computer system. On review of patient #1's medical record, the manager confirmed the PT evaluation on 4/15/2017 by a Physical Therapist indicated the patient required maximum assistance for bed mobility, and, that the patient had not been tested on bed/chair transfer or ambulation due to medical safety concerns. The manager explained that maximum assistance generally means the patient can do 25% of less of the transfer him/herself.
The manager confirmed:
No other PT evaluations by a Physical Therapist had been conducted after 4/15/2017.
On 4/17/2017, the PT assistant had noted patient #1 required maximum assistance for bed mobility and bed-chair transfers. 2-person assist noted for bed-chair transfer.
On 4/18/2017, the PT assistant had noted patient #1 required maximum assistance for bed mobility and bed-chair transfers, total assistance.
The manager explained that although the Physical Therapist had not tested for bed mobility and transfers, a goal had been written that the PT assistant and aide would work towards. He/she also stated that the PT assistant would review the Physical Therapist's evaluation prior to their first visit with the patient. He/she explained that when he/she saw "total assist", it meant two (2) persons were needed to assist with care.
The manager stated that he/she was concerned upon discovering that patient #1 was transferred by only one (1) staff member because he/she believed the PT assistant had stated that he/she had been assisted by an aide on both patient transfers that day.
The manager stated that the PT assistant is competent to make good decisions, had always done well and had received a ninety (90) day evaluation with satisfactory or above scores.

Review of nine (9) other medical records (#s 2, 3, 4, 5, 6, 7, 8, 9 and 10) revealed:
All patients were selected from an Event Log.
All had been Treatment Planned for fall risk.
All events had been reported to the nurse and MD.
All patients had received an RN reassessment following the recorded event.
All MD orders had been completed as ordered.

Review of facility policy 1123-A, Patient Rights and Responsibilities, effective 2/18/16, revealed that it would be the policy of the facility system to identify patient's rights and patient's responsibilities and to inform/educate their patients and staff of those rights and responsibilities; to ensure patient safety; and identify their process to resolve conflict.