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BRATTLEBORO RETREAT
PATIENT RIGHTS: NOTICE OF RIGHTS
Tag No.: A0117
Based on record review and staff interview, the hospital failed to provide the standardized notice to each Medicare beneficiary concerning their rights in 1 of 2 applicable records reviewed in the sample of 10. (Patient #3) Findings include:
1. Per record review, there was no evidence that Patient #3 was provided with the standardized notice "An Important Message From Medicare About Your Rights" within 2 days of admission and not more than 2 calendar days prior to discharge. This was confirmed during interview on 1/5/10 at 9:20 AM with the hospital's Financial Advisor.
No Description Available
Tag No.: A0267
Based on record review and staff interview, an adverse patient event reported to the Quality Department in 1 of 3 applicable records reviewed in the sample of 10. (Patient #5) Findings include:1. Per record review, a progress note dated 12/4/09 for Patient #5 stated, "broke wooden bedframe. Upset and talking to staff." Per interview on 1/5/10 at 10:50 AM, the Director of Standards of Quality confirmed that no incident report was completed and forwarded to Quality for review and would of expected this be done.
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review and staff interview, nursing staff failed to supervise and evaluate the care to each patient in 2 of 10 records reviewed. (Patient # 4 & # 5) Findings include:
1. Per record review, Patient #4's pain assessment was not completed on admission. Physician documentation stated that Patient #4 had right hip pain related to a congenital bone disease. In addition, no daily pain assessment was documented on the "Shift Progress/Reassessment Note" during the patient's hospitalization. This was confirmed during interview with the Vice President of Patient Care on 1/5/10 at 4:45 PM.
2. Per record review, staff failed to complete 15-minute checks on 12/5/09 & 12/6/09 for Patient #5 who was on 15-minute checks due to a history of self-harming behaviors. On 12/5/09 - 12/6/09, the checks were signed off as being done every 30 minutes at 10:45 PM, 11:15 PM, 12:15 AM, 12:45 AM and 1:15 AM and not every 15-minutes as ordered. Per interview on 1/5/10 at 1:30 PM, the Nurse Manager confirmed that checks should have been done every 15-minutes for Patient #5.